When the topic of "rural health" is raised, whether by policy makers, the general public, or even public health professionals, the conjured vision is often one of individuals having difficulties accessing healthcare services due to a lack of facilities and/or providers. While the issue of access to care remains a critical challenge throughout rural America, we must take a broader view of rural health. It is clear that rural citizens face significant health disparities when compared with the general population and that access to healthcare services, albeit important, is only one of many factors influencing their health. Other factors such as health behaviors among rural citizens, persistent poverty, disease surveillance challenges created by smaller populations, unique environmental factors, and too many others to list call for a public health response to addressing rural health concerns.

In August 2001, the National Center for Health Statistics at the Centers for Disease Control and Prevention released the 25th annual statistical report on the nation's health. This report presented the first look at the nation's health status relative to community urbanization level. Specific findings demonstrated a number of disparities in health status between rural and nonrural citizens including teenagers and adults in rural counties were more likely to smoke; residents of rural communities had the fewest dental care visits; death rates for working-age adults were highest in the most rural and most urban areas; rural areas had a high percentage of residents without health insurance; and residents of rural areas had the highest death rates for unintentional injuries in general, and for motor-vehicle injuries specifically.1

Given the clear need for a public health response to these issues, we must look at the ability of the nation's rural public health system to respond. As we do so, however, we quickly find a system ill equipped to address the issues faced by its citizens. Many rural and frontier areas have no local health department, and those public health departments that do serve rural areas often have few (if any) staff with formal public health training.

In 2004, the National Rural Health Association (NRHA) took a critical look at the health issues facing rural Americans and the capacities of both the healthcare delivery system and the public health system to address them. Despite a traditional organizational focus on issues related to access to care, the association recognized that the healthcare delivery system alone will not be able to eliminate the health disparities faced throughout the rural United States and adopted the following policy recommendations2:

* The NRHA believes that all citizens and all communities should have comparable access to agencies and individuals that ensure the provision of the essential public health services. Whether provided locally or on a regional basis, by governmental agencies or the private sector, every citizen has the right to expect access to the full complement of essential public health services in his or her community.

* The NRHA supports greater flexibility in the use of public health resources to respond to local public health priorities. The current public health system is limited by categorical funding that often forces it to address state and federal priorities rather than local needs. Public health works best when it is responsive to locally identified priorities. Funding streams need to support rather than inhibit this responsiveness.

* The NRHA recognizes that public health is a common good and that there is a governmental responsibility to ensure access to essential public health services in every community. Regardless of who actually provides the service, there is a governmental responsibility to provide oversight and the governmental public health infrastructure must be strengthened to support this role.

* The NRHA supports efforts to utilize bioterrorism and emergency preparedness resources to build public health capacity in rural areas. Bioterrorism and other public health emergencies have the potential to impact rural areas both directly (eg, agroterrorism) and indirectly, as residents evacuate targeted urban areas. A strong public health infrastructure will be needed to effectively respond to both of these scenarios. Furthermore, a strong public health infrastructure will also serve rural communities in the event of other emergencies such as natural disasters and infectious disease outbreaks, while enhancing the ability to improve community health status through everyday provision of essential public health services.

* The NRHA supports enhanced training and continuing education of the rural public health workforce that is accessible to them in their rural communities, and that is appropriate for their current level of training and experience. A key ingredient to ensuring adequate public health services is a competent public health workforce. Whether employed in the public or private sector, public health workers must be well versed in their field.

* The NRHA supports strengthening communication systems and technological capacities within the rural public health system. To effectively manage public health emergencies, conduct disease surveillance, or simply receive up-to-date public health information, rural public health must have access to advanced communication systems and technologies.

It is noteworthy that an organization that typically operates outside of the public health community recognizes the need for a strong public health system to address the needs of its constituents. The next step, which would be just as noteworthy, would be for the public health community to recognize rural populations as a group facing significant health disparities and to begin to address the unique factors that contribute to those disparities by strengthening the nation's rural public health infrastructure.

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