What the U.S. healthcare system could learn from the Indian Health Service & the National Indian Health Board to help prevent maternal mortality

A recent study published in the Journal of Obstetrics & Gynecology found that maternal mortality rates amongst American Indian and Alaska Native (“AI/AN”) individuals were higher than among White individuals. AI/AN maternal mortality rates are also higher within their rural populations (for previous blog posts on maternal health in rural areas, look here and here). However, when looking at births within the Indian Health System (“IHS”), these statistics reveal a disparity in outcomes between white individuals and AI/AN individuals. While 90% of AI/AN births take place outside IHS facilities, those 10% that do are having a decrease in maternal mortality rates, with no maternal deaths reported in 2016, 2017, or 2018.

To understand this good news about the IHS, we must look at the primary contributing factors to maternal mortality amongst AI/AN and rural populations:

• Rural areas are often medical deserts (previous posts discussing this phenomenon, especially in the context of COVID-19, are here, here, here, and here). Not only do rural areas have fewer medical facilities, they also have fewer medical providers. 
• AI/AN individuals, especially those residing in rural areas, are more likely to rely on Medicaid, because they are more likely to live in poverty. Medicaid makes individuals eligible for pregnancy coverage only from conception to 60-days postpartum. This means that many long-term effects of pregnancy do not get evaluated or treated. 
• While most states, have implemented maternal mortality review boards, they continue to neglect rural areas. Only three states have directed their legislation towards rural areas, and just two of those require rural representation on the related committees, as of 2018. Of the three states with legislation directed at rural areas, only one is “highly rural” (with 30% or more of the population living in rural areas). The others, Pennsylvania and Texas, require rural representation but are not “highly rural” under the linked studies definition. These two states also have relatively low native populations, less than 3% each. The Maternal Mortality Review Act of Pennsylvania, for instance, makes a point of including rural representatives, likely because of its goal to represent those from areas that are most affected by maternal mortality. This kind of legislation creates the committees mentioned above, which work to review all maternal deaths, identify root causes of said deaths, and develop strategies to reduce maternal mortality. 

IHS has worked on tackling the issues of clinician shortages, lack of sufficient medical insurance, and representation, which likely accounts for their stellar record. They are educating their clinicians on diabetes, which is twice as common in AI/AN populations as in white populations. They have created postpartum care programs to assist individuals with myriad issues, including but not limited to postpartum depression, hyper-/hypo-tension, and lactation. They focus on care for those with opioid dependency (for blogposts on the opiate epidemic as it affects rural areas look here, here, here, here, here, here, here, here, here, and here). This focus is appropriate because AI/AN communities, as of 2017, had the second-highest rate of opioid overdose of any ethnic group in the U.S. White individuals have the highest rates of opioid overdose, though African-American populations have seen an uptick in recent years. 

The National Indian Health Board is also on working to lower maternal mortality. Alongside the CDC, the NIH, has have implemented a campaign, HearHer, to support healthy native pregnancies and maternal health Their main facets are the Tribally Led Maternal Mortality Review Boards, as established and supported by the federal Preventing Maternal Deaths Act (PL115-344). These boards ensure that maternal deaths are reviewed within a year of the child’s birth. They also tackle other AI/AN specific maternal mortality issues such as a lack of prenatal visits, which could discover the risk of hemorrhage and cardiomyopathy.

These native entities have likely succeeded, not only because of their focus on ethnically and geographically specific issues but because of their cultural competency in those areas. This is important not only because cultural differences account for many of the health care discrepancies we see in the United States, but also because they ensure that pregnant people feel comfortable coming back for further health care. Non-native health providers could take a lesson from these entities and try to: employ more culturally competent practices, focus on rural areas and the individuals who make up large swaths of the rural population, and work on creating healthcare that is more accessible financially (specifically to those with Medicaid or entirely uninsured).

How rural jails and prisons hurt rural communities

The rate of incarceration in the United States is higher than that of almost any other nation. California alone incarcerates more people than many countries in the world. According to the Prison Policy Initiative, the U.S. has about two million people behind bars at any given time. About 540,000 of these people are locked up in local jails and another 1 million are in state prisons. Incarceration rates undoubtedly affect communities of color at disproportionate rates, a rural issue since rural communities are home to many Black and Latinx people, especially in the Deep South. 

An interesting phenomenon has been the rise of jails in rural communities. Economic restructuring of rural communities is an important piece in understanding and explaining the rural jail and prison boom. First, as some rural communities suffer from declines in industries that previously dominated such as farming, mining, steel, and coal, coupled with factory closures and a shift to the service sector employment, there have been many social and economic consequences for these areas further discussed here and here. Prisons as an economic development strategy for rural communities have been a way to bring jobs to towns. As the incarcerated population in America increased there was a subsequent demand for prison expansion and state prison and jail populations burgeoned. Prisons then became a convenient way to address the economic problems facing rural communities and a way for politicians to create a facade of aid and increased employment opportunities. 

According to the Vera Institute of Justice's Report of People in Jail and Prison in 2020 (here), the U.S. saw an unprecedented drop in total incarceration rates between 2019 and 2020 due to the COVID-19 pandemic. The decline however was "neither substantial nor sustained enough to be an adequate response to COVID-19." Furthermore, the largest and most sustained jail population declines were in rural areas. These declines were a result of the COVID-19 pandemic and increased awareness of the heightened public health issues prisons and jails face because of close quarters. However, even with these declines rural counties "still incarcerate people at doubt the rate of urban and suburban areas. Three out of 5 people incarcerated in local jails are in smaller cities and rural communities." Since 2013, jail populations have grown by 27% in rural counties. This rural jail boom has been attributed to many factors including the rural lawyer shortage, prosecutor hiring processes, and the rural justice system overall, some of which are addressed in previous blogs here. 

The prison and jail system operate as an arm of the state apparatus, often inflicting violence on rural communities in the form of separating families and continuing the cycle of poverty. Policing of rural communities continues to drive incarceration rates. This policing is skewed not only in urban areas but in rural ones too to affect low-income communities of color. A report by Vera shows that people in some rural areas are punished for not meeting system rules rather than violent or dangerous criminal charges. Prisons, and the nature of the criminal "justice" system in rural communities then become another mechanism to punish rurality. 

