Since 2008, the gap between rural and urban American mortality has been increasing. We now are at the point that death rates from all causes and adjusted for age is 20% greater for rural Americans than for their urban counterparts.
The health issues this part of our country faces are complex, too. Rural Americans are older than urban Americans, experience the highest poverty rates, and endure significant maladies due to decades of lack of access to prevention and treatment services. Let us also remember that rural America, while only 15% of the population, is the primary source of food and energy for all Americans.
“The simple fact is that many rural Americans have no access to primary health care, prevention education and information, and all subspecialty care.”
The COVID-19 pandemic laid bare the long-term problem, with significantly higher fatalities in rural America. In general, as the tools to fight COVID-19 became more available, from monoclonal antibodies to antivirals and vaccines, the access to these lifesaving tools was dramatically lower in rural America. Beginning in 2021, this drove the higher rural COVID mortality.
That was due to the same structural barriers that have been widening the mortality gaps: A lack of primary care, inadequate access to referral specialty care, under-investment in clinical research in rural areas, and poor quality of tribal nation rural health care. The simple fact is that many rural Americans have no access to primary health care, prevention education and information, and all subspeciality care.
Fortunately, the complexity of the issue has been explored and effective solutions are available. This is not about more money, but focused investments in specific areas and populations based on equity and need.
What is required is an integrated approach that brings together local schools, community health institutions, and rural-based clinical research to improve the overall health of communities. At the same time, rural communities need a comprehensive database that ensures accountability, transparency, and an understanding of the impact of programs and their investments.
A clinic worker helps a patient with forms at the Mosi Oa Tunya Clinic in Livingston, Zambia. (Paul Morse / George W. Bush Presidential Center)
The PEPFAR example
We have seen this approach work before in sub-Saharan Africa, where effective strategies changed the course of the HIV pandemic on the continent. The strategies dramatically decreased HIV infections without a vaccine. The model has been tested, is cost effective, and has demonstrated outcomes and impact.
Twenty years ago, 50% of moms and dads in some sub-Saharan nations were infected with HIV and dying of AIDS. Not only was there a global health crisis, but there was an economic and stability crisis. “Between 1999 and 2000 more people died of AIDS in Africa than in all the wars on the continent,” reported UN Secretary General, Kofi Annan. “The death toll is expected to have a severe impact on many economies in the region.”
Action, however, was slow. High-income countries and public health officials made excuses for the lack of investment and definitive action. We especially saw this around access to lifesaving HIV treatments that were routinely available in wealthy countries.
Even within our own government, I heard people say that our focus should be on prevention and not treatment. Colleagues refused to consider treatment in our vaccine trials for those who became infected with HIV. They saw treatment for clients and their families as a diversion of research dollars for new prevention interventions. To some of us, this was unacceptable, so we pushed behind closed doors.
Finally, with the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002 and President George W. Bush’s State of the Union address in 2003, the world woke up and action ensued.
President Bush had seen the data, understood the fabric of African society was being ripped apart, and considered all the reasons not to act in an unprecedented manner. But he stood alone and said the United States would act and bring resources both in direct funding to countries and through the Global Fund. Not just money, but people, infrastructure, and a willingness to combat misinformation, stigma, and discrimination. He knew you were morally required to act once you had the data and understood the depth and breadth of the problem.
At the beginning of PEPFAR and the Global Fund, we had to directly tackle misinformation, herbal cures, lack of access to health care, structural barriers to treatment, and prevention services. It was complicated and hard. Every victory, every issue that was tackled uncovered another issue.
But PEPFAR was grounded in data. Using information to address specific barriers allowed us to see the issue, tackle the problem in deep partnership with the community, and push host governments to adopt policies that facilitate access to services.
We worked on the ground with communities learning in the moment what was working and what was not. We evolved and adapted to meet the new challenges, always grounded in data, community partnerships, and holding ourselves accountable.
“If PEPFAR has taught us anything, what matters is how the money is spent. And the most success comes through local programming that is culturally aware and implemented by the community.”
Together, progress was made, month-by-month, community-by-community. Rates of new HIV infections and new fatalities dropped. We learned together to use data for action.
