Healthcare Disparities for Rural Communities

Hospital closed sign directing patients to the next nearest hospital
Hospital Closed. Source: Nigel Goodman, Creative Commons

Access to healthcare is one of the biggest predictors of health. When someone has access to healthcare, they are more likely to seek treatment for and catch chronic diseases in early stages. This can greatly improve health outcomes and quality of life. However, when access to healthcare is restricted in any way, health outcomes and quality of life decrease, those who need consistent treatment may go without, and preventable deaths increase. Rural areas disproportionately face decreased access to healthcare, which greatly affects the health and productivity of these already disadvantaged areas.

Lack of Insurance

There are many barriers to healthcare that rural Americans face. First of all, there is a lack of insurance. This is mainly because insurance premiums are more expensive in rural areas than they are in urban areas. Urban areas have larger populations, which encourages more insurance companies to compete with each other, driving the costs of premiums down. Additionally, their larger population means the cost of medical expenses can be spread among more people. This also lowers premium prices. Because these two factors are not present in rural areas, they are left without affordable healthcare.

Additionally, many people in rural areas have incomes that fall in the gap between qualifying for Medicare and being able to afford private insurance. Medicare is available to specific low-income groups. In states that haven’t expanded Medicaid, the most common income limit for Medicaid eligibility is 43 percent of the Federal Poverty Line and childless adults are excluded regardless of income. These qualifications leave over 2 million adults in the United States uninsured.  Insurance is important because it can help cover costs of healthcare which can otherwise become insurmountable. Those without insurance are less likely to seek healthcare, and when they do, it is typically worse quality than those with insurance receive.  Additionally, when an uninsured individual does seek healthcare, the costs are sometimes too high and turn into medical debt. Since much of the rural population is uninsured, these problems plague many of them.

Closing Hospitals and Pharmacies

Those that do have insurance still face a bigger problem: many rural areas don’t have hospitals within a twenty-minute drive. 25 percent of those living in rural areas report that they have to drive at least 30 minutes to get to the nearest hospital. In fact, almost one in four rural Americans say access to adequate healthcare is a major issue for them. Additionally, many hospitals in rural areas are shutting down, leaving communities without the healthcare they are used to. Since 2010, there have been over eighty rural hospital closures, mainly in the southeast. These hospital closings have a devastating effect on the communities they were a part of. Mortality rates for accidents, heart attacks, strokes, and anaphylactic shock risedue to longer ambulance rides. Additionally, residents may be unable to attend routine appointments because of transportation limitations; much of the rural population is elderly, which restricts their ability to drive, and public transportation is less common in rural areas than urban areas. This also means that with the onset of troubling symptoms, residents of rural areas may wait longer to see a doctor because of the inconvenience.

Many rural areas also lack pharmacies, which can hurt those who rely on prescription drugs for good health. Even the rural communities that have hospitals may lack a pharmacist, and many of the pharmacies in rural areas are in danger of closing; many have already. This is due to higher costs of medications at rural pharmacies and lack of pharmacists in rural areas. This can have a devastating effect on residents, as many go periods of time without their prescriptions—like Insulin or medication for depression— until they can get to the nearest pharmacy. Additionally, pharmacists in rural areas are helpful in educating the community on when they can use over-the-counter meds and when patients should see a doctor.

But why are hospitals and pharmacies closing? They have few patients, many uninsured, and they are greatly affected by states’ refusal to expand Medicaid. Medicaid expansion, which 14 states have not ratified, would close the gap between those that qualify for Medicaid and those that can pay for private insurance. As discussed previously, those with insurance are more likely to seek medical care, which would bring more business—and therefore, funding—to hospitals and pharmacies, making them less likely to close. Additionally, they lack the staff required to stay open. 99 percent of students in their last year of medical school report they plan to live in communities with over 10,000 residents. Without a staff, a hospital cannot stay open.

Lack of Specialists

In many rural areas, including those with hospitals, there’s a lack of specialists, like oncologists and OB/GYNs among others. Specialists typically work in large hospitals that have adequate resources, so they tend to reside in cities. This means that those with specialized needs often have to drive to the nearest city to receive care. Traveling can pose a problem to many rural Americans as many of them are older, but this also affects many younger rural inhabitants as they may not have the time off from their jobs to drive hours to receive specialized care. This leaves many without treatment that they need and worsens health outcomes. This is especially concerning considering many rural communities have higher rates of diseases than urban communities do. Specifically, “rural African Americans have higher rates of cancer morbidity and mortality than other rural residents and have higher rates of comorbid conditions” according to Robin Warshaw from the Association of American Medical Colleges. Rural African Americans also have higher rates of disease than urban African Americans. This makes the fact that specialists are not easy to access even more concerning, especially considering they are the largest rural minority. Minorities in general have less access to healthcare, and living in an area that doesn’t have easy access to healthcare in general can exacerbate this issue.

