Covering Rural Health: Abandon Stereotypes, Pack Courage

Published on
October 2, 2008

The Jackson County school nurses savor their monthly lunch meeting at the Crawford W. Long Pharmacy, a fixture on the courthouse square in Jefferson, Georgia. The rest of the time they're too busy with the day-to-day demands of looking after 6,200 students – spread over nearly 350 square miles in 15 schools – to sit down and really talk.

I crossed paths with the nurses purely by luck. Like them, I had come to the pharmacy's café for the celebrated chicken salad croissants and authentic Reuben sandwiches, served on colorful crockery in a genteel, country-inn atmosphere. I got all that and more – a lesson in the importance of "bottom up" reporting on health news in rural America.

Although the setting was very Martha Stewart, the conversation was not. Instead, it was the kind of talk that gives health reporters a notebook full of ideas, but gives other folks the creeps.

Head lice topped the agenda. At the start of the school year, the nurses race to identify kids with lice, educate parents about how to treat their kids and clean up their homes, and enforce the rule banning children from school until they are cured. Unless they move fast, whole classrooms will soon be "scratching like dogs with fleas," as one veteran nurse said.

Head lice are not peculiar to any class, race or region. But controlling them is a stressful and heart-wrenching business for school nurses.

Stigma frightens some parents into denying that their children have lice. Poverty makes it hard for others to purchase expensive medicated shampoos, or even do all the laundering needed to decontaminate their homes. And some shun proven treatments in favor of Internet and folk remedies that leave kids vulnerable to recurrent infestations. These, in turn, can cause them to fall behind academically and sometimes scratch so hard that open sores on the scalp become infected with staphylococcus.

Listening to the nurses talk, it dawned on me that their battle with nits could be the anecdotal lead on a dozen different local, regional or national stories. Archetypal connections between health and wealth, physical and mental well-being, stigma and behavior – as well as the eternal struggle between science and superstition – all were embedded in what they were saying.

Yet none of the five nurses I talked with had ever been interviewed by a reporter about anything. Not as local experts on soaring rates of obesity or diabetes among school-aged children, or the dangers of Epi-pens in schools, or how painful and rotting teeth contribute to learning disabilities, malnutrition, and potentially deadly heart problems.

Talking to everyday people is key

So here is my first tip for covering rural health in America: Get out of the office and into the streets. Talk to nurses and pharmacists and the folks who run after-school recreation programs and adult day-care programs.

This kind of "bottom up" reporting is every bit as rewarding and enlightening as the "top down" approach that involves keeping up with scientific journals, regulatory bulletins, FDA approvals, and budget bills inching their way through legislatures.

About 62 million Americans live in rural areas, according to the National Rural Health Association. Compared with people who live in or near cities, rural adults are older, sicker, less educated, less well paid and less likely to have health insurance. Georgia, where I live, is one of many states where rural children are more likely to grow up in poverty and in single-parent households headed by parents who lack a high school diploma or a full-time job.

That's the big picture, in demographic terms, but it's not the whole story. The word "rural" can be defined based on census tract data, county typology, commuter patterns, historical data, and any combination of these or other factors. And there's another term, "frontier," that demographers apply to the nation's least densely populated areas.

Be skeptical of some rural-urban comparisons

Which leads to another piece of advice: Ask how "rural" is defined by the expert you're interviewing or the authors of a study. This is crucial when reporting on rural-urban disparities in access or quality of health care. Be skeptical if a study or a source makes no distinction between the Kansas prairie and a wealthy, equestrian township in Vermont or Pennsylvania, because both have fewer than 20 residents per square mile.

"One size fits all" generalizations about health aren't good enough because some rural populations are more vulnerable than others, and two communities may be the same size, but have radically different resources. For some rural residents, the suggestion that older readers stay limber by studying Tai Chi or yoga is a reasonable one; for others, it is as remote as a first-class flight to Paris.

One pervasive misconception is that rural economies are agricultural, according to Charles Fluharty, founding director of the Rural Research Policy Institute, based at the state universities of Iowa, Missouri and Nebraska. Only one percent of Americans live on farms, and most farm families rely heavily on income from other sources. In fact, people living in non-metropolitan areas are more likely to earn a living in manufacturing, retail, government, health care or hospitality than from farming.

Help with seeing and mapping shortages

Although more than 20 percent of Americans live where the stars shine more brightly than streetlights, only 10 percent of the nation's physicians practice in these communities. Burdened by medical school loans, many doctors feel they can't afford to work where people are more likely to be older, poorer and less well-insured.

Shortages of primary care doctors, dentists, and mental health professionals can be mapped in minutes using an online tool of the federal Health Resources Services Administration Web site. You can also generate maps showing locations for medical facilities, such as hospitals, ambulatory surgery centers, or nursing homes in a selected area.

In rural areas, hospitals and health providers are not just employers and purchasers, Fluharty notes, but neighbors and influential members of the community. Social and interpersonal complexity can either raise or lower barriers to care – such as distance, physician shortages, or inability to pay. Either way, there's a story to be told.

Reporting on the risks of poor quality care is essential, and one place to shop for leads is a federal government-operated searchable database that provides detailed information about clinical outcomes at many of the nation's hospitals. One caveat is that nearly half of Critical Access Hospitals, many in remote areas, handle too few cases to qualify for the database.

Local sources – cultivated before there's an outbreak of infections acquired as a result of medical care or a surgical misadventure – provide a constant stream of story ideas. Lunching with the school nurses or hanging out with the EMTs waiting for calls on a slow day is time well spent. The middle of a crisis is the wrong time to cultivate new sources.

Even when tips are meticulously verified, and serious problems at a local hospital are thoroughly documented, courage is required to put the story on page one. Small-town hospitals are often major employers and valued advertisers – not to mention that publishers often serve on their governing boards.

Plenty of stories to tell

Whether journalists cover rural health as freelancers, or as staff reporters or producers for news organizations, large or small, they will never run out of stories to tell. When my colleagues and I asked low-income adults in rural Georgia and Alabama to rank their top health worries, they wanted to know more about cancer, heart disease, hypertension, accidents, diabetes, environmental pollution, loss of mobility or memory, violence, dental problems, drug abuse, sick kids, alcohol abuse and workplace injuries.

And when we asked about barriers that keep them from obtaining needed care, lack of health insurance and the high cost of prescription drugs were the big two.

Add HIV/AIDS, which doesn't concern rural people as much as it should, and you've got enough topics to keep a health reporter busy for a lifetime. As for the personal anecdotes and full-blown narratives that transform topics into stories, I believe these are easier to see in small towns, without extra people to block the view.

Reporters should also put aside worries that the stories they unearth, in their particular patch of ground, will be the same as everyone else's.

As the Rural Research Policy Institute's Fluharty says, "Once you have seen one rural community, you have indeed seen only one rural community."

Patricia Thomas is the Knight Chair in Health and Medical Journalism at the Grady College of Journalism and Mass Communication at the University of Georgia.