Rollins Goes Rural

In the 1950s, Dr. Stephen Patrick’s grandfather worked on the railroad in Bluefield, W.Va. The railroad served a booming coal industry. But when the industry began declining, things changed. The town’s population is now half of what it was 60 years ago. Jobs are hard to find. 

Bluefield isn’t alone. Across the United States, rural areas have a poverty rate nearly 30% higher than metro areas. And many of the nation’s poorest counties—the ones where more than one in five people live below the federal poverty line—are clustered in the Southeast. 

Rural communities often struggle with high rates of mental health disorders, obesity, heart disease, and dementia. And many lack the resources to diagnose and treat these conditions.

“There are fewer hospitals in rural areas,” says Amit Shah, MD, associate professor of epidemiology. They’re also spread far apart, and often don’t have enough resources. “People are going to have obstacles getting to the doctor, especially in emergency situations,” he says. “For example, if someone's having a heart attack in a rural area, they're less likely to get a catheterization or a stent.”

It’s all part of a vicious cycle of poverty, stress, and disease.

Part of the challenge stems from rural communities’ inherent geography: They are far from urban centers and the jobs and resources those centers provide. Historically, many rural areas have relied on industries like mining and agriculture. “These are counties that had been either producing coal themselves or were supporting that industry,” says Hannah Cooper, ScD, professor of behavioral, social, and health education sciences, describing the communities she works with in rural Kentucky. Coal brought in money—and, in many places, continues to do so—but sometimes at great cost to the environment and human health. Mining carved out huge swaths of mountains and caused countless people, including Patrick’s grandfather, to develop black lung disease. 

But times have changed. 

“Then we have the demise of coal,” Cooper continues. “And there was nothing that replaced it.” 

Trouble was brewing in agricultural communities as well. Increasing worker protections and other costs
have driven up imports of fresh produce. As a result, mine closures and farm consolidations have sapped money from rural communities. 

The shift toward large-scale, single-crop farms has impacted diets. In the old days, family farms may have had vegetables, some chickens, and a cow. Today, few farmers are able to feed their families with what they produce. “Let's say they grow wheat,” Shah says. “By no means is someone only going to be eating wheat for breakfast, lunch, and dinner.” Instead, there’s a growing reliance on fast food joints and convenience stores with limited selections of healthy foods.

 In some rural communities, such as the notorious Cancer Alley along the Mississippi River, industrial plants have moved in, spewing chemicals into nearby air and water. They often promise jobs, but may bring in workers from elsewhere.

 “We've had systematic disinvestment from educational and economic opportunities in these counties for a very long time,” Cooper says, referring to the communities she partners with in rural Kentucky. “Now, some of these counties have the highest poverty rates in the United States.”

For many communities, these challenges are interwoven with a legacy of slavery and discrimination. This is particularly true in the Southeast, which once abounded with rice and cotton plantations. Since then, rural Black communities have dealt with generations of trauma and poverty.

Over time, the stress of poverty, racism, and other challenges can lead to disastrous consequences. Shah calls this “the invisible hand.”

Stress triggers inflammation, an immune reaction to perceived threats. Although brief bursts of inflammation can help tame infections and heal wounds, chronic inflammation is another story. 

For example, there’s a strong link between mental health and heart disease, and inflammation in particular can wreak havoc on blood vessels. Shah and Viola Vaccarino, MD, Wilton Looney Distinguished Professor and endowed chair in cardiovascular research, study this relationship in rural environments. One of their projects uses a mobile clinic and accompanying surveys to screen rural participants in Kentucky, Alabama, Mississippi, and Louisiana for cardiovascular disease and map the effects of long-term stress on the heart. In another ongoing study, they fit rural residents with wearable monitors. Participants fill out regular surveys on stress levels, allowing the researchers to study the real-time effects of stress on heart rate and blood pressure. 

“There is this clear trend, particularly in rural communities, that young and middle-aged women are doing worse [in cardiovascular mortality], and we don't know why,”  Vaccarino says. But she thinks it might have something to do with stress-related inflammation. 

The added stress faced by young women in rural areas could come from many sources. They might have fewer educational and career opportunities, not to mention the added burdens of low wages and child care. These circumstances could make young women more dependent on their male partners, potentially exposing them to intimate partner violence. But this is just conjecture, Vaccarino says. Little data exists for rural communities. She hopes their work will change that. 

But chronic inflammation doesn’t only affect the heart. Along with poor diet and lack of physical activity, it contributes to the development of obesity, dementia, and other chronic diseases—all of which are elevated in rural areas.

Persistent poverty and stress have made rural areas fertile ground for the opioid epidemic to take root. 

