Improvements to rural medicine?

The introduction of the new iPad by Steve Jobs the other day got me thinking, do such devices, which now have real medical capabilities, have the ability to make rural medicine easier and more accessible?

Rural medicine, in some respects, has undergone somewhat of a revival. For example, Obama’s appointment to Surgeon General in 2009 was Regina Benjamin, a rural health practitioner from Alabama. Dr. Benjamin founded the Bayou La Batre Rural Health Clinic in Alabama and was also the Associate Dean for Rural Health at the University of South Alabama College of Medicine, prior to becoming Surgeon General. In fact, upon her appointment, Dr. Benjamin stressed that she would continue her goal of assisting the uninsured and ignored individuals within the United States.

At the same time, many medical schools have begun to push for rural rotations for their students. While part of this might be altruistic, the move also has a practical effect. Having the experience of working and living in a rural area gives students an idea of what life is like in a rural community – to make an informed choice of whether they would like to practice in such an area.

It is evident, however, that the practice of rural medicine has a long way to go. First, many rural areas do not have hospitals in the first place to facilitate residents and medical students having a place to practice. Second, many medical students and residents have never lived in rural communities before, and do not understand the workings of the area or the was to interact with the residents – clearly this could have a detrimental effect on providing proper and accurate care to individuals who need it. Third, many rural areas may not have the proper tools and devices necessary to give proper health care to rural communities (and perhaps this is where the iPad comes in).

Even if the iPad does have the capabilities of broadening rural medicine, some additional woes still exist. While family medicine in rural areas has been increasing, in this article, the downsides of slow Internet, lack of cell phone service, and a limited potential of dating – all of which seem rather trite – may in fact have a detrimental effect on young professionals who move into these areas to practice medicine. As the article states, “What more can be done to attract primary-care physicians to areas that need them, and then to keep them there?”
While it is still not a clear line to providing medicine to rural communities, clearly the recent interest in doing so can only be a beneficial improvement. Nonetheless, it is important to take into consideration the woes of the residents and future doctors who may in fact be providing such health care in these areas. It also seems incredibly important to consider the need for faster internet access and cell phone service. Ultimately, tools like the iPad may exist and be useful, but broadband access and the means of communication need to be available too.

Mental health in rural areas

We all know that recovery from a serious illness is not only about healing physically, but also about healing mentally. Ideally, supportive friends and family assist a recovering patient, in addition to psychological services, should they be necessary. This mental health component has become more apparent in recent days, as we have witnessed injured soldiers return from wars abroad, with physical injuries that are often exacerbated by psychological ones. In the case of veterans, there has been continual investigation and legal battles into mental health services for veterans and access to those services for people with PTSD and psychological issues relating to TBI.

Coming back to the mental component of recovery from illness more generally, I recently read an article that discussed a study examining the mental health of recovering lung cancer victims. Specifically, the study conducted by a professor at the University of Kentucky, looked at levels of mental distress in lung cancer survivors in rural versus non-rural areas. Although one would suspect, or stereotype, that rural areas are more tight-knit and therefore have a stronger support system for people recovering from illness, the study found that when it came to recovering mentally, people in rural areas fared worse on mental health outcome variables. While the study found that these disparities were in part correlated to lower levels of education, the smaller social networks seemed to work against the mental healing process as well. Seeking psychological services might go against social norms and carry a stigma. Importantly too however, is the lack of mental health resources in rural areas.

While I am not sure that the social constraints that seemed to inhibit mental health recovery for these lung cancer survivors is the the case in all rural communities, there is less debate that there is a shortage of mental health resources in rural areas. A newsletter from the Center for Rural Affairs explains that the reasons are not only tied to affordable mental health care, but also general access and availability to mental health care providers. In Minnesota, the Minnesota Consortium for Advanced Rural Psychology Training (MCARPT) is seeking to alleviate the shortage of mental health professionals in rural areas with a one-year post-doctoral program. The program aims to train psychologists in rural mental health issues and provide trainees with rotation opportunities in rural communities. The program trains psychologists in a variety of areas that contribute to mental health services available to people living in rural communities.

Recognizing that mental health on its own, and in conjunction with physical healing from injury, is a vital element of a person's overall well-being, it is important that it doesn't get overlooked in the larger battle for adequate health care for all Americans. While only briefly knowing about MCARPT, it seems like a step in the right direction of increasing access to mental health care to rural areas and I hope that there are other programs out there like it.

