ose that hospitals try to keep all the people in their communities healthy. 

We've known for decades that we should be paying more attention to preventing disease, yet very little has actually been done. If we want to save money on health care we should be keeping people from getting sick, but treating heart disease pays very well. Preventing it doesn't.

This is old stuff. When the Health Planning Act of 1974 was getting rolling, a widely used video cartoon featured a community building a marvelous system for rescuing people who fell off a cliff into a river. Boats could race downstream after drowning victims, fish them out, get them into ambulances and whisk them to the local hospital with wonderful efficiency. They were very proud of their system. 

Then someone suggested building a fence to keep people from falling into the river. The name of the video was, "Upstream, Downstream."

I was startled last week to come across precisely the same "upstream/ downstream" figure of speech in a doctor's blog lamenting the number of people with preventable troubles who wind up in the emergency room. 

My point? We've agreed on the need for a focus on preventive services for close to 40 years but left it to individuals and a few exceptional clinicians to actually do it.

Lots of rural counties have people with really poor health. Bill Bishop and Roberto Gailardo, writing in the Daily Yonder, have published tabulations of the life expectancies of rural men and women by county (see Life Expectancy for Rural Men; The Lifespan of Rural Women). The news is pretty good if you live in Iowa, Minnesota, Wisconsin, New Hampshire or Vermont; or, if you're a man in Utah or a woman in North Dakota. Otherwise, if you're a rural person, chances are you won't live as long as your city counterpart. 

[img:FemaleLE2009528.jpg]

And the situation is even bleaker in many rural counties. I encourage you to have a look at your state and county on the Yonder maps. Oversimplifying, draw a line connecting the northern border of New Mexico to the northern border of Pennsylvania. People in most rural counties south and east of that line and those borders die early, as do those in Indian Country. So do others in more scattered counties.

Somebody should be taking responsibility for bringing the science of health promotion and disease prevention to rural communities. A couple of health fairs a year aren't cutting it.

At the same time, putting it bluntly, small rural hospitals are at risk of becoming a solution in search of a problem. Although we picture hospitals as places with people lying in beds, that role is gradually going away. 

Granted, there are exceptions, but the long term trend is against acute inpatient care in small unspecialized facilities. The small hospitals I'm familiar with get 70 percent of their money from their clinics and the middle sized hospitals get over half. Hospitals should be looking at every community health need and thinking whether and how they can meet it.

The Affordable Care Act requires a not for profit hospital to do a "community needs assessment"; that is, in return for its reprieve from paying corporate taxes, every hospital must study the needs of its local people and how it can meet them. All the premature death in rural America suggests we need more focused, science based effort on helping people stay healthy.

Making this happen will take lots of changes. There is a body of knowledge on what works and does not work in community health promotion. That technical knowledge will have to be brought to people actually doing the work. 

Our national public health organizations and agencies focus on large populations and will have to learn to find rural America. Rural health and management professionals will have to learn new skills. Targets and best practices will have to be updated. Payment patterns will have to change.

Of course there will be lots of other stuff going on at the new "health mall," which was once mostly full of in patients: the emergency room is in back, and there are some hospice and recuperating patients upstairs. 

In person and telemediated day and evening clinics, health department functions, prenatal and young parent classes, the mental health center and various therapies are housed here. 

The cafeteria overseen by a talented dietician is the best place in town to eat. 

Seniors stay to visit with their friends after the diabetic exercise class. The swimming pool and exercise room stay open until 9. All the local health related activities are here.

The health promotion issue tends to become personal for me. I'm about the average dying age for rural men, and I haven't got the hay baled or the firewood in for the winter. 

My dad started out in West Virginia, spent most of his working life in the Oklahoma and Texas oil fields, and died in his fifties in the Missouri Ozarks of chronic cigarette and bacon fat poisoning. All these remain early death states. A determined effort might finally break up that great American emphysema and apple pie tradition, and give some rural hospitals a new lease on life.

Wayne Myers is a retired pediatrician and rural medical educator. He directed the federal Office of Rural Health Policy from 1998 through 2000, and was President of the National Rural Health Association in 2003. He and his wife, JoAnn, farm in rural Maine. This article first appeared in The Rural Monitor.