Low Health Literacy

The healthcare system is complex, which means that patients have to work to understand what care they need and when they need it. The ability to do so is called health literacy. Studies have shown that health literacy is important to health outcomes. The higher level of health literacy a person has, the more likely they are to seek out preventative care, such as screening tests and immunizations, that can catch diseases in early stages or prevent them altogether. If a patient doesn’t understand what the doctor tells them, they are less likely to be comfortable enough to seek care. Additionally, higher health literacy rates make it easier to understand how to manage existing conditions. In addition to less access to healthcare, rural Americans have lower health literacy, which compounds their health problems. However, because rural citizens are less likely to have access to health care, it is especially important for them to have high health literacy, which can be attained by using programs that work to educate patients and clinicians on the importance of patients having an active role in their healthcare.

Solutions

Rural healthcare in America is a big problem, but it can improve. In addition to the health literacy programs, there are many solutions to close the gap in healthcare between rural and urban areas. While the common medical school experience trains students for work in populated areas, a consortium of 32 medical schools has created a rural healthcare track with their medical schools. This not only puts more doctors in rural areas, but also trains them for rural areas’ specific health needs. While the program is too new to see a significant increase in rural healthcare professionals, the majority of students who have gone to residency have stayed in rural areas and are studying specialties that are in much needed in rural areas. Additionally, there are many scholarships for those planning on practicing medicine in rural areas, further encouraging medical students to practice in areas in need of doctors.

The Plastic Problem

A crushed water bottle lying on its side.
Crumpled. Source: Jesse Wagstaff, Creative Commons

The world is built to run on cycles.  The water-cycle.  The food-cycle.  The carbon-cycle.  The resources on Earth exist to be used and reused.  At some point, humanity lost sight of that, our eyes drawn to the concept of disposability.  Now we must face the consequences.

Think for a moment: when garbage day comes, how much trash have you collected?  If the millions of people who send their trash to landfills every week have as much as you, what does that look like?  It is important we remember that, after the garbage truck drives off into the distance, our bags of trash do not simply disappear from existence.  They must go somewhere, and they pile up.

Reduce, Reuse, and Recycle.  You have heard it before.  Place your plastic bottles and paper in the blue bin rather than the trash can.  Take shorter showers.  Unplug electronics when they are not being used.  This is often accepted as doing enough.  The sad truth is that this makes a very small dent in the pollution of our environment.

Background

Despite being aware of its impact on the planet, most of us cannot imagine day to day life without plastic.  However, the world has not always relied on plastic as we know it.  Though naturally derived plastics have been in use for ages, the first fully synthetic plastic was not developed until 1907.  In the 1930s, its use was common in aspects of the war such as military vehicles.  Since then, plastics have become increasingly commonplace and depended on in everyday life.  It is estimated that over 8.3 billion tons of plastic have been produced since the 1950s.

Plastic does not decompose like other materials.  It is estimated that it takes at least 450 years to decompose but may never actually do so.  It shrinks and is often mistaken for food by animals or ends up in our water.  More than five trillion pieces of plastic are already in the oceans due to litter and mismanaged trash that never even reaches a landfill.  According to the United Nations, it is possible that the oceans will hold more plastic than fish by 2050 if something does not change.

We are constantly surrounded with promotions of the concept of “out with the old, in with the new.”  Replace clothes every time a new style gains popularity.  Replace technology as soon as newer models are released.  Perhaps this is why we are so comfortable with the concept of “disposable” products.  We have developed a frame of mind where the norm is to dispose and replace.  The results of this attitude have huge, negative impacts on the environment, and by extension, human beings.  In his TED talk, “The economic injustice of plastic,” Van Jones sums it up perfectly: “In order to trash the planet, you have to trash people.”

Human Rights

The pollution of the environment is a human rights and public health issue.  In the Universal Declaration of Human Rights, Article 25 states that we have the right to a standard of living that supports our health and well-being.  The United Nations also recognizes many specific environmental rights.  For example, we have the right to “a safe, clean, healthy, and sustainable environment.”  We also have the right to seek information regarding environmental issues and to “participate in public decision-making.” Plastic pollution is an increasing contributor to violations of the human rights of people all over the world; we have the right, as well as the responsibility, to be a part of the solution.

Landfills are a specific example of how plastic harms people.  Many items that end up there contain toxins that often leak in to water and soil and remain for years.  Problems can also be found when organic materials, such as food waste, are in landfills.  When they start to decompose in the middle of an enormous pile, they are deprived of oxygen and produce methane, a serious greenhouse gas that can become dangerously flammable.

