What will it take to improve the health and health care outlook for rural westerners, and how can we best marshal the resources of Stanford University toward that goal? These questions were central to the conference “Uncommon Dialogue: Improving Health and Health Care in the Rural West,” which brought together a diverse group of interdisciplinary researchers and practitioners to confront a growing crisis.
Photographs by Vladimir Choloupka
Rural Americans have some of the nation’s highest rates of disability, mortality, and chronic disease, and face under-resourced and fragmented health care delivery systems. These outcomes are exacerbated by an aging population, and – for younger rural residents – a deficit of economic and educational opportunities.
The 13 million inhabitants of the rural American West face an additional challenge: the burden of large travel distances.
To Phil Polakoff, consulting professor at Stanford Medical School, it is both the best of times and the worst of times. Play “We've had some great advances in technology, no question. We've had new pharmaceuticals that work,” but the state of public health in the rural West, he said, is a different story. “We've got a lot to do, and that's where Stanford can play a major role. There's no shortage of intelligence here, no shortage of interest and technology.”
Three strategic goals emerged from the day’s sessions:
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“It is so easy to understate the impact of the environment on wellness,” said David J. Hayes, the moderator of a panel on the environmental roots of public health. “The rural West has some of the worst air pollution particulate levels in the U.S.,” said Hayes, executive director of the NYU Law State Energy & Environmental Impact Center Play . He added that “lack of access to drinking water plague the Southwest and the Central Valley of California. So there is much the rural West may teach us about this important connection.”
Asthma, for example, is on the increase in rural areas, and not just because of growing pollutants. Social determinants like poverty and lack of access to care are also major contributors to the problem, said the health researcher Mary Prunicki, Stanford MD. Play In the Central Valley, she said, pollutant exposures exceeded federal standards by more than 40 percent, evidenced by a 34 percent higher rate of asthma and two-thirds higher rate of allergies in Fresno compared to the national average. She advocated for improved communication access like broadband internet, deeper educational and self-care support, and cost-benefit research to determine the most effective interventions.
Craig Criddle, a civil and environmental engineer at Stanford, presented experimental truck-based mobile biotechnical labs that can analyze local wastewater. Play The units can offer immediate detection of antibiotic-resistant organisms and pathogens, as well as more general metrics of community health like as dietary habits, evidence of drug abuse, and the presence of heavy metal contaminants. “You can get a huge amount of information,” said Criddle. As an example, he cited a pilot project on whose website, he said “you can see how much use of cocaine there is in all these different cities across Europe.”
The scientist Chris Field spoke about our understanding of the relationship between climate change and the onset of acute and chronic disease, malnutrition, mental health, and quality of life problems, as well as overall physical fitness. Play “We think about the risk coming from climate change as really the overlap of different kinds of processes,” he said, describing the increased threat of extreme weather and natural disasters, the risk of unpreparedness, either in infrastructure, public health resources or individuals' own state of health.
Looking at the California wildfires of the fall and winter of 2017, he said, “wildfires are so complicated for two totally different reasons: one, it's really hard to contain the physical damage, but it's also really hard to contain the air quality impacts from wildfires.” Field argued that controlled burns could greatly reduce the fuel load in western forests, but that state policies stand in the way. For example, he said, California counts controlled burns against the state’s carbon emissions, but does not count wildfires. “If that forest went up in flames in a wildfire those emissions wouldn't count,” he said.
Field, the director of the Stanford Woods Institute for the Environment, suggested that a key solution in developing impactful policy is to find the overlapping interests among the affected communities.
Ann Arvin said that an additional 200,000 children received immunization shots as a result of a tightening of California's immunization requirements. Play The measure had been promoted by health professionals but was given additional urgency by a 2014 measles outbreak at Disneyland. The resulting immunization increase of three percent was especially large in rural areas, said Dr. Arvin, the vice provost and dean of research, and professor of pediatrics and microbiology and immunology at Stanford School of Medicine. This speaks to the power of well-timed news and communication efforts to drive health policy, she said.
