Many factors contribute to the development of health disparities in rural areas, including economic, historical, and cultural forces. Four
speakers at the workshop discussed several of these factors in detail, including community attributes that are associated with economic and employment growth, the availability of financial services, and incentives to purchase and consume healthier foods.
Ever since the major recession of 2008 faded around 2010, the United States has been adding jobs, although the numbers have slowed in the past few years. Still, most states have more jobs now than they did before the start of the recession.
Alabama is one of six states that continues to have fewer jobs today than it did before the recession (see Figure 4-1), observed Brian Lewandowski, associate director for the Business Research Division at the Leeds School of Business at the University of Colorado Boulder. However, job growth has varied among counties in Alabama (see Figure 4-2). In 2016—a year in which the state added jobs overall—73 percent of rural counties
and 87 percent of urban counties added jobs. However, 14 Alabama counties lost jobs during that year.
As of 2017, rural Alabama as a whole has seen 51 consecutive months of growth in covered employment, which excludes sole proprietors, and employment is up by about 4 percent from the trough following the recession. However, employment is still 9 percent below its previous peak. The situation is somewhat better for wages paid to covered employees. Total wages paid in the state in rural areas are up 11 percent from the previous peak right before the recession, and average wages have been rising at a rate of 1.9 percent per year in recent years. However, annual average wages are still significantly lower in rural areas, at $37,400, compared to $46,500 in urban areas.
Lewandowski particularly focused on economic resiliency, which he defined as the economic performance of places after experiencing some form of disruption, from an economic downturn to a natural disaster. First, he and his colleagues sorted the approximately 1,900 rural counties in the United States from fastest population growth to slowest population growth on average over a 25-year period, breaking them into quartiles. Alabama has five counties in the top quartile for population growth over this period, and 40 percent of Alabama’s rural counties are in the top half for growth. The other 60 percent of Alabama’s counties are in the slowest half for population growth over this 25-year period.
Lewandowski and his colleagues then conducted the same analysis for employment growth. Only two of Alabama’s rural counties are in the top quartile for employment growth, and only 25 percent are in the top half. The other 75 percent of rural Alabama counties are in the bottom half of national employment growth.
For the nation as a whole, rural America has underperformed in employment growth compared to both the nation and urban America. The same applies to Alabama, where employment in urban Alabama has recovered from the 2008 recession but rural Alabama has not. “Rural Alabama tends to get hit harder on the downturns,” observed Lewandowski, adding that “rural Alabama also recovers less well on the upside compared to urban Alabama.”
Although these statistics may seem discouraging, Lewandowski argued that “there are some things that can be done about it.” A recent study in Colorado compared growth in population, employment, income, housing prices, and other metrics with a variety of economic metrics, including natural resources, education, and economic diversity. These comparisons provide valuable lessons that could be applied to Alabama, Lewandowski said.
First, natural resources tend to provide a competitive advantage for some places. A rich resource, such as fossil fuel development, solar energy,
wind energy, or tourism amenities such as rivers and mountains, can be a source of growth. But many such resources are commodity based, and commodity prices are volatile. In an industry such as the coal industry, which peaked in 2008 and has been declining since, what was once a boon is now an economic detriment to growth because of this decline.
Human-made resources such as interstates, highways, community colleges, universities, correctional facilities, airports, and hospitals also provide a competitive advantage. For example, universities above a critical size provide employment and pathways to more education while also importing young people from outside the community, some of whom will stay and be part of the community. But those assets have mostly been built already, meaning that some counties have them and others do not.
The education level of residents is a powerful force for economic growth. In looking at Colorado’s 47 rural counties, the percentage of the population with a high school diploma, a bachelor’s degree, and a graduate degree was increasingly correlated with a county’s employment growth. The percentage of residents with less than a high school diploma was negatively correlated with growth. “Education matters,” said Lewandowski. Furthermore, this is a good lesson for other places because, as he explained,
There are fewer barriers today for education than there ever have been. Not only are there so many campuses nationally, but through online learning we can continue our education without even having to leave our house. That is a positive story.
