Health inequalities affect millions in rural areas of the United States


Rural Americans, who make up at least 15-20% of the US population, face inequalities that result in worse health care than urban and suburban residents.

These rural health disparities are deeply rooted in economic, social, racial, ethnic, geographic, and health worker factors. That complex combination limits access to care, makes it harder to find solutions, and exacerbates problems in rural communities everywhere.

“If you don’t manage your health, the symptoms of the disease go way further. Cancer patients show metastatic cancer, and diabetics show end-organ damage,” says the University of East Tennessee Quillen School of Medicine. said Joseph Florence, M.D., Professor of Family Medicine and Director of Rural Programs.

Consider a patient who comes to a rural clinic affiliated with Quillen. The man had a large abscess and needed drainage to treat the infection. Rural patients are unlikely to have health insurance, but he did. However, like many in the countryside, he could not find an insurance company within an hour or two of his home.

“There happened to be a free clinic that night, so I took care of him there,” Florence said. “But this is a monthly event to give medical students experience, not a way to provide healthcare.”

Challenges to rural health

From Appalachia and the Deep South to the Midwest and Western states to Alaska and Hawaii, rural communities in the United States share common risks of poor health. These challenges, including few local doctors, poverty and remoteness, contribute to the lack of access to care.

A 2017 North Carolina report found that compared to urban areas, rural people have lower median household incomes, higher rates of children living in poverty, and fewer adults with secondary education. Low numbers, high numbers of uninsured residents under the age of 65, and high mortality rates. Rural Health Research Program (NC RHRP) at the University of North Carolina at Chapel Hill.

Rural residents on farms, ranches, reservations and frontiers often have to travel long distances to reach medical facilities. This means hours away from work for initial appointments and follow-ups, causing many to delay or avoid treatment.

Longer distances mean longer wait times for local emergency medical services (EMS). This may endanger patients requiring EMS therapy. Dr. Gary Hart, director of the Center for Rural Health at the University of North Dakota School of Medicine and Health Sciences, said: fork.

“Access to health care providers is a problem, even for family doctors.

Dr. Gary Hart
University of North Dakota School of Medicine and Health Sciences

A shortage of doctors contributes to many rural health problems.Primary care physicians are stretched thin, and specialists including mental health and substance abuse providers are rare [see sidebar].

“Even for family doctors, access to providers is a problem,” Hart said. “If you want to go to a gynecologist, depending on where in the country you live, you may have to travel 200 miles,” according to a study published in September 2017 by researchers at the University of Minnesota School of Public Health. As of 2014, 54% of rural counties had no hospitals providing maternity services.

According to the US Department of Veterans Affairs (VA), 25% of US veterans live in rural areas. More than half of veterans living in rural areas are enrolled in the VA health system, compared to 36% of urban veterans, but many live far from the nearest VA health center. I live

Some medical colleges deliberately prepare their students to meet the needs of rural areas. Quillen was set up to meet community needs, looking for students who are likely to “return to rural areas for primary care,” says Florence. Students will gain rural experience during their training, including rural immersion experiences and learning from faculty with rural care backgrounds. We will implement a health checkup and head start program for children in rural elementary schools to explore the differences from urban children.

Quillen’s curriculum enhances students’ cultural sensitivity to rural patients. For example, according to Florence, if a rural patient complains of gastrointestinal pain, the doctor should ask, “Do you have well water?” Is it a drilled well or a dug well (high risk of contamination)? Are you working in the fields outside in the heat? “

“There’s this medical textbook you have to cover.

Diversity in rural America

Rural communities share common challenges, but their residents are racially and ethnically diverse and may have clear health inequalities. “We see differences through rural and urban classifications, but when you superimpose issues of race and ethnicity, you see even greater disparities. [within rural populations]said Dr. Alana Knudson, co-director of the NORC Walsh Center for Rural Health Analysis at the University of Chicago.

African Americans are the largest rural minority. The Deep South was once dominated by the use of slaves in agriculture, but some rural counties are now majority or majority African American. “There’s not a lot of out-of-state migration. It takes a lot of time to leave where you grew up,” said Monica L. Baskin, Ph.D., professor of preventive medicine at the University of Alabama at Birmingham (UAB) School of Medicine. I’m here.

Rural African Americans have higher rates of cancer incidence and mortality and higher rates of comorbidities than other rural residents. Americans of descent tend to have higher rates of these conditions,” Baskin said. [in Mississippi and Alabama], they have even greater potential. “

“We see differences through rural and urban classifications, but when you superimpose issues of race and ethnicity, you see even greater disparities. [within rural populations]”

Dr. Alana Knudson
NORC Walsh Center for Rural Health Analysis, University of Chicago

The latest US Census, which measures population change from 2000 to 2010, shows that rural areas are becoming more diverse. Non-Hispanic whites accounted for about 80% of the rural population in 2010, but only 25% of the rural population growth. In the same he decade, the rural Hispanic population grew by about 45% to 3.8 million, roughly parity with rural African Americans. Native American he increased by 8%. The number of Asians has increased by about 37%, but remains a small fraction of the total rural population.

In the Central Appalachian region, the Hispanic community has grown significantly over the past 15 years, according to Florence, and the Haitian population has recently declined. Some are migrant workers, and their health care is “pretty sporadic,” he said. Maybe, but he continues to work every day.”

The NC RHRP reports that at least 80 rural hospitals in 26 states have closed since January 2010. Many of them are in communities with significant black or Hispanic populations. One such Alabama hospital closed his September, in a county where 72% of the population is African American. It takes about 50 minutes to the nearest hospital.

To increase access to specialists, UAB is connecting patients and doctors through telemedicine programs. Using technology will save him four hours driving to Birmingham for some patients, he said, Baskin said. Some areas without internet or broadband coverage may be accessed via conference call or DVD.

High disease incidence and poor outcome

The rural-urban health gap is evident in the breakdown of conditions and outcomes. According to the Centers for Disease Control and Prevention (CDC), the five leading causes of death in the United States: heart disease, cancer, accidental accidents (including vehicle crashes and opioid overdoses), chronic lower respiratory tract disease, and stroke. higher in rural areas.

Overall mortality rates are declining nationally, but the decline is much slower in rural areas. They have higher infant mortality rates and higher rates of mental, behavioral and developmental disabilities in children. and rural veterans have higher suicide rates than urban youth.

Rural residents are also more likely to have cancer associated with modifiable risks, such as smoking, human papillomavirus (HPV), and lack of preventive screening for colorectal and cervical cancer.

UAB has a rural cancer prevention program that trains community members and non-profit organizations to deliver health promotion activities and evidence-based programs. “We make sure the interventions we are doing are scalable and sustainable,” he said Baskin.

Although smoking has declined significantly in much of the United States, “adults in rural counties smoke at the same or slightly higher rates than they did 10 years ago,” Knudson said. Rural youth smoke twice as much as urban youth, so she expects tobacco-related illness and mortality to continue to rise in rural areas.

The CDC also says that opioid overdose deaths are 45% higher in rural areas, but urban patients have easier access to treatment facilities. In Central Appalachia, “we’re just beaten down,” Florence said. Between 2008 and 2014, the number of babies born with neonatal withdrawal syndrome (a condition associated with maternal opioid use) increased in rural areas, about 2.5 times more than in urban areas.

The factors involved in rural health disparities are “not just what our physicians can address,” says Knudson. We need to understand how to make a meaningful difference in improving health.”



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