‘Dismayed, but not surprised:’ Health gap between urban and rural America is on the rise
by Taylor Sisk
When Janice Probst read a report released in March by the federal Department of Agriculture’s Economic Research Service confirming that the health disparities gap between rural and urban Americans is widening, substantially, she was dismayed but not surprised.
According to the report, between 1999 and 2019 the gap in rural/urban natural-cause deaths for those aged 25–54 surged from 6 percent to 43 percent. Researchers also found that the more rural the region, the greater the increase.
Recently retired as a professor of health services policy and management and as director of the University of South Carolina’s Rural & Minority Health Research Center, Probst has long decried the neglect of rural health in particular and rural communities in general.
Probst cites another report, one recently released by the South Carolina state government’s Revenue and Fiscal Affairs Office, which notes that while South Carolina is the fastest growing state in the country, that growth will be primarily in urban areas. Meanwhile, 25 of the state’s 46 counties are projected to decline in population. Rural counties are shrinking, with a dozen expected to have fewer than 20,000 residents by 2042.
This dwindling of rural communities is a reality reflected across rural America, and it doesn’t bode well for the health of the residents of those communities: likely even poorer access to health care and all manner of services and amenities. Or for that of the community as a body: less voice in decisions made at the state and federal levels.
But, Probst further noted, the rural folks of the Palmetto State aren’t sitting idly by. South Carolina’s Office of Rural Health has an action plan that engages the state’s health, education, housing, and employment sectors – a recognition that crafting a healthier rural landscape is about a whole lot more than regular checkups – and communities are envisioning and embracing their future.
Making connections
The folks at the University of Wisconsin Population Health Institute’s County Health Rankings & Roadmaps have been thinking a lot about civic infrastructure and civic participation.
By civic infrastructure, said Michael Stevenson, the programs co-director, they’re referring to the places “where people connect, where they gather, where they share information, and how that fuels civic participation.”
This infrastructure includes many things: parks; schools; libraries; access to the information, resources, and services that support good health.
Regions with relatively under-resourced civic infrastructure, the institute’s researchers wrote, include the Black Belt region in the southeast, Appalachia, counties along the U.S.-Mexico border, and American Indian and Alaska Native tribal areas — regions that “bear a legacy burden of various forms of disinvestment and structural racism.”
In South Carolina’s Orangeburg County, an organization called Family Solutions is a cornerstone of its community’s infrastructure.
Orangeburg County is in South Carolina’s Lowcountry region. It’s within the Black Belt; the town of Orangeburg is roughly 75 percent Black. The county faces the same challenges as so many rural communities: few transportation options, a shortage of well-paying jobs and affordable housing, poor access to health care.
In the USDA report on the widening rural/urban mortality gap, the researchers found that a primary driver is the increase in rural women dying from preventable and treatable diseases. In counties without a town of 10,000 or more people, natural-cause deaths for women in the 25-54 age group rose 18 percent, while for males in this age group the increase was 3 percent.
Family Solutions is a program of the state Office of Rural Health dedicated to reducing infant death and illness and improving the health and quality of life of children, women and families. It’s taken a leadership role in addressing unacceptable health outcomes in five rural counties: Allendale, Bamberg, Barnwell, Hampton and Orangeburg, each of which is among the lowest-per-capita-income counties in the state.
While focused on maternal health, the Family Solutions team recognizes that improving health outcomes and saving lives entails a broad-based approach across the community.
Hope: A ‘powerful thing’
Graham Adams, the Office of Rural Health’s CEO, believes Family Solutions director Lamikka Samuel and her team are so effective in their work because they’re of this community, many born and raised here, some of whom are former Family Solutions clients.
If he’d brought in staff from the home office in Columbia, “I just don’t think we would have had the same results; we wouldn’t have had the trust. And it didn’t happen immediately. It took a long, long time. We’ve been doing this for 27 years.” It took everyday presence.
This work is about building relationships, making connections, leveraging resources. It’s about respect.
“We’re not coming in trying to force you to do anything,” Samuel said. Rather, “we’re advising you as to what’s the best thing for you, health-wise.”
Mistrust is a primary reason many women in her community don’t immediately seek help when they sense they have a health issue, Samuel said.
“They don’t seek help outside of the family, outside of the home, outside of the close-knit community, the immediate neighborhood,” she said, because so often when they have, “they don’t feel heard; they don’t feel respected.”