The percentage of the population between 30 and 64 years old is correlated with employment growth, implying that rural communities would be well served by trying to increase their working-age populations. Lewandowski has asked young people why they might return to the rural communities in which they grew up and found the following:
It is appealing for some of them to come back. They reminisce about the area where they grew up. They want to replicate that for their families. How do you appeal to those people to come back to your community? How do you ensure that there is some sort of opportunity for people when they get there?
The percentage of a county’s economy that consists of agriculture is also negatively correlated with employment growth. This could be because agriculture is continuing to substitute equipment for people, as it has been doing for many decades. It could also be that if much of the value added in a county comes from agriculture, the county’s other activities are correspondingly weaker. Lewandowski encouraged counties to think about what kind of downstream product finishing they could do with agricultural products. If a product could be converted into “some sort
of end user product before it leaves your community, that is a source of jobs and economic development within your community,” he explained.
Finally, economies based on providing services have been growing faster than economies based on producing goods. Communities can work to build up their service economies, especially if they have access to broadband communications. For example, location-neutral businesses or virtual businesses can let employees and contractors live where they want, including rural communities. Similarly, while the tourism industry used to rely on the existence of hotels and other amenities in communities, the growth of VRBO and Airbnb has enabled communities to leverage the assets they have in ways they have not been able to before. “That provides another opportunity,” he said.
Lewandowski and his colleagues also held focus groups in 20 communities around the state of Colorado to ask people what else mattered in economic development. They heard that health care matters, especially in rural aging communities where aging individuals want to make sure that health care is available to them. Families with young children also want to have local health care, and some rural communities in Colorado have been subsidizing hospitals to ensure that young parents do not leave.
Other factors that boost resiliency, according to the focus groups, are industry diversity, good school systems, strong leadership, access to transportation, and a high quality of life. Barriers include a lack of adequate and affordable housing, a lack of available labor, and a lack of child care. Of the positive factors, Lewandowski particularly mentioned local leadership:
We heard many stories and anecdotes about critical individuals—they could be elected officials or they could be key business individuals or nonprofits—who have come together to help build something in their community. If it is putting away land for some sort of industrial complex for down the road for building, if it is building a trail along the river, if it is saving the railroad and turning it into a tourism amenity, there are countless stories where the communities that have been more successful in Colorado point to things that have been done in the past that are paying dividends today.
HOPE, which includes the Hope Enterprise Corporation, Hope Credit Union, and Hope Policy Institute, is a 23-year-old organization founded in the Mississippi Delta that initially focused on small businesses to create jobs that pay good wages and offer good benefits. “It didn’t take long, though, to learn that the Delta needed a lot more than jobs,” said William Bynum, chief executive officer of HOPE. Although jobs are “absolutely
critical,” rural communities need “the same things that communities anywhere need. They need health care. They need housing. They need grocery stores. They need access to basic financial services,” he said.
Since its founding, the Hope Credit Union has evolved from a $1.5 million loan fund in 55 counties and parishes along the river to a provider of banking and financial services in three states. “We are a full-service bank, but we go where traditional banks don’t,” said Bynum. The Hope Credit Union uses every state and federal program it can and leverages policies that affect the communities it serves to build assets and improve lives in economically distressed areas in the mid-South.
A particular focus has been the need for financial services in communities where the poverty level has been greater than 20 percent for three decades in a row. Of the 384 counties that are classified as persistently poor by the federal government, one-quarter of them are in Arkansas, Louisiana, and Mississippi (see Figure 4-3). These counties rank poorly on almost every indicator of economic distress, including high-cost mortgage rankings, poor health, unemployment, and lack of banking services, noted Bynum. For example, all but one county in Louisiana and Mississippi that fall in the bottom quartile for health outcomes are persistent poverty counties. Counties marked by poor health outcomes also tend to have high minority populations. More than half of the 39 counties in Arkansas,
Louisiana, and Mississippi that are primarily African American are also among the counties with the lowest health outcomes. Thirty-five of these counties are also persistently poor.
