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Institute of Medicine (US) Roundtable on Environmental Health Sciences, Research, and Medicine; Merchant J, Coussens C, Gilbert D, editors. Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary. Washington (DC): National Academies Press (US); 2006.

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Rebuilding the Unity of Health and the Environment in Rural America: Workshop Summary.

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1Environmental Health in Rural America*

The problems of the rural environment extend well beyond natural factors such as the quality of the water and the air and also include the built environment in terms of human inputs—the buildings placed on the land, the kind of farming performed and the chemicals that are applied to the land, and the types of industries that are built in rural America—noted Peter Thorne of the University of Iowa. A number of health care issues are specific to the rural environment, particularly those relating to the widening gap in health care services between rural and urban populations, because more people in rural America are uninsured, more often have inadequate access to health care services, and must often commute long distances to seek and receive such care.


Although the definition of “rural” is sometimes subjective, rural areas bring to mind small towns and sparsely populated areas. This definition may vary from one state to another, but in essence it refers to villages, cities, towns, or boroughs and excludes the rural portions of extended cities. According to the U.S. Census Bureau, rural is defined as not being urban, and urban, in turn, is any place incorporated with 2,500 or more individuals. Cities often grow out in tentacles, known as urban sprawl, and the areas between those tentacles are often defined as rural. In Iowa, rural is exemplified by grain bins, farmland adjacent to housing, small towns, and country roads, said Thorne. In the western United States, rangelands mark an area as rural, whereas the typical elements of rural in the northern United States might be forests and lakes. However, the notion of rural is small communities or individual farmland.

Another aspect that differentiates rural from urban was well captured by Wendell Berry in his book The Unsettling of America: Culture and Agriculture. He wrote that “the concepts of country, homeland, and dwelling place, become the environment. Thus, once we see our place, our part of the world, as surrounding us, we have made a profound division between it and ourselves. We have given up the understanding . . . that our land passes in and out of our bodies, just as our bodies pass in and out of the land” (Berry, 1977). According to Thorne, it is the notion of living within the environment, of being part of it in a fundamental way, which rural people experience more often than urbanites. Therefore, one element unique to living in rural America is the feeling of connectedness with the land and the notion that the land is producing food for the nation, so that those who live in the rural environment are somehow connected with this process, regardless of whether or not they are farming. Neighbors become very important in rural areas, partly because they constitute the community. Rural areas also possess a strong heritage of neighbors helping neighbors by sharing the labor involved with daily life in rural settings.

Rural is the notion of living within the environment, of being part of it in a fundamental way, which rural people experience more often than urbanites.

—Peter Thorne


One of the greatest problems facing rural America has been the loss of small towns and their small schools, said Thorne. As a result of school consolidation, larger schools are increasingly becoming the essence of the rural community.

Rural America faces other challenges as well, including poverty and isolation, as well as the limited access to health care mentioned above. In addition, conditions in rural America—such as unmonitored drinking water, dangerous working conditions, and the notion that it is a shrinking demographic—affect the options and opportunities of its residents.

Seventy-five percent of the land mass in the United States is sparsely populated and is considered rural (USDA, ERS, 2005). In four states—Maine, Vermont, West Virginia, and Mississippi—more than 50 percent of the citizens qualify as rural dwellers. Another 18 states have rural populations of between 30 and 50 percent of the total population, and 8 more have rural populations between 25 percent and 30 percent of the total population. Therefore, in a total of 30 states, at least 25 percent of the citizens live in rural areas, a significant demographic by all accounts. In total, the estimated rural population in the United States is 59 million people, of which some 56 million are rural dwellers not living on farms (U.S. Census Bureau, 2000c).

According to Thorne, in comparison with their urban counterparts, a disproportionate number of rural citizens are poor, tend to be older, have limited access to health insurance and health care (Table 1-1), make do with few amenities, and do not expect to become wealthy. Indeed, many do not even consider themselves to be poor. Although these individuals meet the demographic definition of “living in poverty,” they often think of their economic status as being quite average and place a higher value on the quality of life that they have, noted Thorne. Fully a third of those living in rural areas earn less than $7.00 per hour, whereas a fifth of the population in the urban environment earn this amount (U.S. Census Bureau, 2000b).

