Rural Health is Public Health - What is Rural?

(upbeat music) - Welcome back to Everything is Public Health. We're here to talk about how everything is public health. Yet again, my name is MJ. - And I'm Cass. - Um, I, hmm. Have you lived in a rural area? Let me just go ahead and ask. - Yeah. - Oh, do tell. - Well, so I did my undergraduate degree at Central Washington University, which is in Ellensburg, Washington. And at the time I was there, the town's population was 8,000 people. - Including the university? - The town's population was 8,000 people. And when school was in session, the school had around, I guess, 8,000 people. So the population would double in size when the school year was going on, but like, yeah, there were not a lot of people there. - Can you describe more like what that town is like? 'Cause I, fortunately, unfortunately, I don't know, that's not put in a qualified, I have never lived in a rural area. - Yeah, so very small area. And then sort of as you got out of the kind of core city center, like you're surrounded by farms and ranches and all that kind of stuff. And it was not unusual for people to talk about living within ice cream distance of the grocery stores. So like, they lived close enough that they could buy ice cream and it wouldn't melt before they got home or if they needed to bring a cooler or cooler bag when they went shopping. We had two or three restaurants that were popular. When I started my undergraduate degree, which was in 2001, they had just built a Fred Meyer and that was like crazy that they had a Fred Meyer. They were like two main, there were obviously more roads, but they were like two main thoroughfares, one went north south, one went east west. And the biggest employer I think was the university or Fred Meyer maybe was next. Yeah, it was small, actually really liked it. It was an interesting change. So I grew up in a suburban area and we'd go into Seattle and it was like a 20 minute drive, not too far from being in the city. And yeah, it was a big shift, much slower pace. - That's kind of nice. - People were relatively friendly, exceptionally white, except for migrant farm workers who would come seasonally. - Have you ever seen, probably not, but have you seen how migrant farm workers were treated by the locals or is that not something that you witnessed? - Not really, like I was not self-aware at the time or like I was so, you know, I was 18. Just to be fair, I lived in Ellensburg until I moved away for graduate school, which when I was 26. So I started to become more aware of things, but like as we've talked about before, I had no idea what public health was until I went to school. And so like I had really no idea what I was experiencing. - Should have been thinking about or any of that kind of stuff. - So I have never lived in a area that by any consideration would be rural. I mean, I have visited a rural area. When I say visited, I don't mean like drive pass. I don't consider that a visit. When I was in Taiwan, my grandmother lived in the mountains, quite literally in the mountains. So we would have to drive an hour into the mountains to visit her. And that was, that was rural because you're in the mountains. And I think you're right in that. I was too young to be aware of anything. That was going on. And she was like, "Oh, grandma's here." Or "I'm here, grandma, it's great." And then we would go to the creek. There's a creek behind her house. And then we would like build little dams, like kids do to like block off the water, which in retrospect probably not helpful for the fish downstream, but, you know. - I doubt that the dam you built was structurally sound enough to substantially impact the fish down the stream. - It probably wasn't, but it just feels like such a big accomplishment and maybe not like harmful, but definitely annoying to the fish downstream. It's like, but yeah, but I've never lived in a rural area. And I do think that if I were to visit or live in a rural area, my experience would be a lot different just because I'm not white. And I think that's true for anyone who's non-white in a rural area, but this term, and I have to be careful for the rest of this episode. Because the term rural has been increasingly stopped. - The way you say rural. - It's true. - Rural. - How do you say rural? - No, it's not. No, you say, I can't even say how you say rural. - Rural. - Rural. - What am I saying? - I need to be careful for the rest of this episode because I know I have a lot of implicit bias around this word because this term, I'm not gonna say it. This term and concept has been increasingly politicized. Stop it. Increasingly politicized. - Every time you need to say rural, you can just delete yours and just put mine in. - Yeah, it has been increasingly politicized. I'm sure you've seen in the news. There's been multiple multiple thought pieces about how the political divide is a rural, urban divide. And so we need to be careful. We have to remind ourselves that as much as it is political because you can't deny that the political distribution in these different areas is there, it's actually not as stark as you would think. You would think that it is like 90% Republicans, but it's actually not that high. It's only around 60% Republicans in rural areas. I'm sure you've noticed how this term has been politicized, especially in the last decade or so, which is not helpful for them or us to be this politicized. For example, there's a Washington Post piece that said, most residents that live here deeply resent how they're being perceived and treated. - Yeah. - Honestly, fair. That they think that way. And there's many, many opinion people, people write opinion pieces that say, oh, this type of perception is why they believe certain ideology. And we're gonna try to avoid all of that stuff today because that is not the point of this episode. Nor is it the point of this show in general to dive deep into the political landscape of America, but it does exist and we have to acknowledge it. - So I think it's very different for me because I lived for several years in a rural area and got to experience the amazing hikes that we could get to because we were, you know, a stone's throw from the foothills or the amazing weather that we would get, really nice, warm, dry weather and amazing snow. Like it was a great place to live for folks who enjoyed being outdoors. - Yeah. - I also