As Professor Beety discusses in Prosecuting Opioid Use, Punishing Rurality, unique prosecutorial charges such as drug-induced homicide, a popular charge amidst the ongoing opioid crisis "operate in largely insular and sparsely populated rural areas." Beety also makes clear that poverty impacts people of color in rural communities and these people of color are then over-represented in the criminal legal system.

 

The prison system is often wielded as a way to address problems that rural communities face, rather than addressing and understanding the systemic causes that lead to these problems. Overall, the notion that jails help rural communities should be challenged and other forms of justice should be sought to give these communities the healing they deserve. 

Rural toxic masculinity

As we watched Beyonce's CMA performance with the Dixie Chicks, I repeatedly thought about toxic masculinity. While the song Daddy's Lessons progressed, "Daddy's advice" ranged from "shoot," "don't cry," and simply but tellingly, "be strong." The lyrics made me think of men's propensity for violence and bottling up of emotions. But at the time, I was unsure how to relate these ideas to rural lives. 

While thinking about how masculinity affects rural lives, I stumbled upon an exciting article on this question. While discussing Nina Simones's rural upbringing, the author Leah Hampton posits a very revealing thought experiment. Leah suggests closing your eyes and imagining a rural city. 

When I engaged with this question, I almost exclusively thought of dry dirt roads, plotted farmland, and big trucks. 

Leah then begs the question, when imagining rural landscapes, "Are there women in your mind, seated at pianos, playing jazz? Are there any women at all?" She further asks, when imagining the rural land, did you think of any greenery? "does the rural terrain roll and teem? Do the animals and trees live in symbiosis?" Or, like me, did you imagine only dirt roads and barren lands? 

With her thought experiment, Leah posits that culturally, we associate rural lands with places that radiate and perpetuate toxic masculinity. This rural-masculine association is echoed in Professor Pruitt's Gender Geography & Rural Justice. 

This cultural perception of toxic masculinity and its perpetuation leads to a wide array of gendered disparities. For starters, when men are consumed by masculinity, they see themselves as entitled to certain respect and submission, particularly from women. This entitlement leads to feelings of possessiveness that have consistently turned into violence against women and empowerment over them. 

A masculinity study from 2021 on over 17,000 men found that men in rural communities are more likely to have such feelings of possessiveness over women. This increase in possessiveness is likely related to increased intimate partner violence, where rural women report higher levels of intimate partner violence than women living in urban areas. Further, intimate partner violence in rural areas is recorded as more severe, and rural women also have less access to life-saving resources because of rural landscape's spacing and isolation. 

The statistics are grim, and sadly, it should be kept in mind that this violence often goes underreported. 

Unhealthy expressions of masculinity also deeply affect the men that adhere to them. The same 2021 masculinity student found it is less socially acceptable for rural men to be "softer" or express their feelings of depression, anxiety, or general emotions. 

This social pressure on men to not be perceived as soft leads to repression, negatively affecting men's mental health. As reported by the CDC, men are four times more likely to attempt suicide than women. The rates of suicide, however, are even higher for rural men.  

Finally, it is also interesting to consider how the association between masculinity and rural America shapes our perceptions. Does our inclination towards masculinizing rural America lead us to believe rural America is strong enough to handle its problems on its own? What else might we be inclined to think when we associate rural America with conservative toxic masculinity? 

California lawmakers call for investigation into "Wild West" of cannabis and other farm work.

Paige St. John and Adam Elmahrek report for the Los Angeles Times today:

California lawmakers are calling for a sweeping investigation into corruption in the state’s cannabis industry, legislative hearings on the exploitation of farmworkers and new laws to thwart labor trafficking in response to revelations of rampant abuses and worker deaths in a multibillion-dollar market that has become increasingly unmanageable.

The proposals follow aseries of Times investigations last year showing that California’s 2016 legalization of recreational cannabis spurred political corruption, explosive growth in illegal cultivation and widespread exploitation of workers. The Times found that wage theft was rampant and that many workers were subjected to squalid, sometimes lethal conditions.

A spokesperson for the state’s Department of Industrial Relations told The Times last week that the agency is examining the deaths of 32 cannabis farmworkers — never reported to work safety regulators — uncovered by the newspaper.

* * *

The [Los Angeles Times investigation] found that California’s dual state and local cannabis licensing system created fertile ground for corruption by giving thousands of often part-time, low-paid municipal officials the power to choose winners and losers in the multimillion-dollar deals.

Local politicians held hidden financial ties to cannabis businesses even as they regulated the industry. Consultants and elected officials told of backroom lobbying and solicitations for cash — while criminal investigations were isolated and scrutiny was sporadic.

* * * 

Sheriffs confronted with cannabis workers living in squalor, without food, pay or the ability to leave, said they lack local resources to address the problem. They said the number of workers at risk is huge: The state has tens of thousands of illegal cannabis farms spread across vast remote regions, and even licensed farms are not closely watched.

“There used to be some state support,” Trinity County Sheriff Tim Saxon said, adding that the support focused on ripping out illegally grown plants, not on addressing exploitation of cannabis workers.

Saxon said he is reliant on private outside funding to investigate cases of human trafficking.

The Times investigation found little outreach to apprise cannabis workers of their rights. Those workers who knew to complain of wage theft to the California labor agency waited as long as two years for a decision, even after telling the state that their lives had been threatened. Lawmakers told The Times the labor department suffers from chronic staffing shortages, failing to fill already funded positions.

Interestingly, this story raises some of the same issues about workplace safety, housing, and regulatory state that are surfacing after the shootings in Half Moon Bay earlier this week, as reported in this LA Times story: 

It’s not news to Bernardina Medrano and Margarita Martinez that many migrant farmworkers along the San Mateo County coast live in “deplorable” conditions, as Gov. Gavin Newsom and county Supervisor Ray Mueller have described.

Medrano, 43, who pays $850 a month to share a two-bedroom trailer in Pescadero with four other adults and two children, has been here 16 years. Martinez, who lives in a garage, has been here more than 10.

They say finding affordable and safe housing is one of the community’s biggest obstacles and hope the attention focused on the area after Monday’s mass killing of farmworkers in Half Moon Bay will prompt political decision-makers and the public to finally listen.