Housing affects health in major ways, noted Bynum. Homes that are not physically safe and that are either too hot or too cold put their occupants at higher risk of cardiovascular disease. Residents may not have access to grocery stores or places to exercise. Unaffordable housing can prevent families from meeting basic needs, such as nutrition and health care.
HOPE has worked hard to mitigate the burden of high-cost mortgages in the counties it serves. It is not a traditional bank, said Bynum. Its average mortgage is less than $100,000, and 76 percent of mortgages are to first-time home buyers, 74 percent are to people of color, 60 percent are to women, and 43 percent are made in low-income census tracts. Surveys of its buyers show that when they become homeowners, they are able to move out of low-income census tracts. “Homes are the primary asset that most Americans own. It opens up opportunities to send your kids to school, to start a small business, to climb the economic ladder. Housing is a core part of our work,” he explained.
Bynum also talked about the ways in which health, education, and equity are intertwined. Greater educational attainment leads to better employment opportunities, which lead to better health. HOPE has worked with teachers and administrators in schools to provide them with access to basic financial services so they can better manage their own finances. It also received an $8 million grant from the U.S. Department of Education to finance charter school facilities. “I have mixed opinions on charters,” said Bynum, “but it is a tool that is out there, [and] we want to make sure that communities that need education the most have access to whatever tools exist.”
Mississippi has only eight counties where the unemployment rate falls below 10 percent for African Americans. In contrast, it has only eight counties where the unemployment rate for white residents is above 10 percent. In Kemper County, Mississippi, the African American unemployment rate is 20 percent, while the white unemployment rate is 1 percent.
Stress has a significant effect on health in these counties, Bynum reported. Laid off workers are 83 percent more likely to develop a stress-related condition, such as a stroke, heart attack, health disease, or arthritis. About two-thirds of the jobs HOPE has helped create through its small business loan fund offer health insurance to their workers, helping to reduce stress. “We don’t intuitively connect health and jobs, but it is clear,” he said.
Eliminating food deserts is another focus of HOPE’s work. After Hurricane Katrina, New Orleans had the highest concentration of food
deserts of any urban area in the country. HOPE worked with the city to create a healthy food financing program. A recent study indicated that the level of food access had returned to pre-Katrina levels and was more equitably distributed across the city than before the hurricane. The organization has now received resources from the Michael and Susan Dell Foundation to extend the experience in New Orleans across the rural communities in the three states.
Before they joined the Hope Credit Union, 40 percent of its members did not have a banking account. Yet, having a relationship with a financial institution is one of the most important financial relationships someone can have, said Bynum. It affects people’s ability to build assets, accumulate wealth, and access credit.
Since the 2008 recession, the credit union has grown from seven branches to 30 branches, three-quarters of which are in persistent poverty census tracts. In one four-county cluster in the Mississippi Delta, another bank donated several branches to HOPE that it had acquired through mergers and acquisitions. In less than 3 years, the Hope Credit Union tripled the number of accounts that the previous banks had managed. Bynum described one new account:
We opened an account for a woman who on her 100th birthday opened her first banking account, an African American woman in the Mississippi Delta. Think what it must be like to have to live almost a century before you feel welcomed enough. That is why I mentioned earlier about inviting people in. She finally felt welcome enough to be able to walk in and open her first account.
The credit union has also opened accounts for children. Data show that children are three times more likely to go to college and four times more likely to graduate if they have even a small account, said Bynum, adding “I can’t wait to see what these kids’ futures are going to be like now that they have these accounts.”
Recently, HOPE worked with groups from other parts of the country to access unspent dollars in the Community Facilities Program at the U.S. Department of Agriculture. “We couldn’t, by ourselves in Mississippi, make the case. But collectively, we were able to go to Congress, and they pulled a half a billion dollars out and made it available to organizations like HOPE,” with the money targeted for community facilities, nonprofit organizations, education facilities, municipal facilities, and other resources, Bynum explained.
