Rural Women's Health Conference Summary Report Summary Report  (PDF File, 1.82 Mb) August 13 -15, 2007 Omni Shoreham Hotel, Washington DC

Opening Plenary

The Scalpel and the Silver Bear: A Navajo Woman Surgeon's Story

Keynote speaker Lori Arviso Alvord, M.D., began her presentation by discussing her interest in two disciplines, psychiatry and surgery—the life of the mind and the life of the body. She explained how, although it seems that psychiatry and surgery should be connected, the two disciplines do not speak to each other. Yet psychiatry and surgery are incredibly dependent on each other. People's mind states are very relevant to their physical well-being and vice versa. She said there is one system of medicine that has never separated the two disciplines—Navajo medicine.

Dr. Alvord went on to discuss her experience growing up in Crownpoint, New Mexico, where books were her only access to the rest of the world. She said the term "culture clash" cannot adequately describe the stark contrast between her childhood experience in rural New Mexico and her experience attending college at Dartmouth, which was 2,500 miles from her home. At Dartmouth, Dr. Alvord earned a double major in sociology (Native American studies) and psychology. After college, she worked in a laboratory at New Mexico University and was encouraged to apply to medical school. Ultimately, she was accepted at Stanford University. During medical school, she was advised to specialize in primary care so that she could go back to New Mexico and help her people. Her perspective changed, however, when she met a Native American surgeon and witnessed how he was able to help patients using American medicine and still honor their heritage as Navajo people. This image carried her through medical school and shaped her into the surgeon, and woman, that she is today.

RAW Spirit: Resilience and the Rural American Woman

Plenary speaker Hilda R. Heady, M.S.W., opened her presentation by noting that she was the 2005 President of the National Rural Health Association (NRHA), a nonprofit, non-partisan membership organization that aims to serve as the voice for rural health care. She went on to explain that one of the purposes of her work as a rural health advocate is to focus on what is right about rural America, instead of focusing on what is wrong. According to Ms. Heady, in order to address the "new frontier" in improving health care and access for rural women, people need to consider and connect with the "old frontier," and learn from the strengths and challenges of rural culture.

Ms. Heady outlined the three main points of her presentation:

1. Rural women's values make them and their culture special.
2. Rural women's experiences and values guide their passion in all that they do.
3. Resilience is a hallmark reflection of rural culture.

Ms. Heady then explained her points. She noted that rural women have a natural affinity for putting people first. Whether rural women are factory workers or homemakers, they put people first—in advocacy, policy, work, and service. For these reasons, rural women have a lot to offer as teachers. According to Ms. Heady, "It is important to go into situations with rural women and expect to be taught before we expect to teach." As part of her work promoting the positive aspects of rural America, Ms. Heady coined the phrase, "Rural Beatitudes©." The idea behind the phrase is that rural people learn life skills by dealing with things. Ms. Heady presented a list of her "Rural Beatitudes©: Blessed are the rural for ...

• They are collaborators and self-reliant. If they cannot solve a problem on their own, they will band with someone else to get it done.
• They value their families and are friendly people.
• They value individualism and are personable, independent, and modest.
• They are authentic, direct, unpretentious, and honest.
• They are patriotic and go to war—and allow their children to be sent to war. Ms. Heady noted that research shows rural people and minorities serve in the military at higher rates than the rest of the population. For example, she said 35.7 percent of women in the military are African-American women, a figure which is not proportional to the general population.
• They serve others without being asked.
• They make goods and products for everyone else.
• They have a deep faith, a sense of beauty, and a sense of humor.
• They all deserve high-quality health care.

In closing, Ms. Heady noted that resilience is imbedded early and must be nurtured. "We must remember our special obligation to the next generation," she said. "Our faith in the human spirit is to know that its own sense of innate health can guide us in all our endeavors. Our efforts to define community are less important than our search for common unity."

What Can You Do About Issues Rural Communities Face?

Plenary speaker Marcia Brand, Ph.D., began her presentation by providing an overview of HRSA ORHP, which was established in 1987. ORHP was created to address problems that arose from the implementation of the Inpatient Prospective Payment System, which led to the closure of an estimated 400 rural hospitals. Today, ORHP advises the Secretary of Health and Human Services on rural healthcare issues. Dr. Brand outlined several reasons the country has rural healthcare issues:

1. There is limited access to primary care and specialty care. In particular, it is difficult to obtain oral health care and mental health care.
2. The healthcare system is limited by infrastructure, including hospitals and clinics, providers, and emergency medical services. For example, in Washington, DC, emergency medical services are paid positions; while in rural America, they literally hold bake sales to fund these services.
3. The country is also limited by financing. One result of this limitation is that people are challenged to create economies of scale and to co-locate businesses. An example is the "lose it/ tone it/tan it" business that is a nutritional store, workout facility, and tanning salon, all in one.
4. The country is limited by the special challenges rural communities face. These limitations include geography, population (the population is older with greater health disparities), Federal funding that is population-based, and cultural and social barriers.

