Click here to download a PDF of this story.

Healing Histories Project’s Theory of Change recognizes that our relationship to land shapes our capacity for collective safety, wellness, and sustainability. When we say “land,” we aren’t referring to an object to be controlled and made productive. We understand land as the most essential aspect of our shared life; one of the greatest things we have in common; that which creates our bodies, sustains our capacity for aliveness, and provides the context for all our other relationships. We also center land from an understanding that most of the systems that prop up the Medical Industrial Complex are rooted in the control of bodies for the purpose of extracting resources and profit from land.

Pink, blue, and golden light at sunset over a rolling green field with wooden fence.

Understanding land within the context of the United States means unpacking how the U.S. as a nation-state relates to land. This includes an understanding of which spaces are seen as “land” – mostly rural areas – and which are not. It also means examining who controls land and who does not, and whether they are indigenous to this land or not. It means understanding who has access to which kinds of land, and what that land makes available: nourishing food, root medicines, spaces to live and play safely and with dignity, and connected, continuous spaces for children and youth to grow freely without state surveillance or risk of dying by violence. This story focuses on definitions of “rural” and how collective “health” has been held, managed, or dismissed within a rural context in the United States: often without rooting in memory, imagination, collective dignity, safety, and care.

What is “rural?”

Within Western binary categories, land is seen as either developed or not developed, urban or rural, wild or domesticated. But there is no objective thing called a “rural” community. “Rural” has traditionally been the word used by people living in cities to describe anything that is not a city. In the United States, the “rural” is a story of settlement, of colonial relationships to land and policies towards Indigenous communities, of farming, logging, hunting, mining, enslavement, indentured servitude, and more. It’s the story of a U.S. population that has become increasingly urban, as well as the continuation of the colonial belief that land is an object that can be valued, sold and traded – and if it is not deemed valuable, largely ignored. Only rarely are the voices and opinions of those living in rural communities honored in their own complexity and diversity.

The rural is usually defined by what it is NOT rather than by what it is. Rural refers to the territories that are outside of urban boundaries. In the United States, the definition of a rural community keeps changing, produced by algorithms that attempt to make sense of the fact that certain rural places like Jackson Hole, Wyoming and Napa Valley, California are home to great wealth at the same time as a disproportionate number of high poverty counties are rural. 75% of the land area in the United States is rural… or is it? There are over a dozen different federal definitions of the rural and each definition gives different information.

Algorithms

Green cornfields in the foreground; a weathered red barn standing next to newly-built dwellings that might look more at home in a suburb.

The U.S. Census and the Office of Budget and Management use different criteria for determining what is rural and what is urban. The U.S. Census has always identified rural places based on the number of people living in an area, while the Office of Budget and Management (OBM) uses metrics on population density and the economic and social relationships that exist in an area. This difference is deeply political, and the two metrics paint vastly different pictures of the racial and ethnic demographics and the percentage of those living in poverty in rural places. Census demographics describe a growing rural population that is increasingly more white and less poor, while the OBM data show a rise in racial diversity in rural areas as well as a rise in rural poverty. The OBM would not count Napa Valley as rural, but the U.S. Census does. This raises many questions: is an area still rural if it is largely populated by wealthy people with large landholdings and economic connections to nearby cities? Is it still rural when residents in a sparsely populated area have access to private helicopters they can use to get to a hospital in a nearby city, but their poorer neighbors must drive an hour and a half to see a doctor?

If we work with the Office of Budget Management’s tracking formula and remove high-wealth, urban-connected counties from the definition of “rural,” then some things become clear: while rural areas still have larger concentrations of white people than urban areas (78% of the population compared with 58% in urban/suburban areas), those numbers are shifting rapidly. Since 1990, People of Color have accounted for 90% of all rural population growth. Additionally, People of Color are disproportionately poorer in rural areas than in urban areas. Over the last few generations, rural areas across the country have shared three common experiences: young people are leaving in large numbers, leaving behind mostly aging communities; people from cities are moving into the countryside driven by the rising costs of urban life; and racial and ethnic diversity has increased. Three hundred and fifty-six rural counties are “minority majority youth” counties, meaning they have a majority of nonwhite children, and another 300 counties are close to fitting this description.

Even with the Office of Budget Management’s more complex algorithm, there is still a strong urban bias in how information is gathered and assessed. One example is how food and nutrition are documented as indicators of poverty. Most studies focus on the proximity of people to a grocery store, which places many rural folks in “food deserts.” Most of these studies, however, do not look at how many people have gardens, what they are growing, and how they might be involved in sharing networks for food and other basic necessities. Both can be true at the same time: a lack of access to grocery stores, which is one type of food poverty, and also networks of local food sharing. Urban bias shows up when assessments of neighborhoods are made based solely on what kinds of institutions and infrastructures exist, like grocery stores and clinics, while ignoring other factors of the environment. Urban bias dismisses the truth that proximity to nature is a factor of health, and Western medical bias often ignores that the land is filled with medicine, that many people still know how to make a poultice out of plantain or to counter a fever with willow bark.

A large combine machine moves through a field of golden grain stalks, kicking up dust.

