Leveraging Interest to Decrease Rural Health Disparities in the United States

The work of Case and Deaton¹ highlighting “despair deaths” has brought significant attention to the challenges rural residents face, and J. D. Vance’s recent memoir Hillbilly Elegy² has provided a story to complement the data. Although both shine a welcome light on rural health issues and challenges, it is perhaps the election of 2016 that most amplified these issues, leading many to ask, “What is happening in rural America?”

We need to be cautious to not overinterpret trends on the basis of any one study, memoir, or even election outcome—ultimately, rural America remains quite diverse, and there are innumerous assets in our rural communities. Not everyone in a rural community is a drug addict, one man’s experience cannot be generalized to an entire region, and a national election driven by a desire for change does not necessarily reflect the values and priorities of an entire segment of the population. Nevertheless, there is palpable frustration in much of rural America driven by individuals feeling neglected and left behind. In communities that are struggling economically, with low educational attainment and rising health inequities—where they feel ignored by one party and taken for granted by the other—is it really surprising that a message of change was appealing?

RURAL INEQUITIES

Although the attention the election brought to rural inequities is welcome, as rural health researchers, we are disappointed that it has taken so long to arrive. Health disparities among rural residents were well documented by the Centers for Disease Control and Prevention in their Health, United States, 2001: With Urban and Rural Health Chartbook (bit.ly/2uqwCtV). With support from the Health Resources and Services Administration Federal Office of Rural Health Policy, the nonpartisan and objective research organization NORC at the University of Chicago Walsh Center for Rural Health Analysis developed The 2014 Update of the Rural–Urban Chartbook.³ This chartbook further documents these health disparities and demonstrates many of the trends that we see related to rising mortality rates attributable to suicide and unintentional injury, which includes opioid overdose. We also learned through our work that rural populations are diverse and that rural disparities differ across rural regions.⁴ Work conducted by colleagues at the South Carolina Rural Health Research Center provided an even more detailed look at rural disparities, showing an interplay between geography and race/ethnicity in which rural minority populations fare worse than do rural Whites.⁵ As far back as 2008, we documented rising rates of opioid and heroin use in the Appalachian Region.⁶

Why did it take us so long to get here? We would argue that public health as a field and many funders of public health programs and initiatives have been slow to direct resources to rural communities. We believe much of the reason behind limited public health investments in rural communities is a rational desire to maximize program impact (i.e., focus on larger population centers) combined with rural small numbers challenges that make it difficult to both efficiently direct resources on the front end and demonstrate outcomes on the back end. Although the rationale may be understandable, the end result is that rural populations who feel neglected and left behind are in fact being neglected and left behind by the very institutions that concern themselves with decreasing health disparities and improving health equity. Ultimately, we have reinforced the feelings of neglect that exist in many of our rural communities by our own inaction.

OPPORTUNITY FOR PUBLIC HEALTH

The question before us then is “How do we use this moment in time to decrease health disparities, improve health equity, and advance public health?” We would argue that public health as a field has a tremendous opportunity before it. If we demonstrate empathy by directing resources to address rural population needs; if we provide resources for rural communities to generate locally driven solutions by using their many assets; if we strengthen rural communities by providing tools, resources, and technical assistance to accelerate change; and if we invest in our rural communities, then we are likely to demonstrate how public health can improve health in rural communities and eliminate geographic health inequities.

The basic capacities to use this investment are already in place. Although often not as strong or secure, rural public health infrastructure and capacities exist in many of our rural communities across the nation. Many of our public health workers serve in rural local and state health departments around the country, and they can be our envoys to help address the needs of rural populations, putting a positive face on our field and growing support for the work that we do. (Indeed, 59% of local health departments in the United States are classified as rural.⁷)

Empowering our rural public health workforce to better conduct the work of public health and to more effectively communicate the benefits they bring to their communities will help engage rural residents, which will in turn create demand for public health among rural policymakers. All of us who work in public health, regardless of our population focus or the disparities and inequities that our programs seek to address, stand to benefit from broader support for our field, which includes rural residents, institutions, partners, and policymakers. The bottom line is this: what’s good for rural residents is good for us all.