I propose that hospitals try to keep all the people in their communities healthy. 

We’ve known for decades that we should be paying more attention to preventing disease, yet very little has actually been done. If we want to save money on health care we should be keeping people from getting sick, but treating heart disease pays very well. Preventing it doesn’t.

This is old stuff. When the Health Planning Act of 1974 was getting rolling, a widely used video cartoon featured a community building a marvelous system for rescuing people who fell off a cliff into a river. Boats could race downstream after drowning victims, fish them out, get them into ambulances and whisk them to the local hospital with wonderful efficiency. They were very proud of their system. 

Then someone suggested building a fence to keep people from falling into the river. The name of the video was, “Upstream, Downstream.”

I was startled last week to come across precisely the same “upstream/ downstream” figure of speech in a doctor’s blog lamenting the number of people with preventable troubles who wind up in the emergency room. 

My point? We’ve agreed on the need for a focus on preventive services for close to 40 years but left it to individuals and a few exceptional clinicians to actually do it.

Lots of rural counties have people with really poor health. Bill Bishop and Roberto Gailardo, writing in the Daily Yonder, have published tabulations of the life expectancies of rural men and women by county (see Life Expectancy for Rural Men; The Lifespan of Rural Women). The news is pretty good if you live in Iowa, Minnesota, Wisconsin, New Hampshire or Vermont; or, if you’re a man in Utah or a woman in North Dakota. Otherwise, if you’re a rural person, chances are you won’t live as long as your city counterpart. 

[img:FemaleLE2009528.jpg]

And the situation is even bleaker in many rural counties. I encourage you to have a look at your state and county on the Yonder maps. Oversimplifying, draw a line connecting the northern border of New Mexico to the northern border of Pennsylvania. People in most rural counties south and east of that line and those borders die early, as do those in Indian Country. So do others in more scattered counties.

Somebody should be taking responsibility for bringing the science of health promotion and disease prevention to rural communities. A couple of health fairs a year aren’t cutting it.

At the same time, putting it bluntly, small rural hospitals are at risk of becoming a solution in search of a problem. Although we picture hospitals as places with people lying in beds, that role is gradually going away. 

Granted, there are exceptions, but the long-term trend is against acute inpatient care in small unspecialized facilities. The small hospitals I’m familiar with get 70 percent of their money from their clinics and the middle-sized hospitals get over half. Hospitals should be looking at every community health need and thinking whether and how they can meet it.

The Affordable Care Act requires a not-for-profit hospital to do a “community needs assessment”; that is, in return for its reprieve from paying corporate taxes, every hospital must study the needs of its local people and how it can meet them. All the premature death in rural America suggests we need more focused, science-based effort on helping people stay healthy.

Making this happen will take lots of changes. There is a body of knowledge on what works and does not work in community health promotion. That technical knowledge will have to be brought to people actually doing the work. 

Our national public health organizations and agencies focus on large populations and will have to learn to find rural America. Rural health and management professionals will have to learn new skills. Targets and best practices will have to be updated. Payment patterns will have to change.

Of course there will be lots of other stuff going on at the new “health mall,” which was once mostly full of in-patients: the emergency room is in back, and there are some hospice and recuperating patients upstairs. 

In-person and telemediated day and evening clinics, health department functions, prenatal and young parent classes, the mental health center and various therapies are housed here. 

The cafeteria overseen by a talented dietician is the best place in town to eat. 

Seniors stay to visit with their friends after the diabetic exercise class. The swimming pool and exercise room stay open until 9. All the local health-related activities are here.

The health promotion issue tends to become personal for me. I’m about the average dying age for rural men, and I haven’t got the hay baled or the firewood in for the winter. 

My dad started out in West Virginia, spent most of his working life in the Oklahoma and Texas oil fields, and died in his fifties in the Missouri Ozarks of chronic cigarette and bacon fat poisoning. All these remain early death states. A determined effort might finally break up that great American emphysema and apple pie tradition, and give some rural hospitals a new lease on life.

Wayne Myers is a retired pediatrician and rural medical educator. He directed the federal Office of Rural Health Policy from 1998 through 2000, and was President of the National Rural Health Association in 2003. He and his wife, JoAnn, farm in rural Maine. This article first appeared in The Rural Monitor.

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