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Duke Medical Ethics Journal

Healing in Nature: Rural-Urban Health Disparity in The Past and Present U.S.

By: Morgan Biele
"Why is it that the rural landscape is advantageous for those that seek it, yet adverse to those who are born in it? Why is the rural landscape a place of health for some, and the lack thereof for others?"

I. Introduction

In Henri Troyat’s biography of Anton Checkhov, he describes his first meeting with Leo Tolstoy: the two swim in a river together, separated from their urban lives, Tolstoy’s reputation is washed away and the two share a very simple, healing experience as a result of floating in the water [18]. During the COVID-19 pandemic, the power of swimming was not lost on those in quarantine: health humanities writer Suleika Jaouad in “The Isolation Journals” newsletter tells her readers that she would walk to a swimming hole every morning of quarantine—even, and especially, as it got colder—for its healing properties. According to Pew Research, moves out of Brooklyn, Chicago, and Los Angeles during March 2020 were double the rate of moves out of these cities the year prior, and net moves out of Manhattan had tripled. In Houston, the rate of moving out that March increased 62%, and San Francisco by 68% [8]. Conversely, parts of Northern Florida saw a doubling in the number of people moving in as well as in Maine and New Hampshire, and Vermont saw its first net positive migration rate in over a decade. People have always headed to rural destinations as a health-seeking behavior [8, 16].

However, from 2005-2009, the average life expectancy of someone born in a rural area was 76.8, compared to 78.8 for someone born in an urban area. From 2010-2019, rural areas saw a decrease in life expectancy, while urban areas saw an increase, only exacerbating this difference [26]. 

Why is it that the rural landscape is advantageous for those that seek it, yet adverse to those who are born in it? Why is the rural landscape a place of health for some, and the lack thereof for others? In this piece, I seek to explore this shortcoming of rural health. I consider it in the context of social determinants of health and through the lens of social prescription and narrative medicine. I also explore the potential applications and limitations of increasing implementation of social prescription and narrative medicine infrastructure as a possible method to combat the disparity. 

II. Historical Cases of Seeking the Rural to Heal

In 1885, Edward Livingstone Trudeau created the first American sanatorium, claiming he was healed of his tuberculosis at Saranac Lake in the Adirondack Mountains. Residents were required to spend much of their days outside, with horseback riding, walks, and places just to rest in the sun. By 1925, the U.S. was home to 536 sanatoriums, having been recognized by public health experts for their ability to also prevent the spread of communicable diseases—namely tuberculosis [12]. While its initial intention of curing disease proves ineffective, the sanatorium functions as a prominent example of the health benefit experienced of retreating into rural spaces from the industrializing dense cities of America. The Sanatorium model for Tuberculosis, as developed in 1854 by Hermann Brehmer in Germany, would be known as the “Open-Air” treatment as a systematic response to the illness that was believed to emerge as a result of compounded

heritable factors and way of life— creating an early emphasis on social determinants of health as a risk factor for infection [27]. As industrialization and waves of immigration to major cities coincided with rapid increases in population density, infrastructure could not meet the sanitary demands of so many people, and infections like cholera and typhoid became rampant in urban settings. The same prevalence was not observed in rural locales. 

Through an interview in 1982 with Laurie Mercier for Oral History conducted by the Montana Historical Society, we learn that in the Spanish Flu Pandemic of 1918, Jarussi’s father was experiencing symptoms but unable to be diagnosed. “He was going to go to Thermopolis to the springs. He thought going there would help him. And just before he was leaving, he went to the doctor. Dr. Gardner was the doctor at that time, his doctor.” Jarussi recounts, “And he said, ‘Dr. Gardner, I’m going to try and go to the springs and see if that helps me.’ And he said, ‘Well, Louie, it might help you’” [14]. By 1930, the United States had over 2,000 hot and cold-spring resorts for wellness, featuring a vast array of procedures for an equally vast range of health needs under the umbrella term of “hydropathy”. In City Water, City Life, Carl Smith explains hydropathy as the cure for the well-off urbanite, the illness of the “overly refined life characteristic of cities”. In 1946, 649,000 baths were taken in Hot Springs, Arkansas on Bathhouse Row [7]. 