The landscape of employment in rural areas has been dramatically transformed through the ongoing industrialization of American farming, which has almost entirely destroyed the stability of family farms and left many rural people unemployed. Additionally, legislation designed to protect the environment has impacted traditional forms of rural labor such as coal mining and natural gas production. And finally, timber production and other elements of the North American rural economy such as beef, corn, and soy have struggled to “compete” in the global economy. Meanwhile, independent and gig work (short-term jobs) are increasing in rural areas. With an increase in technologies that allow for at-home work, the gig economy has grown by 15% in rural communities over the last ten years. This is a slower growth rate than in metro areas, but has had a greater impact in rural areas where employment can be harder to find. The rise of the gig economy–where workers largely receive no benefits–is also greatly impacting who has access to health insurance and healthcare.

In his recent book, Big Farms Make Big Flu: Dispatches on Infectious Disease, Agribusiness and the Nature of Science, Rob Wallace writes about the relationship between industrial agriculture and disease. In particular, he examines how emerging pandemics such as the avian flu and swine flu have been able to gain traction because of the practices of large-scale, multinational agriculture. As it has become increasingly harder for small-scale individual farmers to sustain themselves, they’ve turned towards growing for the corporate agricultural system. This system holds them accountable to desired profit margins, which requires them to increase the use of synthetic fertilizers and genetically-modified, high-yield seeds. All of this leads to more independent farmers becoming overwhelmed by debt and dropping out of agriculture. The overall health and strength of rural communities has been compromised, decreasing rural resistance to disease outbreaks that emerge from agricultural production. The response to these outbreaks is usually an increase in chemical warfare on diseases or insects, rather than a turn towards crop diversity and sustainable growth. In the same way that our bodies are becoming resistant to many antibiotics, so too are diseases tied to large-scale agriculture becoming resistant to the pesticides and other forms of chemical warfare used to control them. This will likely lead to an increase in the frequency, impact, and duration of these epidemics.

Rural healthcare

Map showing rural hospital closures since 2005, clustered with greater density in the South.

In the case of healthcare, the rural/urban divide is extreme – that is, when not counting wealthy rural counties with high-end clinics and urban hospitals accessible at the end of a helicopter ride. Only 10% of all of the physicians in the United States practice in rural areas. Additionally, because unemployment, self-employment, and underemployment are often higher in rural areas, fewer people have access to health insurance through their jobs. More than 100 rural hospitals (4% of all rural hospitals in the U.S.) closed between 2013 and 2020. There have been 380 rural hospital mergers between 2005 and 2016, with some rural hospitals merging more than once. The Government Accountability Office (GAO) reports that more than twice the number of rural hospitals closed between 2013 and 2017 than in the previous five-years. The ten states with the highest number of hospital closures were Alabama, Florida, California, Kansas, Oklahoma, Missouri, Georgia, North Carolina, Tennessee, and Texas (Johnson, 2023).

As a result of these closures, rural residents in these areas had to travel about 20 miles farther for common services like inpatient care (e.g. maternity care), and 40 miles farther for less common services, such as alcohol or drug treatment. Many people living in rural communities use telehealth for medical advice, but at least 17% of people living in rural areas lack broadband internet access, compared to 1% of people in urban areas. Not all rural people struggle equally with lack of access to health care: rural pregnant people, Native Americans and Alaska Natives, and veterans have higher rates of difficulty accessing care. By 2030, it’s expected that rural gynecologists and midwives will only meet half of the demand for labor and delivery in rural communities. One third of veterans live in rural areas and have less access to mental health services and support in comparison with their urban counterparts.

According to the Centers for Disease Control and Prevention (CDC), rural Americans are more likely to die from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke than their urban counterparts. Unintentional injury deaths are approximately 50% higher in rural areas than in urban areas, partly due to greater risk of death from motor vehicle crashes and opioid overdoses. It’s important to pause and remember who is responsible for the opioid crisis. While the attack on family farms and rural economic systems has led to depression and struggle which increases the likelihood of different kinds of self-medication, that is not where the crisis began. “Big Pharma,” the profit-driven pharmaceutical industry, flooded rural physicians’ practices with opioids, marketing them as “safe” pain management, while knowing all along that Oxycontin and other opioids are highly addictive. (We go further into the opioid crisis with the Story of Opium.) And since farm injuries from agricultural work remain one of the most dangerous occupational hazards amongst all industries, there is a high need for pain relief in rural areas (CDC, 2019).

In general, residents of rural areas in the United States tend to be older than their urban counterparts, as many rural young people leave rural areas in search of employment and community. They also tend to have more health conditions, due to many factors, including those described above as well as environmental toxins from pesticides and herbicides and lack of access to easy preventative care. The rate of disability increases from 11.8% in the most urban metropolitan counties to 15.6% in smaller micropolitan areas and 17.7% in the most rural counties, with highest rates in the South.

Contrary to stereotypes that queer people always leave rural places, the Movement Advancement Project (MAP) estimates that 15 to 20% of LGBTQ+ Americans live in rural areas, approximately 2.9 million to 3.8 million people. Rural youth are equally likely to identify as LGBTQ+ as their urban peers, and rural LGBTQ+ communities face heightened barriers to accessing affirming care (Poquiz et al, 2021).

