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  • The Context for Rural Health Care
  • Thomas C. Ricketts, PhD, MPH (bio)

The context for rural health care—rural America—has always been changing. The population in rural counties has changed in its size and composition, the economics of rural life have changed, and the connectedness to urban America has been transformed. Once a primarily agricultural and mining nation, the United States has rapidly and irreversibly urbanized. However, rural populations grew as the nation grew. Paradoxically, the population of those counties that were classified as rural and remained rural increased even as more and more of those counties became part of urbanized areas or transformed into urban centers on their own. Additionally, the labor-intensive agriculture of the past century has gone, mining and natural resource extraction has been transformed by mechanization, and communications and logistics networks have reduced distance and isolation. All of these trends might yield a resilient rural America, but such resilience is not always realized.

Fundamental changes have occurred that may signal problems with the trends cited: 2012 marked the first year that the population in rural counties declined. The decline is primarily due to outmigration—while birth rates have steadily declined since 1982, they have stayed above zero.1 There had been a net outmigration from rural counties between 1982 and 1988, but during that period the birth rate was high enough to counterbalance those losses. That birth rate has now dipped to the point where any outmigration leaves rural places with fewer people overall. That trend may have abated with a small rebound, but it remains a concern for the future of rural America.2

The loss of population is not evenly distributed across rural counties. However, for the first time, the majority of rural counties have lost population in recent years. That is becoming a dominant characteristic of many (though not all) rural places—population and economic activity are declining. The regional picture shows a continuation of the de-population of rural places in the geographic middle of the nation, from North Dakota down through west Texas, while there are mixed patterns in the East, South, and Midwest (overall) while the rural places in Western states are more often gaining in population than losing.

Some call this a “hollowing out” of America as the losses are most visible in the middle parts of national maps. However, there is a pattern that is less obvious when looking at maps and that is the loss of population in what I would call “distributed centers”—the middle-sized and smaller cities that are at a distance from the vibrant and growing metropolitan areas. In my state of North Carolina cities such as Jacksonville, [End Page ix] Rocky Mount, and Elizabeth City are at the top of the list in percentage population loss. It used to be that their distance from larger urban centers enabled such cities to serve as regional commercial, trading, and cultural centers. The new economy of centralized delivery and distribution and entertainment transmitted directly into homes has made their asset of proximity to rural places a liability. Just as Americans have long referred to fly-over states, they might now refer to pass through towns . . . places one leaves as quickly as one enters while traveling to the beach or the mountains for recreation. The same towns are passed by as commerce seeks efficient networks that are larger and larger in scope.

Efficient telecommunications networks today depend on a density of users well beyond what is now found in rural communities. Central mechanisms of commerce have undergone fundamental changes as a consequence of the extraordinarily fast changes in such networks, including communication, transportation, and logistics. To build communications infrastructure including cell phone towers and fiber-cable switches requires a minimum concentration of proximal users. To justify the interruption of the chain of delivery, the development of a node in the supply chain requires a concentration of consumers or producers. These concentrations seldom exist in rural communities.

The middle-sized towns in the center of what are essentially rural counties may retain enough activity to survive—especially as the structure of county governments supports jobs and maintains the identity of a central place, but small...


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