Health in Rural America: Remembering the Importance of Place

Historically, public health has been viewed through a variety of lenses. One lens focuses on the contrast between the science and the practice of public health.1 Another focuses on individual versus social responsibility for health.2 A third lens visualizes the contrast between an emphasis on disease categories and an emphasis on functional communities.3 A fourth focuses attention on the distinction between market forces and social justice.4 Of particular importance for public health professionals interested in rural health is that lens through which one sees an important part of the history of public health’s development as oscillation between a focus on health issues facing populations defined by their demographic characteristics and health issues in populations defined by their geographic location.

Many of the early public health efforts in the United States focused on specific populations, such as merchant seamen and the urban poor,5 or specific outbreaks of disease, such as cholera, smallpox, tuberculosis, yellow fever, malaria, and typhoid.6 With the challenges created by the burgeoning industrial machine that dominated the late 19th and early 20th centuries, the roots of public health became deeply intertwined with the muck and mire of specific places—the urban slums that fed the industrial machine.7,8 This emphasis on poor populations in urban slums may have sprung from the self-interest of industrial and urban elites fearful about epidemics and their own physical health. It may also be attributed to the need for an adequate urban workforce that could be exploited for economic benefit or to a philanthropic ethos that required the more fortunate to assist those less fortunate than themselves. If nothing else, the consistent focus on simplistic causal explanations for the ill health of the urban poor probably indicates that public health’s focus on urban slums originated from some admixture of all these factors.9

A RENEWED EMPHASIS ON PLACE

More recent developments, in the late 20th and early 21st centuries, have moved public health toward assessing, planning for, and assuring the health of special, vulnerable populations largely defined by demographic or cultural characteristics.10 Few public health professionals would argue with the logic, if not the necessity, of this emphasis. Investigating and attacking health disparities is a realization of the finest aspects of public health as a profession and of the profession’s emphasis on social justice. In addition, there has recently been a renewal of interest in geographic characteristics and place within public health, particularly in the areas of international health and community development. It seems to be an appropriate time to expand this renewed interest in “place” to encompass rural health as an important context for public health efforts, particularly given the health disparities between rural and suburban areas.11

However, it is important to realize how deceptive perceptions of geography and place can be. The images conjured up by the term “rurality” in the minds of the general population are quite consistent. Rural Americans are seen as hardworking individuals with a strong sense of family and community and traditional religious beliefs.12 Metropolitan dwellers believe that rural folk have freely chosen their location and lifestyle because farming, ranching, and the interconnect-edness of rural or small-town life are important values for them.12 This consensus captures as much of the reality of rural life in modern America as does Grant Wood’s iconic image of rurality in his painting American Gothic. We hope the articles in this issue will help public health professionals see rural America, in all its diversity, more clearly; improve our understanding of the health problems faced by rural Americans; and strengthen our knowledge of the strengths and weaknesses rural settings bring to the battle for better health.

COMPOSITION AND CONTEXT

As noted by Probst et al.,13 it is important to recognize that rural public health problems may be viewed as largely compositional, largely contextual, or arising from some mix of composition and context. Health problems in rural areas are compositional when they derive from the characteristics of people residing in rural settings, and rural health issues are contextual when they derive from the special characteristics of rural areas. Agricultural accidents are an example of a contextual rural public health issue. Such accidents can only occur in a rural setting, as Peek-Asa and her colleagues indicate,14 because rural areas are the only place where agricultural activity occurs. Auto accident fatalities are probably best thought of as arising from a combination of context (rural roads) and composition (lower use of preventive measures).14 Health risks such as smoking and obesity have a large compositional component related to the educational and socioeconomic characteristics of the rural population.

Some might argue that only those problems that are largely contextual are truly “rural” health problems. Such an argument is analogous to an argument that HIV is not an international health problem because HIV appears in the United States as well. Context always modifies the nature of health problems and their possible solutions. Even if an issue is largely compositional, to ignore the context in which it occurs will reduce our understanding of the dynamics of the problem and the potential for its resolution. Rural settings have unique sets of dampening and multiplier effects that must be considered when dealing with public health problems, even those that are largely rooted in population composition.