know, I knew a lot of people I was engaged and a lot of activities and I know that there's a very, ideologically diverse group of folks living there. Maybe not the most demographically diverse, but the people that lived there had a range of perspectives and there were different reasons why they lived there and, you know, why they were raising their kids there. And so I have, from my own personal experience, a different perspective, which is really something that is a common piece. Like when you get to know people or places that changes how you think about them rather than the assumptions we might make other ones. - Yeah, this is why, like, exposure is so important. Like, for example, homophobic people oftentimes when they find out one of their family members or close friends is LGBTQ, they change their mind and you like to say gun owners on a monolith and people who live in those areas are also not a monolith. They are actually, like you said, a really diverse. Like we have done, not we, the Pew Research Center has done surveys and they are a lot more diverse than people think. Not demographically, you are correct on that one. It is largely white, but in terms of belief, there are a lot more diverse than what people think. But, you know, just keep that in mind. And the reason why I want to do this episode is because I think this is a concept that has been either neglected or perhaps politicized in the last few years, but it is nonetheless an important part of public health. Like essence of public health is that we care about everyone. And guess what? There are people living in these areas that we also need to care about. So the first question that I sought to seek is, how do you define rurality? - Well, so I do know, I'm not gonna get into the specifics. I'm sure that there are a lot of details here, but I do know because my doctoral candidate, soon to be Dr. Julie Ward, is doing some of her research assessing differences in her outcome by rurality in different sort of urban, suburban and rural areas. And one of the things I've learned through her work on her dissertation is that there are multiple ways, at least two or three ways to define rurality, I think it's three, and depending on which definition you use, you might get different distributions of urban, suburban rural. I think urban is like relatively the same across all three, but which one you use can impact sort of rurality and what ends up in that. But there's like one based on zip codes, one based on, I can only remember the zip code one, but I know that there are probably two others. There's many, so this is a recurring thing on this show where I think to myself, oh, it shouldn't be that difficult, I should be able to figure this out. That has never happened. Never once did I say, oh, something is simple. I should turn out being simple and never, it is very complicated. And I'm sure future Dr. Ward would be more versed in this than I ever will be in, you know, 90 minutes. It's a amount of time that I spend looking at this. Like you said, many different definitions. There are some main ones, but honestly, it's not one of those hard and fast boundaries. Any researcher could potentially be like, oh, actually, I think this needs a little bit more judgment, so I'm gonna throw in this factor. Like I'm sure you know what that process is like, but we're gonna talk about the main foundation of how rurality is defined. Obviously, when you think about how geography is defined, where do you go? You go to the census bureau because that is sort of their stick. Here is something funny. They don't have a definition of rurality. They have a definition of urban, so they just said, you know what, if it's not urban, we consider it rural, which is not the crispest of definitions. Urban areas are defined as 50k or more people in that area. The problem with this is that suburban areas are often categorized as rural because they don't have a rural category so if it's not urban it's rural but there's a lot of suburbs that no one would consider rural in their right mind. Where I live right now inapolis I think our actual population is like around 30,000. But it's not rural by any means. But being the state capital like this is not even remotely a rural place. So if you think about okay fine census bureau might not be that much of a help. Where would you go next? You go to the place where I would not have expected that them to define stuff like this. The office of management and budget or the OMB have you encountered them before like what do they usually do? I think they look at like the cost of different programs cost of bills that are going to be put forward and they sort of just generally are looking to see are we going over budget under budget? It's always over but yeah why do they have a definition for this? I'm sure there's a reason I didn't look into the reason why they have a definition for this but they define counties again they have a negative definition any counting that is not a metro county they consider rural so a metro county being an urban core of 50k or more now as you know and as I know some counties are huge okay some counties are so big that a lot of rural areas are counted as metro simply because they live in the same county as a urban core in fact 54% of people living living in rural areas are technically in a metro county by the OMB standard so not great as a measure for reality especially some counties how are county lines drawn I want to say arbitrarily by someone in the past. Are any of our map lines drawn sense is there a river that goes through or a creek sometimes that's the line sometimes yeah so oftentimes researchers would take those two into consideration but they would use something from the USDA which again not a agency that I would expect to have a definition for this but actually that kind of makes sense not I think about it well yeah because they're doing sort of all kinds of agricultural related stuff yeah I'm pretty sure that's why they have a definition they have something called the economic research service which has a or the name of the index hold on the name of the index from the economic research service is called are you see a which is the rural urban commuting area codes and this is way more complex to the point where I didn't even bother clicking on the thing that defined it because it's really complex they take into consideration population