Eighty percent of rural America is considered medically underserved, according to the most recent analysis by the National Institute for Health Care Management Foundation (NIHCM). The NIHCM considers an area “underserved” if it has few primary care providers, high infant mortality rates or poverty rates or a high senior citizen population. As we embrace this new year and look at opportunities on the horizon, the fact of the matter is we are still dealing with longstanding issues. Health care in America, particularly in rural America, remains a challenge our country continues to grapple with year after year.
The murder of UnitedHealthcare CEO Brian Thompson by suspect Luigi Mangione opened Pandora’s box on the status of health care in the U.S. and what role the government, nonprofits, insurance companies and other involved shareholders should play in improving the system. There has been a growing discourse among Americans about the frustrations around the health care system and how health insurance operations and cost-related barriers inhibit access to medical care.
While this topic is often viewed through a national lens, evidence supports the notion rural America is getting the short end of the inequitable health care stick.
Rural health care access is an issue right here in my home state of North Carolina. The concerns around this topic echo within small towns only locals know the name of. I wanted to talk to the public health workers and leaders who serve these areas to get a firsthand perspective on the topic and how it relates to broader American society.
“Our community sees a lack of both mental and physical health care access,” said Melissa Elliott, mayor of Henderson, N.C., and a Level 4 Community Health Worker. “We have people waiting prolonged periods of time just to get basic physical checkups. And as for mental health, our youth are grossly underserved. We have adolescents waiting for months to get a bed in a psychiatric hospital and are stuck in limbo in emergency rooms [ERs].”
During our interview, Mayor Elliott went on to explain how the town of Henderson is considered a “traumatized community” due to gang, domestic and gun violence. Crimes related to intimate partner violence (IPV) in rural communities are exasperated by a lack of health care access and related resources and social support.
“Many of our youth have experienced trauma related to IPV, gang and gun violence and deal with conditions like PTSD, depression and anxiety,” Elliott added. “The reality of having youths in mental distress just waiting in ERs re-traumatizes them. Often, police officers are there to just babysit in a way until some kind of more permanent care is implemented.”
Henderson is an example of many other small towns in North Carolina and America overall that struggle to give residents the physical and social resources they need.
“We recognize that accessibility is a key issue when we talk about this problem, but it is also availability,” stated William Pilkington, DHA, HOPE Program Director, Julius L. Chambers Biomedical/Biotechnology Research Institute. “Because even if you can get to available services, are they available in the hours you can use them? Many families have one car available only in the evenings, and a lot of clinics are not open in the evenings. So, when the one car arrives home, there’s nobody to take anyone to health care facilities at that time.”
Dr. Pilkington went on to highlight the importance of the acceptability of care in regard to the quality of health care and its cultural awareness. Sometimes the quality of available health care services in rural communities is lower than that of their urban counterparts due to issues like health care worker shortages.
Closely related to the accessibility of health care is the accessibility of a secure food source. Dr. Pilkington stated rural areas often are in food deserts, which are areas where more than 30% of residents live in poverty and are located at least a half a mile away from a supermarket, supercenter or large grocery store. Rural North Carolina also continues to deal with a lack of public transportation, which is a national issue that contributes to people not having access to health care and other crucial resources.
“In addition to the need for chronic care and prevention screening, there is the issue of food security and availability,” said Dr. Pilkington. “We have too many food deserts too close to urban areas, unfortunately. And I mean, I live in a fairly urban area that has a huge food desert in it, and we just don’t have grocery stores with opportunities that folks can go in and get fruits and vegetables and easily get them and have them available, so we still haven’t done enough work being done there.”
Dr. Pilkington and Mayor Elliott discussed how North Carolina Central University (NCCU) hosts monthly food drives in target areas, among other initiatives to address health inequities. Many of the people who attend such events are single women and those living alone with a mental health condition. The lack of mental health care exasperates the needs these individuals already have.
“We serve high numbers of people who live alone, and that means nobody might know if they don’t have enough food or are struggling in other ways,” said Dr. Pilkington. “So, we’ve got all those issues, and I just don’t see community leadership around the state responding to these issues as being a problem. For example, we’re not addressing homelessness as still being as big of a problem in rural areas as it is in urban areas. We’ve got the cold weather here now. The shelters do not have enough room to take all of the unhoused people in.”
According to the 2023 Annual Homeless Assessment Report from the Department of Housing and Urban Development’s (HUD), North Carolina has 9,754 unhoused, with 657,100 unhoused throughout the U.S. There have been significant increases in the number of unhoused persons in North Carolina and nationwide due to factors like the rising costs of housing and the end of COVID-19-related financial resources.
