I find it hard to see how rural America is going to get healthy. I’ve been to a few largely rural states over the last couple of years and am always overwhelmed by the challenge. If I was a health leader there I’d be asking myself where to even start.
I find the vastness almost overwhelming. I’m a city boy through and through. I may venture to rural places for treks now and then but it’s always safe in the knowledge that it’s a break from my norm. I can enjoy vastness on holiday but day to day, and especially when I think of the health consequence of those places, rurality basically scares me.
How, I ask, do you get anywhere fast in an emergency? At medical school they taught us about the door to needle time (in cardiac emergencies). The door, I understood, was the patient’s front door. We learnt in terms of minutes but is that scale even practical in the vastness of rural America? It somehow seems unlikely.
The places I’ve been have been well equipped with good roads. Indeed, the driving has been a joy (once I got used to being on the wrong side of the road). But when I speak to local health leaders they talk about residents living up less accessible roads. How do you cope with that, day to day, let alone in an emergency?
Vastness and inaccessibility feel almost insurmountable to me.
The vastness seems to mean that driving anywhere for anything is the norm. I’m just back from Missouri and saw a drive through Starbucks. Perhaps they’re normal in that part of the world but it’s the first time I’ve seen one. The whole set up seems to be to make it possible to live without getting out of one’s car and – crucially – walking, getting some exercise.
Likely related to the above, there are a lot of overweight people. To be fair, there are a lot of overweight people in the USA full stop, but you get the feeling that a higher proportion are overweight in the more rural areas.
And that brings me to the food.
It’s highly likely that my exposure to food options is skewed but whether it’s road side or in the fancy hotels I end up staying in I find the options severely limited and rarely healthy. Roadside are the predictable options of McDonalds, Subway, Wendy’s, and all their competitors, some of which I know and some that are new to me. One might expect more variety in the fancy hotels but it’s the usual fare of burgers or salads soaked in deeply unhealthy dressing. And there’s a huge amount per portion. An insane amount. These days I order only starters knowing full well that they’ll be enough. I’ve grown tired of how much food I waste when I’m in the US.
I realise I’m just talking about diet and exercise here. There’s way more to health, as my own work has shown me. But when I’ve been in rural America I can’t help feeling that my own work is indulgent, or perhaps just too urban. Is the core challenge to enable health care to better partner with communities or just ‘sort out’ the environment? My logical, perhaps academic, head tells me it’s both but my practical head says start with the environment.
Of course, there is something deeply patriarchal, if not condescending, about that. Who am I, a Londoner there for only a few days, to say what’s needed? But it’s hard not to have an opinion (I guess I also found it hard not to express it – hence this post). And I say that knowing full well that the view I’m expressing essentially says they need to take on the corporations that shape their world.
The corporations, of course, will say they’re just responding to consumer demand. They’re probably right. But supply and demand are not independent forces. They influence each other, and supply unchecked often shapes demand. All of which gets me to the idea of influencing supply – which means some kind of intervention.
That’s highly unlikely. My understanding is that rural America tends to vote ‘right’, Republican, small government. And so, if intervention by government is undesirable – if not abhorrent – what’s left? Clearly, ‘the people’. But will ‘the people’ really organise to reduce the supply of the thing they’re demanding? And even if they do want more choice, will the suppliers of alternative (less unhealthy) choices be able to sustain their businesses? It’s hard to tell but it somehow seems unlikely – at least not without some kind of subsidy.
So, all in all, I’m left with a sense of paralysis about rural environments. Of course, it’s highly likely because I’m an urbanista. I ‘other’ folks from these parts, despite having actually published an interview of someone doing important work on health in rural California. I’m likely held back by my own biases that I’m struggling to fully surface and account for.
But even with that self awareness I’m not sure I feel much more than overwhelm when it comes to improving health in rural America.
The photo behind the title is by Jakob Owens via Unsplash