As many other speakers at the workshop observed, listening to the community is critical. “We are a community-owned financial institution. They hold us accountable. That 100-year-old woman is my boss. She owns the financial institution. She votes on the board. We listen to those folks,” Bynum explained. Also, the more tightly anchored an organiza-
tion is to the community, the more it will be able to meet the needs of local residents, Bynum said. HOPE has been working with local mayors, he said, “essentially playing the role of their economic and community development staff,” helping them talk with local residents and make strategic plans.
“It is only through pooling our efforts that we are going to close the gap between poverty, health, education, housing—all the needs that exist in these economically distressed places,” Bynum concluded.
Farmworkers Self-Help represents farmworkers in Dade City, Florida, and the rest of the state. Most of the farmworkers with whom the organization works are undocumented, but they need health care, legal aid, and other services as much as other people do. “They are a part of our big family in this country,” said Margarita Romo, the organization’s founder and executive director. “They do great work,” she said.
Founded in 1979, Farmworkers Self-Help has, from the beginning, been based on self-reliance and resourcefulness. One of the first tasks the group faced was mastering English. For 7 years before the organization existed, Romo had served as a translator in farmworker camps. These camps tended to go unnoticed, as she explained:
Most people didn’t know that there were 15,000 farmworkers in Pasco County. Not even the governor knew that. When I began to call Tallahassee to find out what we could do, I remember one of his aides saying “Are there farmworkers in Pasco County?” I said, “Are there Cubans in Miami?” We still laugh about that when I see her.
The local college that Romo was attending gave the organization a room in which it could hold English classes. Soon other issues rose to the forefront. The group began working on immigration and amnesty issues, at which point Romo began representing the group in Washington, DC. The group “began to see how we could change the laws,” she said, adding that “we started to find other people in Florida who wanted to do the same thing.” The Immigration Reform and Control Act of 1986 “wasn’t exactly what we wanted, but it was better than nothing,” Romo said.
Farmworkers Self-Help trained and organized paralegals to process individuals and families under the provisions allowing legalization of immigrants who had entered the United States before 1982. The organization processed thousands of families and taught other organizations in Florida how to do the same.
It then turned to health care issues, working with other organizations around Dade City. “There are people alive today because of the organizing that we were able to do,” said Romo. It began working with the health
department and started its first Promotores de Salud program. “We learned about breast cancer. We learned about cervical cancer. We learned about diabetes because it was killing our people. We learned about hypertension. All of those things we began to teach our community women,” Romo explained. The program provided information to farmworkers through clinics, hospitals, and partnerships with colleges and universities. “We have had to navigate our way through all of these things,” she said.
The organization brought farmworkers to Tallahassee to speak with state legislators, which led to legislation providing legal immigrant children with health care without a waiting period. It also helped pass legislation granting immigrant children in-state tuition. Five young people who fall under Deferred Action for Childhood Arrivals (DACA) provisions have graduated from St. Leo University in Dade City, Romo observed.
Farmworkers Self-Help has done work to revitalize the Tommy Town neighborhood of Dade City, organizing bus service, a 4-H club, and a youth entrepreneurs club. Undocumented people are “part of your community,” said Romo. “I am praying that we will have a way to have a new immigration reform so that we will be able to have more people free. They have already worked out there in the fields. They have given you all they have,” she added.
“We all have something to share,” Romo said. “Sometimes we have to shake each other to remind us of that, but we do have it. When we bring that out, it gives us hope that other people may not have,” she concluded.
The Diné Community Advocacy Alliance (DCAA) was formed in March 2012 in response to the high rates of obesity, diabetes, and the complications of these health problems among children, youth, families, adults, and elders living in Navajo communities. The alliance comprises grassroots-level community health advocates from various communities, with a mission of raising awareness, informing, educating, and mobilizing community members to combat obesity, diabetes, and other chronic health issues. In Navajo, the alliance promotes the idea of shánah daniidlįįgo as’ah neildeehdoo—let’s live a long life.