Dr. Brand continued by stressing that healthcare providers must try to work directly with communities for a number of reasons:

1. There are many different ways to be rural; one solution doesn't fit all of the challenges.
2. Limited financial and technical expertise makes engaging local, State, tribal, and Federal governments difficult.
3. Rural communities cannot afford to make mistakes or engage in programs that will not work for them—they must get it right the first time.
4. Often, the Government does not hear from the rural communities.

With these reasons in mind, Dr. Brand outlined four simple steps healthcare providers can take to accomplish working directly and effectively with communities.

Step 1: Have the information

Dr. Brand explained there are numerous resources available for finding the information you need. One is the Rural Assistance Center at www.raconline.org. A second resource is ORHP—it can be accessed through www.hrsa.gov by clicking on Rural Health. Another extremely important resource that ORHP encourages people to use is the appropriate State Office of Rural Health. Dr. Brand noted that you can locate each State's Office of Rural Health by accessing the ORHP site and clicking on States.

Step 2: Decide if it is a policy or resource issue and at what level

If the issue is a policy issue, Dr. Brand explained you need to determine on what level it exists—Federal, State, tribal, or local. For example, if you do not know whether your area is in a Health Professions Shortage Area (HPSA), that is a Federal policy issue. If Medicaid does not pay for dental care, that is a State policy issue. If the county is no longer providing obstetrics and gynecology services, that is a local policy issue. Dr. Brand noted there are numerous avenues for finding help with policy resources. On the Federal level, there are ORHP, the Centers for Medicare and Medicaid Services, other agencies in HHS, your Congressional delegation, and national professional organizations, to name a few. On the State level, there are the Governor, State legislature, State Office of Rural Health, and State organizations. On the local level, there are local government, local hospital boards, civic groups, and community organizations.

Dr. Brand then explained, if the issue is related to resources instead of policies, there are also several avenues communities can access to improve rural health care:

• Rural Assistance Center (www.raconline.org) and other Web-based tools
• ORHP's outreach and networking grants
• Health Center expansions
• National Health Service Corps, which is looking for health professionals
• 3RNet—job placement service
• Area Health Education Networks
• Other HHS resources
• U.S. Department of Agriculture, which has numerous non-agriculture resources
• Foundations
• State resources

Step 3: Determine who else cares about the issue

First, Dr. Brand noted, we must think beyond the healthcare sector. Educators and business people can be powerful allies. For example, if you are seeing children with unmet mental health needs, so are the schools. There are allies all around. Next, Dr. Brand stated, we must put the "good guys" out front. For example, if dental caretakers are talking about increasing access, it will be seen as a business proposition. But if you put the Parent-Teacher Association out in front, it will be seen as positive. Finally, we should not be afraid to "look up"—to both State and Federal officials.

Step 4: Set reasonable goals

Dr. Brand explained that when we are setting goals, we first must remember that rural communities have limited infrastructure. Next, we must be aware there is a "risk averse" culture of health care—rural communities simply do not take big risks. Finally, people must also think about sustainability from the beginning—how to keep something going even if the State or Federal dollars go. After outlining the four steps, Dr. Brand concluded her presentation by walking participants through the process using a familiar healthcare issue as an example—the lack of access to oral health care for adults and children in the community. Dr. Brand reminded participants that step one is to have the information. For example, one-third of all adults have untreated cavities. In addition, tooth decay is the most common chronic childhood disease—it is five times as common as asthma and seven times as common as hay fever. Children miss 51 million school hours per year for dental problems and dental visits, and adults lose 164 million work hours per year. In addition, 108 million Americans lack dental coverage. For each adult without medical coverage, there are three without dental coverage; and for each child without medical coverage, there are 2.6 without dental coverage. In addition to these statistics, the scientific evidence that poor oral health has a significant impact on physical health continues to grow. In addition to this big picture information, Dr. Brand noted that you also need to gather information on other levels. For example, you should be able to describe oral healthcare access in your State and community. After you have the information, Dr. Brand reminded participants that step two is to decide if it is a resource or policy issue. She noted that oral healthcare access is both a policy and resource issue. On the policy side, Medicare does not pay for oral health care. On the resource side, there is a lack of dental insurance, limited number of providers, and limited infrastructure. Dr. Brand then walked participants through step three, which is to determine who else cares about the issue. In the oral health care example, potential collaborators on the local level may include employers, educators, provider groups, and especially local hospitals, considering the frequency of dental-related ER visits. On the State level, collaborators may include employers, educators, provider groups, hospital associations, the State rural health association, the State legislature, and State government. On the Federal level, collaborators may again include employers, educators, provider groups, and hospital associations, as well as the NRHA, Congress, Federal Government, American Association for Retired People, and the Children's Defense Fund, to name a few. Finally, Dr. Brand reviewed step four, which is setting reasonable goals. She noted that this may include establishing a mobile clinic; recruiting an additional healthcare provider; getting other healthcare providers to perform some basic dental services, such as varnishes; or providing service through schools or nursing homes. In closing, Dr. Brand stated that these are four straightforward strategies for thinking about rural health.

Current as of October 17, 2008