By Shree Mukilan Pari
Writing for AAMC News, Robin Warshaw details a litany of disparities affecting tens of millions of rural healthcare consumers in the United States. Fewer health insurance choices. Fewer in-network healthcare providers for those fortunate enough to have insurance. Lower incomes. More pervasive mistrust of the medical system. Under-equipped clinics and hospitals.
The list goes on. And the situation is no better in the rest of the world. In many parts of the Global South, such as sub-Saharan Africa and the Indian subcontinent, it’s far worse.
These disparities directly contribute to worse healthcare outcomes that reduce collective quality of life and increase mortality. “When you don’t get your health care taken care of, you wind up with disease presentations that are much farther along,” an exasperated rural doctor tells Warshaw. “People with cancer show up with metastatic cancer, people with diabetes show up with end-organ damage.”
Is geography inevitably destiny when it comes to healthcare? Or are there real, meaningful steps that policymakers, the healthcare community, and the general public can take to change this state of affairs?
There are. These five action items — some the purview of policymakers, others of healthcare providers themselves — can truly make a difference.
Incentivize Well-Trained Generalists to Work in Rural Areas
Many rural areas contend with chronic shortages of physicians and mid-level healthcare providers, such as nurse practitioners. As of 2014, notes Warshaw, more than half of all rural counties in the U.S. lacked obstetric facilities. Patients in some parts of the country need to travel hundreds of miles to consult specialists.
Simply incentivizing primary care providers, OB-GYNs, and intensivists to practice in rural areas would do much to address care disparities. Higher pay, career advancement opportunities, and the promise of a better work-life balance are key.
Improve Problem-Based Learning Protocols
In many parts of the world, substandard physician education is partly to blame for rural health disparities. For example, this paper published by me, Shree Mukilan Pari, identifies the outdated lecture-based learning (LBL) method as a cause of poor anesthesia outcomes in rural Indian hospitals. In places where problem-based learning (PBL) is the standard, such as North America and Europe, anesthesia outcomes are better, even when controlling for geographic and patient-specific factors.
Invest in Telehealth Solutions
Whereas incentivizing primary care providers to work in rural areas is absolutely feasible, it’s not practical to expect to draw many specialists and subspecialists to tertiary hospitals far from major cities. Local demand simply does not justify their presence.
Fortunately, there’s another way: telehealth. The coronavirus pandemic forced (with government support) many health systems to embrace telehealth solutions they’d previously resisted. Doubling down on these investments could be vital to bridging the rural-urban healthcare divide in the coming years.
Utilize “Trusted Messengers” to Encourage Use of Preventive Care Resources
According to the CDC, five common chronic health conditions are responsible for thousands of excess deaths in rural America. With more consistent utilization of preventive care resources, many of these deaths could be prevented.
“Trusted messengers,” like faith leaders and local elected officials, could contribute to the solution by spreading pro-preventive care messages and addressing legitimate concerns some have with the healthcare system. “Get your flu shot” and “don’t forget to schedule your annual checkup” mean more coming from people we know and trust.
Enable Smaller Hospitals to Remain Competitive
Small rural hospitals aren’t just understaffed. They are also often underequipped, making do with creaky or even obsolete medical equipment and facilities. As time goes on, the path of least resistance for these facilities is to close or accept a buyout by private equity firms or large for-profit healthcare companies that prioritize shareholders over patients.
Policymakers need to recognize that neither outcome is good for rural healthcare consumers. Struggling rural hospitals and health systems need support to invest in equipment and procedures that keep them competitive today — or they’ll be gone tomorrow.
The Healthcare System Should Work for Everyone
We live in a society of “haves” and “have nots.” But some things are too important to distribute unevenly on the basis of geography or material wealth or social class.
Healthcare is one of those things. It’s often said that healthcare is a right, not a privilege, but it’s far too often treated as something that some people deserve more — and more of — than others.
That’s wrong. Fortunately, we know what needs to be done to make it right. We know from years of public health research that the solutions described here will significantly improve healthcare literacy, access and outcomes in rural areas, particularly among the rural poor. Now, we just need to do what’s necessary to implement them.
Shree Mukilan Pari is an aspiring medical student, philanthropist, and food security advocate from northern California