Rural Americans excluded from inflation data, though inflation may be higher in rural places

Steven Weiler of Colorado State and Tessa Conroy of the University of Wisconsin-Madison wrote a few days ago for The Conversation under the headline, "Rural Americans aren’t included in inflation figures – and for them, the cost of living may be rising faster."

When the Federal Reserve convenes at the end of January 2023 to set interest rates, it will be guided by one key bit of data: the U.S. inflation rate. The problem is, that stat ignores a sizable chunk of the country – rural America.

Currently sitting at 6.5%, the rate of inflation is still high, even though it has fallen back slightly from the end of 2022.

The overall inflation rate, along with core inflation – which strips out highly volatile food and energy costs – is seen as key to knowing whether the economy is heating up too fast, and guided the Fed as it imposed several large 0.75 percentage point interest rate increases in 2022. The hope is that raising the benchmark rate, which in turn increases the costs of taking out a bank loan or mortgage, for example, will help reduce inflation back to the Fed target of around 2%.

But the main indicator of inflation, the consumer price index, is compiled by looking at the changes in price specifically urban Americans pay for a set basket of goods. Those living in rural America are not surveyed.

As economists who study rural America, we believe this poses a problem: People living outside America’s cities represent 14% of the U.S. population, or around 46 million people. They are likely to face different financial pressures and have different consumption habits than urbanites.

The fact that the Bureau of Labor Statistics surveys only urban populations for the consumer price index makes assessing rural inflation much more difficult – it may even be masking a rural-urban inflation gap.

To assess if such a gap exists, one needs to turn to other pricing data and qualitative analyses to build a picture of price growth in nonurban areas. We did this by focusing on four critical goods and services in which rural and urban price effects may be significantly different. What we found was rural areas may indeed be suffering more from inflation than urban areas, creating an underappreciated gap.

The rest of the piece is organized under these headings:

1. The cost of running a car in the country

2. Rising cost of eating at home – and traveling for groceries

3. The cost of growing old and ill outside cities

4. Cheaper home costs, but heating and cooling can be expensive

Here is the conclusion:

Inflation – a disproportionate burden

While there is no conclusive official quantitative data that shows an urban-rural inflation gap, a review of rural life and consumption habits suggests that rural Americans suffer more as the cost of living goes up.

Indeed, rural inflation may be more pernicious than urban inflation, with price increases likely lingering longer than in cities.

On gun violence in rural America.

These past couple weeks three mass shootings devastated communities across California. On January 23, a gunman opened fire on a mushroom farm in Half Moon Bay. The elderly shooter murdered seven farmworkers, all of them Chinese or Mexican immigrants.

This came a few days after another mass shooting in Monterey Park. That day, an elderly gunman opened fire in a dance studio after a prominent Lunar New Year celebration. He killed eleven people, all of whom were AAPI.

Just five days before that, a mass shooting in the rural town of Goshen left six people dead, including a teenage mother and her infant. Police have linked the Central Valley shooting to the rural drug trade, but have yet to identify the perpetrator.

Gun violence weighs heavily on my mind. Less than a month into 2023, 40 mass shootings have occurred across the United States. Unfortunately, such a high number is as normal as it is tragic.

The proliferation of mass shootings has made me think about gun violence in rural America. The truth is that I do not know much about the topic. When I think of gun violence, my brain conjures images of "lone wolf" hate crimes, Chicago, and urban gang wars (thanks, Fox News).

Imagine my surprise when I found out that gun violence is actually worse in rural areas than cities. The Center for American Progress found that in 2020, the total gun death rate per capita for rural communities was 40 percent higher than it was for large metropolitan areas. On top of that, from 2016 to 2020, 13 out of the 20 U.S. counties with the most gun homicides per capita were rural.

The majority of these counties were in Southern and Midwestern states with strong gun rights politics such as Alabama, Arkansas, Missouri, Mississippi, North Carolina, and South Carolina among others. These counties and states vote Republican and overwhelmingly oppose gun control.

It is no secret that Republicans tend to support greater gun access than Democrats. White Americans are also much less likely to view gun violence as a problem in America. This geographic phenomenon is well documented and easily discernible in today's politics.

These facts are similarly reflected across the urban-rural divide. Pew Research conducted a poll that found rural Americans significantly favor more expansive gun access while Americans in urban places prefer more restrictive policies. This is right in line with geographic gun ownership: 46% of rural Americans own a gun, as opposed to 28% of suburban Americans and 19% of urban Americans.

This begs the question: if gun violence disproportionately harms rural communities, why do rural areas continue to support gun-loving politicians?

First, I firmly believe that Republicans have successfully implemented propaganda campaigns to sway working class white Americans from voting for their own interests. This includes exacerbating racial tensions and overemphasizing America's "culture war." If you would like to read more, I have written about this previously.

One of the major consequences of this is a sort of media blackout about rural gun violence. Not only is there very little coverage of rural gun violence, the media often ignore guns as the main driver of the recent rise in violence. If major media, especially conservative platforms such as Fox News, fail to accurately and comprehensively cover mass shootings (or shootings that kill three or more people) in rural areas, then there are few ways that Americans can actually learn the true extent of rural gun violence.

Another reason rural areas may support stronger gun access is rural American culture. A fundamental aspect of rural culture is the American Dream-esque pride in "pulling yourself up by your bootstraps." Hard work, independence, and self-sufficiency are important parts of this and are highly valued in many areas of rural America.

This culture likely extends to guns. For example, 82% of rural gun owners say that owning a gun is essential to their own sense of personal freedom. Additionally, the most cited reason for owning a gun among rural Americans is protection, with hunting coming in a close second. Truly, what is more free or self-sufficient than protecting yourself or hunting for your own food?

Without a gun, some rural Americans might have to rely on the government for assistance and protection. This is not always reliable, especially considering the rural shortage of police officers. With the immediacy of emergencies and the hours it may take police to arrive to these remote areas, it is understandable that rural Americans may favor greater gun access to protect themselves.

