Wholesome environment?
You’d think country living, with fresh air and open spaces, would be healthier than city dwelling. But key health measures show just the opposite. One reason: More public health attention goes to metropolitan populations. “We’ve made a lot of efforts to improve care in urban areas, and we’ve been rewarded with a lot of success,” says Dr. Ernest Moy with the National Center for Health Statistics, part of the Centers for Disease Control and Prevention. “Rural areas are often more challenged in terms of getting interventions in places, so they tend to lag behind.” Read on for specific examples of rural health and health care gaps.
Preventable deaths
Heart disease, cancer, unintentional injuries, chronic lower respiratory disease and stroke are the top five causes of death in the U.S. Compared to metropolitan areas, rural death rates are higher for all five, according to a study in the Jan. 13 Morbidity and Mortality Weekly Report, co-authored by Moy, that examined “potentially excess deaths” or higher-than-expected death rates in people under 80 in 2014. Urban areas have made progress in reducing health risk factors and improving disease prevention, detection and treatment, says report co-author Dr. Macarena Garcia of the CDC. Unfortunately, rural areas haven’t kept up.
Vanishing hospitals
From January 2010 to the present, 80 rural hospitals have closed in the U.S., according to the North Carolina Rural Health Research Program. “We have to change how we’re delivering health care in a rural context,” says Alan Morgan, CEO of the National Rural Health Association, a nonprofit advocacy group. “We have to move more toward an outpatient and primary care delivery model. We have to make sure we have access to emergency room service 24/7. We have to transform a lot of these old rural hospitals that were built in the 1950s with 150 patient beds — that model just doesn’t work anymore.”
Opioid onslaught
America’s opioid epidemic, with misuse of prescription painkillers leading to overdoses, is hitting rural areas hardest, the CDC researchers note. Methadone, oxycodone (including Oxycontin) and hydrocodone (including Vicodin) are the most common drugs involved in these deaths, according to the CDC website. In addition, synthetic opioid drugs like fentanyl are increasingly involved in fatal overdoses. A 2014 study in the American Journal of Public Health found death and injuries from opioid misuse was most concentrated in states like Kentucky, West Virginia, Alaska and Oklahoma, all with large rural populations.
Traffic’s toll
From 1999 to 2014, the death rate from unintentional injuries — many caused by car crashes — was about 50 percent higher for rural Americans than their urban counterparts. Severe trauma from high-speed crashes contributed, combined with greater travel distances to advanced trauma centers. “The area that is most troublesome from a public-health standpoint is that unintentional injury has increased,” Garcia says. Drug and alcohol use play a part, and seat belt use is lower in rural areas, making traffic injuries more lethal.
Stuck on smoking
Smoking — a prime risk factor for cancer, heart and lung disease — is more prevalent in the country than the city. Smokers living in rural areas are more likely than others to smoke 15 or more cigarettes per day, according to CDC figures. Adolescents in rural areas begin smoking earlier in life, and are more likely than their suburban or urban counterparts to smoke daily. Unfortunately, nationwide reductions in smoking rates have not been matched in rural settings, Garcia says. And smoking raises the risk of debilitating, life-shortening conditions such as chronic obstructive pulmonary disease, or COPD, lung and other types of cancer, heart attacks and stroke.
Health provider shortages
“Rural America is 90 percent of the landscape and 20 percent of the people in the U.S.,” says Jan Probst, director of the South Carolina Health Research Center. “But it is served by less than 10 percent of physicians.” Lack of amenities and the fact that it’s harder to earn a living keep many health professionals from practicing “in the woods,” says Probst, who is a professor with the Arnold School of Public Health at the University of South Carolina in Columbia. To help, high-shortage areas of nurses, dentists, mental health and primary care practitioners qualify for federal loan repayment, visa waiver and other incentive programs to attract more practitioners.
Aging in place
While young people leave rural regions to seek greater opportunity, aging relatives tend to stay put, Probst points out. Isolation, a health threat for older adults, is accentuated in remote rural areas. In general, older adults are more likely to have chronic health conditions. Added to the smaller pool of health providers, higher average poverty levels and greater distances to emergency rooms and hospitals, health risks are stacked against seniors living in rural areas.
Less leisure-time exercise
Working hard is different than working out, and rural residents are less likely than others to be physically active in their free time. “Rural areas experience higher rates of obesity and overweight than the nation as a whole, yet many rural communities do not have the resources to address this critical health concern,” according to the Rural Health Information Hub. Gyms and other exercise facilities are less available, and even with more available outdoor space, public amenities that promote walking and other physical activity — such as sidewalks and parks — may be lacking.
Food deserts in farm country
Odd as it may seem, fresh, healthy food can be harder to find in some rural areas, due to an absence of local grocery stores or markets. Convenience stores offer a smaller selection, often dominated by less-nutritious and higher-calorie processed foods. Many rural areas are considered food deserts, Morgan says, particularly in more sparsely populated states and in the Southeast. The U.S. Department of Agriculture has mapped nationwide food access, as determined by distance to and number of area stores, average neighborhood income and availability of vehicles and public transportation.
Dental gaps
Too few dentists serving rural communities and lack of dental insurance threaten residents’ oral health. “In rural South Carolina, for example, the third most common reason for uninsured people to visit an emergency room is tooth pain,” Probst says. Fewer providers and greater distances to dental practices make it more challenging to keep up with regular dental checkups and care. Medicaid programs in some states, including South Carolina, have recently added dental coverage for adults who qualify. Medicaid’s Healthy Connections program offer annual cleanings, oral exams, X-rays, tooth extractions and fillings.
Double disparity
African-Americans in certain rural areas face even wider health gaps than their white neighbors. A 2016 study in the Journal of Rural Health looking at the “rural mortality penalty” in the U.S. found that in 2012, even “the most advantageous regions of mortality for blacks exhibit higher morality than the most disadvantageous regions for whites.” In areas with the worst disparities, excess death rates per 100,000 people were nearly 40 percent higher for African-Americans. Racial and other rural health disparities differ nationally. Within the new CDC mortality data. Moy says, drilling deeper revealed wide variations in urban-rural health gaps.
Rural health efforts
Health care advocates are working on many fronts to help rural health catch up. Telehealth lets specialists reach more patients in remote areas, for instance using telemedicine robots to accelerate diagnosis and treatment of stroke. The Affordable Care Act gives more rural Americans access to preventive care. However, rural insurance exchanges are shrinking as major insurers opt out, the Kaiser Family Foundation reports. Providing more health education at the local level is another strategy. For example, providers can reduce traffic fatalities by counseling patients to wear seat belts on every trip and properly use car seats and booster seats for kids.
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