For most of the history of the United States, statistics on “rural” healthcare were not tracked. As the Story of Marine Health illustrates, public health emerged for the purpose of controlling immigration and epidemics in increasingly crowded urban areas. The primary focus of any organized healthcare was cities. When early public health officials referred to epidemics or illnesses in rural areas, they usually focused on the difficulty of tracking isolated populations where little to no formal medical care was available. There was also a systematic gutting of public resources for rural communities as urbanization expanded in the 1800s and 1900’s, which limited opportunities for community-led care infrastructure to develop in rural areas without financial support.

During the early 1900s, the likelihood that a newly trained physician would set up a practice in a rural area declined by 40% (Moehling et al., 2019). This was heavily influenced by the release of the Flexner report in 1910, which was funded by the Rockefeller Foundation and pushed hard for standardized medical education and the “professionalization” of medicine. This decreased the accessibility of the newly standardized medical schools for students from rural areas; increased costs of medical education, making it prohibitive for poorer rural students; and encouraged newly-graduated physicians to gravitate towards hospitals with “top of the line” medical equipment. Additionally, the Flexner Report led to the closure of many Black medical schools. At the time of the Report, there were seven Black medical schools; after the period of standardization, only two remained open: Meharry and Howard. This directly contributed to a lack of health infrastructure for rural Black communities.

The rural health infrastructure that did exist in the early 1900s largely focused on maintaining the productivity of workers. Rick Brown’s book, Rockefeller Medicine Men, tells the story of the Rockefeller Sanitary Commission, which was established in 1909 under the leadership of Louis Gates to eradicate hookworm disease in the tidewater counties of North Carolina. Hookworm causes lethargy, lowering workers’ productivity. While the Commission's marketing focused on ending Southern poverty, Brown’s book illuminates their central focus on ensuring that workers–in this case farm laborers–were healthy enough to remain productive at work. The nuances here are important to hold: providing additional health care to migrant and seasonal farmworkers was (and remains today) essential, due to the overwhelming lack of access to adequate care these communities face. But when that care treats farmworkers merely as a source of labor rather than as full, autonomous people, it can support the bare minimum of health needed to ensure a productive workforce without providing the broader care that promotes overall wellbeing.

In 1921, The Sheppard-Towner Act was passed, providing funding to open more hospitals and clinics across the country with a particular focus on prenatal and infant health care. Proponents of the Act noted high rates of infant mortality, particularly in Black and migrant communities, and the decline in physicians practicing in rural areas. Many rural doctors had historically been independent physicians practicing as members of local communities, but as medicine became increasingly standardized and legislated, it became harder and less cost-accessible for these physicians to remain in practice. Even during this period, when more than half of all Americans lived in rural areas, 80% of doctors lived and worked in cities.

A black and white image of a large house with a front porch, with a water tower behind and sparse pine trees surrounding.

Ironically, the sanatorium movement was at its peak at the same time, with over 526 sanatoriums primarily built in rural areas all over the country, dedicated for use specifically by white families. Sanatoriums were retreat spaces created to stop the spread of infectious diseases such as tuberculosis and were primarily used by people from cities fleeing overcrowding to recuperate. Unsurprisingly, many of these sanatoriums were built in rural communities that did not have access to regular healthcare. They were marketed as places to build health through fresh air, fresh food, and rest.

While health infrastructure remained largely inaccessible to rural communities in this era, many worked to develop strategies for improving rural health. In the 1920s (as detailed in our Story of Tuberculosis), the Negro Health Movement emerged under the the leadership of Booker T. Washington and modeled after the Women’s Club in Atlanta. The movement intended to support the health of rural Black communities in the South. This network of Black-centered care continues to both flourish and be attacked up to the present day. Today, maternal morbidity and mortality rates (especially for Black women) across the rural “Black Belt” are staggering. The range of Black community initiatives in response to this crisis continue to flourish and grow, but the general public response has been underwhelming. While federal and state agencies continue to make pronouncements about the crisis and put money into various kinds of programming, it is becoming increasingly more dangerous to be Black and pregnant in many parts of the South (Sausser, 2023). This is, of course, about more than what kind of healthcare is available. Instead, it is the direct result of generations of significant poverty and violence and a tradition of racial violence in medical care, including the 1932 Tuskegee Syphilis Study, that has been most concentrated in these communities.

As the Negro Health Movement was emerging and building networks of community members focused on preventive care, some of the same initiatives were being taken up by white farming women in other parts of the country. Also in the 1920s, the Frontier Nursing Service emerged in Appalachia specifically focused on birth support. Nurse midwives rode on horseback into isolated towns and very quickly were able to increase the number of healthy births. From 1945 to 1975, a movement led by farming women established the Council on Rural Health, an arm of the American Medical Association. Led by community members, community health councils were established to provide peer-led preventive care and to draw attention to the lack of access that farmers had to physicians and regular healthcare.