The solution to reducing gun violence in rural areas, thus, cannot simply be a flat ban on guns. It is also understandable, then, why Republican fear mongering about Democrats taking rural Americans' guns is so effective. Democrats need to do a better job of including rural communities in gun control policymaking conversations (For example, remember Obama's "Bittergate" comments about how working class voters "get bitter" and "cling to their guns and religion."). Republicans need to acknowledge that something (anything) needs to be done about gun violence. In the end, we need to remember that we all should have the same goal of minimizing gun violence in all parts of the U.S.

Paul Krugman splatters on rural America, again

The New York Times columnist wrote yesterday under the provocative headline, "Can Anything Be Done to Assuage Rural Rage?"  It's little more than a redux of a column Krugman wrote in October, and which I blogged about here.  This time, instead of responding to scholars Munis and Jacobs, Krugman is responding to Thomas Edsall's column of a few days ago.  Here are some highlights--or perhaps I should say lowlights--of the Krugman column: 

Rural resentment has become a central fact of American politics — in particular, a pillar of support for the rise of right-wing extremism. As the Republican Party has moved ever further into MAGAland, it has lost votes among educated suburban voters; but this has been offset by a drastic rightward shift in rural areas, which in some places has gone so far that the Democrats who remain face intimidation and are afraid to reveal their party affiliation.

The answer will depend on two things: whether it’s possible to improve rural lives and restore rural communities, and whether the voters in these communities will give politicians credit for any improvements that do take place.

This week my colleague Thomas B. Edsall surveyed research on the rural Republican shift. I was struck by his summary of work by Katherine J. Cramer, who attributes rural resentment to perceptions that rural areas are ignored by policymakers, don’t get their fair share of resources and are disrespected by “city folks.”

As it happens, all three perceptions are largely wrong. I’m sure that my saying this will generate a tidal wave of hate mail, and lecturing rural Americans about policy reality isn’t going to move their votes. Nonetheless, it’s important to get our facts straight.

Krugman then goes on to rely on questionable constructions of "facts," including the notion that entire states are "rural," a notion that Kaceylee Klein and I recently debunked in our article on "Rural Bashing."

Prof. Ann Eisenberg of the University of South Carolina, a scholar of the rural, offered this short tweet storm in response to today's Krugman column.  

It reads"5 Mistakes Paul Krugman Made in Today's NYT Op Ed" and then "#1 Conflating rural and white conservative.  White conservatives are everywhere.  many rural residents do not vote.  Many are liberal.  Substantial populations are indigenous, Black and Latino (or otherwise not white). 

#2. Dismissing the idea that "city folks" are every disrespectful to rural people.  There are entire fields of study on this.  Decades of research.  So many slurs linked to rural.

#3 Assuming that Democrats are unquestionably, obviously great for rural communities.  They are in many ways, but that ignores the many policies Democrats have favored that are unfriendly to rural communities, like liberalizing trade and transportation deregulation.

#4 Missing the chicken for the egg in rural "subsidies."  Public policies have contributed to rural regions being poorer, which contributes to apparent "urban dependence."  There are many models for capacity building that can and do make distressed communities more prosperous. 

#5 Forgetting rural-urban interdependence.  "Giving" rural regions a better economy isn't just charity.  It means better food, jobs, resilience, & infrastructure for everyone.  A lot of big systems in the country are broken, & rural people are caught up in them like everyone else.

If you want a more informed, more hopeful op ed, check out this by @lisareneepruitt [Lisa R. Pruitt] @ShoemakerJess [Jess Shoemaker at University of Nebraska] and me. 

And here is part of the response from Tony Pipa of the Brookings Institute: 

Sexual and gender minority health care in rural America (Part I): The state of affairs

When I told my family practitioner that I was having sex with men, he walked out of the consultation room and never treated me again. The medical profession was not, as I had naively hoped, immune to the stigmas that permeated the rest of my life as a gay kid living in rural Virginia (prior post on LGBTQIA+ bullying here). 

A few years later, I expressed an interest to my replacement doctor in starting Pre-Exposure Prophylaxis (PrEP), a preventive treatment commonly used by gay and bisexual men, among other at risk populations, which decreases the risk of contracting HIV sexually by 99% according to the Center for Disease Control and Prevention (CDC) (prior post on rural HIV treatment here). My doctor informed me that he had "never heard of that" and was "not comfortable prescribing" it to me.  

My experiences with health care providers are far from unique for sexual and gender minority (SGM) populations residing in rural America. In a CBS News article headlined "Transgender people in rural America struggle to find doctors willing or able to provide care," Tammy Rainey, a transgender woman who needs hormone estrogen, details her inability to access gender affirming care near her hometown in rural northern Mississippi. I mention Rainey, specifically, because my own doctor's words echo in her doctor's response to her request for an estrogen prescription: 

I just don't feel like I know enough about that. I don't want to get involved in that.

I now drive an additional 35 minutes towards Washington, D.C. for doctor's appointments. Rainey has to drive 170 miles round trip to pick up her estrogen from a provider in Memphis, Tennessee.

It is well documented, including by the CDC, that rural Americans suffer significantly poorer health outcomes relative to urban Americans. These disparities arise from a myriad of social determinants of rural health, many of which have been discussed on this blog, including financial constraints and the intertwined phenomena of rural doctor shortages and hospital closures. 

SGMs in rural America, a population estimated to be up to 3.8 million, face the same health disparities as their non-SGM counterparts, but also confront unique challenges as SGMs that are amplified by the rural experience. Specifically, heteronormativity, discrimination, and stigma distinguish the health of SGM groups in ways that demand specific attention from academics, public health professionals, and policymakers. 

As Ilan Meyer identifies in an editorial in the American Journal of Public Health, from an institutional perspective heteronormativity contributes to health disparities by disadvantaging SGM people in: 

the selection of research priorities, the design of public health prevention and intervention programs, the development of standards of care, access to care, and the provision of culturally sensitive care.

A WVUToday article from last year summarizing Zachary Ramsey's research highlights specific examples of obstacles SGMs face as a result of heteronormativity in health care systems, including insurance plans that fail to cover imperative SGM treatments and a knowledge gap between health care providers' training and SGM health needs. The existence of this knowledge gap is evident in a 2019 study conducted by the Movement Advancement Project (MAP), "Where We Call Home: Transgender People in Rural America," which found 23% of transgender people in rural America had to teach their provider about transgender health care needs in order to receive necessary care.