TABLE 1-1. Comparison of Key Demographic Parameters Between Rural Citizens and Their Urban Counterparts.


Comparison of Key Demographic Parameters Between Rural Citizens and Their Urban Counterparts.

Many people in rural areas are either self-employed or work at a low-wage job or for small businesses that, in general, do not provide the medical insurance benefits offered by larger employers. It is estimated that approximately 25 percent of rural citizens in the Midwest are uninsured; and for many who do have medical insurance, it might be rather limited, with high deductibles, and provide tenuous coverage at best, said Thorne (Pol, 2000). It is not uncommon to find rural dwellers who are reluctant to make insurance claims for fear of losing their insurance, said Thorne. This fear may manifest itself in detrimental ways, such as parents not wanting to have a diagnosis of asthma made for their child because such a diagnosis might result in the loss of their medical insurance.

Isolation is an environmental health issue in rural areas. Some people are socially disconnected in the rural environment. As a result of this isolation, problems such as domestic violence remain hidden and unaddressed. Mortality rates arising from injury, in turn, can be adversely affected by factors such as the long response times to medical emergencies or fires, noted Thorne.

Limited access to health care is also a major problem for rural America. According to the Center for Studying Health System Change, there are 53 primary care physicians per 100,000 rural residents, whereas there are 78 primary care physicians per 100,000 urban residents. The disparity in the availability of specialists is much greater: 54 and 134 specialists per 100,000 residents in rural and urban areas, respectively (Reschovsky and Staiti, 2005). Moreover, the rate of use of preventive care is lower in rural settings, and more rural dwellers than people living in urban areas depend on Medicaid and state-based plans.

Limited access to health care is a major problem for rural America. Twenty-one percent of American citizens live in the rural environment, whereas 90 percent of physicians live and practice in urban areas.

—Peter Thorne

Although the rates of physical inactivity are lowest in rural areas, the prevalence of obesity among adults in rural areas is increasing. Data from the Behavioral Risk Factor Surveillance System indicate increased rates of obesity among rural males and females and whites and blacks who are not Hispanic, and for all age categories (CDC, 2001). Therefore, the obesity problem in rural America cuts across all demographics: gender, race, and age (Table 1-2).

TABLE 1-2. Rates of Obesity in Urban Versus Rural Populations (percent).


Rates of Obesity in Urban Versus Rural Populations (percent).

Exposures in the rural environment tend to be less related to national ambient air quality standard criteria—that is, to pollutants such as ozone, sulfur dioxide, nitrogen oxide, and particulate matter—unless the area in question is in close proximity to a major metropolitan area. However, hazardous air pollutant exposures are of greater concern in rural areas. In Iowa and other agricultural states, livestock operations are a source of pollutants, such as hydrogen sulfide, ammonia, and odoriferous vapors, that result from animal husbandry activities and manure storage and handling. The organic dust that arises from agricultural environments and the by-products of operations and businesses that process agricultural commodities are also of health concern to rural populations. Additionally, the economy of the rural environment relies heavily on small businesses that often generate exposures associated with manufacturing and farming and that, in comparison with larger industries, receive little scrutiny from the Occupational Safety and Health Administration, noted Thorne.

Water pollutants in the rural environment are derived from nutrient runoff from fields, soil and river bank erosion, and pesticides and other farm chemicals that enter surface water and groundwaters. In Iowa, about 25 large-scale fish kills occur each year, and these are most often attributable to the contamination of surface waters with manure or, in some cases, ammonia. An emerging problem that is receiving more scrutiny is the contamination of water supplies with the growth-promoting agents used to raise livestock, especially nontherapeutic antibiotics. The latter are being examined because of concern over the potential emergence of antibiotic-resistant pathogens that may arise as a result of exposure to antibiotics.

While urban drinking water suppliers provide water to 100 percent of urban dwellers, those who live in a rural environment and who have a rural public water system—estimated to be about 30 percent of rural dwellers—depend on very small systems. Such water systems are cooperative in nature and are defined as having 15 service connections or regularly serving an average of at least 25 individuals daily at least 60 days out of the year. In addition, while urban residents receive an annual Consumer Compliance Report produced by EPA, about the levels of approximately 80 contaminants that are monitored in their water, the majority of rural residents have private wells of various depths, and the owners are responsible for monitoring the water quality. Typically, these wells are monitored only for coliform bacteria and nitrates, but the scrutiny of water from wells is less vigilant than that of water from urban public drinking water supplies, noted Thorne.

