1. Health Disparities in the Rural American West
Michele Barry, MD, FACP, FASTMH
Professor of Medicine and Tropical Diseases
Senior Associate Dean for Global Health
Director, Center for Innovation in Global Health
Senior Fellow, Woods Institute for the Environment
Stanford University

2. Rural Americans vs. Urban Americans
Health Issues:
Rural Americans vs. Urban Americans
Less health insurance, and trauma centers
Older, poorer, and sicker
Higher rates of cigarette smoking, htn, and obesity
Lower rates of physical activity and seat belt usage
National Vital Statistics System, 2014

3. Rural California

4. Rural California Rural Health Clinics (RHCs)
- Medicare/medi-Cal and undocumented people
- Account for 44% of total rural primary care
- Largely financially unstable
Patients in RHCs
- High food insecurity
- Smoking and cardiovascular diseases
- Obesity and diabetes
- Difficulty accessing care
California Health Care Foundation (2012)

5. Rural California & Agricultural Workers - 800,000
Of migrant and seasonal workers
- 41% got treated by private providers
- 31% at Migrant Health Centers
- 14% at dentists’ offices
- 11% at hospital/emergency room
- 3% unreported
Only 3/5 of agricultural workers reported using US health care services in last 2 years; 8% used health care services in other countries.
Transition into rural physician shortage leading to barriers to access
National Agricultural Workers Survey (2012)

6. Physician Shortages in Rural Areas
While almost 20% of Americans live in rural areas, only 10% of all practicing physicians do.
Gondi & Patel (2016)

7. Physician Workforce
Conrad30 State Program:
Conrad30 (2010)

8. Projected US Physician Shortages
AAMC, Center for Workforce Studies (2014)

9. Rural Physician Workforce
2/3 of all Health Professional Shortages are in rural areas
There are 75 physicians/100,000 residents in urban areas, compared to 55 physicians/100,000 residents in rural areas
Conrad30 (2010)

10. Growth in Number of Medical Schools
Selected countries with growth rates greater than 25% since 2002:
2/3 of all Health Professional Shortages are in rural areas.
US – 20 new medical schools established, from 178 to 198, with 7 new schools currently awaiting accreditation
AAMC (2016)

11. Growth in Number of Medical Schools
Selected countries with growth rates greater than 25% since 2002:
2/3 of all Health Professional Shortages are in rural areas.
US – 20 new medical schools established, from 178 to 198, with 7 new schools currently awaiting accreditation
United States
178 20
11.2%
AAMC (2016)

12. Brain Drain and Globalization
Country
Physicians/100,000 Population
% IMG Workforce
% from low-income country US
293
25%
60% UK
231
29%
75%
25% of physicians are international medical graduates
International Medical Graduates-Specialties
37% of all US Internists
28% of all Pediatricians
27% of all Family Medicine physicians
Primarily work in underserved or rural areas
Bundred et al., Migration of Health Professionals, Harvard Policy Review, 2004
Mullen, F., The Metrics of the Physician Brain Drain, NEJM, 2005

13. International Medical Graduates
H1b Worker Visas
Conrad 30 J-1 Visas – rural services
7,500 physicians
Allows employers to bring in skilled foreign workers. High demand and lottery based
Expedited processing is currently halted under Trump administration
1500 medical trainees each year
Waive 2-year home residency requirement for J1 visa
Conrad 30 participants are required to work in rural or medically underserved areas for a minimum of 3 years
Currently, this is one avenue that we are using to address physician shortage, as there is a lack of physicians in rural healthcare, so visas could be one motivation.
To our knowledge, Conrad 30 J1 visas have not yet been affected by Trump administration policies.
President Trump’s temporary immigration ban in January further restricted IMGs from all countries
Put a strain on rural and underserved communities that rely on these physicians
CNN (2017)

14. Loan Forgiveness
National Health Service Corps (1972) student loan repayment for med students/$120,000—3 year commitment
NHSC-approved sites include Rural Health Clinics and Federal Indian Health Services
Licensed health care providers earn up to $50,000 toward student loans in exchange for 2-year commitment at NHSC-approved site
Individual State Loan Repayment Programs also exist
Medical (MD or DO) and dental (DDS or DMD) students may earn up to $120,000 in their final year of school through the Students to Service Loan Repayment Program (S2S LRP). Students must commit to serving at least three years at an approved NHSC site in a Health Professional Shortage Area of greatest need.
Not being cut by Trump as we can tell.
NHSC (2017)

15. Community Health Care Workers (CHW)
CHW are public health workers
- trusted members of the community
- speak the same language
- share the same ethnicity/socio economic status
CHWs provide
- basic health screening tests
- referrals to health and social services
85, ,000 CHWs practice in US, (5.0 million worldwide)
CHWs help to bridge physicians and patient communication barriers.
CHWs are particularly valuable for bridging linguistic and cultural barriers (IMGs)
Perry, Zulliger, and Rogers (2014)
Rural Health Information Hub (2017)

16. Community Health Care Workers (CHW)
CHW are public health workers
- trusted members of the community
- speak the same language
- share the same ethnicity/socio economic status
CHWs provide
- basic health screening tests
- referrals to health and social services
85, ,000 CHWs practice in US, (5.0 million worldwide)
CHWs help to bridge physicians and patient communication barriers.
CHWs are particularly valuable for bridging linguistic and cultural barriers (IMGs)
Concept of Task Shifting
Patient-Provider Communication
Perry, Zulliger, and Rogers (2014)
Rural Health Information Hub (2017)

17. Rural Health and Technology
Telecommunication allows rural PCPs to consult with specialists at faraway urban centers
Telehealth also allows rural areas to receive time-sensitive consults in emergency situations
Google Glass has allowed expert clinicians to advise on physical exams and surgeries remotely
Drones used to deliver medication and telehealth capabilities.
Limited technology and internet, associated with worsened health outcomes
Drones and telehealth
Gondi & Patel (2016)

18. Where to Go Next to improve Rural Care??
Increased loan forgiveness for rural PCPs
More research on urban-rural disparities
Community Health Care Workers and Task Shifting
Increase science education/outreach for rural students
Food Security
Preventive Health Care
Discuss Stanford’s scope in each of these recommendations
Paying attention to domestic health disparities, in addition to global health disparities.
Addressing drones; Research in urban / rural disparities; Increased loan forgiveness; Community healthcare workers; Telemedicine, telehealth, science / educational outreach
Telemedicine & Telehealth
Stronger rural advocacy to inform healthcare policy
Disruptive Technology
Global Health is Local Health