The data is clear about rural health care
Here we are again, though. We have tracked the declines in the health of specific areas of rural America and among races and ethnicities. We have charted the poor uptake of vaccines among adults over the past decade. We have charted the opioid epidemic and it’s geography. We have charted the high rates of maternal mortality by race. And we have charted the dramatic and accelerating deterioration of the health in rural communities among tribal nations and Black, brown, and white residents.
All the while, we have watched the gap widen. And we haven’t acted in a comprehensive manner, driven by data, and focused on changing outcomes. We didn’t look at the depth and breadth of the issues, define root causes, develop an implementation plan, and use results to track program effectiveness.
“What is required is an integrated approach that brings together local schools, community health institutions, and rural-based clinical research to improve the overall health of communities.”
Nor did we do the behavioral research to understand the unique barriers to health access in rural America. As one example, we didn’t do the deep dive into vaccine hesitancy across communities.
And, as with HIV, many have made simplistic excuses for why this neglect was happening. That includes implying it was linked to how Americans voted since there were dramatically higher rates of deaths in rural (red) America than in urban (blue) America. For some, this was the clear evidence that there were two American realities.
Meanwhile, rural primary care and community hospitals closed, further worsening health outcomes. Then COVID came to America.
Yes, the first wave was primarily kept to urban areas and the immediate suburbs. As a country, we prevented spread beyond 30% of our major metropolitan areas. But every surge since has devastated our tribal nations and our rural communities.
We continue to talk and make excuses about rural health care. We cannot just keep collecting data, making political arguments, and watching people die. All of the Department of Health and Human Services (HHS) and Congress are morally obligated to act.
Again, we don’t need just more money. We need the money we have to act, and we need to use data in real-time to see if we are having outcomes and impact. If PEPFAR has taught us anything, what matters is how the money is spent. And the most success comes through local programming that is culturally aware and implemented by the community.
There are excellent cost-effective community programs that can be taken to scale, including amazing tribal nation initiatives. The locally owned clinics and services that the Fond Du Lac branch of the Chippewa Tribe operates are a good example of an initiative that is culturally relevant and can be directly funded.
“We need to get into communities, create new partnerships with the private sector, non-governmental organizations, community-based organizations, and faith-based organizations. We should hold town halls and answer the communities’ questions without eye-rolling and condescending jargon. Our goal should be: teach, empower, build, and hold ourselves accountable.”
HHS should commit 15% of all of its dollars for research, community programming, and health programming, including for mental health care, to the 15% of Americans in rural areas. The department should do this in states through local institutions that are linked to a community, such as K-12 campuses or colleges.
The initiative should be grounded in up-to-the-minute data that leads to continuous evidence that outcomes are being improved and the health of the community strengthened. If this happens, our health and research institutes will pivot and engage rural communities in the necessary health and research efforts.
The education, communication, and outreach needed in rural areas across race and ethnicity will help Americans make informed decisions about their health. We must educate and not just mandate to try to improve outcomes.
These steps will matter, too:
*Hospitals and clinics need to receive bonuses for decreasing the rates of obesity, diabetes, and cardio-vascular disease in their communities.
*Community hospitals need to be adequately funded places of overall improvement for inpatients and outpatients and held accountable for their work.
*The Center for Medicare and Medicaid Services (CMS) must require definitive diagnoses of all community-acquired infectious diseases in order to use that code for speedier reimbursements. CMS also should make the diagnoses available promptly to communities. That way everyone knows what is circulating in their communities and the tools they have to combat specific infectious diseases.
These tools will help change the reality on the ground. We need to get into communities, create new partnerships with the private sector, non-governmental organizations, community-based organizations, and faith-based organizations. We should hold town halls and answer the communities’ questions without eye-rolling and condescending jargon. Our goal should be: teach, empower, build, and hold ourselves accountable.
These approaches particularly matter as the world continues to confront COVID-19, which killed more than 250,000 Americans from acute COVID in 2022 alone. This year, COVID-19 will kill half as many Americans as all cancer deaths and nearly a third as many Americans as all cardiovascular deaths. This is just from acute COVID. We are not tracking and changing the health consequences of medium- and long-COVID.
We have the tools today to prevent 90-95% of all COVID-19 deaths as well as to improve rural health. If we use these tools effectively, we have the roadmap for improving the overall health of all Americans, no matter where they live.