“Pharmaceutical companies like Purdue very intentionally and strategically targeted those counties for fraudulent opioid marketing,” Cooper says, describing the beginnings of the crisis in rural Kentucky. The companies convinced doctors that it would be unethical not to prescribe opioids to patients in pain, and promised that the risk for addiction was marginal. Pill mills began to emerge.

“So it's two hits, where maybe there weren't jobs, whether it's the loss of the coal mining industry in West Virginia or rural hospital closures, and then you couple that with an infusion of opioids,” says Patrick, chair of health policy and management. “What we're now seeing is this cascade effect of overdose deaths and other complications.”

Rural areas quickly became ground zero of the opioid epidemic. These communities tend to have higher rates of substance use (including tobacco and alcohol), overdose, and suicide. 

To learn more, Cooper began collaborating with April Young, PhD, an alumna of the Department of Behavioral, Social, and Health Education Sciences. Through community coalition meetings held by their Kentucky partners, the duo learned about the shocking collateral of the opioid crisis. “People kept telling us that arrests and incarcerations were going through the roof and causing all these problems,” Cooper remembers. 

Intrigued, they decided to investigate the community members’ observations. The team compared decades of arrests in 12 Kentucky counties to that of the nation’s largest urban counties. The results revealed that in the 1980s, the rural counties had an incarceration rate half that of the urban ones. But as urban incarceration rates plateaued and slowly began decreasing, the incarceration rate started to rise in the rural Kentucky counties, and eventually surpassed the urban rate. 

“The war on drugs started in cities with the very explicit intention of trying to replace Jim Crow,” Cooper theorizes. Over time, this punitive strategy was applied to reinforce another division: socioeconomic status.

But one thing was very different from the original war on drugs. “Our response to crack cocaine was filled with systemic racism,” Patrick observes. “We've seen a different approach in the opioid crisis because it initially affected non-Hispanic white populations.” 

A general sense of empathy, rather than judgment, meant a greater acceptance of harm reduction programs like clean needle exchanges. “Will our societal approach remain empathetic as non-white populations are increasingly affected?” asks Patrick, pointing to a recent rise in opioid overdoses in non-rural and non-white areas across the country. “We have to ensure it does.”

But increased policing and harm reduction aren’t mutually exclusive. Cooper says, “In these predominantly white rural areas, we have both a scale-up of the war on drugs and simultaneously great investment in harm reduction.”

The opioid crisis has downstream effects on HIV, hepatitis C, foster care, and more. Patrick’s work has shown how factors like low education level, unemployment, and shortages of mental health providers can impact rural counties’ rates of hepatitis C among pregnant women and opioid withdrawal among newborns.

The rise of rural HIV and hepatitis C outbreaks makes sense, Cooper reasons. “If you look at the social networks of people who are injecting drugs in rural Appalachia, and in particular, Kentucky, they're very dense,” she says. “People have a lot of different ties to one another, and that is exactly the kind of network where once HIV is introduced, the virus is going to transmit like wildfire.”

On average, rural communities have older populations with higher rates of dementia. They also have far worse access to both medical and nonmedical care programs, not to mention the transportation necessary for such services. Plus, rural areas simply don’t have enough workers to staff these programs. These workers are often undertrained and underpaid, leading to a high turnover rate.

Regina Shih, PhD, professor of epidemiology, studies older adults’ access to home- and community-based services (HCBS). To learn more about barriers to care in rural areas, she interviewed state Medicaid directors, patient advocates, and service agency providers. Their response shocked her: They said people simply weren’t asking for services. 

“It’s this chicken and egg problem, where a lot of rural people don't see good access to services, so they don't access them,” Shih explains. “But it's not because they don't need them. They're actually finding family care,
or they're finding neighbors to help care for them.”

This phenomenon is called the gray market. In rural areas, people with dementia are five times more likely to rely on this under-the-table care, according to Shih’s research.

“Maybe they cannot find regulated care,” Shih explains. “Maybe they don't want it. Maybe they have political beliefs about enrolling in Medicaid, so they'd rather pay out of pocket. Maybe they are Medicaid beneficiaries, but there aren't enough good options for Medicaid HCBS. So they're like, ‘You know what? I'm gonna take it into my own hands. I’ll hire my friend from church to come take care of my dad.’”

Rural areas often have a culture of independence. But that doesn’t mean residents are on their own. Even though rural networks may be spread over a large geographic area, their bonds are tight. “There is this sense in rural areas more often than in urban areas, that ‘I'm going to be self-sufficient,’” Shih says. “‘I can take care of myself. And I have a community of people around me that are like-minded. And we take care of each other.’” She believes this attitude could be tied to the increased use of gray market care in rural areas. 

