Notes From the Urban/Rural Divide: Medical Care

There’s a lot discussion right now about the health care system in the United States and its shortcomings. Everything from lack of ability to pay for services and dying as a result to overcrowded emergency rooms with poor standards of care is getting air time in the media, and rightly so. Our system for providing health care is fundamentally broken and appears to be more so every day. Things that people think of as individual problems are actually embedded, systemic ones with a very broad scope. We need a fundamental reframing of the way we approach health care, and the way we think about health and bodies.

One thing that doesn’t get as much air time is the significant divide between rural and urban health care. Rural areas tend to be more poor, which means that deficiencies in services are higher. It also means that people are less likely to be able to afford health care, because they are poor, and as a result many rural areas are struggling with things like preventable and treatable diseases. Many people in rural areas, for example, have bad teeth, not just because of the exploding meth problem, but because they cannot receive even basic dental care for most of their lives, and consequently, their teeth are in poor condition. This, in turn, leads to a myriad of health care problems that could have been prevented simply by being able to visit a dentist. It leads to situations where people are struggling in the workplace because they are trying to ride out a tooth ache, since they cannot go to the dentist to get it dealt with.

It’s not just that we have trouble accessing care and that the safety net for poor people has big holes in it. The care available to us is also more limited. If you live in a rural area and you need the services of pretty much any medical specialist; cardiologist, rheumatologist, hepatologist, fertility specialist, neurologist…you are out of luck. What we see here are general practitioners, emergency medicine specialists, obstetricians, and, sometimes, orthopedic surgeons, depending on the region. Rural hospitals and clinics often have trouble attracting doctors and sometimes their qualifications and continuing education are not of the best. Yes, you can probably get a broken leg set, but if it’s a complex fracture, you might not receive the greatest available care.

And if you have any kind of chronic illness or disability that requires you to see a specialist regularly, you will have to travel. You may have to travel quite far to access a specialist. If you are in a catastrophic car accident, the closest trauma centre is not five minutes away by ambulance. It is not 20 minutes away by ambulance. It is 45 minutes away. By helicopter. If the helicopter can land. If you’re lucky, you can get picked up in the field and you reach a facility within the golden hour. If you’re not, you may be transported to a hospital with basic services (20 minutes or more) and then taken to their helipad and transported to a more appropriate facility. Far more than an hour elapses. Oh, and you can expect to pay through the nose. The base price for a helicopter ride is usually around $12,000. And they charge by the minute.

This means that, in rural areas, things that may seem pretty basic are actually extremely difficult. Disabilities and chronic illnesses people can manage and control in an urban area with the help of access to specialists become a serious problem. Because every time you need a medical appointment, you have to travel. It’s easy to start thinking you should skip appointments because you’re doing ok or you don’t have time or you don’t have the money to travel. And it’s hard to access services that require routine, steady treatment in a high level facility. Fort Bragg, until very recently, did not have a dialysis clinic. People had to go to Ukiah for dialysis. Can you imagine driving an hour and a half one way three or more days a week for dialysis?

A ‘routine’ visit to a specialist can become a two-day trip. If you have to drive to San Francisco or Palo Alto from here, that’s four hours or more in the car to get to the doctor. Then you have to deal with parking in an unfamiliar place, you may have to arrange a hotel, you have to hope your appointment is not canceled. If you are trying to see multiple specialists to deal with a complex illness or disability, you cross your fingers in the hopes that the appointments won’t run over, won’t start to conflict with each other, that if you need testing, you can get it on the same day or the next day, because you have to go back home. You have to get back to work and care for your children.

Fixing the disparities in rural health access is difficult. We can’t support highly qualified specialists because there are not enough patients. Some specialists rotate and will travel to offer a day of appointments on a first come, first serve basis, but they often lack the equipment they need. If you want high level diagnostic imaging, our hospital doesn’t have that and can’t afford it, which means that even if, say, a neurologist can travel to examine and meet with you, you may still have to go to Santa Rosa (two hours away) to get the brain images the doctor needs. These are not easy things to solve.

Improving hospital facilities and addressing diseases caused primarily by poverty and lack of access to services is vitally necessary, and as people talk about health care reform in this country, I hope they give some thought to how to address problems in rural areas, because our needs differ from urban areas (how many traumatic chainsaw amputations do they see at San Francisco general every week?) and our needs are in a critical state right now.