Bill Bishop has published a series of articles in the Daily Yonder showing that people in a lot of rural counties die awfully early. The data were worked up by the Institute for Health Metrics And Evaluation at the University of Washington. There are lots of data ranging from really interesting to really scary. In the scary category is the finding that in 561 rural counties women were dying younger in 2007 than a decade earlier. Those counties were the home of one-fourth of rural Americans. Scary may be too bland. Shameful? What adjective would you choose?
Lifespan is determined by a lot of things: prosperity versus poverty, genetics, what people eat, smoking history, exercise, health care. Nobody knows how a lot of the factors interact and there are lots of puzzles. In the world of health statistics and policy, a difference in health or lifespan is termed a “health disparity.” The world of health disparities is quite politicized.
This politicizing came about because the gaps between the health of African Americans, Native Americans and whites were large and drew attention early. When the NIH Office of Minority Health and Health Disparities was being created in law in the mid-1990s, tempers flared a time or two over the question of whether the legislation and the Office should recognize disparities other than “racial and ethnic disparities.” Appalachian people were later included as a population of concern. Only recently has rural begun to be included—the NIH Health Strategic Plan and Budget for 2009-2013 includes “rural persons” as a health disparities population.
More important, what are we going to do about the health handicap of many rural counties? It would help to make all rural people prosperous but that isn’t likely. In the last column I hoped that local hospitals could gradually grow beyond being sick houses to being health promotion places.
Studies of why people die too soon rank the factors like this: behavior and the environment—how we eat and drink and live and play accounts for over half the variation in length of life. Rich people have a lot more control over these factors than poor people. The growing rich/poor gap in our society is a life and death issue.
Genetics accounts for about one-fifth of early deaths. A famous doctor once said, “To live a long life, choose your ancestors carefully.” Lack of health care only accounts for one-tenth of early death, but that is where we spend most of our health improvement money. The better potential return on investment is in giving people a shot at better choices and a better environment for themselves and their families. Everything from land use to schools to playgrounds to jobs to neighborhood stores to sidewalks, streets and roads may help with better health in your community.
In several cities the health departments are taking the lead in improving health. It’s a huge undertaking. It involves where people live, what opportunities they have, the choices they make for themselves and their children, lots of aspects of personal and political life. Health departments are a good choice to lead the effort because they understand the issues, understand local politics, but aren’t themselves very political.
Rural local Health Departments look different in different states but most have too few people and too little money to do what they’re already expected to do: inspect eating places, give baby shots, manage water and sewage issues, track down cases of reportable diseases, and maybe run a Medicaid clinic.
The hospital and its associated clinics are natural if not traditional allies with the health department. The people understand at least some of the vocabulary and can learn the issues. The local elected officials need a truly meaningful comprehensive issue. The officials of Kansas City, Kan., found that even success in economic development, (e.g., building a business park), was not keeping their poor kids in school or spreading prosperity. The county still ranked at the bottom in health in Kansas. The mayor joined the County Health Department and other stakeholders to frame a range of social and economic determinants of health in community development terms. That broad strategy gets you a healthier community as well as a more prosperous one.
Local officials, health departments, and hospitals can get help from the University of Wisconsin Population Health Institute’s Health Rankings and Roadmaps project. The traditional “go-to” resource for health departments, the U.S. Centers for Disease Control and Prevention (CDC), is rooted in analyzing disease patterns in large populations and isn’t of much help to rural communities. (The Arctic Investigations Branch in Anchorage is a notable exception.) The Health Resources and Services Administration (HRSA) knows about rural and knows about racial and ethnic disparities, but hasn’t yet gotten the idea of rural health disparities. National philanthropy probably won’t help much. RUPRI, the Rural Policy Research Institute, finds that only 3 percent of foundation giving goes to rural communities.
But having the information gives us an important starting point. We have not just been feeling sorry for ourselves for no reason. We’ve got problems. We’ll have to do most of the fixing ourselves. Let’s get started.
Wayne Myers is a retired pediatrician and rural medical educator. He directed the federal Office of Rural Health Policy from 1998 through 2000, and was President of the National Rural Health Association in 2003. He and his wife, JoAnn, farm in rural Maine.
Opinions expressed in this column are those of the author and do not necessarily reflect the views of the Rural Health Information Hub.
Back to: Fall 2012 Issue