Map showing

In 1946, the Hill Burton Act was passed to further increase funding for the construction of hospitals. At this time, 4.5 hospital beds existed for every 1,000 people; nationally, this was understood as a crisis. In 2022, the U.S. had only 2.38 hospital beds per 1,000 people. but this fact doesn’t receive nearly the same degree of national attention. The Hill Burton Act provided funds to nonprofit organizations for the construction of skilled nursing facilities that would meet certain definitions and hospital-like building standards. The act contained a "separate but equal" provision, which stated that discrimination on the basis of race was acceptable if there was “equitable provision on the basis of need for facilities and services of like quality for each such group.” Because each new facility had to prove its economic viability as a hospital, few new hospitals were built in the poorest parts of the country. This strongly impacted poor rural communities.

Political winds continued to shape the conditions of rural poverty, rural struggle, and rural health. In 1967, President Lyndon Johnson commissioned the Left Behind Report, a report that documented a rural poverty rate 25% higher than urban poverty. The report established tracking criteria for rural poverty, which began to steadily decline for about ten years in response to new policies until plateauing in the late 1970s. The report also pointed out that persistently high-poverty counties are disproportionately rural and are geographically concentrated in Appalachia, on Indigenous lands, in the Southern “Black Belt,” in the Mississippi Delta, and in the Rio Grande Valley. What the report didn’t say directly but which we know is that these were also counties with high percentages of either Black people and/or Indigenous people.

Telehealth was first applied as a public health model for rural communities in 1970. The Tohono O'odham (formerly known as the Papago) Nation agreed to partner with the U.S. Indian Health Service (IHS), National Aeronautics and Space Administration (NASA), and the Lockheed Corporation on a project called STARPAHC (Space Technology Applied to Rural Papago Advanced Health Care). STARPAHC focused on evaluating the practicality of a large-scale telemedicine project as a way of building rural healthcare systems. Tribal authorities promoted the “space-age medicine” they believed would improve medical care for the 10,000 tribal residents living in villages across a three million acre reservation. STARPAHC provided a medical clinic, medical personnel, television cameras and monitors, computers, and a microwave receiver and transmitter. NASA was largely compelled to support the project by the concern that they would be unable to justify spending for the space program if their technology did not have application on earth. Unlike many research partnerships of the time, however, the tribe played a significant role in shaping the project.

A person sits at a laptop with a medical provider wearing a mask on the screen.

STARPAHC was the beginning of a wider movement towards telehealth as the primary strategy for reaching rural areas without access to adequate healthcare. While telehealth provides some kinds of access, it cuts out the intimacy of the provider-patient relationship. As rural hospital closures and mergers continue, telehealth cannot single-handedly replace strong community healthcare systems. It is a reform focused on efficiency as much as on rural health. After the STARPAHC project was completed, continued improvements in healthcare for the Indigenous nation were all but abandoned.

In 1977, the Rural Health Clinic Services Act was passed. This Act designated funding for rural health clinics and allowed clinics to be established without a primary physician to staff the clinic. This provision gave nurse practitioners the ability to act as primary care providers, a significant change in the healthcare hierarchy which had previously only legitimized doctors as heads of clinics. The shift allowed many more rural health clinics to open and provide needed care.

During this time period, the feminist health clinic movement was also an important form of resistance in rural spaces. While the feminist health movement was most visible in urban areas, the movement extended into some rural areas and was led by Indigenous women, Black women, Puerto Rican women, and Chicana women. The movement included initiatives focused on ending forced sterilization in isolated rural communities, as well as ending the contexts and conditions for higher birth mortality in places such as in Beaufort, North Carolina, where Black women advocated for affordable healthcare and clean water (Post, 2023). Members of the movement also partnered with universities and other urban institutions to establish reproductive health centers and primary care clinics in areas where previously none existed. Many of these clinics were then targeted a generation later for closure and mergers as federal funding was removed from supporting clinics, particularly feminist health clinics, that provided abortion care.

When the Reagan Administration came into power with a commitment to building the private sector and decreasing public funding, hospitals were again closed across the United States. The closures of the 1980s particularly impacted hospitals in rural areas, especially poor Black, Indigenous, and migrant communities, where hospitals relied mainly on the government for funding. Urban hospitals were more frequently owned by private entities and therefore considered more profitable by the Reagan administration. One outcome of this wave of closures was a shift in the “mortality penalty” from urban to rural areas. A mortality penalty is a decrease in a community’s length and quality of life due to a particular factor, such as where they are located. Prior to the 1980s, people living in urban areas experienced higher mortality rates than people living in rural areas. In the 1980s, for the first time since the establishment of the United States, the mortality penalty shifted to people living in rural areas.

The smoldering remains of a burnt out tractor; black smoke rises with the dome of the white house in the background.

This was largely linked to the Farm Crisis, which affected the entire nation but was particularly impactful in the Midwest. In some parts of the Midwest, the price of farmland dropped 60% over four years. Farm foreclosures exploded and more than a third of all farmers were dangerously affected. The process of farm consolidation, or the move away from small independent farms to large corporate farms, has followed the same path as the wider economic system in the United States: consolidated industries seek to lower the cost of labor in order to ensure higher profits for those who own the larger farms and ranches. It's not as simple as “bigger is better.” It's that “bigger” creates more profit for a smaller number of farm and ranch owners.