With an increased colloquial understanding of how to prevent acute infectious diseases—and the increase of occupational and chronic illness with the Epidemiological Transition in the 20th Century—we began to see psychological illnesses such as broadly defined “depletion of nervous energy” in workers. Examples such as “neurasthenia” demand treatment with “camp cures” and more outdoor time for men, with more bedrest and domesticity for women [20]. In addition, the presence of Black Lung, lead exposure, poor factory conditions, and illness as a product of working conditions also saw a call to gain access to the fresh air. Yet, alongside political and economic ideology and policy changes to emerge after the 1940’s, much of the systemic and environmental public health was replaced with a pathology-based, clinical, and individual-centric healthcare that allocated the corresponding social systems to non-health divisions such as those specific to labor or housing [11]. This transformation led to the closing of facilities for health retreats and a focus on moving a narrow view of health inwards to hospitals rather than outwards to nature in the latter half of the 20th century.

In a re-emerged uptick in this practice, as a result of the commercialization and commodification of “Wellness” in addition to healthcare in the 21st century, according to Global Wellness Institute, the Wellness Tourism Industry was worth $639 billion. Holistic approaches to feeling healthy around the year 2017 demonstrated the return of an apparent rural health benefit in healthcare. Now, the Global Wellness Institute projects that post pandemic wellness tourism will increase by over 20% annually [23].


III. The Rural Disparity, The Need to Be “Out of the Woods”

The history of those born and raised in rural America hasn’t aligned with this same vision of health as demonstrated by urban desire for rural resources. Public health as a field largely was founded with a lens for the urban lifestyle, ensuring sanitation and the prevention of communicable diseases in places of greatest population density—in part because it needed to respond to the recurrence of specific outbreaks that had occurred already endemic to more populous areas. In addition, the “Poor Law” model brought from the U.K. created an expectation that in small enough communities, health could be maintained by neighbors taking care of each other [11]. More official hospitals would only be needed in more urban spaces, and would require formal structure to reach all of those who needed healthcare. 

In the 20th-century, as healthcare and public health placed more emphasis on health-specific infrastructure, with attention to clinical care, pathology, and health facilities—and even the decline of “home visits” from community physicians—rural America faced a crisis of access. In 1918, formal rural health efforts commenced through the U.S. Public Health Service, but there was still a dearth of hospitals, physicians, and healthcare workers in these rural areas [11]. In 1946, the Hill-Burton Act was passed by Congress to construct more healthcare facilities in rural locations, with the expectation that these new facilities would serve underserved populations, in particular those without the financial means to afford adequate healthcare. While this Act was implemented to improve access to these facilities, it also further reinforced the emphasis on facilities and health as dependent on healthcare services [13]. It even perpetuated racist policy at the time through the construction of segregated hospitals and healthcare facilities [19]. 

The Council on Rural Health existed from 1945 to 1975 as part of the larger American Medical Association (AMA) to improve access to health in rural regions, a movement headed by farming women. Edna Sewell of Indiana was a prominent vocalizing advocate for attention to rural health, and developed an annual conference as well as community health councils with the AMA with attention to the needs and specific characteristics of health in rural America. What emerged in these conferences was an initial focus on the personnel shortage and need for rural physicians as well as a network for them. Considering specific health practices for rural communities—like farm and agricultural safety, sanitation, and diet—and noting a discrepancy where residents thought the biggest hurdle was getting a physician to them, the AMA brought to light that a physician’s work depends on the health of the community. Much of this work culminated at the National Rural Health Safety Conference held in 1963 [4]. 