Landfills also have a direct impact on the lives of entire communities.  As of 2003, the NAACP Legal Defense Fund co-represents the Ashurst/Bar Smith community (ABSCO) in a Title VI complaint against the Alabama Department of Environmental Management.  ABSCO’s complaint is that the department has discriminated against the community, “by permitting the Stone’s Throw Landfill to open and expand its operations in their predominately (98%) Black community without conducting an assessment of the Landfill’s disparate and discriminatory social, economic, and health impacts on the majority-Black community.”  The landfill had been closed but was reopened in 2002.  Landfills are often placed near low-income, black communities, especially in Alabama.  Many members of the community can trace their family’s ownership of their land back many generations, such as Phyllis Gosa, whose great-grandparents bought the land as former slaves in the 1800s.  As decades have past, such families have been able to see the changes that have occurred since the start of the landfill.

The effects of Stone’s Throw Landfill reported by ABSCO include fear of toxic run-off polluting their water sources, health problems like cancer, respiratory problems, migraines, and dizziness, and gardens no longer producing food.  In the past, this community has been heavily self-reliant, using their own water sources and growing their food on their own land.  Due to the impacts of the landfill, they are now having pay significant costs to replace what their resources can no longer provide.  The EPA closed the complaint in 2017, but the problems continue.

This case is not unique.  Landfills pose daily threats to the health and well-being of people across the country, and yet they continue to grow.

A pile of old, worn down toothbrushes that have been thrown out.
Plastic Toothbrush Debris. Source: NOAA Coral Reef Ecosystem Program, Creative Commons

Legislation

The implementation of some large-scale efforts to decrease the use of plastics and their detriment to societies and the planet have increases as the world realizes the problem that plastic creates. China, who had been the world’s main destination for plastic recyclables until January, banned the import of plastic waste this year.  The European Commission has proposed a ban on nearly all single use plastics.  In 2016, France implemented of a “four-year phase out” of single use plastics such as cutlery and plates.  California banned single use plastic bags and began to require a ten-cent charge on recycled plastic bags in 2014, supporting the use of non-plastic bags for carrying purchases home from the store.  Nearly all of Hawaii’s highly populated cities have banned non-biodegradable plastic bags and paper bags that are made from less than 40% recycled material.

However, the United States as a whole has a lot of catching up to do.  According to the Environmental Protection Agency (EPA), we produced 258 million tons of solid waste, and 136 millions of those tons were sent to landfills.  Multiple states, including Michigan, have gone so far as to ban plastic bag bans.  They have prohibited the creation of legislation that regulates “the use, disposition, or sale of, prohibiting or restricting, or imposing any fee, charge, or tax on certain containers.”  Supporters of this law often consider themselves to be protecting businesses from having to make changes that disturb regular operations.  The question is whether or not it is worth it.  Is it worth accepting the harm caused by plastic bags in order to prevent businesses from being inconvenienced?

What We Can Do

While the average person cannot do very much about the landfills that already exist, we can help by not adding to them and limiting our waste.  Half of all plastic that is produced is only meant to be used once.  This leads to an enormous amount of plastic destined for landfills, even if we disregard any that could potentially be recycled.  Cling wrap.  Candy bar wrappers.  Ziploc bags.  The list goes on.

A lot of it (if not all of it) is completely unnecessary.  Take it from Lauren Singer.  She has minimized her waste production to the point of being able to fit all the trash she could not compost or recycle from four years of her life into a single mason jar.  She promotes the “zero waste” lifestyle through many different media, such as her blog, Trash Is For Tossers.  According to Singer, being zero waste means to “…not produce any garbage.  No sending anything to the landfill, no throwing anything into a trash can…”

How does she do it?  Through her blog, Singer has offered a lot of information on how to work towards living a zero waste life.  For example, to replace plastic toothbrushes, she recommends opting for a bamboo one, which can be composted when the bristles are removed.  Instead of buying all-purpose household cleaner, she suggests making your own, which is often cheaper and healthier for you to use.  Additionally, single use menstrual hygiene products can be replaced with washable and reusable options, such as menstrual cups and reusable pads.

Many people who are part of the zero waste community abide by the five Rs: refuse, reduce, reuse, rot, and recycle.

The Five Rs

1) Refuse.  Do your best not to accept things that are unnecessary or that will end up being thrown away.  Before accepting that free pen, think twice about how much you actually need another one.

2) Reduce.  Try decreasing the amount of stuff you bring home, especially if you are only going to use it once.  Consider buying products that have multiple uses and/or can be bought in bulk.  This leads to less plastic and is often less expensive.

3) Reuse.  Buy items of higher quality that can be washed and reused repeatedly, such as a stainless-steel water bottle.  Bring your own cutlery instead of using plastic ones.

4) Rot.  Compost anything you can.  Here you can learn about how to start your own compost and about what can be composted.

5) Recycle.  While it is good to recycle anything you can, it is important to note that it is at the end of the list.  Strive to find the need to recycle as little as possible, especially when it comes to plastic.  It still involves buying more disposables that will most likely end up in a dump (or worse).

If you decide to try out being zero waste for yourself, please remember that it is not about being perfect.  It is about doing the most you can to maximize the positive impact you have on the world.