She similarly pointed to the impact on rural children's health in states that opted to expand Medicaid as part of the Affordable Care Act, as well as recent renewal of the CHIP program providing health insurance to children. In 2015, the uninsured rate for children dropped below five percent for the first time ever, with rural counties at six percent, “so not a tremendous disparity there,” said Dr. Arvin. On average 48 percent of children in rural areas receive Medicaid – almost a 40 percent increase in rural areas since the Affordable Care Act passed. “What this tells us,” she said, “is that the impact of this legislation was most important for those children in rural areas, and that means they are going to be more vulnerable if those changes are not sustained.”
James Gibbons of Stanford Engineering shared research on telemedicine programs for patients with chronic conditions. Play The trial project, “Connect.Parkinson,” provided “virtual house calls” by doctors to a randomized sample of 195 people across 18 states. Gibbons said that patients were very satisfied overall with the calls: “As my wife and I live a long way from the nearest neurologist, this technology is a blessing,” wrote one participant; “I find it easier to be more comfortable expressing my [Parkinson's disease] via a remote device than I do during a face-to-face visit,” said another. Gibbons said the trial suggested that virtual visits offered a comparable quality of care to in-person visits, with the added bonus of greater frequency: “the regular intervals of seeing my neurologist through a virtual visit allowed my neurologist to treat more of my symptoms that emerged gradually,” wrote one patient. Physical distance remains a challenge, however. The trial system depends on reliable and high-quality broadband internet, which is not universally available in the rural West.
Beginning with the above quote from Utah State University scholar David Rich Lewis, Ben Robison offered a sobering picture of health and wellness in the Sicangu Oyate Nation (Rosebud Sioux Tribe) in South Dakota. Play There he witnessed poverty, neglect, and drug abuse on a reservation where the unemployment rate is estimated to range from 50 to 80 percent, while nearly nine out of ten of its 9,000 residents are under the poverty line. “The most startling statistic,” said Robison, a recent School of Medicine Graduate and healthcare education consultant, “may be that the the average life expectancy for a male, in Rosebud, in the United States, is 47 years. And that is a year less than Haiti.”
Robison said that opportunities for engagement and support include expansion of their community health worker program and the development of an economic vision based on health and healthcare education and self-governance.
Looking at pregnancy and childbirth, the economist Maya Rossin-Slater began by pointing out that the United States as a whole fares poorly by comparison to other developed countries – and additionally it is the only OECD country with a rising maternal mortality rate. Play She described how, in rural California, mothers more frequently deliver high birth weight infants, a risk factor for childhood obesity and hypertension. In rural communities, she said, women receive less prenatal care than women in urban settings, and deliver babies in hospitals less frequently. Rossin-Slater, a faculty fellow with the Stanford Institute for Economic Policy Research (SIEPR), identified insurance rates and coverage as a key concern for rural communities, in light of the fact that rural residents more frequently pay directly for care, which may lead to less frequent take-up of care.
In her keynote address, New Mexico's secretary of health Lynn Gallagher talked about growing up in rural Truth or Consequences, NM; Play her struggle to overcome family obligations to become the first college graduate; and later, going back to administer to father who was dying of kidney failure. “To deliver hemodialisis, draw blood, and do all of those things,” she said, gave her first-hand experience at the difficulty of caring for sick and aging parents in a rural community. There, the complexity of navigating the health care system was especially hard, she said. “I called the nephrologist to say he had an aortic aneurysm and she responded, 'that's not my field.'”
Gallagher laid down a blunt challenge. “Why are physicians going overseas when we have so much need here?” she asked. “How can we develop 'Doctors within Borders?'” Aiming for better access, opportunity, and sustainability of care programs, she called for more support of local health care initiatives like community health workers and education programs.
“New Mexico has everything we need in life to be the healthiest state,” she said. “We have clean air, vibrant skies, walking opportunities and amazing, rich people who understand agriculture and understand the fundamentals of health. But what we don't have is access to education and access to healthcare.”