For Mayor Elliott, the issues of lack of health care, food and housing security and community violence often intersect. She has personally witnessed the devastating effects when these challenges persist.
“We recently had a young lady, 24 years old, who was shot in the neck during a dispute and died on one of our city streets,” recalled Elliott. “I knew her. I actually taught her about 10 years ago. In our community, death by gun violence has become so normal. But it’s not normal. I saw over 500 people at a vigil for her, and I noticed this little boy, this girl’s nephew, sitting there holding her dog. He was eight, and he’s hyperventilating with the dog in his hand. I’m standing in the pulpit because I’m a preacher, and I’m reading a passage from Scripture. I saw him, put my Bible down and I walked out and just hugged him. I told him to just hug me tight. He did, and then he began to breathe.”
Mayor Elliott recounted this story with a great deal of emotions and a mix of sadness, frustration and disappointment with the current state of health care and related services in rural communities like hers. This tragic story she recalled has been played out far too often for residents in these towns.
“I thought about everyone in the entire church,” said Mayor Elliott. “We come in and out of these spaces. People have no aftercare. No one is talking about trauma. No one is coming and asking these people, ‘Let’s talk about how you are feeling about this’. This problem ties back to mental health, as we have mentioned. But I wanted to throw that out there because it’s becoming so common to go into a funeral of someone that’s under the age of 25 and wearing a t-shirt with their picture on it.”
Mayor Elliott again highlighted the lack of mental health care in these communities, which is a great need in light of tragedies like the one she recounted. However, the mental health services that are present do not always provide the standard of care she feels the community needs.
“We’ve had community health events hosted by George Washington University and NCCU to discuss trauma and its effects on youth and their communities,” said Elliott. “A lot of the providers take a cookie-cutter approach to treating mental health in African American communities and do not realize some of the specific experiences and needs we have. Even worse, some of these places do not consistently give empathetic care. We’ve had some parents give accounts of their children going into ERs to get mental health care and being shackled to beds until they were able to get placed into inpatient facilities. These kinds of things happening make African Americans not want to seek care out of fear of being labeled as ‘crazy’ and being treated poorly.”
As Mayor Elliott and Dr. Pilkington dissected some of the key issues surrounding rural health care, other members of the panel I interviewed noted that all social determinants of health like economic stability, environmental health and education opportunities are just as critical.
“If you are traumatized as we see in many individuals in these communities, and you can only get certain types of food for your family once a month, your income is limited, your transportation is limited, you have the genetic propensity for hypertension or diabetes or are dealing with obesity, you aren’t focused on managing these conditions,” said Claudia Alberico, Ph.D., Program Manager, BBRI, North Carolina Central University Center for Health Disparities Research. “So, what I tend to see in rural communities, especially across eastern North Carolina, is a survival mindset. You think about Maslow’s hierarchy of needs. If I have to worry about that bottom rung, you know, housing, shelter and food, I’m not going to care about what my blood pressure is. I’m not going to care about what my waist circumference is looking like, which could cause gallbladder disease or fatty liver disease or diabetes. So, I think a lot of those underlying social drivers help to contribute to the lack of preventive services and preventive actions that we see in our community.”
Dr. Alberico went on to explain how people living with chronic conditions need to make lifestyle changes and often do not get the support they need in that journey.
“Band-aids are being put on these conditions,” Dr. Alberico said. “The doctors toss you some pills. You might be able to access those medicines. You might not be able to access those medicines, and this approach to health care contributes to a lot of the health disparities that we see.”
To offset some of these disparities, NCCU joins other community health partners to host preventative health screenings and offer fresh produce to the people who come out.
“We see a lot of the people that come out to these health events are very receptive to getting fresh produce, but when we bring up participation in clinical trials and getting more in-depth into managing their chronic conditions, they are apprehensive,” notes Dr. Alberico. “Often, their immediate response is no. They tell us they’ve already been to the doctor, which is sometimes not the case. Often, this behavior stems from a lack of knowledge about their condition. There is a lack of public health services to educate these communities. There is also a mindset in many of these people that if they don’t know they have these conditions, then they don’t exist.”
The apprehension people in these communities face comes from the lack of awareness around health topics that Dr. Alberico described. It also stems back to mistrust in some institutions, something that was very prevalent during COVID-19 and community health workers in rural communities saw.