When the drug trade comes to town

Anyone tuned in to the news in recent years has probably noticed that rural America appears to be under siege by drug traffickers and drug-related crime. We are all familiar with the fact that our country’s war on drugs takes place in the meth labs of abandoned rural buildings just as much as it does in the back alleys of our major metropolitan cities.

Many Americans blame the increase in drug use and drug violence in rural areas on lack of access to treatment programs, reluctance of addicts to seek treatment and, in many cases, the “boredom” associated with spatial isolation and lack of economic and other resources.

A recent article in The Boston Globe posits that there is nothing necessarily unique about rural people that “breeds” drug abuse and violence, but rather that drug dealers are more frequently using rural towns as meeting places for drug transactions, simply because they are less likely to get caught.

The article describes the recent fatal shooting of a 21-year-old drug dealer in the small town of Ashby, Massachusetts, population 3,059. A local state trooper who had been monitoring the area for drug activity fired the fatal shot when the young man refused to stop his vehicle and began driving toward the officer. Community members were understandably shocked by what they considered to be a rare happening in their “sleepy, quiet town.”

However, residents of Ashby did admit that there were many signs that the drug trade had come to town even before the shooting. From the unfamiliar vans with tinted windows that drove through on occasion, to the hypodermic needles often strewn along nearby walking trails, it was clear to residents that drug addiction was nothing new.

Although the fact that drug dealers are making use of conveniently isolated rural locations for their transactions does increase exposure and access to the drug trade for rural residents, it cannot be the sole factor in rural America's growing difficulties with drug addiction and related crime. It is likely that the encroachment of urban drug traffickers on rural locales combined with other factors such as high unemployment, poverty, and lack of drug education and prevention programming is a more complete explanation.

The solution to the drug problem must be more than just enforcing anti-drug laws in rural areas. A more holistic approach would be to increase funding for drug treatment and prevention centers, as well as economic opportunities in general. More educated and financially stable communities could create viable alternatives to joining the drug trade for rural residents, and encourage drug dealers to do their business elsewhere.

More thoughts on the foundation of rurality

Our class discussion today about metronormativity and the LGBT community left me thinking again about one of the underlying themes of this semester: What defines the rural? Is it simply a matter of spatiality (i.e., small populations relatively cut off from certain resources and services) molding social norms, or is there something unique about rurality that one might distinguish from the physical rural environment? Is there a “type” of person attracted to particular spatial challenges, and therefore a rural culture/psychology that chooses its space, rather than the other way around?

Such a choice between culture and space presents a largely false dichotomy. Neither the chicken nor the egg properly comes before the other; each inherits characteristics from its counterpart and introduces its own variations in the ongoing sequence of evolution. However, such a back-and-forth between two forces does not necessarily imply an equal balance of influence. In the case of rurality, I believe the balance between culture and environment tilts decidedly in favor of the latter. In the end, spatiality provides the most powerful constant behind what we would describe as rural.

I began by mentioning that the idea of metronormativity led me down this particular rabbit trail, so I should explain that term. As is relevant for this blog, metronormativity posits that rural communities are relatively hostile to the LGBT community, so the only true path to fulfillment as an LGBT person is to escape to urban oases of tolerance. See Judith Halberstam, In a Queer Time and Place: Transgender Bodies, Subculture Lives 34-37 (NYU Press 2005); Bud W. Jerke, Queer Ruralism, 34 Harv. J.L. & Gender 259 (2011).

However, as our discussion today brought up, recent studies indicate that hostility toward LGBT people is roughly proportional between rural and urban communities. In no sense are cities free of bullying and homophobic violence. Indeed, there are even decades-old lesbian and gay oases in rural communities that enjoy considerable tolerance (if not open-armed acceptance) from their supposedly intolerant neighbors, possibly due to the stereotypical rural respect for solitude and privacy.

Here, then, is another example – and a powerful one at that – of how deeply varied and complex rurality is. It can be amenity-rich and prosperous, or it can be barren of resources and steeped in poverty. It can revolve around agriculture, rustic tourism, or extraction economies. It can be comprised of a handful of families who have lived in the same area for generations, or it can consist of recent urban refugees bearing new money and gentrification. And last, it supports “values” that can lead to unspeakable violence or to acceptance of diversity.