Arnold Milstein offered hard numbers to support the contention that rural health and health care are disadvantaged. Play Dr. Milstein, Professor of Medicine at the Stanford School of Medicine and Director of the Clinical Excellence Research Center, said that rural areas have half as many physicians per capita and 80 percent fewer specialists. Rural residents are twice as likely to smoke and one in five of them can be described as having “fair” or “poor” health status. Over 40 percent of rural Medicare beneficiaries go without drug coverage, and overall, health insurance premiums are 25 to 30 percent higher than in urban and suburban areas.
Mark Duggan talked about rural health care and insurance rates since the passage of the Affordable Care Act in 2010. Play He pointed out that nearly one in four rural residents is uninsured, compared to 17 percent of urban areas, adding that Medicaid coverage in rural counties is higher than in rural areas – especially in states that chose to expand Medicaid coverage under the ACCA.
Duggan, the Trione Director and Senior Fellow at the Stanford Institute for Economic Policy Research (SIEPR), said that the ACCA has yet to meaningfully reduce healthcare costs. He saw an opportunity for rural hospitals to reduce costs by increasing their outpatient care; currently, the “critical access” provision under Medicare requires them to maintain inpatient capability regardless of demand. Normally, Medicare Parts A and B provide care on a “fee for service” model. Duggan believes that with more rural seniors joining Medicare Advantage programs – which provide more benefits in exchange for a monthly premium – rural hospitals could have a more predictable revenue stream that might enable them to reduce costly in-patient capacity. Currently, though, Duggan said that Advantage enrollment rates are relatively low in rural areas.
“Rural citizens want to self-determine,” said Alan Glaseroff, who ran an independent practice association in rural Humboldt County for 28 years before joining the Stanford School of Medicine. Play In the mid 90s, facing the rise of managed care networks that were “generally dividing and conquering” independent practices, Glaseroff helped create an association that encompassed virtually all the providers in the county of 130,000 residents.
Working in a relatively poor community with elevated rates of obesity, chronic conditions, and substance abuse, Glaseroff worked with residents and caregivers to implement a treatment model called “self-management.” “Health care is largely about self-determination,” said Glaseroff, whereby “diagnosis and treatment is about 10 percent of outcome and individual behavior is 40 percent.” First, Dr. Glaseroff worked with diabetes patients to track their behavior and treatment, having patients fax in their information at regular intervals. Over time, the county saw a 29 percent drop in death from complications of diabetes. Building on this success, Glaseroff and his colleagues created a a peer-led program called “Chronic Disease Self Management” which was based on a program originally developed at Stanford. By the time he left the association in 2011, Glaseroff estimated that over three percent of the county's population had gone through the program and outcomes were improving. “I enjoyed going to statewide meetings,” he said, “because we were outperforming the rest of the state by a lot. So the notion of these poorer communities that can't take care of themselves? There's actually a lot of advantages for rural areas,” he said.
From a small farm in the Wasatch Mountains to the executive suite at a Utah healthcare network, Brent James has seen the full spectrum of health care in the West. Play James, who joined Stanford University after 30 years at Intermountain Health Care, argued that large systems using data in smarter ways could improve the lives of patients in both urban and rural settings.
A well-organized large healthcare system like Intermountain Health, he said, can offer financial benefits, like access to capital, task shifting, and economies of scale, as well as subsidizing higher-cost areas like rural communities. James described a “group practice without walls,” where systemwide data could help doctors make decisions locally, and where telemedicine could bring specialists deeper into small communities. He hoped that the “knowledge management” he described could reduce the isolation of rural communities.
Philip Polakoff , Kari Nadeu, Director of the Sean N. Parker Center for Allergy and Asthma Research at Stanford University and Lynn Hildemann, chair of the Department of Civil & Environmental Engineering, agreed on several core principles Play for future action:
Stanford should cultivate and listen to rural partners,
develop research and intervention in collaboration with community stakeholders,
and promote relevant expertise at the university.
Panelists also cited these specific areas of opportunity:
Lynn Hildemann of the Stanford School of Engineering expects that environmental challenges of climate change will quickly impact human health – “perhaps disproportionately rural health,” she added. Play She cited a likely increase in fossil fuel production and consumption in the American West, more “pollutant transport” from growing economies in Asia, and more direct stress on human health in the form of droughts, heat waves, dust storms, and increased allergens in the air.