density obviously urbanization and commuting time and I think commuting time is one of the big factors that separates this out from the census bureau definition and the OMB definition brightly so I think it's a good thing for to include when you're calculating reality these are the jumping off points I think researchers oftentimes will be like this not adequate so let me throw something in this these are jumping off points for a lot of researchers yeah very complicated because again lines are arbitrary how do you define something as we were urban is actually a very complicated academic subject but some stats I don't know if you seen may fashion bring us up there's that map where each county is painted red or blue depending on whether they voted republican or democrats and they're like see most of america 97% of america by land this is what america is right you know the tagline that they often use but then the rebuttal to that is people vote not land right yeah and it's a very small proportion of our population that lives in that very large open land so I set 97% of land you want to guess at what percentage of population lives on 97% of the land 97 that's a huge that's majority of america 18% 19% you're so good at this 14 depending on how you define rally 14 to 19 is what I've been seeing but 14 from I believe from the yeah that was hard because we were just talking about how sort of the what are these definitions but yeah so I do know the vast majority of our land is empty less populated right we we have very very dense urban areas and one of the measures that we didn't talk about here but one that we sometimes try to account for when we're thinking about population population density etc is what proportion of the population for a given state lives in a metropolitan statistical area and so that's that's another way to think about it but I do know that right but as we were just saying that there are very very few people spread out over a very large space yes a 14% to 19% depending on one definition you use roughly 46 million us residents on 97% of the land so that graphics of like this is what america is someone did a transformation on that graphics where they blow up each county or shrunk each county based on how many people live there and you can very starkly see the difference in terms of political political affiliations if you if you take population into account and I think this is one of the reasons why it's so politicized and so politically divided is because I could imagine that people who live in those areas feels neglected by a lot of policy to be fair they're probably right well so there's a really interesting book by Jonathan Metzel called dying of whiteness and it's about is a new no it's been on my bookshelf for a long time it's a great book I'm pretty sure I bought it in the before times so I don't I don't remember exactly when it came out this is not like you read this 20 years ago right this is no no no so relatively new you know in the last 10 years most it got a ton of attention when it first came out but it talks a lot about some of the things that we see in these flyover areas yeah which a lot of people refer to the center of the country is these flyover areas you fly from coast to coast you're not really focused on these places but like deaths of despair with alcohol and and other issues and yeah dying of whiteness it's a good book checking out I'll pick it up there are other stats associated with a reality so this is from the Pew Research Center which I think is pretty reputable as a survey I think they do a lot of surveys if you don't know the Pew Research Center 2019 wow that's very recent those the before times relatively recent it was about five years ago for you and you recommended yeah oh yeah Jonathan Mezzle is great he's a Vanderbilt super super smart cool very thoughtful the full title is dying of whiteness have the politics of racial resentment is killing America's heartland I would love to read that book although I would imagine quite depressing so other stats and I think these are not surprising stats yeah we talked a little bit already I sort of alluded to a lack of demographic diversity so these rural areas tend to be more white for a variety of reasons including economic stagnation and and lack of economic opportunities in general there tends to be stagnant population growth so these places are not growing in size the same way some of our more suburban and urban areas are you also mentioned that while the majority of people living in rural areas are Republican it's actually not as much as you think you said around 60% yeah it's not the overwhelming 80 or 90 that people living in an urban area might expect yeah yeah and I know this from my experience living in a rural area like the people that are there tends to have been there for a long time with the exception of like people come in for for school for maybe a new job opportunity but then once you sort of get established in these areas like families will have been in these places for a long time they tend to be people who are living there for a long time average living time is tend to be around a decade plus in those rural areas which you know not surprising and they tend to report that they've been neglected by federal dollars in terms of funding and political attention that's very complicated can of worms we're not going to get into um I think so I will just say one thing sure go forward which is something that we talked a little bit about in our prior episode on Medicaid some of the reasons why individuals in these rural areas feel neglected by federal dollars is because their state policymakers yes are choosing to not expand programs to receive more federal dollars right so like there's this there's a narrative that oh we're being ignored by the federal government they're not investing in us but some states are making concrete actions to prevent the access to those resources so we don't need to say anything more than that go back and listen to the Medicaid episode and we can talk more about what states didn't didn't expand Medicaid and access this is the can of worms that's not surprising but also there's that that lack of understanding so it's you know I I said this before I'll say it one more time just because I think it's hilarious when people say get the government out of my Medicaid it's this is the can of worms like um okay it's