To support her point, Shih also points to the Village Movement, a nationwide network of community-based organizations that help people age in place. According to Shih, the first one started when a group of older adults got together and said, “You know what? I wanna take care of the older adults in our community. I’m gonna pay it forward.”

Several years ago, Shih evaluated the Village Movement’s preparation for climate emergencies and made a toolkit to support those efforts. Her research showed that village members looked out for each other. She runs off a list of examples “When there's a snowstorm they go help clear sidewalks,” Shih says. “They do telephone trees to check on people. If they're socially isolated, they just check on them every day. They help them with changing their smoke detectors, they help them with gathering supplies. If there's a hurricane coming, they help them
with sheltering in place or evacuating in the case of a wildfire or heat event.”

What’s more, Shih thinks public health efforts should build on this strength of community. She wants to see better recognition of—along with funding and training for—gray market providers, villages, and other community-based supports.

“There is something unique in rural communities, the sort of collective, caring for your neighbor,” Patrick says.

This care for the community might not always look like you’d expect. In one project, Cooper interviewed rural pharmacists about dispensing buprenorphine, a drug used to treat opioid use disorder. She found that some were eager to dispense buprenorphine as a way to protect and heal the community from the opioid crisis. Others worried that it would cause another wave of addiction, just like the original opioid prescriptions had years earlier. 

“One thing that both groups shared was the sense that they were a part of a beloved community,” Cooper explains. “They had been living in this community all their lives, they had close relationships with their patients, who were often their neighbors. And that's something that was really important to them. They were trying to protect their community in both cases, but they landed with different practices.”

At the same time, that fierce community loyalty—and accompanying suspicion of outsiders— can hamper public health. 

“One of the things that I hear from folks in places like West Virginia is, ‘Here's another outsider coming to fix my problem,’” says Patrick, referring to his home state. Too many times, researchers have come in with promises to help, extracted the data they wanted, and left, never to return.

Rollins strives to do better.

The Emory Prevention Research Center (EPRC) has been working with its partners in southwest Georgia since its inception in 2004. 

“We've stuck with our partners through thick and thin, when we've had funding and when we haven't had funding,” says EPRC Director Michelle Kegler, DrPH. Everything revolves around collaboration. “We don't come in and say, ‘We'd like to do this, will you do that with us?’” she says. “It's more like, ‘What should we do? How should we do it?’”

Over the years, this attitude has fostered a strong relationship built on trust. That trust showed during the height of the COVID-19 pandemic, when community partners asked EPRC to research vaccine hesitancy.

Many people in southwest Georgia were worried about the threat that had mysteriously appeared from outside their community, and often were suspicious of federal mandates designed to control the spread of disease. But while many rural communities didn’t want government oversight, they were still motivated to help their community through food drives and other supports. Meanwhile, many people who chose to get vaccinated did so to protect their friends and families.

This sense of loyalty was the centerpiece of the VAX Up! Southwest Georgia Initiative, a project funded by the Centers for Disease Control and Prevention. Rural residents might hesitate to listen to outsiders, but they had a deep trust in their fellow community members. Led by Kimberly Jacob Arriola, PhD, Charles Howard Candler Professor of Behavioral, Social, and Health Education Sciences, the project identified and trained more than 30 trusted local community members on vaccine safety. Then those community members carried the message to others. “They spread information on the vaccine being safe, tried to dispel some conspiracy theories, and then helped people navigate getting vaccinated,” Kegler says.

Community engagement is important for another reason: Every community is different. What works in one town might not work for another. 

Kegler gives the example of the Smoke-Free Homes initiative, which is now on the National Cancer Institute’s list of evidence-based cancer prevention and control interventions. The program, developed by the EPRC, was initially based on research conducted in southwest Georgia. Now it’s being adapted for places as far away as the countries of Georgia and Armenia, as well as in collaboration with tribes in Michigan and the Great Plains.

“In general, interventions are much more effective if there's community buy-in,” Patrick concludes. “So what does that look like? In some communities it means you have a place for health care from people that you know and trust. It could mean a partnership that draws in expertise from another area but maybe leverages community health workers, leverages telehealth. We need to be thoughtful and creative.”

Doing so could bring about huge benefits. “We've seen really positive things come out of communities,” Patrick says. “My sense is that part of what we need is more of a collective focus to address this in a more comprehensive way. It’s going to take all of us.” 

Story by Deanna Altomara
Designed by Linda Dobson
Illustration by Paul Tong
Photography by Erik Meadows & Bita Honarvar