As the result of the trauma of foreclosures and consolidation, farmer suicides and rural murders began to rise. Small businesses that supported farming communities also began to close. It is estimated that for every four farms that closed, one rural small business closed. The Farm Credit System, a collective system that supported farmers, collapsed and the federal government had to bail it out. The impact of the Farm Crisis was largely invisible outside of rural communities. Farmer protests worked to change that, sending “tractorcades” to the White House to draw attention to the rise in farm auctions as foreclosures exploded.

When the federal government stepped in to address the crisis, it provided more funding to support the consolidation of small farms into larger farms. As more small family farms disappeared, the next generation of farmers that remained shifted to largely becoming “farmer managers,” relying on undocumented migrant workers and other forms of low-paid labor. These workers are subjected to extremely difficult labor conditions without healthcare benefits or support. Undocumented workers – whether seasonal laborers or permanent members of the community – are often prevented from speaking up about labor conditions due to the threat of deportation. The consolidation of farms has also resulted in the depopulation of many rural communities, as small businesses have continued to close and local economic networks have frayed.

Two workers handling an engine on an assembly line; many colors and a blur of motion.

Large scale industries began to be built in small towns in the U.S. as early as the 1930s and 1940s, when large northern companies moved south to hire cheaper labor and buy large tracts of inexpensive land. A second wave of rural industrialization followed in the 1980s, in an attempt to revive the failing U.S. auto industry. New auto manufacturing centers began to pop up in rural areas across the United States. In both instances, many rural communities had recently experienced depopulation. In the 1930s and 40s, the depopulation had largely stemmed from the Great Migration, as Black workers left because of increased lynchings by white supremacists and the Jim Crow South laws to find work in northern industries. In the 1980s, the depopulation was in response to the Farm Crisis.

In most cases, the infrastructure of rural communities was not built to withstand the sudden population growth of industrialization, creating profound impacts on the remaining residents. This included a strain on clean water and sanitation structures as well as healthcare systems. Additionally, while proponents of the auto plants argued they would bring employment for local people, many of the workers were actually transplants, either directly brought in by the companies or people moving to find work. This included a significant number of new immigrants, particularly across the Midwest and in some parts of the South, which led to increased racism and xenophobia and contributed to a political shift in many rural communities. During the late 19th century and through the first half of the 20th century, many rural communities were strongly Democratic with a pro-labor and pro-working class stance. By the end of the 20th century and beginning of the 21st century, many rural communities had shifted to identifying as strongly Republican with an anti-immigrant and white isolationist stance. This shift was cultivated by corporate industries seeking to foster division and competition among workers in order to decrease the likelihood of worker organizing such as through labor unions. These strategies of division often include white supremacy, xenophobia, and other forms of relational violence.

In 1987, Congress created multiple bodies to focus on rural health needs. Rather than directly funding clinics and hospitals, Congress focused on funding a networking and policy creation infrastructure. This was particularly ironic given the Reagon administration’s focus on decreasing public spending and decreasing federal bureaucracy. The new programs included the Federal Office of Rural Health Policy, the National Advisory Committee on Rural Health and Human Services, and State Offices of Rural Health, and multiple Rural Health Research Centers. These agencies were created to ensure that federal state healthcare planning was inclusive of rural experience and to assess and create strategies to meet rural healthcare needs.

Map with blue dots showing critical access hospitals, with the highest concentration in the Upper Midwest.

One outcome of the work of these new agencies was the creation of the Critical Access Hospital designation in 1997. To be eligible, rural hospitals must have fewer than 25 acute care inpatient beds, be located more than 35 miles from another hospital, provide 24/7 emergency services and have an average length of stay of 96 hours or less for patients. Critical Access Hospital designation opens up additional funding and support services when they are available. While the critical access status has supported funding in areas without adequate healthcare, the funding has inadvertently worked against clinic growth. Once the hospital grows larger than the critical care size, the funding will disappear which means that many hospitals struggle with not enough beds but an inability to grow larger than what the funding allows.

Other incremental shifts have been implemented over the last 30 years. In 2004, recognizing that all forms of healthcare are less accessible in rural areas, the Alaska Tribal Health System created the first “dental therapist” program to provide dental care to isolated communities; this model then spread across the country. Similar to the policy shift that allowed rural clinics to be led by nurse practitioners, these programs train non-dentists to provide preventative dental care. Access to dental surgery remains difficult, but these programs have expanded preventive care.

At the time of the 2010 census, there were 308 million people in the United States. Of those, roughly 65 million, or 21%, reside in rural or small town America. About 25% of those living in rural areas are People of Color. Only 11.4% of physicians practice in rural locations. Rural physician shortages had been documented for 85 years, and these shortages were not improving. In subsequent years, other studies have shown that rural residents are less likely to have employer-sponsored health insurance coverage, are more likely to be beneficiaries of Medicaid or another form of public health insurance, are more likely to be unemployed, have less post-secondary education, and have lower median household incomes compared to urban residents.