When people were asked during the enrollment to the Agricultural Health Study why they chose rural life, many responded that they love the outdoors and feel the need to see the sun rise and set; some said that cities are concrete jungles where nobody cares about you.

—Peter Thorne

A vast consolidation of farms and changes in farming practices toward larger and less diverse farms have occurred over the past 40 years. Although the amount of farmland and production have not changed much in the United States in the past 60 years, the number of farms has decreased from about 6 million to less than 2 million, and the average number of acres per farm has gone from 175 to close to 500 (USDA, NASS, 2002). Livestock production has changed from being very widely distributed on mostly family farms to being more of a system with an industrial design with vertical integration, in which agribusinesses bring feed from other areas of the country and process animals in slaughterhouses operated by the same company. This takes money away from the local communities and further increases the environmental sustainability problems within them, said Thorne. Furthermore, the fact that the decisions about how these facilities are operated are in the hands of people who are not living in the community can lead to strife between those business owners and the members of the local community.

Farm injuries are an important cause of morbidity and mortality in rural areas. According to the National Institute of Occupational Safety and Health, every day about 228 agricultural workers suffer injuries that result in lost work time, and about 5 percent of these result in permanent impairment. Nationally, farm children and farm visitors (hired workers or visiting youth) experience approximately 22,000 injuries each year; this is equivalent to 12.7 injuries per 1,000 youth, of which about one-third are work related and one-half are in the Midwest (NIOSH, 2005). The injuries include tractor rollovers, all-terrain vehicle or four-wheeler accidents, power-takeoff injuries, suffocations in grain bins and confined spaces, and collisions on or off roads. About one-half of farm injuries among youth occur among those ages 10 to 15 years, and one-third occur among children younger than age 10 years.

When participants were asked during their enrollment in the Agricultural Health Study—discussed in greater detail in Chapter 4—why they chose rural life, many responded that they love the outdoors and feel the need to see the sun rise and set; some said that cities are concrete jungles where nobody cares about you. Many people who have children express a desire to have their children grow up in the way that they did and to be able to allow their children to play outside and not worry about the dangers that they associate with cities. Some have tried living in the city and have come back to what they know and appreciate: the life that they know because they were born on a farm or in the rural environment and the fact that this is what they really call home. In conclusion, Thorne quoted Jacques de Lacretelle, who said, “the city has a face, the country has a soul” (21st Century Dictionary of Quotations, 1993).


The 2002 Farm Bill covers some environmental health aspects. Senator Tom Harkin of Iowa, who had a brief tenure as chair of the Senate Agriculture Committee, introduced various new ideas and programs into the bill. Eileen Huntoon of Senator Harkin’s office provided the Roundtable with an overview of Senator Harkin’s contribution to the 2002 Farm Bill. Aside from funding existing programs his vision was to add new value-added rural development programs, and, for the first time ever, to have renewable energy be a part of the Farm Bill.

The new Farm Bill included an expansion of land and water conservation programs, said Huntoon. A total of $17 billion in new funding over the life of the bill was added to create new conservation programs and to fund existing conservation programs, such as the Conservation Reserve Program (CRP), which is based on 10- to 15-year contracts to set aside sensitive croplands in grass and trees and targets erodible lands, filter strips, and buffers for water and air quality, and the Wetland Reserve Program (WRP), which is based on permanent and 30-year easements for enhancing wetland wildlife habitat, noted Huntoon. These programs focused on subsidizing farmers who are applying good conservation practices. Conservation programs became more important because, at the time, the United States had ongoing trade discussions in the World Trade Organization (WTO) regarding its heavily subsidized agricultural production—farm subsidies—the solution to which will require the elimination of such subsidies. Other member countries of WTO objected that world competition does not work well with the system that exists in the United States. Therefore, as those farm subsidies decrease, rather than paying farmers to produce more, U.S. farmers need to be offered support in the form of a “green payment,” which is $4 billion a year. The Bush administration has endorsed so-called green payments to farmers who practice land, water, and wildlife conservation on the more than 900 million acres of farm, ranches, and forests. Funding for conservation programs would expand greatly under the House and Senate farm bills, which would encourage practices that enhance the environment. The result of these changes will be cleaner water and an opportunity to save the soil.

