Rural Health Improvements Are Possible

Preventable deaths were higher for residents in rural counties than in urban counties every year from 2010 to 2022, according to a report from the Centers for Disease Control and Prevention (CDC).

The CDC report focused on preventable deaths in people younger than 80 years, using vital statistics data to derive excess deaths compared with benchmarks of expected deaths. By 2022, rural counties had caught up to where urban counties were in 2010 regarding preventable cancer deaths. Meanwhile, urban areas moved that to no preventable cancer deaths.

Macarena C. García, DrPH, a report author and the scientific lead at the CDC’s Office of Rural Health, noted that cancer screening programs are more readily available in urban than rural areas, contributing to that mortality gap.

“The delta between rural and metro areas is getting wider and wider” for causes of death like unintentional injuries (which include drug overdose) and heart disease, said García. There is also a rural-urban divide in deaths due to stroke and chronic lower respiratory disease (CLRD).

“For strokes, the delta’s massive,” added García, noting that people should be in an emergency room within an hour of a stroke, which is not always possible in rural settings. And smoking rates are higher in rural than urban areas, contributing to the higher share of deaths from CLRD.

While rural-urban differences are stark, García believes local health officials have the power to reduce them. Rural medicine clinicians who spoke to Medscape Medical News offered ideas for strengthening health in their communities and described the unique satisfactions of serving in rural settings.

Not Enough Doctors to Go Around

On one day Jennifer Bacani McKenney, MD, may conduct a colonoscopy, followed the next day by delivering a baby. Both occur in her hometown of Fredonia, Kansas, which had 2151 residents per the 2020 census.

This small size has advantages when working with adults who would benefit from weight loss or more exercise.

“Most of the time I know who their kids are, who their parents are,” McKenney said, and she uses these ties to motivate healthier behavior so people can participate actively in the lives of their loved ones with a lower risk for heart disease.

Besides her family medicine practice, McKenney is the associate dean for Rural Medical Education at the Kansas University School of Medicine in Kansas City, Kansas.

“My job is to expose medical students to rural health and rural medicine in the hopes that they will enjoy it and find it fulfilling and maybe go into rural practice,” McKenney said.

Odds are against making that choice; family medicine and primary care practitioners earn less than specialists, and there have long been more physicians in urban than rural areas per capita.

Kansas offers a loan repayment program for physicians who practice in the state after residency, a practice that McKenney recommends policymakers in other states with rural health workforce challenges consider.

McKenney also encourages policymakers not to signal that rural health is less important, recalling long waits for personal protective equipment in rural Kansas during the COVID-19 pandemic compared with the situation in urban centers.

“That mentality of ‘you guys get what’s left over’ is very hurtful for rural communities,” McKenney said.

Responding to the Opioid Crisis

The CDC’s unintentional injury category includes poisonings such as drug overdoses from opioids.

McKenney has set up bins at the local hospital where people can dispose of opioids that they do not want laying around at home, with no questions asked. And increasingly, prescriptions for opioids like hydrocodone include an additional prescription for naloxone, McKenney added, to reverse overdoses before they become fatal.

“We’re trying to treat naloxone like we treat epinephrine,” McKenney said; just as epinephrine can stop an allergic reaction, naloxone can stop an overdose.

Recently, McKenney used grant funding to hire a peer educator who can help people overcome addiction. The educator once faced addiction themselves, McKenney noted, and can help someone struggling with any kind of dependence including alcohol or opioids.

For the past several years, McKenney has offered medication-assisted treatment with suboxone to blunt the effects of opioids like fentanyl. This approach requires close monitoring and frequent visits to her clinic, which is why it is important to McKenney to offer it locally rather than requiring patients to take long drives to cities they rarely visit.

“It’s all about access,” McKenney said.

Bringing Cancer Research to Rural New Mexico

Healthcare access is important across the board for rural residents. For example, many clinical trials of potential oncology treatments occur in large cities, requiring long trips and time commitments for people in rural areas. The New Mexico Cancer Research Alliance (NMCRA) works to change that.

“We have a very dramatic underserved patient population need,” said Carolyn Muller, MD, chief of the Division of Gynecologic Oncology at The University of New Mexico, Albuquerque, New Mexico, and NMCRA board chair. So if a clinical trial — of a potential cell therapy, for example — requires travel to The University of New Mexico, the NMCRA provides travel and lodging funding if needed. If a trial can be conducted locally, without needing travel, the NMCRA does that.

Survivorship rates for many cancers have increased in recent decades, Muller noted.

“All of that is because of clinical trials. Clinical trials changed the standard of care,” Muller said, leading to new immunotherapies, antibody drug conjugates, and cell therapies. And these trials should be offered equally to everyone, Muller added.

The NMCRA targets trials based on cancer trends throughout the state. If one region shows a spike in breast cancers, for example, and another a rise in colorectal cancers, the NMCRA offers trials of treatments for these cancers in those regions. This depends on data from the New Mexico Tumor Registry, a state-level epidemiologic resource.

García, at CDC, pointed out that state mortality data are available more quickly than federal vital statistics and can guide public health interventions.

“You have your own mortality data, so it can be a little bit more real-time,” García said. These data usually include enough detail to determine mortality trends in a state to inform interventions. Maybe new blood pressure screening clinics are needed in one pocket of a state and additional cancer screening sites somewhere else.

Once the statistical code is developed to see these trends, it is possible to monitor health throughout a state indefinitely, García said. The CDC is happy to help with this.

“We can work on a pilot study that, if it can scale to other partners and other rural health departments, that’s a win-win situation for all of us,” García said.

García, McKenney, and Muller had no conflicts of interest.

Marcus Banks is a freelance journalist.