Healthy food is a Navajo tradition, said Denisa Livingston, a member of the Navajo Nation and a community health advocate for DCAA. But many Navajo people have been what she called “hijacked” by the unhealthy food industry. When the Navajo people were moved to a concentration camp at Bosque Redondo in New Mexico, they were given salt, sugar, flour, and canned meats to eat. “We are still trying to address that prison food,” said Livingston. The Navajo Nation is the size of West Virginia but has only 11 grocery stores, so in many cases, people have
to drive hundreds of miles each way to buy groceries. One out of three Navajo people are diabetic. “Every Navajo family is affected by this. This is the reason for our work,” Livingston said.
The people she represents are eager for change, Livingston observed. They want to be seen as assets rather than liabilities. They have supported advocates like Livingston to make a difference in their lives. “Just as it takes a community to raise a child, it takes a community to raise a community advocate,” she said.
DCAA has focused on policy and legislative changes. First, it has sought to eliminate a 5 percent Navajo Nation sales tax on healthy foods and to add a 2 percent sales tax on unhealthy foods. In 2014 these initiatives led to the elimination of the 5 percent sales tax on fresh fruits, fresh vegetables, nuts, nut butters, seeds, and water. Livingston explained, “The main area of this healthy foods tax law was to put an emphasis on our cultural foods . . . the foods that empower us, that make us strong, that strengthen us.” Then, the Healthy Diné Nation Act of 2014 was enacted and took effect in 2015, which imposed a 2 percent tax (on top of the existing 5 percent tax in most areas of the Navajo Nation) on unhealthy foods high in salt, saturated fat, and sugar.
The greatest success of the legislation was raising awareness of unhealthy foods, said Livingston. Nothing in the Navajo language meant “junk food,” so with support from the elders and Navajo language speakers, a new term was introduced: ch’iyáán bizhool, with ch’iyáán meaning “the scraps, the leftovers, the nonnutritious pieces,” according to Livingston. The law imposed a tax on five categories of food:
- Beverages: soda, energy drinks, flavored water, iced teas and coffees, fruit and veggie drinks, alcohol-free and alcoholic drinks, etc.
- Sweets: candy, frozen desserts, pastries, cakes, puddings, etc.
- Chips and crisps: baked, toasted, fried products
- Fast food: ready to eat, quick, available, quickly served foods, canned meats
- Flavor enhancers: salt, sugar, sweeteners
Each of these categories is defined in much more detail, and the places where food is sold are specified so compliance with the law can be ensured.
The 2 percent tax, through the first quarter of 2017, had raised $2.6 million, even with just partial compliance. This revenue has been going back to the communities through disbursement to all 110 Navajo chapters to fund community wellness projects, said Livingston. These community-based and community-owned projects address improvements to the physical and social environment of the community. Allowable projects include
instruction, equipment, the built recreational environment, the social setting, education, community food and water initiatives, and health emergency preparedness. Specific projects within these areas might include developing biking and walking trails, traditional craft classes, healthy cooking classes, wellness workshops, horse workshops, and farming and gardening initiatives. Disallowable projects include meetings. The goal is to “allow community members to take control over their social environments and their physical environments to implement what is needed in their area,” Livingston said.
In response to the argument that a 2 percent tax on some kinds of foods is a regressive tax, Livingston argues that the tax has progressive benefits. As Michael Pollan has pointed out, Livingston said:
We can’t afford the food that we are eating—the unhealthy processed food, the junk food, the cheap food, the oppressive food, the fast casual food, or in Navajo, ch’iyáán bizhool. We can’t afford the heavy price that comes with it from the value menu. We can’t afford cheap food because we are going to pay the consequences in dialysis centers, stomach stapling, health care costs, and unhealthy eating. It is something that we take to heart every day that we do our work.