Interestingly, despite these efforts for increasing infrastructure access, from 1969-1971, the difference in life expectancy for urban to rural Americans was 0.4, and this has only increased to the 2 year age difference of 78.8 to 76.8 years old respectively for 2005-2009 as mentioned previously. When breaking this data down further by race, gender, and income, it becomes apparent that the rural poor and rural Black communities share the life expectancy in 2005-2009 that the urban wealthy and urban White communities had four decades prior. [22] An article by Philips and McLeroy in the American Journal of Public Health refers to a  Hartley 2004 paper: “The history of rural health research… is deeply rooted in concerns about access to care and an equitable distribution of health personnel. However, many of the major public health problems faced in rural areas (e.g., obesity, tobacco use, failure to use seat belts) are not likely to respond to an increased presence of general practitioners, physician specialists, or physician extenders” [17]. 

IV. Social Determinants of Health

How do the social determinants of health come into play? As the Hartley piece raises, the major problems faced in rural areas can not entirely be captured by what happens in an exam room or in contact with healthcare structure and systems. This points to the larger framing brought forth by the Social Determinants of Health, defined by the U.S. Department of Health and Human Services as “conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks” [2, 15]. The U.S. Department of Agriculture Economic Research Service notes that the median household income is lower in rural areas than urban, and cost of living is generally lower as well, but also that there are lower employment rates in rural areas, and this too is complicated by the fact that rural areas have older populations and higher rates of disabled residents. After the Recession of 2008, job recovery lagged more in rural locations than urban, with 0.8 percent annual employment growth to 1.9 from 2010-2015, respectively [25]. In addition, in 2019, 21 percent of rural adults over age 25 held at least a Bachelor’s degree in an increasing trend, while the same demographic from urban areas stood at 35% [6]. These considerations of socioeconomic status mediate much of the conditions of how people live. The picture this seems to paint is that those who seek rural resources for health benefits tend to have the agency and accessibility to choose what to make use of, for how long, and in what ways. For those living permanently in rural areas, that agency is lost, to expand upon the social determinants of health is not an option. The natural resource benefits may be present for all who experience rural areas of America— fewer people, more space, more access to natural surroundings — but a choice in using them is not. 

V. Social Prescription and Narrative Medicine

The phenomenon of social prescribing has been most prominent in the UK, and is a practice where healthcare workers, primarily general practitioners, can prescribe patients to formal local, non-clinical services to support their well-being. Social prescribing is built on theory to implore people to take control of their own health practices, outside the four walls of any health system. Social prescribing tends to look like community-based organizations reducing isolation through group gatherings based on common interests, arts participation, gardening, cooking, and engagement in exercise with procedures in place to meet the demands of social, emotional, health, and practical needs. In one example, at the Bromley by Bow Centre in the UK, a community connector essentially facilitates the referral process of patients to local social practices they might like trying, stating that it ranges from swimming lessons to financial services. Initial studies of health systems using social prescription have shown decreases in hospital visits, decreased anxiety, and decreased loneliness in those who had partaken [5]. Looking towards trends in the U.S. rural health disparities, it seems as though benefits of social prescribing are in some ways at play for those who choose to seek health benefits in rural areas, and also were reflected in the goals of the Council of Rural Health and the National Rural Health Safety Conference in the effort of connecting people across divides to procedures and processes specific to their lifestyle with which they could engage to improve health. In models of expanding health care facilities however, this is lost; as the Hartley paper points out, the facilities take away attention from the behaviors these facilities would treat. These behavioral and situational components —like obesity, substance abuse, and isolation—could be treated in part outward from a facility, but instead continue to be confined to limited capacities inward.