As Eberhardt and colleagues’ work shows,15 health problems, conditions, and behaviors often do not have a monotonic relationship with rurality. Monotonicity implies that the relationships under review are fundamentally linear. The implication is that more rurality, as indicated by each category in some ordinal classification schema, should be accompanied by a continuing increase or decrease in the chosen indicator of health. Unfortunately, as is so often the case, reality is more complex. A variety of health problems have a curvilinear relationship with rurality. As a result, the most isolated rural areas often look more like central cities than suburban areas or small towns. If rural populations aspire to some goal with regard to health issues, it is to be more like suburban areas than any other type of setting. It is in suburban areas that one often finds the lowest prevalence of many public health problems. Thus, those engaged in both practice and research must eschew the simple distinction between metropolitan and non-metropolitan areas as the most appropriate representation of place. Finer distinctions that separate central cities, suburbs, towns, and isolated areas will provide a much clearer picture of the needs and resources for health issues.

What occurs in rural areas is also important for urban populations. Our system of agricultural production and the corporatization of food production may impose burdens on all of us. Osterberg and Wallinga describe some of the externalities associated with rural food production, including manure and other environmental contaminants associated with large-scale food production, reductions in air and water quality, and potential effects on antibiotic-resistant strains of pathogens.16 Clearly this is a commons issue17 and requires a policy and regulatory response. Moreover, because state legislatures may be reluctant to restrict agricultural production—and because the effects of these externalities are frequently multi-state, national, or even international—the response may need to be at a national level.

TAILORING PROGRAMS AND SERVICES TO MEET RURAL NEEDS

The traditional emphasis on access to care as the principal issue in rural areas is important, but it is too restrictive to enable the resolution of the myriad of rural public health challenges. The history of rural health research, as Hartley so clearly indicates, is deeply rooted in concerns about access to care and an equitable distribution of health personnel.18 However, many of the major public health problems faced in rural areas (e.g., obesity, tobacco use, failure to use seat belts) are not likely to respond to an increased presence of general practitioners, physician specialists, or physician extenders. Instead, these challenges call, as Hartley indicates, for a population health perspective with a focus on prevention and a healthy lifestyle.

The delivery of public health services in rural areas faces daunting challenges, including low population density, transportation issues, lack of access to grant funding, lower public funding levels for rural services and programs, difficulties in recruiting staff, and potential fragmentation of scarce resources. This suggests that we cannot simply rescale public health programs and services from urban areas and expect them to be successful in rural areas. Rather, we need to consider alternative models for program delivery. Berkowitz provides information on some of the alternative models developed through the Robert Wood Johnson Foundation Turning Point Initiative.19 In addition, the material developed as part of Rural Healthy People 2010 also provides models of programs with proven records of success in rural settings.20

It is also important to think beyond the delivery of health and public health services in order to address the needs of rural areas. Many rural areas are undergoing major demographic and social transitions. For example, the outmigration of younger individuals contributes to the differential aging of rural populations. Technological innovations and the corporatization of agriculture may reduce the availability of agriculture-related jobs. In-migration of retirees and older populations into rural areas may increase the demand on the service sector and increase service-sector employment. Rural areas, particularly those adjacent to urban centers, may become suburbanized.11

Rural areas frequently have many strengths, including dense social networks, social ties of long duration, shared life experiences, high quality of life, and norms of neighborliness, self-help, and reciprocity. Addressing the needs of rural areas, then, requires building upon the positive aspects of rural life while addressing the health, public health, infrastructure, and economic needs of rural areas. In the end, those of us concerned with rural health believe that progress in facing health problems in rural areas requires a clear recognition that rurality is a contextual issue that demands special attention from public health researchers as well as practitioners. We cannot assess problems, develop policies, and ensure the delivery of services in rural areas without recognizing that the public resources, social capital, and social networks in those settings are fundamentally different from those in other areas.

In some sense, we need to treat rural health as a context similar to that of international health. We would be remiss in our efforts to improve the health of populations in Uganda if we did not recognize the social and cultural context of our efforts. Why should we approach public health problems in the hollows of Appalachia, on the rolling prairies of the Texas Panhandle, or the flatlands of rural Oklahoma in a less contextually sensitive manner?

Figure 1.

A woman hangs clothes to dry in Toledo, an old turpentine-making community of slave descendants in an isolated part of South Georgia near the Okefenokee Swamp.

Photo courtesy of Melissa Farlow/Aurora/IPN.