Zooming in, a 2021 Center for American Progress article, "Protecting and Advancing Health Care for Transgender Adult Communities," details how recurring exposure to discrimination, stigma, and the threat of violence, in conjunction with disadvantageous sociopolitical and economic risk factors, materially contributes to worsened overall health outcomes for SGMs, such as increased rates of chronic health conditions. Notably, mental illness among SGMs resulting from regular psychological stress is of particular concern in rural areas, where specialized SGM mental health resources are almost never available.   

Moreover, as I experienced in rural Virginia, the trauma of anti-SGM discrimination and stigma is frequently reenacted by poor clinical care. According to MAP's 2019 analysis, one in three transgender people in rural America experienced discrimination by their health care provider in the past year. Similarly, a 2021 Williams Institute survey found 38.3% of SGM patients expressed concern about being judged negatively when accessing health care due to their SGM status. Experience and fear of stigma in health care settings has significant implications beyond concerns of bedside manner. A 2016 study published in PLOS ONE identified that higher stigma in health care settings directly correlated to lower utilization of primary care services by rural SGM groups, thereby contributing to health disparities.       

Refocusing on rural contexts, MAP's 2019 analysis highlights four ways rural life exacerbates negative health consequences experienced by SGMs: (1) increased visibility, (2) ripple effects, (3) fewer alternatives, and (4) fewer support structures. First, increased visibility, arising from decreased population and heightened sense of community, renders non-conforming SGMs more at risk for harassment. Second, the intimate nature of rural communities increases the likelihood that ostracization by a portion of the community, such as a religious body, will have a ripple effect that spreads unlike it would in an urban setting. Third, scarcity of rural health care providers is especially challenging for SGMs because accessible providers often are not informed on their distinct needs and sometimes are religiously affiliated, such that, they can deny service under state religious exemption laws. Finally, geographic isolation means fewer support structures generally, a reality which leaves rural SGMs struggling to find adequate support in virtually every area ranging from social to legal.        

While I have painted a bleak picture of the American public health landscape as it pertains to SGM populations in rural areas, there are actionable ways in which we as individuals, local communities, and a nation can improve this state of affairs (prior post on improving transgender health care in rural Colorado here). Critically, adopting an intersectional framework that centers SGMs existing at the axis of multiple marginalized identities, specifically transgender people of color, is necessary for effective mitigation of SGM health disparities. 

Never again a poor man in a rich country, lessons from Pedro Castillo's downfall

Professor Pruitt recently wrote about the coup and prosecution of Peruvian President Pedro Castillo and the violent suppression of protests that have occurred in its aftermath, acts that have garnered the condemnation of governments throughout Latin America, including from Mexico and Honduras (Professor Pruitt's blog posts on the topic can be found here, here, and here). Given the failure of President Castillo to implement the political program he campaigned on as a member of the socialist Peru Libre Party, an agenda captured by his campaign slogan "never again a poor man in a rich country," I think it is worth evaluating his tenure in office in comparison to how Bolivia's Movement for Socialism (MAS) Government leveraged popular power in order to win gains for their country's rural poor.

President Castillo faced an onslaught of structural and political obstacles in enacting and implementing the policies he campaigned on, notably the ratification of a new constitution written by a constituent assembly and the development of Peru's rural Andean countryside fueled by revenue generated from the nationalization of natural resources like gold, lithium, and copper (which Peru is the second largest producer of in the world). 

The obstacles Castillo faced included a legislature in which the Right controls a majority of seats as well as the threat of capitalist disinvestment from the economy encapsulated by the political science concept known the structural dependence of the state on capital. This concept posits that capital can leverage their power to create economic crisis to rein in economic programs that run counter to their class interest, such as large-scale wealth redistribution and nationalization. This topic was discussed in detail in this past blog post regarding capital strikes and constraints imposed upon the Brazilian President Luiz Inácio Lula da Silva's socialist program during his first stint in power. 

The impediments to President Castillo advancing his bold agenda were compounded by Peru's lack of a organized, mass base to rally around his agenda and leverage their relationship to power into policy victories. While President Castillo himself was a leader of a teachers' union strike, Peru's trade union movement has historically been weak. The Peruvian Left has struggled for decades to make inroads in rural communities due to a “cold war mentality” associating socialist politics with the Shining Path terror group. Peru Libre, Castillo's party, was an obscure, minor socialist party prior to Castillo's victory. 

Given the isolation of the political Left within the legislature, the lack of an organized base for economic justice, and the risk of a capital strike, Castillo did not have a ready-made organized constituency to offer an effective defense of his agenda of rural economic justice. Instead, he would have had to build one from essentially the ground-up while undergoing the day-to-day tasks of governing a large country without institutional political experience, a difficult task given the array of forces invested in his failure. As Castillo's poor polling numbers and failure to create a stable government, encapsulated by the five Prime Ministers he appointed during his tenure, indicate, Castillo was overwhelmed by the political and structural forces opposed to the socialist transformation of the countryside that he campaigned on. 

Perhaps Castillo may have been more successful had he taken a more confrontationist posture early in his presidency. This would entail attempting to mobilize the large groups of rural people currently protesting the coup-government that ousted him in defense of his agenda. One model he could have used is adopting something like the tone from FDR's "I welcome their hatred" address, identifying the country's wealthy elite as the forces undermining his administration. However, it is likely that such an aggressive posture would have intensified the risk of capital strikes and other destabilizing acts. Thus, without a ready-made mass base to rely on, Castillo's hands were likely tied. 

Castillo's supporters from the overwhelmingly underdeveloped, impoverished Andean countryside do not have to look far for inspiration regarding building and exercising political power. Unlike the attempt to build a socialist movement to empower the rural countryside from the top-down, the rural peasantry in Bolivia began their political project by building social movements from below. 

In Ann Chaplin's journal article "Social Movements in Bolivia: From Strength to Power", Chaplin detailed the decades-long process by which exploited, predominantly rural and poor indigenous Bolivians organized to advance their interests locally and in their workplaces with organizations encapsulated by federations of coca growers and the miners' union. Chaplin discussed how these organizations flexed their power in a number of ways, notably during the “water war” in which protestors successfully defeated the government's proposed water-privatization policy. 