Underlying these alternative manifestations of rurality, the only true constant is the physical environment. The people involved share similar space, but they vary wildly in the norms they have established within that space. In defining “rural,” then, the lodestar must be spatiality. There is no more reliable characteristic.

Queering rurality: asking for visibility for rural queers

Industrialization in the United States during the last century created a national social narrative of evolving one's personal self through relocation from the "farm" (rural) to the city (urban). Relocating oneself from the rural to the urban also relocated one's presumed access to greater possibility of increasing personal economic class privilege. The binary journey linking self-betterment to self-urbanization through rural to urban migration has only been magnified in the social history and identity narrative of queer Americans.

Queer scholars like Judith Halberstam in A Queer Time and Place identify this process as "metronormativity" and further suggest that the actual physical migration of a queer person from rural to urban parallels the "psychological journey from closet case to out and proud." Layered into the assumptions of this dichotomous trajectory are the typical stereotypes equating rurality to backwardness or social stagnancy. As Halberstam illustrated, these stereotypes are profoundly magnified in the current socially encouraged trajectory for queer Americans.

Urbanization as the acceptable normative queer American social experience results in an invisibility of non-urban queer Americans. Queer metronormativity also increases the assumptive associations between safety/coming out linked to the city and hate crimes/being closeted linked with rurality. Possibly similar to the social narrative of many other American minorities struggling for power and visibility, rurality has become something queer Americans leave behind for the presumed safer and more diverse haven of city life. Scott Herring in Another Country: Queer Anti-Urbanism and Mary Gray in Out in the Country: Youth, Media and Queer Visibility in Rural America further analyze the urbanization of this queer social narrative through examinations of films, art, media and other expressions of rural queer Americans throughout the last century.

Citing countless resources and examples, Herring addresses the complexity of the intersection of rurality and queerness through providing robust support for a long history of rich rural queer visibility. Herring aptly surmises that such queer rurality complicates

"geophobic claims that ruralized spaces are always and only hotbeds of hostility, cultural and socioeconomic poverty, religious fundamentalism, homophobia, racism, urbanoia, and social conservatism, their works question knee-jerk assumptions that the 'rural' is a hate filled space for queers as they archive the complex desires that contribute to any non-metropolitan identification."

Herring goes further to examine how the urban has become linked with homonormativity; or that to be a 'good queer’ is to be an ‘urbanized queer.’ The book's worth of examples that Herring provides deeply impress his overall argument that to be a rural queer is to be inherently "infinitely disruptive" to the current model of homonormativity.

Rural queers face many challenges in everyday living very specific to being both rural persons and queer persons. An integral step in eradicating the daily oppressions faced by rural queers is to redefine queer rurality according to the merits of its own experience, not just as the backward "other" to the modernized, urban "normative" queer. Gray summarizes the importance of such increased visibility of rural queers as a tool to reconfigure the social narrative of queer identity:

"..the narrative of rural to urban migration graphed gay visibility as a political accomplishment onto the space of the city. A politics of visibility needs the rural (or some otherness, some place) languishing in its shadow to sustain its status as an unquestionable achievement rather than a strategy that privileges the view of some by eliding the vantage point of others."

Mercy Mount Shasta to close skilled nursing facility

Last spring one of Siskiyou County’s only operating hospitals announced it would be closing its skilled nursing facilities due to budget cuts. With my own cohort of ailing grandparents, I was taken aback. Where would the center’s 32 patients go? Three years ago, my grandfather suffered a major stroke. He needed skilled nursing to make a good recovery but we were hard pressed to find a facility that would take him. Mercy Mount Shasta was full along with most of the facilities in the nearest metropolitan center, Redding. We did finally settled on a Redding elder center that housed patients three to a room. Grandpa would stay up nights unable to sleep for the noise of the other patients. I cried when I first saw him, once the strength of our family and capable of great big bear hugs, in that cheerless place that smelled like urine and TV dinners. While there was a capacity problem in these facilities two years ago, now there are no skilled nursing centers in Mt. Shasta or Dunsmuir and I can just imaging the Redding facilities squeezing extra beds into their crowed brown wallpapered rooms.