The message has gotten through to the tribal leaders, said Livingston:
They are eating more healthfully. They are buying more water. Our current Navajo Nation vice president, Jonathan Nez, runs marathons. It is changing the mindset, even in the leadership. Other tribes and groups around the world are considering similar policies regarding unhealthy foods, and the actions of the Navajo Nation can be an example for them.
An important lesson from the experience has been that community people can come together, increase awareness, and create legislation. “As community members, we are able to sit at these different tables with the executive branch and with these different departments. . . . [We] are changing the conversation,” Livingston said. Problems and resistance to change will continue to arrive, and holding on to past gains and continuing to make progress will not be easy. But past successes have been “making a history for our future,” Livingston acknowledged.
Livingston pointed toward several future objectives. One is to improve indigenous public health systems by using a model that focuses on community advocacy, tribal sovereignty, economic development, traditional food sovereignty, sustainable community wellness projects, community empowerment, and encouraging women to step into leadership roles. “For me, as a Navajo woman, my community and where I come from is a matrilineal, matriarchal society, where women are the ones leading. Yet, we don’t see that reflected in our own government,” she noted.
Another goal is to look harder for solutions to current problems
through food. The problems are rooted in community members, and so are the solutions. CRAP (carbonated, refined, artificial, and processed foods) needs to be replaced with real FOOD: F for fresh fruits and vegetables, O for organic lean proteins, O for omega-3 fatty acids, and D for drinking more water. Healthy foods can help Native people reclaim their identity and change the narratives in their communities from being victims to being victors.
“Our currency was always produce. It was food. It was the exchange of these goods,” Livingston said. “Our mindset of prosperity is also different. We are not only prosperous in having economic development but also spiritual health, cultural health, resiliency, and all of these different areas of well-being,” she concluded.
A major theme of the discussion session was the value of investing in young people to address inequity and oppression and to take advantage of the rapid changes going on in society. Working with youth is like “going to a different country,” said Livingston. They are social media experts, whereas older people need to be shown how to work with technology. People in the Navajo Nation are very interdependent. If young people know they are part of a team working for a vision, everyone can move forward together to achieve a goal. Livingston particularly called attention to young mothers, who “know everything that is going on” through social media. They are “key people you want to reach out to. They have a lot of voice. They can spread the message and be a part of the purpose,” she said.
Romo made many of the same points and noted that her organization is involved with camps where children can learn about social justice and with a theater group that has given a performance at the capitol in Tallahassee on immigration. Children “are our future,” she said, adding “If we don’t share with them and if we don’t expose them to the wider world, they are not going to go there.”
On a related note, the presenters talked about the potential of technology to alleviate some of the inequities in rural areas. Lewandowski pointed to the push by the Colorado legislature to ensure broadband access in rural areas. The last mile of connection “is the most expensive mile to complete, just as it was for roads and for electricity,” he said, adding that “we are seeing subsidies and incentives for companies to finish that last mile. That is not only to connect households but, importantly, to connect schools.” Broadband provides opportunities for businesses to locate anywhere, such as someone doing software programming out of their house or working for a company remotely. “We have even
seen a trend where some companies are not recruiting people to a location but are finding people in a place and are building a remote office in that place,” he said. A company in Boulder, for example, could find four people it wants to employ in Colorado Springs and quickly establish a remote office using technology.
Romo pointed out that the man who started the Youth Entrepreneur Students program for her organization is young and technologically proficient. “We have made room for a small office for him to have as much tech as he can bring together to teach our people and teach our kids, mostly. . . . This is part of the new regime coming up,” she said.
Livingston observed that technology is a big issue in the Navajo Nation, explaining that “we normally don’t have LTE or 3G. We have extended 1X. [Sometimes] you can’t even send an email in a few seconds.” At the same time, many Navajo also face more pressing issues, such as a lack of running water or electricity.
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