Thus, when the Movement for Socialism (MAS), the political arm of the social movements, won the presidency under the leadership of rural indigenous, coca producer leader Evo Morales in 2005, MAS had a mass-base which could leverage power at the local and workplace-level to support their political and economic program. This program involved the enactment of a new constitution which recognized the rights of indigenous people and substantial wealth and power redistribution. For example, during Morales's tenure as President, extreme poverty was reduced by 60% as Bolivia's economy became the fastest growing in South America. 

Bolivia's social movements' strength was highlighted during the 2019 coup which removed Evo Morales from office. The anti-MAS coup government lasted for about a year and was forced to accede to the social movements demands for elections after constant protest and mobilization. Those elections saw MAS’s return to power under the Evo Morales's Finance Minister, Luis Arce. 

The cases of Castillo in Peru and MAS in Bolivia provide an interesting lens to consider sources of power and organizing strategies that the exploited and immiserated in rural, underdeveloped areas can explore as we consider the urban-rural development divide. Obviously, historical and material conditions differ from place to place, but it's interesting to consider how models can be adapted based on those specific conditions. I'm also interested in seeing whether the protest movement in Peru coalesces into a broader, more-organized movement that can serve as a base for social change in Peru, like Bolivia's social movements. 

Is Half Moon Bay, California "rural"?

Half Moon Bay, California, population 11,975, burst into the news on Monday afternoon when a gunman killed seven on the outskirts of town.  

I've been to Half Moon Bay a few times, and I have friends who live there.  When I visit, I see the posh parts--like the Ritz-Carlton resort and other somewhat less luxurious coastal hotels and amenities.  Many who live in the small city and nearby communities like Montara commute to San Francisco or over the mountains to Silicon Valley.  I think of it as exurban San Francisco, and it lies within densely populated San Mateo County.  

I was thus surprised to hear NPR repeatedly refer to Half Moon Bay as "rural" in the news coverage the morning after the shooting. 

When I started thinking about it, though, I realized that the town does have rural and agricultural aspects.  In particular, when you approach Half Moon Bay from Silicon Valley (rather than from San Francisco, via Devil's Slide), you drive past nurseries and other agricultural enterprises.  Further, the small city is known for its pumpkin festival.  

There's also the fact that the killings happened at two agricultural establishments--one the Mountain Mushroom Farm where the shooter is said to have lived.  The victims were Asian and Hispanic and all were farm workers, some of them migrant.  The shooter was also a farm worker, and the killings are now being characterized as "workplace violence."  Still, I've found it odd that the place is being depicted as essentially rural, when its character of Half Moon Bay is really much more nuanced than that.  Indeed, as I think about it, it's a great example of dramatic inequality crammed into a compact space.  

NPR's subsequent coverage included this description of the community.  Note the "close-knit" cliche associated with rural places.  

Half Moon Bay is a close-knit community known for its ranching, farming and fishing, officials said in a news briefing Tuesday. That sense of security and closeness was shattered with Monday's tragedy.

Here's how the Washington Post characterized the town: 

In Half Moon Bay, a tranquil agricultural town about 40 minutes from San Francisco, local officials were anguished as their home joined a grim fraternity of American communities scarred by gun violence.

Postscript:  Follow up coverage of the shootings indicates that several of those murdered lived in San Francisco.  This means they had a lengthy commute from a very expensive housing market to farmworker labor.   

This is a characterization of Half Moon Bay from the Los Angeles Times: 

Half Moon Bay is a rural beach town where the bedrock industry is vegetable and flower farms, though many, particularly the flower farms, have closed in recent years, affecting job opportunities. Farm owners have also pointed to the state’s extreme weather, with floods and heavy winds, devastating their fields and the surrounding infrastructure.

About 2,500 to 3,000 farmworkers live in the town at any given time, officials said. Many settle in the wealthy community after finding steady work, often living in mobile homes or trailers on the farms where they’re employed — just a short drive, but out of sight, of the town’s multimillion-dollar coastal homes.

This part of that story touches on the extreme inequality in Half Moon Bay:

Eric DeBode, executive director at Abundant Grace Coastside Worker in Half Moon Bay, said his charitable organization primarily serves the homeless population of the Half Moon Bay area but also farmworkers. The organization runs a farm whose produce is given for free to the very people working low-wage farming jobs that produce much of the area’s food.

A “large portion of folks we serve,” DeBode said, “are making the food we eat and aren’t able to afford it themselves.”

On Thursday, another organization serving farmworkers and other community members was overflowing with goods in the wake of the massacre.

Volunteers were stacking boxes of produce, snacks, eggs, milk and frozen chickens at Ayudando Latinos a Soñar. The group had gathered mounds of clothing, and its food pantry was overflowing from the community response.

A man emerged from a Lexus outside the group’s small, bright yellow building and dropped a bag on a table with a thud. “You said you needed underwear,” he said before returning to his car.

The community’s interest will wane eventually, said volunteer Victoria Sanchez De Alba. But, she said, unacceptable housing conditions for workers will remain: “Why can’t we hold these farm owners accountable?”

She added that, oftentimes when housing violations are reported, “officials red-tag the housing and the families get displaced.”

DeBode called the housing conditions on the farms “shocking” and “deplorable,” adding that farmworkers and the tourists who come to the area “are living in two different worlds.”

Monday’s rampage stunned the entire community. The gunman opened fire at the two rural locations.

The Associated Press also covered the extreme inequality in Half Moon Bay as part of its coverage of the murders:   

The state’s labor department is looking into possible labor, workplace safety and health violations at the farms where the shootings happened, a spokeswoman for the Department of Industrial Relations said Thursday. Newsom’s office said some of the farmworkers told him they made $9 an hour and lived in shipping containers. The state minimum wage is $15.50.

“The conditions farmworkers shared with the Governor ... are simply deplorable. Many workers have no choice but to tolerate the conditions provided to them by their employers,” Newsom spokesperson Daniel Villaseñor said in a statement.

Edsall puts blame for current state of politics squarely on rural voters' shoulders

Thomas Edsall's column for the New York Times this week was alternatively titled, "Republicans are Riding High on Place-Based Resentment" and "The Resentment Fueling the Republican Party Is Not Coming from the Suburbs."  Here's the lede that, like the second headline, places blame for Trump on rural folks:  

Rural America has become the Republican Party’s life preserver.