The number of rural hospitals has decreased even further through mergers. There were 380 rural hospital mergers between 2005 and 2016, with some of the rural hospitals merging more than once (Williams & Thomas et al, 2018). These mergers were widespread across more than 20 states. The majority were considered "critical access" hospitals, and the majority are in the southern part of the United States. Most closed due to a lack of funding, and most were located in states that did not expand Medicaid after the passage of the Affordable Care Act–states with high health disparities that are connected to geography, income, and race.

Beginning to assess the impacts of racism in rural health

Protestors in masks and sea foam green scrubs carry signs that read:

Starting in the mid-2010s, studies have finally turned to look at racial and ethnic health disparities in rural communities. Up until this past decade, most rural health policies and practices were “race neutral,” focusing specifically on rural health as compared with urban and ignoring the specifics of demographics. While rural communities are less racially/ethnically diverse than cities, rural Communities of Color have always existed and continue to grow. And in some rural areas–such as the Mississippi Delta, the borderlands between the United States and Mexico, and Native reservations–Black, indigenous and Latinx people make up the majority of the population.

The impact of generational and present day racism on rural Communities of Color is apparent in numerous ways: decreased hospital access, reports of violence and harm within healthcare settings from nurses and physicians, higher rates of survival strategies for dealing with stress such as smoking and substance use, and higher rates of specific forms of stress-related illness and disease. A study released by the NC Rural Health Research Program in 2022 found that rural hospital closures between 2010-2020 had a higher impact on Black and Latinx communities than in previous decades (Planey et al., 2022). Additionally, activists in the Black Lives Matter movement and public health whistleblowers have brought vital attention to racism as a public health crisis, but this has not yet led to the structural changes necessary to actually shift the impacts of over 500 years of racial violence.

In 2022, a report from the Center for Healthcare Quality and Payment Reform (CHQPR) found that over 150 rural hospitals closed between 2005 and 2019, and in 2022 an additional 600 were at risk of closing (CHQPR, 2022). These closings primarily impacted poor and working class rural communities, a disproportionate amount of which are located in counties with large Black and Indigenous populations. The number of closures represented nearly 30% of all rural hospitals throughout the country, and have directly harmed millions of people who no longer have access to hospital care. The CHQPR report identified reasons for closures including higher costs of care, lack of government support, and inadequate payouts from insurance.

With no substantial changes, reports have continued to emerge of the dangerous lack of healthcare access in rural communities. In 2023, a national report from the Maine Rural Health Research Center found that 4.5 million Americans live in “ambulance deserts,” or 25 minutes or more from an ambulance station (Jonk et al, 2023). These ambulance deserts became highly visible during the first years of the COVID-19 pandemic, as many rural areas reported patient deaths caused by the inaccessibility of respiratory support. Four out of every five counties across the U.S. have at least one ambulance desert, with the South and the West having the highest percentages. Eight states–Nevada, Wyoming, Montana, Utah, New Mexico, South Dakota, North Dakota and Idaho–have less than 3 ambulances per 1000 square miles of land. Many of these are on Indigenous lands. Rural areas that are close to urban areas, such as by helicopter, struggle because urban hospitals, while holding more Intensive Care Units than their rural counterparts, rarely have extra beds. This means that critically sick patients are stuck in low resourced rural hospitals without the ability to transfer to urban hospitals for better care.

Research on rural health that takes race and Indigeneity into consideration is new, but the impacts of racism and colonization are not. We know that when the state refuses to provide a systemic response to the historic displacement and erasure of communities, the result is always some form of violence. Native, Black, and other People of Color communities have always lived in rural areas, whether as forced or migrant labor or as people who are indigenous to the land. There is a long history of land theft from Indigenous communities as well as Black farmers, who were systematically denied access to USDA loans throughout the 20th century leading to the loss of 90% of all property owned by Black farmers from between 1910 and 1997 (Holloway, 2021). Ignoring these histories maintains the violence of white “frontier” mentality as the primary narrative about the rural United States: rugged white settlers conquering the land under the European Christian ideal of land “management.”

Additionally, as dictated by treaty agreements, Native communities receive care through the Indian Health Service. While largely underfunded, there have been continual attempts to undermine or disappear this funding entirely. In 1992, however, the Indian Health Act was amended with the intent being to reaffirm the United States' responsibility and legal obligation to provide the highest quality health care possible for Native people and to increase the number of Native people trained as medical practitioners.

Climate change and environmental injustice

Climate change impacts everyone: urban, suburban, and rural. However, climate change has a particular impact on rural communities because it disrupts agriculture and other foundational rural economies. Forced migration due to climate disruption has brought migrants from across the country and world to rural areas, as well as to urban and suburban communities. And wealthier urban communities have also begun to shift towards rural areas seeking refuge from coming climate changes. The repeated defunding and closure of rural healthcare systems has left them unprepared for these urban to rural movements, which are only likely to increase as the impact of climate change grows more visible.