Thinking of rural flight we tend to focus on the youth who leave for financial opportunity. Indeed, nearly all of my high school friends from my home town of Dunsmuir, California no longer live in Siskiyou County. But more and more, I am noticing those who are forced to leave because they are aging and cannot receive the care they need in this rural region. My grandparents, for example, have set up a permanent residence in Redding to have easier access to their doctors and to avoid the treacherous winter snow and ice of the mountains. This year my sister-in-law’s grandmother, found herself in the same center my grandfather had, but unlike him, she will not be leaving. Her family is now unable to provide the physical support she needs. With the closure of the skilled nursing facility in Mount Shasta there are no real options left for the elderly persons in need of full time care, but to leave. Their families can choose to leave with them or make the hour commute to visit them in the valley.

Rural communities often suffer lesser access to services including elder services, which is interesting when contrasted with a 1995 study that indicates that rural areas are disproportionately aging compared to urban areas. The study suggests that states invest in elder care options in these regions. Given the age demographic, this is a good policy approach for improving elder care. If we continue to ignore these areas then elder care facilities in urban centers must continue to grow their capacities to accommodate the rural drift. Moreover, rural residents must move to their elderly, content themselves with losing their elderly to distant centers, or somehow invest in the transportation necessary to make the commute to visit their loved ones. As it stands, both the elderly and the family members suffer from reduced quality of life due to the lack of local services.

You can take the rural out of the farm, but...

Despite the fact that studies have all conclusively proved that only a very small minority of rural people are involved in agriculture or farming (7%, according to the W.K. Kellogg Foundation), it appears that not only do non-rural people still equate the rural with agriculture, but the United States government still structures itself so that "rural" is equated with "farm" as well. Although not surprising, the so-called Department of Rural Development is located as a subsidiary of the US Department of Agriculture.

What are its goals, you may ask? According to its website, the DRD is dedicated to "helping improve the economy and quality of life in rural America."

Our financial programs support such essential public facilities and services as water and sewer systems, housing, health clinics, emergency service facilities and electric and telephone service. We promote economic development by supporting loans to businesses through banks , credit unions and community-managed lending pools. We offer technical assistance and information to help agricultural producers and cooperatives get started and improve the effectiveness of their operations. We provide technical assistance to help communities undertake community empowerment programs.

The Department of Rural Development not only has a national secretary and under secretaries, but it also has a director appointed for almost every state in the union--thankfully, there is no director for the state of Rhode Island, which, I can assure you, is so densely populated that not a single inch of it could be classified as rural.

Perhaps the federal government does not want to waste money re-structuring its programs just because populations have shifted, or technology has enabled farming to become something that is less labor-intensive, but placing its Department of Rural Development squarely under the USDA, which monitors, among other things, the country's food and nutrition, seems like it might largely be ignoring the true needs for adequate social programming for rural families and children-- such as education, job opportunities, and access to holistic medical care.

Of course, I'm sure entire courses are taught in Political Science discussing the origins and functions of government bureaucracy, so the process of changing which Department administers the Rural Development Department may just be more work, time, and effort than would be deemed necessary or appropriate. However, it seems perfectly clear that the general publics' assumptions about rurality being overwhelmingly linked to agriculture may be reinforced by the federal government's continued insistence that the two go hand-in-hand.

Lessons from North Africa

North Africa is in a turmoil. Tunisia's Jasmine Revolution started it, achieving regime change via civil resistance and political protest demonstrations. Cairo's Tahrir Square protests followed in Egypt, toppling Mubarak's U.S.-backed administration. But so far, few of the media circling this hot spot of news material has pointed out the significance of these two countries' rural poverty at the root of their initial discontent.

This report on NPR (and only a few others, such as Al Jazeera) stated the obvious: rural Tunisians fared worse than their urban counterparts. As this blog post already stated, to a large extent, Ben Ali's regional neglect and cronyism caused investments from the West (U.S. and E.U., mostly) to flow to the cities, with little or not trickle down to the rural central and southern regions. Maybe it was just that trickle down economics does not really work. Or maybe the neglect of the countryside stemmed from a rather sinister motivation. As NPR said:

Ben Ali came from the Tunisian coast, so there was an added sense in the rural areas that the ousted dictator favored the coastal resort towns while people here got nothing.

Reuters reported similar sentiments from rural Egypt:

The protests may have begun with an educated youth and liberal, urban elite, but a tour of the Nile Delta suggests discontent is more widespread. ... The capital and its central Tahrir Square has been the epicentre of protests, but cities across the Delta north of Cairo, those far to the south and others to the east have also had streets filled with demonstrators demanding Mubarak go. ... Two-thirds of Egypt's population is under 30. That age group accounts for 90 percent of the jobless. Protesters want wealth from economic liberalisation, promoted by the former cabinet, to spread beyond a business elite linked to the ruling party.