“The communities we served were being decimated from COVID-19 because it was being transmitted in the meat-packing facilities many of the residents worked in,” explained Leatrice Martin, MBA, CHES, Public Health Education Lead, North Carolina Central University Center for Health Disparities Research. “During a Juneteenth vaccine clinic in Duplin County, we ran back in 2021, we could only get nine people during the entire event to get vaccinated. We were met with some hostility from some people due to their concerns about the vaccine. So, a lot of basic health education and fostering trust is really needed.”
Community health workers were deemed essential during the pandemic and served on the frontlines of education and treatment efforts. The role of community health workers in underserved communities remains vital but recognition and support for what they do has waned as COVID-19 has become a part of our daily reality.
“It was the grassroots work of community health workers engaging with local residents and leaders that led to the push for vaccine access in underserved communities,” said Martin. “We saw the value of community health workers, especially in rural communities. But a lot of rural communities didn’t have that infrastructure already in place and didn’t have adequate resources for community health ambassadors and community health workers. They’re struggling right now. They got a bolster and they had work during COVID-19. And now, since COVID-19 is being better managed like a regular respiratory illness, these workers are being displaced. We know the value of community health workers helping to disseminate that information because they are trusted messengers and a lot more of that is needed. A lot more infrastructure is needed to be built around that in our rural communities.”
As the panel highlighted, the need for improved physical infrastructure such as more public transportation, health care facilities, grocery stores and pharmacies is great in rural communities. But there is also a digital divide between rural and more urban communities that is an additional barrier to health care.
“I would say that the digital divide and digital literacy is a significant barrier,” said Seronda Robinson, Ph.D., Professor of Epidemiology, Public Health Education North Carolina Central University, HOPE Program Co-Director. “So, when there are services available, sometimes people are not aware of those services or how to access them. They don’t know how to schedule appointments, or if walk-ins are welcome or if certain types of insurance are needed.”
Dr. Robinson also stressed many people seeking services feel uncomfortable going to these care providers because they fear being stigmatized, thus creating another barrier that prohibits them from seeking care. Having healthy representation in the health care field can help make people feel more comfortable opening up about their challenges.
“That lack of diversity leads to a lack of understanding,” Dr. Robinson stated. “If people go to seek services, and the staff in these places aren’t educated about the culture of those they serve, they may not understand that the social determinants of health are impacting these people’s overall wellness. They might say, ‘Well, go get this prescription’, and aren’t realizing that there are issues like transportation barriers.”
Dr. Robinson went on to explain there is implicit bias in areas such as medication description that keep people from reaching out for care.
“Some people feel like those seeking treatment are just drug seeking and things of that nature, or there are barriers when it comes to getting the food that is necessary to take with the medicine,” said Dr. Robinson. “So, there are just a lot of things that create additional barriers that people may not understand when there is lack of diversity in the health care field.”
With the lack of public and private sector investment in health care infrastructure in many rural communities, it is often other societal institutions like nonprofits and churches that strive to fill the gaps in services.
“The people in these institutions are trusted messengers on the ground,” said Deepak Kumar, Ph. D., Associate Provost and Dean of Research and Sponsored Programs, Julius L. Chambers Biomedical/Biotechnology Research Institute. “They have the ability to galvanize all types of people in one space, to bring them to where they feel comfortable and
safe and give them the right to share what they’re feeling about issues, whether it’s mental health or physical health. Having this presence with organizations like North Carolina Central University’s partnership with the Rural Community Resilience Center (RCRC) says that we are here for people and that they just aren’t numbers to us.”
Dr. Kumar went on to say that oftentimes people in underserved communities get help from temporary sources that are not fully invested in these communities, something that he wants to address through the work of NCCU and the RCRC.
“Our message is that you actually matter to us enough that we’re going to stay present and visible in your community, and not just show up once a quarter,” said Dr. Kumar. “We have community health workers on the ground to make every possible difference we can in each area of social determinants of health so rural communities can thrive.”
If health is wealth, then people in rural communities like those in my home state are impoverished, like sadly they are in many areas. With it being a new year and a new term for elected officials across all levels of government, the hope of people in rural communities and those that serve them remains that they will no longer be left out of America’s guarantee of life, liberty and the pursuit of happiness.
If you want to learn more about the North Carolina Central University’s efforts to address health disparities in rural communities, visit www.nccu.edu/rcmi/program-information.
Featured image by Josep Monter Martinez from Pixabay
Edited by Abbigail Earl & James Sutton