feeling neglected what type of representative do you vote for but we're not gonna work on okay anyway moving on so rural areas they tend to have worst health outcomes by pretty much every measure we can throw at them there's lower life expectancy higher rates obesity diabetes higher rates of smoking poverty uninsurance rate greater risk of fatal car crashes now that one is interesting but also not surprising help is very perhaps very far away and road design is not I think about the roads that I drove on when I was living in a rural area and like not the city the city was fine but when you got out to the sort of edges of town or we're going out to other places the roads were not always up to the same design standards as we would expect with you know good well-designed guardrails that aren't gonna plow through your car that kind of stuff yeah higher rates of suicide And now this is particularly true with the opioid epidemic, much higher rate of overdose, which I don't know, they often have what I call hospital deserts or provider deserts, but somehow they're getting those opioids. So there were a lot of stories during the crackdown on opioid prescription abuse kinds of things. There were rural areas of the country where there were hundreds, if not thousands of prescriptions written for people like, even if you counted babies that were living in this particular area, there were like hundreds of pills per person of worth of prescriptions being written. So they're just like being flooded with these prescriptions. And we didn't talk about this directly. But we know that firearm ownership tends to concentrate among white Americans. We know that, you know, there's a higher density of white Americans living in rural areas. And there's higher gun ownership as a result. And so we see higher rates of suicide, which is often firearm suicide, because those are responsible for about half of all firearm deaths or all sorry, firearms are responsible for half of all suicide deaths, firearms are responsible for half of all firearm deaths. That was. We will definitely, definitely, and this is, I've been planning this for a while. We will definitely do an opioid episode because we have to like is such a such a big topic. And I will get to the bottom of why in an area where there's a hospital and provider desert, where are these things coming from? Because someone is prescribing them where they, I don't know, but there's also food deserts in a lot of these areas, all factors of social economic. What is it? Social determinant. Yeah, there we go. And pretty much all dimensions of social determinants of health apply here. Like they're just not doing well. And there's also lack of attention, lack of resources. For example, the trained development in East Palestine, Ohio, we saw that lack of attention and lack of resources play out in real time. And we're not going to summarize that. That's all over the news by this point. So I guess the next question for us to wrap up on is, why is rural health public health? I think it's important to consider rural health as public health because as we've talked about so many times on the show, you are not doing public health if you're only caring about a certain proportion of the population's health and wellbeing. Now, that does not mean that for particular topics, we might prioritize a focus on a certain subgroup or certain geography. But at the end of the day, if we are practicing public health, we are thinking about everyone at the population level. And so it's important to think about the unique public health and other health challenges that face rural versus urban areas and not to minimize any issues in either of those places, but to recognize that there may be different needs for intervention, different targets of opportunity that we need to lift up. And so it's important to be thinking about this as well. Yeah. And I think you've got to spot on like they are people and public health, we care about people. They are people and we care about people. And then one way to care about them is to one, making sure that they have good representation to be fair. That's not what I meant. It's more like their actual needs may not have been represented fairly by whatever representative that they themselves elect. But which can be true across, it could be true across the spectrum, right? Like you may think that your elected official is going to do a certain thing because they said that in a campaign. And there's a variety of reasons why they might not do that. But that's important to you. And they didn't do a thing. You need to, you know, call them on the carpet and hold them accountable for that. For political affiliation, they have big can of worms. But yeah, so we just like peaked, we just peaked out of the little can, we just burped the can. We burned the Tupperware just a little bit. Oh, by the way, if your sealed can has like gas in it, it's bad. You shouldn't eat it. That means bacteria has infected the can if there's gas in the can. That's why I moved away from Tupperware, right? We're burping the Tupperware lid on our left house. Yeah, that makes more sense. All right. Thank you so much for listening. Thank you so much for listening to this episode of Everything is Public Health. Rural health is public health. And by including them in continue, how do I continue after this? And by including them in the part of the conversation, perhaps we can start bridging the cap. New episodes or at least Thursday on Spotify, Apple Podcast, or wherever you get your podcast, please give us a rating and a review wherever you listen. It helps the show immensely. If you have any questions or comments to everything is public health at gmail.com, reach out if you think we miss an important perspective or suggest a future episode topic. Follow us on Twitter at everything is p h or instagram at everything is public health. We're also on mastodon at everything is public health. You can also find me on Twitter at doctor for façade. More information regarding this episode can be found in the show notes below. Listeners, we have a Patreon page that is also our website. Visit us for all major updates and bonus material. If you want us to support the show directly, you can support us on our Patreon page as well. I will also be posting frequently on mastodon going forward. And remember, everything is public health. Everything is public health.