To further complicate the picture, not only is the Egyptian population, but as this blog post points it out, it is also increasingly rural.  Young, rural, and unemployed.  These reports seem to indicate that the rural-urban divide in North Africa is also a class-based divide, a disparity of opportunity, of the presence of diverse businesses and supportive institutions. Sound familiar?

We discussed earlier that even though the rural U.S. is discontent, an increasing amount of that discontent is aimed at policies that have little to do with economic opportunity. Thomas Frank argues in What's the Matter with Kansas? that the formerly progressive population of Midwestern, agrarian and rural states, such as Kansas, were "won" over by the Conservatives, who succeeded in mis-educating the working classes there, and managed to transfer their discontent to unobtainable, culture-war issues.

I tend to agree with this view. Even if one disagrees, however, it is hard not to realize that the economic discontent over the loss of rural opportunity may, one day, fuel a revolt here in our own country. Are we, Americans of the coastal regions, resolved to ignoring our own good people for decades? In other words: are we like Ben Ali?

On the skin of the Earth: dirt.

Dirt! The Movie

Doubtless the most significant benefit to being married to a science teacher is that I can watch all the science documentaries I want without feeling the least bit guilty.  A couple of nights ago, we watched Dirt! The Movie with our four-year-old daughter.  She was paying attention closely, a considerable feat for her age, and became very much distressed that by living in suburbia, consuming imported goods, and driving everywhere we are potentially destroying dirt.

The movie talked about how ages ago the people populating Earth understood that dirt (that is, soil: fertile, sweet-smelling, crumbling dirt) is a treasure to be cherished, as it is the sole source of our nutrition.  But we became increasingly urbanized, industrialized, and removed from the dirt. By being removed from the dirt, we become uninterested in maintaining it.  By moving farther away from the dirt, we need to move things that grow in dirt closer to us, on paved roads, by trucks, on railroads... and we make now things from oil, manufacturing plastic, putting things in plastic, and sometimes even eating plastic... And we are using huge ships to lug containers after containers full of plastic STUFF... Instead of using materials that grow from the dirt, close to our home.

I get it, I do.  And so does my four-year-old.  She wants now wooden toys, cotton stuffed rag dolls. ("Down with the Barbies!" I say, the feminist in me rejoicing. I just can't imagine a rag doll with 36DDD boobs.) And she understands why I scout the shelves at the grocery store for organic produce and products, and why I grow lettuce in my backyard, instead of, say, tulips.  

1491 by Charles C. Mann

But what really struck me in the movie was how we are depleting the dirt, then wonder about the methods to revive it.  Peoples of the agricultural ages had this knowledge: the Mesoamerican milpa was not a monoculture: a milpa was growing maize, squash, and beans together in one plot, so the squash and the beans could climb onto the corn stalk.  It reduced the need for fertilizer, weeding, and provided a complete nutrients package: grains, oil, fiber, protein, all vitamin-loaded.  Jared Diamond has written extensively about the benefits of Mayan and Aztec agriculture, especially compared with the now-prevalent monocultures, which originated in the fertile crescent. (Note here how the once fertile crescent is by now a decidedly unfertile piece of real estate.)  And Charles C. Mann describes in 1491 all the knowledge that was lost when European settlers, "accidentally" interfered with, and destroyed, the Native American systems of agriculture.  By encouraging monocultures, we are endorsing an agriculture that is headed towards disaster.  

And that got me thinking about how the rural-to-urban migration destroys not only the dirt, but the knowledge that is necessary to restore the balance of it. By enacting policies that force rural residents to abandon agriculture as a lifestyle, and adopt an urban, or suburban lifestyle, we are destroying the knowledge base that was passed down generation to generation, for over may thousands of years.  Knowing how to work with the land, not just work on the land is the quintessential problem of agriculture as an art.  And I am worried that this art is going to be lost for future generations.

Dirt! The Movie features roof-gardens as a probable solution to the droughts in Southern California's urban desert.  It also shows us a group of urbanites who settled in up-state New York after scouring the literature for sustainable farming methods, and starting accumulating this knowledge anew.  Before you scoff and discount them as boutique-farmers, consider this: they did what pretty much we all should be doing.  Sustainable growth is a global issue, as population of the planet approaches 7 billion mouths to feed.  And the more urbanites and suburbanites realize how important it is to save the dirt, the faster we get to sustainable living on the planet.  I can already contribute my four-year-old suburbanite to the converted.