Less densely settled regions of the country, crucial to the creation of congressional and legislative districts favorable to conservatives, are a pillar of the party’s strength in the House and the Senate and a decisive factor in the rightward tilt of the Electoral College. Republican gains in such sparsely populated areas are compensating for setbacks in increasingly diverse suburbs where growing numbers of well-educated voters have renounced a party led by Donald Trump and his loyalists.

The piece covers some familiar territory of late, including discussion of Munis and Jacob's recent work on rural political resentment.  

What annoys me most is how it places blame for the state of American democracy on rural voters.  Yes, Trump's margins were better in many rural places than in many suburban ones, but far greater numbers of folks live in those suburban places.  This means that even if the Trump/right-wing margins are greater in rural areas, the suburbs still have more power to determine political outcomes.  One of the headlines for this column says the "resentment" isn't coming from suburbs.  This makes me wonder what is coming from the suburbs--what emotion or rationale is causing so many of those voters to support Trump.  Is it greed?  

Also, Edsall doesn't take up the issue of how the Democratic Party has largely abandoned rural America--that is, they're not vying actively for the rural vote, a matter I document here.  What role does that phenomenon have in the rural shift to the GOP?   

Since when is it so bad to be "rich?"

Last week our class discussed When COVID hit, a Colorado county kicked out second-home owners. They hit back., by Nick Bowlin in High Country News. The article explores an election cycle in small, nonmetropolitan Gunnison County, Colorado, population: 16,918.

When Covid first hit, county officials implemented a temporary ban on nonresident property owners to try offsetting the burden that the nonresidents put on local resources such as health care, public services, first responders, and food supplies. The nonresidents fought back by creating a super PAC to influence the upcoming election for two open seats on the board of county commissioners. Basically, the town divided into two sides: 1) the nonresident, second homeowners whose property was mostly used as vacation homes, and 2) the native residents who worked to sustain the local economy that provided the second home owners with their getaway activities. 

The article is filled with themes of rural gentrification. Another blog about Gunnison, Colorado, and more rural cities that have been gentrified, written by Melissa Stratton, is here.

The ringleader of the super PAC was Jim Moran, a Texas native and former private equity firm manager. As the article states, his second home, where he lived during the Covid lockdown, is a $4.3 dollar mansion perched on a bluff above Crested Butte, a ski resort, in Gunnison County.

A particularly interesting part of the article was the nonresidents' disdain for being called "rich" or even comparatively wealthy. Pulling from the comments of the Facebook group created by the nonresidents, a group member stated, "'I'm certainly not 'rich.' I've worked for my entire life to have the properties I own." When Nick Bowlin asked Jim Moran if he and the other nonresidents who own multiple properties are considered wealthy in comparison to the locals who are struggling to pay their own rent, Mr. Moran responded that he thinks that is wrong--that they're not wealthy. 

This made me ask myself the question: since when is it an insult to be labeled rich? 

When I think about all the people I know, making a lot of money is the main motivator in most of their lives. As I'm scrolling through social media, I can't escape content surrounding themes of "how to get rich quick," "creating passive income," "establishing generational wealth," etc. Most of the songs I listen to revolve around having massive amounts of wealth and showing it off. In the City Girls' Where the Bag At, the two Miami based rappers list their requirements for a partner, which starts with having plenty of money and being eager to spend it on them. In A Boogie wit da Hoodie's Ballin', he begins the song bragging about spending thirty thousand dollars on each outfit. In Baptiize by Future, a song about spoiling women with jewelry, clothes, cars, and private jet fueled vacations, the Atlanta rapper states, "making money is the only thing that excites me."

Moreover, when I was growing up, I remember spending so much time trying to convince everyone around me, and sometimes even myself, that my family and I had a lot more money than we actually did. Since a young age, my mom always stressed how important it is to look well put together so no one would think we were poor. Since then, I have heavily associated my outward appearance with class. By always dressing nicely, I felt like I was proving and somewhat manifesting my spot as part of the upper middle class. 

I took this desire to look wealthy extremely far in undergrad. This was the first time I was surrounded by truly rich people, and I felt incredibly insecure. I remember not paying my utilities bill for almost an entire year because it felt so expensive, but I bought lots of clothes online every time my biweekly paycheck deposited into my bank account. No one could see my utilities bill climbing to over $1000 but everyone loved my adorable outfits and that was way more important!

In hindsight, all of this was very silly of me and I'm glad I've matured enough to at least pay my bills before I go shopping. Still, I can't help but think about how I spent so much time, energy, and anxiety on convincing people that I was well-off. If someone mistook me as rich, I would have exploded with happiness.

In contrast, the nonresidents in Bowlin's article are living in their mansion vacation homes and organizing super PACs to resist local government, all while insisting that they are not wealthy. 

Why is it that Moran and people like him are so strongly against being labeled rich? Based on Moran's Facebook comment, there seems to be some association between being "rich" and not working hard, but do that many people actually believe that? Most working-class people I know idolize the rich and give them nothing but props for getting where they are, no matter how they got there. Moreover, are the residents of Gunnison County, who had no vacation homes to escape to, not also hard-working despite their lack of property ownership?

Possibly the most pressing question of all is this: if rich people don't want to be labeled rich why don't they just stop being and acting so rich? During the global pandemic where millions died, thousands lost their jobs, hospitals were overflowing with bodies, and people were scrambling to feed their families, who else but the rich would start a super PAC because, in Moran's own words, "There has never been a better opportunity for change, and we intend to exploit that to the fullest extent." 

All of those being labeled "rich" have the power to donate the excess of their wealth, sell their additional properties, and live like middle-class, everyday Americans who don't have the money or power to influence elections when they are annoyed by politicians. 

I understand why they don't do this. I wouldn't either if I was in their shoes (but I would donate a lot and always invest in my community!!). But also, if someone called me rich as I was looking down at the ski resort my property sits atop, I would definitely take it as a compliment and feel grateful that I never have to worry about my utilities bill ever again. 

Mass shooting in rural "island" in California's Central Valley linked to drug trade

Here's an excerpt from the Los Angeles Times most recent coverage of the murders of six, including a teenaged mom, her infant, and a 72-year-old grandmother in Goshen, California, population 3,006.