Team members accompany women to their appointments, helping them “understand the language,” Samuel said.
“When you’re looking at someone who, first of all, has a lack of trust for the medical system, the clinical community, and then what they have to go through in order to get to the appointment – the hours that it may have taken them to get to that appointment – frustration may set in for that person. And it’s like, ‘If this is how I’m going to be treated after all of this, then I’m just not going to come back.’”
“We can help to mitigate some of those issues,” Samuel said. It’s about supporting them through the process, “making sure they understand why they need the medication — not just because Dr. So-and-so said it, but because this is how it can impact whatever it is that you’re dealing with.”
The Family Solutions team works with providers to better understand their patients and the challenges they face and helps prepare nursing students at the local community college for what it’s like to practice in a rural community.
The program offers childbirth classes and doula services. “We’re going into their homes monthly, doing the education around maternal health and infant health,” said senior program manager Tracy Golden.
“We’re connecting the dads,” Golden said. Male involvement coordinator Kelvin Gadson offers talks in local barbershops, discussing “those male issues, things that they are dealing with.”
Adams said the initial federal grant, in 1997, for Family Solutions funding was in response to a county the program now serves having one of the highest infant mortality rates in the country.
“This state still struggles with infant mortality, as well as maternal mortality,” he said. “But there have been numerous years that our program participants in the counties we serve have had zero infant deaths.”
Romaine Stephens is Family Solutions’ community engagement coordinator. She recently became pregnant at an age considered beyond the range of ideal child-bearing years. She was scared. It really brought home to her how important this work is.
“To feel like, ‘I don’t want to die being pregnant’; nobody should have to feel like that,” Stephens said. “Having all this for them — having the therapist for them, having these resources for them — if you can take a little bit of stress off somebody, to give them hope — hope is a powerful thing.”
‘Come in’
A new Family Solutions service is its Resource Center, one of a number throughout the state, each designed to meet a community’s particular needs.
“This is our community arm. This is the resource that is available to anybody,” Samuel said. “If you’re a resident of the community and there’s a resource that you’re in need of and we have it here, come in.”
Services include legal aid, sessions on financial literacy and insurance awareness, classes in father involvement and in reproductive education, sewing and wreath-making classes.
The South Carolina Infant Mental Health Association offers its assistance. HopeHealth provides HIV and hepatitis B testing. Diabetes Free SC is yet another partner. The state Department of Social Services comes in to help applicants of Temporary Assistance for Needy Families.
Families can also come in for free household supplies or diapers. And there’s a place for kids to play while their caregivers receive services.
‘Shouting from the hilltops’
“One of the things that I’ve been shouting from the hilltops for years,” Janet Probst said, “is that we have got to stop funding rural hospitals and rural health care in general as though it was some sort of optional purchase, like, ‘I need some mascara.’”
Health care, she believes, should be treated just as we treat electricity, “which is that it goes to every house, even though it costs a lot more to send it some places than others.”
But Probst also recognizes we must consider what it takes to not only keep people healthy but communities robust — the social and physical infrastructure to secure and sustain a healthy community.
Rural communities aren’t waiting around for a lifeline. Probst pointed to a report from the Federal Reserve Bank of St. Louis indicating that less than 7 percent of philanthropic funding supports rural communities. And she suggested that while there are quite a few federal grants available to rural communities — through the USDA, for example — they can be daunting to navigate.
(There is, it must be noted, a very substantial chunk of federal funding available that the South Carolina state legislature has thus far declined: South Carolina is among the 10 states that have yet to expand Medicaid as allowed for under the Affordable Care Act. Those people who fall into the coverage gap, Probst noted, are less likely to see a provider at the early signs of a health issue and more likely to face greater consequences.)
Solutions are within. The research Michael Stevenson and his colleagues conducted finds that communities with healthier infrastructure are more likely to vote, to join unions, to respond to the census. Their voices are more likely to be heard. They’re more likely to chart a path forward.
“Whenever we have the opportunity to have a voice heard about what’s happening in rural South Carolina,” Lamikka Samuel said, “we take advantage of those opportunities.”
“Sometimes I think they’re sick of hearing our voices,” she added. Those voices will be heard.
This article first appeared on The Daily Yonder and is republished here under a Creative Commons license.
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