By Kathryn Haenni
Rural health, as it relates to the field of medical study, can be divided into two categories: health and health care delivery. Rural healthcare is lacking, to say the least. The barriers rural populations encounter are not just complex geographically, but also socioculturally. These socio-barriers include race, gender, sexuality, religion, etc. With the 1,077,304 rural patients provided healthcare in North Carolina, I propose a study of the disparate health and healthcare as a result of poverty.
The relationship between healers and patients is crucial to the delivery of healthcare. Healers are defined as the providers of healthcare, whether they be traditional healers or biomedical physicians. By acknowledging the active role healers play in the poverty cycle, there then exists a path toward improvements in the healthcare system at large.
Comparatively, recipients of healthcare (i.e., patients) are actors in the poverty cycle too and inherently enable the system to function, whether it functions adequately or . The relationship between a healer and a patient, however, relies heavily on locational socioeconomics.
Socioeconomics of Rural Healthcare
Class asymmetries between urban and rural areas highlight the inadequacies of healthcare in the rural South. For example, the average life expectancy in Swain County, North Carolina is 73 years while neighboring Orange Country has a life expectancy of 81.4 years. Poverty rates, health insurance, and prenatal care can affect life expectancies— all of which differ along county lines. Understanding not just what disparities exist, but also why they do, is crucial to the exploration of rural health as a whole.
A 2018 study found that poverty could explain almost 50% of the variation in age-adjusted premature mortality rates in rural US counties. Even more so, after controlling socioeconomic variables, rural mortality disparities became negligible, only explaining about 1% of the variance in premature mortality. Ultimately, poverty, to a great extent, is responsible for healthcare disparities in the rural South. So what, if any, is the causal relationship between rural residency and inadequate health and health care delivery? And how do socioeconomic disparities play a role in this relationship?
North Carolina (NC): A Brief History
Rural communities, made up of both healers and patients, across North Carolina have experienced disparities in illness experience and consequent mortality for years. When urbanization took effect in the Southeast, North Carolina quickly developed. However, where there are geographic disadvantages, disparate wealth and health follow. The outermost areas of North Carolina mark the more rural areas. Henry Toole Clark, Amber Miller, and Sandra Williams discuss the effect the structure and administration of healthcare in rural North Carolina had on either their administering and/or receiving of healthcare.
Healthcare Narratives in the Rural South
The System: Henry Toole Clark
Mr. Clark grew up in rural Halifax County, NC. His commitment to the local healthcare system came to fruition when he was appointed the chief administrative officer of the 1950 Division of Health Affairs at UNC through which he focused on North Carolina’s poor ranking for healthcare delivery. The robust healthcare system he directed is what still exists today, notably prominent in urban areas (e.g., the Triangle). Clark describes the function of the healthcare systems as localized economically and socially. This suggests that rural populations inherently receive poorer healthcare delivery than their urban counterparts simply because the system was set up locationally. He notes the initial worry of North Carolina’s healthcare system was “freedom,” that of both providers and patients. However, later he recognized that the focus shifted away from freedom and toward access. Clark notes the “huge need” for developments in rural North Carolina’s healthcare system. Insurance was introduced as a result. Ultimately, Clark admits that the system, including himself, fell short, declaring the leading reason for healthcare inadequacy in rural areas to be poverty.
The Healer: Amber Miller
Ms. Miller grew up in Buncombe County, NC where she was both a caregiver of her father and patient with Uromodulin-Associated Kidney Disease (UMAKD). Growing up observing the care provided to her father as a patient of UMAKD, Miller was set on a path to eventually be a registered nurse in the heart of North Carolina’s Blue Ridge Mountains. Miller illustrates how, in nature, rural health is multigenerational and results in patterns (or cycles). Having grown up alongside recipients of rural healthcare, Miller emphasizes the importance of the patient’s illness narrative: “I’m no better than anyone else [and] no one else is better than me.” As a provider, Miller illustrates how the needs of the provider are also not adequately met. She describes how without proper resources the healthcare system cannot function sufficiently in rural North Carolina no matter “how well the staff [treat patients, or how incredible the nurses are, or the education that they give].”