Humanity's greatest accomplishment? the city!?!

A new book, "Triumph of the City" by urban economist Edward Glaeser, proclaims just that. The book is just out from Penguin Press, and here's how the publisher is promoting it:

America is an urban nation. More than two thirds of us live on the 3 percent of land that contains our cities. Yet cities get a bad rap: they’re dirty, poor, unhealthy, crime ridden, expensive, environmentally unfriendly… Or are they?

As Edward Glaeser proves in this myth-shattering book, cities are actually the healthiest, greenest, and richest (in cultural and economic terms) places to live. New Yorkers, for instance, live longer than other Americans; heart disease and cancer rates are lower in Gotham than in the nation as a whole. More than half of America’s income is earned in twenty-two metropolitan areas. And city dwellers use, on average, 40 percent less energy than suburbanites.

Glaeser also calls the city our "best hope for the future."

I'm looking forward to reading Glaeser's book. Meanwhile, I can't help wonder how much better rural dwellers would fare vis a vis their urban counterparts if governments actually invested in rural livelihoods--with services and infrastructure--in a more equitable fashion.

When an entire county goes to pot

I grew up in the Marijuana capital of the world: Humboldt County (“Humboldt”). Humboldt, which is part of the “Emerald Triangle,” is a region in Northern California consisting of three counties (hence the triangle reference): Humboldt, Mendocino, and Trinity. The Emerald Triangle has been world famous for its pot since the early 1980’s. That’s when it became one of the first places in America to grow marijuana that could compete with pot grown in places like Mexico, South America, and the Caribbean Islands.

The Pot industry in Humboldt was began by Hippy refugees who cultivated huge fields of marijuana in the most rural parts of the County. The majority of the county’s families who did not grow pot made their living by working for the thriving timber and fishing industries of the North Coast. However around the early 1990’s both of those legitimate industries had all but dried up. Now the economies in the Emerald Triangle, especially those in Humboldt and Mendocino counties revolve almost completely upon the revenue derived from exporting Marijuana.

It is no longer only the fringe elements of the region who grow enough pot to support their families. Thanks to sophisticated advancements in pot growing techniques it is now possible to grow thousands of dollars worth of pot indoors, and not just in warehouses. Now, much like in the Showtime series “Weeds” even Susie homemaker types can raise her family entirely on the money she makes by converting one of the three bedrooms in her house into an “indoor grow scene.”

Families who’s breadwinners who traditionally worked as loggers, truck drivers, and mill workers often turn to growing pot in order to get by. Much of the younger generation of Humboldt locals have grown up seeing this as one of their only options for making money. Take for example Tony Sasso now 42 and serving a 14-year sentence at the federal penitentiary in Atwater: He'd begun growing pot as a teenager in the mid-1980s, when police helicopters forced growers to hide their plants indoors.

His harvests paid for expensive trucks, skydiving in Maui, boogie-boarding in Chile and a five-bedroom home with a four-car garage. He eventually owned five ranches, including two in Oregon, and says he took in as much as $11 million a year.

"I grew up believing that the only way to make money was to grow marijuana, and I was good at it," said Sasso, Now with the production of marijuana skyrocketing in California thanks to the legalization of medical marijuana, profitability has declined sharply, and cases like Sasso’s are the minority. Now it is the average college student; high school drop-out; the single mother; the video game playing bachelor; and the young couple who all grow pot to make a living. It is conservatively estimated that one in seven homes now contains an indoor grow scene.

In urban parts of Humboldt County for example, electrical use per household has leaped 50% since 1996, when voters approved the state's medical-marijuana initiative, according to a study by the Schatz Energy Research Center at Humboldt State University.

In Arcata and unincorporated areas of the county, average electrical use rose 60% during that time -- while California's overall use remained virtually flat. This trend is only becoming more common. Unfortunately for many however, something will eventually have to give, whether that something is outright legalization; stricter county regulations; or landlords refusing to rent to anyone suspected of looking for a spot for their indoor grow or a combination of all three. What will happen to those who have no plan B? What will the economy of Humboldt County look like in twenty years? It remains to bee seen, but the trend is towards increased regulation, and decreased revenue.