6

Final Reflections

In the final session of the workshop, members of the Roundtable on Population Health Improvement and the Roundtable on the Promotion of Health Equity commented on the themes that emerged from the workshop, which are presented in Chapter 1, and on areas where further research, discussion, and action are needed. While not an exhaustive list, the insights and ideas shared by roundtable members capture both the progress that has been made and the many challenges that remain.

• Expertise of many different types is needed to understand the disadvantages facing rural communities, including the expertise of economists, geographers, and sociologists. All of them could be involved more extensively in analyzing the problems and potential solutions to rural inequities in health. (George Isham)
• Little information is available about the Asian/Pacific Islander population in rural America. Yet, groups such as the Hmong in California and the Marshallese in Arkansas are changing rural America and face many health challenges. The demographics and dynamics of many rural areas are changing, and Asian/Pacific Islander populations are just one aspect of those changes. (Winston Wong)
• The “three Es” at the heart of the work of the Roundtable on Population Health Improvement—equity, economics, and education—all need to be understood better in developing ways to overcome inequities. (George Isham)

• Rural areas are very different and require different approaches. “Coming here from California, I really have to remind myself—not only out of respect but out of humility—that we can’t presume to have all of the answers for Alabama or New Mexico.” In one rural community, a hospital that is struggling financially might be kept open even though people have the option of traveling another 20 minutes to a tertiary care center that offers a variety of services, such as a trauma center and a newborn intensive care unit. In another community, a hospital might close but then be used as a wellness center to improve health. (George Flores)
• Just as definitions of the term rural can be debated, the definition of community is not settled. Along the border, immigrants are not necessarily considered part of communities, and other marginalized groups can feel the same way. Strength and creativity originate in communities, which means that communities need to be considered holistically to maximize their capacities. (Octavio Martinez)
• Elections and voting are factors in inequities. “We didn’t talk much about politics today, but they are the elephant in the room. Until we get better representation for communities of what they need in governance, many of the resources that need to flow to those communities will be absent.” (Marthe Gold)
• People from areas of persistent poverty need to be elected to governmental positions so they can make a difference in their communities. “We have a lot of volunteers and a lot of people working in organizations in these persistent-poverty communities. . . . Maybe the next step is to do some training programs and get those community members to feel that they have an opportunity to be elected to government positions.” Women’s voices in particular have had a pivotal effect in communities and could be further emphasized. (Mary Pittman)
• If young people in rural communities can be engaged so they acquire the skills that contribute to the development of healthier and more prosperous communities, they will be more likely to stay in their communities and invest their talents in rural areas. “Civic engagement is a critical piece to cultivate at a very early age.” Maintaining that, as well as education and skill building, will ensure that young people can help the community thrive in the future. (George Flores)
• The rural justice system can be a lever for change. Sheriffs, judges, and the juvenile justice system can have a large effect on health disparities, not only at a particular time in a person’s life but for years into the future. Rural jails, for example, have a major influence on behavioral health. The rural justice system is becoming even more

• critical given the opioid and mental health crises affecting rural areas. (Octavio Martinez)

• Despite the wisdom of taking “what we have to make what we need,” money needs to come into communities to support education, or people will remain trapped in a low-education, low-wage economy. (Marthe Gold)
• Society is on the verge of profound changes, particularly as automation, robotics, and artificial intelligence change the nature of work and daily life. These changes could transform rural life, just as the industrial revolution did before. They will create “an opportunity to overcome some of the traditional challenges of rural sparsity [and] new problems.” (George Isham)
• The most hopeful people at the workshop were those who were “closest to the ground and who had not left behind the people they loved.” Mapping and acting on the hopeful and generative aspects of rural communities may be the best way to invest in the future rather than focusing on what is broken and how much worse some things are getting. (Gary Gunderson)
• A single person who gives voice to others can make a difference, even at the federal level. “I am leaving this conference on rural health equity with a good feeling about hope for the future.” (Ned Calonge)

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