WASHINGTON, D.C. – Rural Maine is in the midst of a public health crisis, and U.S. Senator Angus King (I-Maine) today pressed two federal health agencies to explain what is being done to help address it.

Calling the crisis a “slowly emerging, catastrophic injustice”, Senator King in a letter to the Department of Health and Human Services and Centers for Disease Control and Prevention highlighted how people in rural Maine are facing health challenges of an unprecedented magnitude. Senator King noted that the five leading causes of death in the United States from 1994-2014 were cancer, heart disease, chronic lower respiratory disease, stroke, and unintentional injury – with Maine leading all New England states in both the number and rate of deaths from these causes. He also noted that rural suicide rates have doubled or tripled across the country, that the proportion of Maine infants dying before their first birthday has increased, and that studies indicate that life expectancy for older, white Americans has decreased.

            “Rural areas of the United States – and Maine is 61 percent rural – suffer from a public health crisis of increasing magnitude. The divide between our rural and urban areas grows stark. ‘Urban’ increasingly has come to mean ‘healthy,’ and ‘rural’ has become another word for ‘sick,’” Senator King wrote in his letter.

In his letter, Senator King told federal officials that he wants to see more public health resources and workers deployed to rural areas like Maine and that HHS should prioritize expanding the number of Federally Qualified Health Centers, mental health centers, and National Health Service Corps participants.

He also pressed the officials to explain what is being done within their departments to expand access to care in rural areas, to bridge the disparity that exists between rural and urban areas, and to address the infant mortality crisis in Maine.

“The crisis in rural public health is a slow-moving one, making it easy to miss and easy to ignore,” Senator King continued. “Small investments now can produce tremendous results for the future. But we must act. If we do not, we will pass a tipping point beyond which it will be more difficult and expensive to ensure the good health of our citizens and to promote the general welfare.”

The complete text of Senator King’s letter can be read HERE and is below:

+++

May 3, 2017

Don Wright, M.D., M.P.H.

Acting Assistant Secretary for Health

United States Department of Health and Human Services

200 Independence Avenue SW

Washington DC 20201

Anne Schucat, M.D. (RADM, USPHS)

Acting Director

Centers for Disease Control and Prevention

1600 Clifton Road

Atlanta GA 30329-4027

James Macrae, M.A., M.P.P.

Acting Administrator, Health Resources and Services Administration

United States Department of Health and Human Services

200 Independence Avenue SW

Washington DC 20201

Dr. Wright, Dr. Schucat, and Mr. Macrae:

Maine is in the midst of a public health crisis that is a bellwether for the imminent challenges of public health in the United States, particularly in rural areas. I write to request information on federal government responses, as well as action on funding and programs related to this problem.

In a region with generally good health for adults, urban or rural, Maine stands out for the degree of “excess death” among its rural residents. (“Excess death” or potentially preventable deaths are deaths of persons under 80 years old that exceed the death rates for the states with the lowest rates.) The five leading causes of death in the United States from 1999-2014 were cancer, heart disease, chronic lower respiratory disease, stroke, and unintentional injury (“accident”). Maine, unfortunately, led all the states of New England in both the number and rate of deaths from these causes.[1] A recent CDC study indicated that suicide rates have increased more rapidly in rural areas than in urban areas. Rural suicide rates have doubled or tripled, with the largest increases in areas with the lowest population.[2]

Recent pathbreaking work by economists Anne Case and Angus Deaton indicates that this problem may only get worse in coming years. Case and Deaton’s research shows that in recent years while many groups in the U.S. have gained in life expectancy, non-Hispanic whites over 50 have suffered setbacks in life expectancy.[3] Maine—the state with the oldest average age and a high proportion of non-Hispanic whites—faces particular danger from this demographic trend.

From 2005-2014, the proportion of Maine infants dying before their first birthday has increased—the only state in the United States for which this is the case.[4] One significant reason for this increase is the rural nature of Maine. Nearly 40 percent of women from isolated rural areas of my state had low levels of income and low levels of education. Both of these factors are associated with higher rates of pre-pregnancy risks and pregnancy complications,[5] each of which can lead to infant morbidity and mortality.

Rural areas of the United States—and Maine is 61 percent rural—suffer from a public health crisis of increasing magnitude. The divide between our rural and urban areas grows stark. “Urban” increasingly has come to mean “healthy,” and “rural” has become another word for “sick.”

I want to know what the Department of Health and Human Services, particularly your branches, is doing about this slowly emerging, catastrophic injustice.  Please answer the following questions:

1. Rural areas receive less funding for health because federal assessments prioritize absolute numbers of people reached. What steps are you taking to correct the disparity created by the bias of current federal efforts toward cities and suburbs?
   1. Rural areas—by definition—have fewer people than urban or semi-urban areas. Rural areas currently face higher rates of most health problems and health risk factors. Funding, however, goes to those places where it can reach a higher absolute number of people. So the federal government bypasses a rural county with heart disease, for example, that is two or three times higher than in an urban area.
   2.  
   3. What steps will you take to address the infant mortality crisis in Maine?  There is a clear need for additional resources to understand and treat this epidemic of infant deaths. Please provide a summary of any actions taken to date to address increases in rural infant mortality, as well as evidence that such interventions were effective.
      1. I do not think that “safe sleeping” practices are the major culprit here. HHS infant health data indicate that Maine’s levels of safe infant sleeping are relatively high. Other factors seem to be at work in Maine’s high infant mortality rate.

1. What sources and amounts of funding is the department using to address rural disparities? Which of those are particularly and predominantly given over to rural health issues?

1. What plans does the department have to expand access to care in rural areas? At a minimum, I would request that you prioritize expanding the number of Federally Qualified Health Centers, mental health centers, and National Health Service Corps participants in rural areas.

1. While medicine focuses on health for individual patients, public health steps back to address the needs and health of populations. A public health approach will be critical to rural populations, and I would like to see more public health resources and workers deployed to rural areas like Maine.
   1. What means will you use to deploy more public health professionals and analysis to areas of crisis? How will you work to ensure that these resources continue to improve and protect rural health, even after positive change occurs in the trends?

The crisis in rural public health is a slow-moving one, making it easy to miss and easy to ignore. Small investments now can produce tremendous results for the future. But we must act. If we do not, we will pass a tipping point beyond which it will be more difficult and expensive to ensure the good health of our citizens and to promote their general welfare.

I look forward to your suggestions as to how we can work together to address the health challenges of rural places like Maine.

###