Meanwhile, media outlets argue over what is taking place. Some call for urban development as the answer to climate change, as denser populations require less land, while others call for an end to “urban supremacy.” Suburbs have become “inner-ring suburbs” and “exurbs;” all words for an ever-growing urban space that is highly dependent on rural areas around the globe. As urbanization continues to expand, including new land-use strategies in rural areas that develop the land rather than allow it to rest, the threat to multiple species rises. Habitat loss is accelerating extinction rates across the planet, including in the United States. Extinction rates have been rising since the advent of industrialization but more rapidly spiking since the 1960s (Associated Press, 2014). Large-scale development in rural areas is destroying the migration routes and habitats for plant and animal species and impacting the stability of ecosystems. These plant and animal lives are worth saving for their own sake–and, from a human health perspective, extinction also means the loss of potential medicines, as well as the destruction of natural environments needed for the survival of our species and all of our more-than-human kin.

Changing weather patterns increase crop failures and livestock loss from severe drought and flooding. Climate change brings damage to rural infrastructure such as roads and flood mitigation systems from extreme storms. Farmers are impacted by changes in planting and harvesting cycles from shifting temperatures as well as floods, droughts, and forest fires. Severe weather events such as tornadoes and hurricanes are often strongest in rural communities since urban areas are protected by urban heat domes. Storms can take years to recover from, and sometimes recovery is not possible. In communities with minimal health infrastructure, the impact is even greater.

Much of the land where rural Indigenous and poor Black communities live, once considered less valuable, is now being sought after by corporate interests. In many cases, this is motivated by the desire to extract natural resources. Companies are mining for antimony, an element used in new technologies, on tribal lands in Idaho (Healy & Baker, 2021), and mining for lithium on tribal lands in Nevada (Trahant, 2023). Additionally, the construction of new pipelines to carry gas and shale oil is being fought on tribal lands all over Turtle Island, from the Dakota Access Pipeline to the Pacific Connector and many more in between (Indigenous Environmental Network, 2021).

A crowd holds colorful signs that read:

While tribal communities often take the lead in fighting these pipelines, the impacts of the pipelines are felt by all rural communities: reduced property values and land use options, decreased livability, increased noise, the risk of leaks and spills, and increased stress (Thompson, 2021). The irony is that the gas and oil being transported through these pipelines is generally headed for urban areas or exported out of the United States.

Conclusions

The Healing Histories Project’s Theory of Change states that the first step of collective care and healing is ending violence. In the context of rural health, the violence that must be ended includes the many barriers to accessing healthcare (both Western and cultural/traditional) and the increasing threats to the rural environment: industrialized agriculture, factories, urban expansion, pipelines, and a changing climate. The U.S. must acknowledge and address these realities, rather than perpetuating romantic myths about rural life that frame the rural as a place where rugged individualists own their own farms and work hard to extract profit from the “wilderness.”

The health of rural places is connected to the health of the entire United States. Federal farm subsidies largely support a cash crop economy focused on corn, soybeans, and livestock. These subsidies have incentivized farmers to move away from growing fruit, vegetables, and other grains (Fields, 2004). As new industries emerged to expand the use of corn, high-fructose corn syrup became ubiquitous as a sweetener in processed foods. The focus on growing corn has also led to the rise of ethanol and corn-fed livestock. The corn being grown today has been hybridized to be high in sugar and simple carbohydrates, and no longer resembles the grain that is indigenous to the Americas. Cheap and inexpensive food produced from hybridized corn has health impacts across the United States. For people living in poverty, who can only afford low cost food or only have access to convenience foods because of a lack of nearby grocery stores, the health impacts have been particularly dramatic. While rural and urban healthcare are connected, there are also differences. One example is that farming communities deal with a high level of pesticide-related illness not found in urban areas.

The shift to industrialized agriculture has had devastating impacts for the American farmer. In recent years, declining prices for agricultural commodities as the result of globalization have led to trade wars and an overall decrease in exports, particularly to China, leading to increased xenophobic sentiment. This has caused farmers to accumulate more agricultural debt, which increased by almost a third between 2007 and 2013 alone (Cagle, 2013). Climate change and “bad weather” are also compromising production. Mental health struggles have skyrocketed, and farmers have one of the highest suicide rates in the nation. A new crisis hotline called Farmer Aid received more than a thousand calls in its first year. This trend continues despite the passage of the Farm and Ranch Stress Assistance Act in 2008, which provides behavioral health programs to farmers through state grants. Most of the funding has not been used, and the wave of farmer suicides has continued.

With the continued closure and merging of hospitals and clinics, the lack of access to preventative care and care for chronic conditions has direct impacts on rural health. We know that this significantly impacts rural Black, Indigenous, and borderlands communities. We also know that it impacts all rural communities that are not enclaves of the wealthy. And finally, we know that all of our health is interconnected, regardless of who we are and where we live. We must build healthcare strategies, whether rural or urban, from this core understanding – shifting how we think about care and no longer defining some lives as more valuable than others.

