Transitioning from Urban to Rural: Challenges Seen through the Eyes of a Recent Bioethics Doctoral Graduate

In my bioethics doctoral program in a mid-sized, urban American city, I undertook coursework in end of life issues, emerging technologies, global bioethics, and multiple clinical ethics rotations that were largely focused on decision-making and treatment issues near the end of a patient’s life. My dissertation focused on the notion of corporate social responsibility applied to the pharmaceutical and biotechnology industry, a fascinating and timely subject that I was and remain passionate about. I even had the opportunity to work for a year as a bioethics consultant with a major European-based pharmaceutical company. And then, as that job fizzled out, I began my first faculty appointment, at a rural family medicine residency program in a central Alabama town—population: less than 3,000.

I was hired to aid in managing the residents and fellows, develop and oversee curriculum, teach on various topics, and direct healthcare research for the residency and our ambulatory clinic system. While I was prepared for encountering bioethical issues and the precipitous medical learning curve that was ahead of me, I was not prepared for the multiple issues surrounding healthcare disparities. These issues are less characterized by conversations of emerging technologies and end-of-life topics that so readily exemplify modern bioethics, and are more characterized by issues of access to care and access to resources, which is broadly construed here. It is these “less glamorous issues,” that are nonetheless significant and deserve attention, which are the focus of this account.

In doctoral work, healthcare disparities were, predominantly, what happened in other places— low- or middle-income countries (LMICs) whose healthcare systems are not nearly as robust and sophisticated as ours in the US. Access to health-care, lack of secure funding, scarcity of indigenous research, and barriers to care caused by simple inequality were prevalent in the literature I read on LMICs. Yet, disparities within the US healthcare system that was dependent upon context, such as rural vs. urban, was not on the radar.

This umbrella term “access” can signal a variety of conditions, including access to care and access to various resources. Access to care is a genuine concern in many rural settings. My doctoral curriculum taught me plenty about the bioethical concept of justice, applied mainly in a global health framework. To say that I was naïve of inequalities in regards to healthcare in my own country would not be accurate, yet I was uninformed of the scale of these inequalities and the many systemic issues that feed them. For example, in the rural community, access to prenatal and obstetrical care can be a major challenge. In 2010, 49% of the 3,143 U.S. counties lacked an ObGyn. These counties are predominantly rural, situated in places such as areas of the rural south, midwest, and mountain states.

Very curiously, Alabama has the highest infant mortality rate, on a state-by-state basis, in the country—9.1 deaths per 1,000 live births. Some individual counties rival low-income countries. This is of note because access to local maternity care is firmly established as a necessary, though an insufficient component of optimal maternal-child outcomes. If it were not for our rural community hospital having re-opened their labor & delivery (L&D) department a few years ago, expectant mothers would have had to drive more than 40 minutes to the nearest urban L&D department to receive obstetric care.

Access to care in my context also means significant transportation issues for patients. Even if a patient has insurance or can afford our sliding fee schedule, simply getting to our out-patient clinic can be a challenge. In a town of 3,000, we have no city buses, and a taxi or Uber service is simply impractical due to financial hardships that many rural patients face. Our family medicine residents make regular home visits, but even with these ardent strides to ensure patients are seen, the challenge of transportation is ever-present. Having lived and worked in urban settings, access to care is not something I...