Rural parts of the San Joaquin Valley have become some of the most violent places in California, with a bustling drug trade and among the highest rates of murder and lowest rates of solving murders.

* * *  

According to a report last year from California Atty. Gen. Rob Bonta, Kern County had the highest homicide rate in the state in 2021, with 13.7 killings per 100,000 people. Merced County came in second, at 9.5, followed by Tulare, where the massacre happened Monday, at 8.8. The homicide rate statewide was 6. In Marin County, it was 0.4.

* * *

Little-known rural enclaves such as Goshen — which many Californians glimpse from the window of car speeding between Los Angeles and Yosemite or Sacramento or Lake Tahoe — have become coveted transit points for methamphetamine, fentanyl and other drugs. Layers of criminal organizations including Mexican cartels, prison syndicates and local street gangs all vie for a piece of the real estate.

* * *

Assemblyman Devon Mathis (R-Visalia), who represented the area until the most recent redistricting, said Goshen is one of many “county islands” in the valley — small unincorporated communities, impoverished, lacking their own police forces. Gangs and drug smugglers dig in there, knowing law enforcement presence is sparse.

“We have a vulnerability, and it is being exposed,” Mathis said.He is dismayed how many of his colleagues in the Assembly are flabbergasted to hear about ferocious gangs in the San Joaquin Valley, viewing it as a problem for cities, not for rural areas.

* * *

The rural areas — with few officers on patrol and located along one of the West Coast’s major north-south transportation corridors — have long been attractive for drug traffickers. Tulare County has, despite its population of less than half a million, historically played a prominent role in the transnational movement of drugs, money and guns.

A prior post about the relative lawlessness of rural areas is here. 

Rural workers less likely to have access to family leave

Kaiser Health News and NPR reported a few days ago from Elko, Nevada, population 18,927.  The headline is "With less access to paid leave, rural workers face hard choices about health, family," and the story is reported by Jazmin Orozco Rodriguez.  An excerpt follows:  

Wild variations in paid leave regulations from state to state and locally mean those choices [about taking leave] can be further complicated by financial factors.

And workers in rural areas face even more challenges than those in cities, including greater distances to hospitals and fewer medical providers, exacerbating health and income disparities. Companies in rural areas may be less likely to voluntarily offer the benefit because they tend to be smaller and there are fewer employers for workers to choose from.

While a growing number of states, cities, and counties have passed laws ensuring paid sick leave or general paid time off in recent years, most states where more than 20% of the population is rural haven't, leaving workers vulnerable. Vermont and New Mexico are the only states with a sizable rural population that have passed laws requiring some form of paid sick leave.

Experts say the gaps in paid leave requirements mean workers in rural areas often struggle to care for themselves or loved ones while making ends meet.

"The problem is, because it's a small percentage of the population, it's often forgotten," said Anne Lofaso, a professor of law at West Virginia University.

More rural unrest in Peru

I wrote about the rural-urban split in Peru last month when Pedro Castillo was forced from the president's office.  That story continues to be in the news, including this today from NPR:  

Peru's capital is bracing for large demonstrations against the government over coming days. Thousands of rural residents have been streaming into Lima to demand justice for the more than 50 people killed in weeks of protests.

* * * 

Protesters also want to bring attention to long-standing social and economic inequality in the country. The wealth gap between Peru's indigenous south and the urban capital has long been present, but has widened in recent years.

Dina Lopez came to Lima from her highland city of Ayacucho to participate in protests. "No one pays attention to us out there — where are our human rights?" she said. She spoke to NPR as police attempted to remove her and fellow protesters from the doorsteps of a church.

"That woman is deaf to our suffering," Lopez added, referring to President Boluarte.

Here's the New York Times coverage of recent events from a few days ago.  Here's an excerpt from that story:

Rather than fade, protests in rural Peru that began more than a month ago over the ouster of the former president have only grown in size and in the scope of demonstrators’ demands, paralyzing entire sections of the country and threatening efforts by the new president, Dina Boluarte, to gain control.

The unrest is now far broader than anger over who is running the country. Instead, it represents a profound frustration with Peru’s young democracy, which protesters say has failed to address a yawning gap between the rich and the poor and between Lima and the country’s rural areas.

Democracy, they say, has largely helped a small elite — the political class, the rich and corporate executives — accumulate power and wealth, while providing few benefits to many other Peruvians.

Postscript:  Here's more coverage from the NYT newsletter on  January 22, 2023: 

Many of Castillo’s supporters are poor or middle class Indigenous people, part of the roughly two-thirds of the country’s population living outside of the capital, Lima. As a colleague of mine put it, many feel politically excluded while also feeling tokenized by Peru’s tourism industry. When news reached his supporters in rural areas, they were angry he had been removed from office. Castillo was their hope for change.

So tens of thousands of protesters took to the streets in an effort to shut down the country, what they felt was their only way to be heard.

* * * 

While some people living in urban areas dismissed these demonstrators as extremists, at least one trusted poll shows a majority of Peruvians support the protests.

Here's a vignette from Juliaca (population 276,000), in southern Peru, where police killed 19 protestors  earlier this month.  The person answering the questions/speaking is Julie Turkewitz, the Times Andes bureau chief.  

What did you learn from speaking with protesters?

Being there helped me understand why people feel the Peruvian democracy is not working for them. People feel the system is rigged against them. And on the ground, I could really see why they believed that.

What did you see?

We found one example when we went to a public hospital and spoke to many people who had suffered gunshot wounds in the city’s deadly protest. Human rights groups have accused police of shooting directly at demonstrators. The wounded had not been given their medical reports, even though that was their right. Several people said they believed that they were being punished for their association with the demonstrations.

At the hospital, patients lacked access to basic services. They pay for their own water and there is no toilet paper or soap in many hospital bathrooms. The hospital director, appointed by the government, said, basically, everything is fine here. He didn’t tell me that the victims needed more help. This idea that people feel forgotten by Peruvian democracy was visible in the hospital.

Postscript:  On February 1, the Los Angeles Times published a feature on the Peruvian unrest under the headline, "'They don't see us as humans': In Peru, protests over racism and neglect spill from the Andes." Kate Linthicum reports.