I would like to see a comprehensive rural health agenda where the first line reads like this: Save the earth!
I am a health policy expert. I spend my days deep in data and discussion about how best to structure the organization and financing of health care delivery systems and the programs and policies that are needed to improve the health of people (especially women and children), families, and communities. I have published over a hundred research papers, generating knowledge that has informed policy dialogues and led to policy changes. But I have been missing the point: the foundation from which all health is drawn is our land, air, water, plants, and wildlife.
July 2019 was the hottest month ever. Ever. In the whole world. The concentration of carbon dioxide in our atmosphere is the highest it has been in 3 million years at 408 parts per million. Signs of climate change are everywhere, including events such as droughts, floods, heat waves, wildfires, extreme weather events, and sea-level rise. Rural communities, including Indigenous people living on tribal lands, are at greater risk.
Rural U.S. residents also face health risks that are unique and growing. Rural hospitals are shutting their doors. Suicide rates have increased 33% since 1999, rising to the highest level since World War II. Rural residents are more likely to die by suicide than urban residents, with some rural residents being especially vulnerable, especially rural men, and people living in counties with less social capital.
On a daily basis, both climate change and health risks generate crises in rural America. One set of facts is not worse than the other or more or less deserving of attention. Rather, they are inextricably linked, and efforts to improve rural health must include attention to our changing climate.
I have come to see the connection between climate and health most intimately in rural and tribal communities. Health and public policy leaders too rarely listen to rural and Indigenous folks. If they did, they would know that the way rural and Indigenous people value and care for the health of our environment is directly related to the health of the plants, animals, and humans that depend on the land and water. For example, farmer mental health is shaped by severe weather events, which affect crop yields and finances. Rural infants are more likely than urban infants to die before their first birthdays. That disparity may be related to exposure to toxins such as smoke or pesticides, but this has not yet been fully examined, and it should be. Additionally, natural disasters are occurring with increased ferocity and frequency, affecting both rural and urban communities, but media coverage, as well as disaster relief efforts and resources, tend to concentrate in urban areas, leaving rural and Indigenous victims at greater risk for stress and other health challenges.
In the parlance of public health, we often refer broadly to the social determinants of health, the conditions in which people are born, grow, live, work, and age that affect health and well-being. It is well-known that health care delivery systems account for only about 10-20% of overall community health, and public health leaders frequently decry the underinvestment in aspects of health outside of medical care. Yet this dialogue does not go nearly far enough. Recent efforts to center the role of climate change by the American Public Health Association and others are welcome, and we should build upon these in our internal conversations, our personal choices, our policy platforms, our research, and our daily work as public health professionals.
To be sure, health policy remains critically important, and repeal of reforms enacted through Obamacare would have swift and dire consequences on the health of rural people and communities. Unfortunately, there are many other events – from policy decisions to weather events – that can inflict swift and dire consequences on the health of rural communities. We need to recognize that both a hurricane or tornado and the closure of a hospital have the potential to affect the health and well-being of communities, with potentially tragic consequences. Attention to both is warranted. However, if our planet is sick, keeping a rural hospital open will not save us.
Addressing the social determinants of health starts with climate awareness and activism. Rural knowledge – including Indigenous peoples’ knowledge – of the land and its vitality should guide systemic change in environmental, economic, and health policy. Those of us with power to generate knowledge, make policy, or allocate resources ought to make rural knowledge the foundation of efforts to improve rural health, starting with combating climate change. That begins with acknowledging our connection to the earth and to one another. This sacred connection is a fundamental value for rural and Indigenous people, and it can guide us all to better health.
Katy Backes Kozhimannil is Associate Professor at the University of Minnesota School of Public Health and Director of the University of Minnesota Rural Health Research Center. She was born, raised, and lives among forests and lakes in Minnesota. Follow her on Twitter @katybkoz.