The Patient: Sandra Williams
Ms. Williams grew up in Warren County, NC. She asserts the family unit as an actor in the healthcare system and describes the prominence of familial relationships in rural North Carolina and their effects on healthcare delivery and acceptance. At length, she details the homeopathic care she and her family received and still receive. This highlights the differences between urban areas and rural areas untouched by the biomedical world. She outlines the interconnection between race, poverty, and health, pointing out that there are midwives and “real doctors” in the rural south. She recounts “self-care” as a recurrent remedy: “Granny, my father’s mother, she would stir stuff up, boil stuff, and [say] ‘Here, take this.’” The cultural and racial differences cause rifts in the care pipeline that allow room for homeopathy to pervade the care culture. This highlights that, while the poverty cycle is a determinant of the success in the healthcare system of rural North Carolina, it is not the sole reason biomedical care struggles to be delivered— it is not an economic problem we face, but a socioeconomic one.
While healthcare delivery by healers and acceptance by patients are limited in the rural South, the Stories to Save Lives (SSL) project highlights the cultural tapestry that makes up the healthcare system. Strikingly, the topic of rural healthcare is not always one of tragedy. Instead, both parties on either side of the Rx slip are individuals with real-life experiences that inform the care they give and receive.
Anderson, Timothy J., et al. “A cross-sectional study on health differences between rural and non-rural US counties using the County Health Rankings.” BMC health services research 15.1 (2015): 1-8
De Marco, Molly, et al. “Growing Partners: Building a Community–Academic Partnership to Address Health Disparities in Rural North Carolina.” Progress in Community Health Partnerships: Research, Education, and Action, vol. 8 no. 2, 2014, p. 181-186. Project MUSE, doi:10.1353/cpr.2014.0021.
Green, Bethany, and Erminia Colucci. “Traditional Healers’ and Biomedical Practitioners’ Perceptions of Collaborative Mental Healthcare in Low- and Middle-Income Countries: A Systematic Review.” Transcultural Psychiatry, vol. 57, no. 1, Feb. 2020, pp. 94–107, doi:10.1177/1363461519894396.
“Health Statistics and Data.” NCDHHS, https://www.ncdhhs.gov/divisions/office-rural-health/office-rural-health-programs/analytics-and-innovations-program/health-statistics-and-data.
Interview with Amber Miller, 22 July 2019, Y-0075, in the Southern Oral History Program Collection #4007, Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Interview with Henry Toole Clark by Frances A. Weaver, January 20 1994 C-0268, in the Southern Oral History Program Collection #4007, Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill
Interview with Sandra Williams, 27 June 2019, Y-0139, in the Southern Oral History Program Collection #4007, Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Long, Alexander S., Alexandra L. Hanlon, and Karen L. Pellegrin. “Socioeconomic variables explain rural disparities in US mortality rates: Implications for rural health research and policy.” SSM-Population Health 6 (2018): 72-74.
Ohl, Michael E., and Eli Perencevich. “Frequency of human immunodeficiency virus (HIV) testing in urban vs. rural areas of the United States: results from a nationally-representative sample.” BMC public health 11.1 (2011): 1-7.
Rosenfeld, Stuart A. “Bringing business clusters into the mainstream of economic development.” European planning studies 5.1 (1997): 3-23.
Staff. “Obituary: Dr. Henry T. Clark.” The Archive of The Carrboro Citizen, 2 Oct. 2008, http://www.ibiblio.org/carrborocitizen/main/2008/10/02/obituary-dr-henry-t-clark/.
Stebbins, Samuel. “US Metro Areas with the Shortest Life Expectancy.” 247 Wall St, 24/7 Wall St., 20 Nov. 2021, https://247wallst.com/special-report/2021/11/20/metros-with-the-shortest-life-expectancy/10/.
“Study: Where You Grow up in North Carolina Affects Your Life Expectancy.” NC Child, 27 Feb. 2020, https://ncchild.org/study-where-you-grow-up-in-north-carolina-affects-your-life-expectancy/.