Sources Cited:

American Planning Association. (1951). Impact of Large Industries on Small Communities. https://www.planning.org/pas/reports/report31.htm

Associated Press. (2014, May 29). Extinctions now 1,000 times faster than before humans. https://web.archive.org/web/20230712161307/https://www.cbc.ca/news/science/extinctions-now-1-000-times-faster-than-before-humans-1.2658571

Ellison, A. (2016, February 12). The rural hospital closure crisis: 15 key findings and trends. https://web.archive.org/web/20200822085415/https://www.beckershospitalreview.com/finance/the-rural-hospital-closure-crisis-15-key-findings-and-trends.html

Cagle, S. (2013, March 20). Farmland prices soar -- along with farm debt. Grist. https://web.archive.org/web/20230312053859/https://grist.org/food/farmland-prices-soar-along-with-farm-debt/

CDC. (2019). Agricultural Safety - NIOSH Workplace Safety and Health Topic. https://web.archive.org/web/20230310185247/https://www.cdc.gov/niosh/topics/aginjury/default.html

CHQPR. (2022). Rural Hospitals at Risk of Closing. Center for Healthcare Quality and Payment Reform. https://web.archive.org/web/20230321045152/https://ruralhospitals.chqpr.org/downloads/Rural_Hospitals_at_Risk_of_Closing.pdf

Fields, S. (2004, Oct). The fat of the land: do agricultural subsidies foster poor health? Environ Health Perspect. 2004 Oct;112(14):A820-3. doi: 10.1289/ehp.112-a820. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1247588/

Healy, J., & Baker, M. (2021, December 27). As Miners Chase Clean-Energy Minerals, Tribes Fear a Repeat of the Past. The New York Times. https://web.archive.org/web/20230410161159/https://www.nytimes.com/2021/12/27/us/mining-clean-energy-antimony-tribes.html

Holloway, K. (2021, November 1). How Thousands of Black Farmers Were Forced Off Their Land. The Nation. https://web.archive.org/web/20230312110046/https://www.thenation.com/article/society/black-farmers-pigford-debt/

Indigenous Environmental Network. (2021). IRAC The Frontline Fights. https://web.archive.org/web/20231129155148/https://www.ienearth.org/irac-the-frontline-fights/

Johnson, S.R. (2023, June 22). States With the Most Rural Hospital Closures. US News. https://web.archive.org/web/20230826000218/https://www.usnews.com/news/healthiest-communities/slideshows/states-with-the-most-rural-hospital-closures

Jonk, Y. et al. (2023, May). Ambulance Deserts: Geographic Disparities in the

Provision of Ambulance Services. Maine Rural Health Research Center. https://web.archive.org/web/20231019025214/https://digitalcommons.usm.maine.edu/cgi/viewcontent.cgi?article=1013&context=ems

King, R. (2022, March 22). Study: Rural hospital closures over latest decade affected more Black and Hispanic residents. Fierce Healthcare. Retrieved October 21, 2022, from https://web.archive.org/web/20220425100632/https://www.fiercehealthcare.com/providers/study-rural-hospital-closures-over-latest-decade-affected-more-black-and-hispanic

Moehling, C. M., Niemesh, G. T., Thomasson, M. A., & Treber, J. (2019). Medical education reforms and the origins of the rural physician shortage. Cliometrica. https://doi.org/10.1007/s11698-019-00187-w, https://niemesgt.github.io/files/MoehlingNiemeshThomassonTreber2019.pdf

Planey, A.M. et al. (2022). Since 1990, Rural Hospital Closures Have Increasingly Occurred in Counties that Are More Urbanized, Diverse, and Economically Unequal. NC Rural Health Research Program. https://web.archive.org/web/20230923031259/https://www.shepscenter.unc.edu/download/24168/

Post, G. (2023, June 19). How a Black Community Brought Affordable Health Care and Clean Water to Rural South Carolina in the 1970s. NACHC. https://www.nachc.org/how-a-black-community-brought-affordable-health-care-and-clean-water-to-rural-south-carolina-in-the-1970s/

Poquiz, J., Moser, C. N., Grimstad, F., Boman, K., Sonneville, S. A., Turpin, A., & Egan, A. M. (2021). Gender-affirming care in the midwest: Reaching rural populations. Journal of Rural Mental Health, 45(2), 121–128. https://doi.org/10.1037/rmh0000174

Sausser, L. (2023, December 8). Being Black and Pregnant in the Deep South Can Be a Dangerous Combination. KFF Health News. https://kffhealthnews.org/news/article/black-women-pregnancy-risk-infant-mortality-deep-south/

Thompson, Elizabeth. (2021 July13). America’s Natural Gas Pipeline Routes and Environmental Justice. EOS.

Trahant, M. (2023, June 21). This time it’s different? The rush to mine Indigenous lands. ICT News. https://web.archive.org/web/20230905172428/https://ictnews.org/news/this-time-its-different-the-rush-to-mine-indigenous-lands

Williams, D., Thomas, S. et al (2018). Rural Hospital Mergers from 2005 through 2016. NC Rural Health Research Program. https://www.shepscenter.unc.edu//wp-content/uploads/dlm_uploads/2018/08/Rural-Hospital-Mergers.pdf

The Story of Rural Health