If social prescribing were implemented in rural America, as it gains traction more readily in urban settings already, the advantages seen by those who seek the rural landscape could improve health by the social determinants for those that live permanently in rural areas. What urban social prescribing has that rural locales would need to generate, however, is the formal, standardized and normalized community-based organization model with which to make frequent referrals and have capacity for the users in need. Often shortcomings of the social prescription model are due to the lack of standardization and of capacity which allows those referred to get lost and fall between the

cracks. In addition, social prescription doesn’t often provide the quantitative empirical evidence of a clinical trial that contributes most smoothly into the clinical knowledge economy, but rather can be slow, subtle, and qualitative, which can require more effort and development to get buy-in and retention. This can still look like gardening, lessons on using technology in agriculture, financial services, or swimming lessons, but needs facilitators, funding, and the structure in place to make sure it can still work even with few people who are dispersed. It also demands a in-depth cultural competence and knowledge of the space within which a healthcare practitioner makes their referrals. Much work is being done to highlight that rural living is far from a monolith.

The Narrative Medicine Model, as developed by Rita Charon, is another tool with which the history of this disparity can be analyzed and the future can be planned. Narrative Medicine is defined as “medicine practiced with these skills of recognizing, absorbing, interpreting, and being moved by the stories of illness” [1]. By inviting patients and caregivers to view health through story, it has potential to encompass and capture social determinants of health disparities head-on and further develop a sense of self and autonomy in health experience. In addition, with physician shortages in rural areas, the potential for burnout is large, and narrative medicine works to implement adjustments to the clinical encounter to prevent it. Narrative medicine can make health specific to the ways it is felt in everyday life— wanting to learn about the workplace, home life, relationships, and all of the contributors to a person’s health story. What narrative medicine also does is create the possibility for reframing and meaning-making—to decide to view moments and situations as narratives themselves or part of a larger narrative. One way we can see this active meaning-making is in the rise of the sanatorium; it drastically improved quality of life with tuberculosis without having cured it, improving the feeling in the experience of the illness. Charon also describes narrative medicine as a kind of partnership, as “physicians can reach and join their patients in illness,” which calls back to the mutuality built in the “Poor Laws” structure in rural health dating all the way back to the 18th century [3]. 

Narrative medicine could hold potential for future implementation to reduce the disparity in rural health conditions, expanded from its urban origin in New York City. Through the process of creating partnerships in health, there is an active isolation reduction and rehumanization. Narrative medicine grants a kind of newfound toolbox to view behavior, well-being, and feelings as contributors to meaningful narratives which can lead to health promotion changes in lifestyle. It can make health systems of non-health systems, and make health systems feel a part of non-health systems, integrating “recognizing, absorbing, interpreting, and being moved” into life as needed [1]. There is emphasis on flexibility in how narrative medicine can and should show up for people. 

Narrative medicine of course demands a critical look at its limitations too in this setting. Firstly, in the Angela Woods 2011 critique, the necessary reminder is shared that some people choose, prefer, or struggle with thinking in narrative frameworks, and would not actually rather think of health in conjunction with the narrative toolbox [28]. Narrative is also sometimes construed quite narrowly, more so as storytelling than a broader meaning making, and this can sometimes represent a colonial norm of knowledge production which can be limiting or marginalizing. In addition, narrative medicine can exist by any interaction between people regarding health, but traditionally does emerge through intention, training, and specific key practices. That being said, narrative medicine’s accessibility is limited to those who know about it and choose to practice it with that intention. As a result, there is a call to increase the awareness of narrative medicine in order to enact its benefits in rural America. 

VI. Conclusion

Rural versus urban population health is nuanced and the culmination of many variables and deep histories, far too complex to interpret or improve with simple suggestions. The idea of “rural America” is also far from homogeneous, and each  community itself is far from homogeneous. Across transformations of depicting health—from the environment or behavior, energy or bacteria—people in rural America continue to experience a lack of representation in healthcare despite pressing needs. While the social determinants of health merely function as a model to analyze potential causes for lower life expectancy, taking a more holistic approach grants the opportunity to better understand what communities need in order to live. Using social prescription and the narrative medicine framework, we create room for building upon the strengths of history’s rural health to improve it in the future. 

Review Editor: Olivia Ares
Design Editor: Simone Nabors

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