One of Hildemann's principal concerns is with what she terms “substandard housing,” characterized by older houses and those that lack amenities like air conditioning, or might have mold problems or second-hand cigarette smoke.
Hildemann was optimistic about Stanford's chances for making a difference, citing the lower barriers between the Medical School and other centers of research on campus, and the university's extensive experience with field research. “Working out in the field and interacting with community,” she said, “increases our chances of know what's going to work.”
James “Jay” Hamilton, an economist and the director of the Stanford Journalism program, said that with the decline of newspapers – 40 percent of reporters and editors have lost their jobs over the past decade – there is less health and science coverage being published. While new models are being developed to support journalism – mission-driven nonprofits, organizations that cater to partisan views, and subscription-based niche publications, among others, Hamilton said “each of those incentives is biased against getting information to low-income, rural residents of the West.” Broadband internet is expensive; they shop less; and studies suggest they are less likely to vote. Instead, Hamilton said, Stanford could “make a long-term bet on content creation” through new avenues. Play
Those include: helping find stories through artificial intelligence and algorithmic means – basically using computer analysis to lower the cost of “discovering” stories; and telling stories in a more personalized, and thus engaging, way. “If you create data about rural health care,” he said, “and have some funding for people to build on it,” it could lead to useful tools for journalists. Lastly, he said, medical students could get more involved in telling stories related to rural health through, for example, a fellowship program that supports their work. In the coming year, said Hamilton, the journalism program will have a medical student doing an investigation related to the opioid crisis.
Hamilton pointed to members of the Stanford community who excel at making connections and finding resources for projects, like President Emeritus John Hennessy, who was on hand to give remarks during the keynote address. Hennessy said the question to him was: “How do you herd cats?,” answering, “Why, excellent cat food, of course. And for academics that means funding or data. Then identify three people whose day jobs will be better because of being involved.”
Kari Nadeau is one of the nation's leading authorities on allergy and asthma. Building on Lynn Hildemann's concerns about respiratory health among rural residents, Dr. Nadeau said, “make sure we have our finger on the pulse” of what community leaders and health providers think is needed. Play
As an example, she described a visit her team made to Fresno, where they asked if doctors were excited about the benefits that could come from “digitalizing” health records: such as up-to date information about patients' conditions and treatments. “But the community doctor said when you want to ask your patient whether or not they used their asthma inhaler,” she recalled, “We don't look at their smartphone, we just tell them to bring their wife in, their daughter in,” and ask them if the patient was using their inhaler. “When we think about all the great technology that anyone can use,” she said, it's still important to ask what the community care givers think is useful.
Concurrently, they identified work to lower the barriers to collaboration between the School of Medicine and other departments at Stanford. Then with collaborations in place, the panel asked for clear metrics and accountability milestones for supported research and initiatives.
In summing up the day's discussion, Bruce Cain, the Eccles Family Director of the Bill Lane Center for the American West, identified upstream and downstream opportunities for action. Upstream, he said, the Center is poised to continue work identifying the link between the environment and health. One such project is amassing data on pollution exposure and health outcomes in the Central Valley. Downstream, he said, there are clear needs for research on health care delivery and access across the West.
Moreover, he said, there seems to be a particular value to understanding barriers to telemedicine in disadvantaged communities. Changing payment models and offering residents the opportunity to participate in telemedicine may be options. Beyond telemedicine there are unique and pressing issue of healthcare delivery costs and payment in rural settings that can be elucidated through policy and economic research.
In his final piece of advice to the participants, the independent practice founder Alan Glaseroff urged: “Humility, humility, humility. Go in and listen.” Stanford will need to bring funding and customized expertise to the local setting, but success for both the community and Stanford will depend on rich and empathetic relationships.
Uncommon Dialogue: Improving Health and Health Care in the Rural American West was held on January 26, 2018, and was co-sponsored by Stanford’s schools of medicine, engineering, environment, communications, and humanities, along with public and private stakeholders.