In the 1980s, most federal funding for conservation was provided under CRP, which takes hilly land out of production and seeds it and which restores wetlands. The Senate Agriculture Committee wanted to keep CRP as well as to spend money on working farmland because land in production also affects water quality. Under the Conservation Security Program, practices such as the placement of more buffer strips, the use of no-till agricultural practices, the use of complete manure management systems on the farm, and the elimination of runoff would receive funding through a tiered process.

Renewable energy systems are also within the scope of conservation. The Senate Agriculture Committee funded a new grant program whereby farmers and small businesses in rural America can obtain a grant for 25 percent of the cost of various projects, such as putting in small wind, geothermal, and solar energy generators or anaerobic digesters. A total of $23 million will be available nationally for these projects, said Huntoon.

The Senate Agriculture Committee also included grants for research and development on carbon sequestration as well as some money for biodiesel education, but these were not funded.

Similar to the situation years ago, when a whole recycling revolution ensued after the federal government decided to give preference to recycled paper if the costs were the same as those for regular paper, the 2002 Farm Bill includes a new biological products–based program that directs the government to purchase such products if they are available, cost the same as regular products, and perform just as well as regular products. Thus, soybean-based grease for trucks and railroad cars is being made in Iowa. Huntoon noted that if the U.S. Department of Defense were to buy this type of grease, sales would be extremely high. Researchers at Iowa State University are developing another promising product: paper plates made out of cornstarch. In fact, all parts of corn and soybean plants can be used to make something. For example, cornstalks instead of petroleum derivatives can be used to make fiberfill for pillows. Funds for the development of these products have been authorized, but there is a need to work on the marketing of these products so that consumers will purchase them.

Other grant programs added to the Farm Bill focused on biological product–based energy: ethanol, biodiesel, biomass research and development, and biorefinery development. The Farm Bill is evaluating whether second-generation biorefineries that would produce ethanol and biodiesel should be financed.

Nutrition programs are another important part of the 2002 Farm Bill and are important for the health of rural and urban citizens alike. Nationally, the Food Stamp Program typically requires about $27 billion per year—and this amount is increasing—and school lunch programs cost about $960 million per year (USDA, FNS, 2005). The Senate Agriculture Committee added an additional $6 billion over the life of the Farm Bill for some special nutrition programs. Food stamp benefits were restored, without a waiting period, for legal immigrants who were not receiving them and for disabled individuals, said Huntoon.

A pilot program that addresses vending machines in schools was also added to the 2002 Farm Bill. Four states are participating in this program. Children in various schools—28 schools in Iowa—receive free fruits and vegetables as snacks in the morning and in the afternoon. As a result, some schools have removed vending machines, and the program is being expanded to 53 schools, noted Huntoon. The program is managed by the U.S. Department of Education, which selects the schools in rural as well as urban areas.

Research on organic food production was added to the Farm Bill for the first time. Funds were allocated for the collection of data on the cost of organic food production, the fastest-growing sector of agriculture in the United States.

Despite all the efforts and dreams that went into the Farm Bill, some major challenges remain, said Huntoon. Some of the farm programs were not funded, some were reduced, and some were eliminated. Nevertheless, some solid ideas for development of the next Farm Bill, which will be legislated in 2007, have been laid out.

In conclusion, Huntoon pointed out that a strong constituency of individuals from rural areas for rural development and policy issues does not exist. Often, people go to Washington, D.C., and ask for funding for rural water programs but not for rural health programs. There is no broad collaboration among groups from rural areas, and there is a need to develop such a strong rural constituency of many groups and communities working together.



The views expressed here do not necessarily reflect the views of the Institute of Medicine, the Roundtable, or its sponsors. This chapter was prepared by staff from the transcript of the meeting. The discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics.

Copyright © 2006, National Academy of Sciences.
Bookshelf ID: NBK56977


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