Rural America had been left out of the economic boom that was heralded regularly in newspaper headlines and political campaigns. This has been true of agricultural communities where, for example, one recent account asserted that in one four county consolidated school in eastern Iowa, there was an effort to buy hams to distribute to those people who had been getting food from the local food pantries. The school has 102 children, 75 of them qualify for the school food assistance program.
Poverty in rural America is often unseen, unacknowledged, unattended. Currently the U. S. government bases its determination of the "poverty line" as the amount of income needed to purchase a minimally adequate basket of goods and services. (Utilities, clothing, food) In actuality, the market basket was based in effect on one commodity—food. The formula assumes that poor families spend one-third of their income on food, and therefore the cost of a minimally adequate diet was multiplied by three to arrive at the income poverty threshold. Thus, it might appear confusing to urbanites to realize that rural areas, seen as places for food production, have a poverty rate based largely on food needs. In the film, "A Farmer’s Wife," for example, it was shocking to many urban viewers that the family of farmers got their food from programs for the poor, rather than from their own gardens. The poverty line is based upon food, and many rural areas suffer from its lack.
The U. S. Bureau of the Census uses this measure of poverty in order to assess the number of poor people. The federal Office of Management and Budget uses it to set the eligibility standards for federally funded income maintenance programs. In 1996, the poverty line was $15,911 for a family of two adults and two children, $10,815 for a family of one adult and one child, and $8,163 for a single individual.
More than 51 million Americans live in areas classified by the U.S. Office of Management and Budget (OMB) as nonmetropolitan. They comprise one-fifth of the U.S. population. Rural populations are found to be older, poorer, sicker, less educated and to have a perception of worse health status than their urban counterparts. They also have higher infant mortality and injury-related mortality rates, fewer hospital beds and physicians per capita, and are much less likely than urban residents to have private or public health insurance. The rate of uninsured is more than 20 percent higher in rural areas than in urban areas. Fewer rural people enroll in Medicaid. States in the Southwest and Southeast have the highest percentage of uninsured people. And, even if they’ve got insurance, they still need to deal with the question of access.
"Trampled Dreams" a recent study from the Center for Rural Affairs in Walthill, Nebraska documents widespread poverty and hunger in agriculturally based communities of the Great Plains. In a recent report from the hunger relief program, Second Harvest, there is talk of parents who go hungry so their kids can eat, who put off paying utility and phone bills, who insist that their children attend remedial summer-school programs simply so that they can get a meal. "Families are struggling in a way they haven’t done for a long time," said Brian Loring, executive director of Neighborhood Centers of Johnson County, Iowa, which provides lunches to more than 200 kids at five locations during this summer. It probably is startling to hear the dimensions of physical hunger in the heartland, where the Governor of Iowa speaks of his own state as "the food capitol of the world."
A proud generation of farmers and ranchers in the world's most advanced agricultural society is depending on donations of food from social service agencies, church pantries and soup kitchens to feed their families. The rural poverty rate is 23 percent higher than in urban communities and in some areas it's nearly three times the national average. Some farmers in the United States have lived below the poverty line for more than 40 years. In South Dakota, where agriculture accounts for 23 percent of the state's gross output, 17 percent of individual farming operations were eliminated in the last five years. A survey of low-income, rural people living in Minnesota found that of the respondents who experience someone in their family going to bed hungry, 53 percent must at times decide between buying food or prescription drugs, 99 percent would use free meals if they were available, and 55 percent represent households that include one to three children. The clientele at a food pantry in North Dakota includes farmers, the unemployed, couples barely earning a living on minimum wage, and the elderly on fixed incomes. In the eastern part of the state there has been an increase in emergency food requests from laid-off construction workers, telemarketers and seniors. The Regional Food Bank of Oklahoma provides food and grocery products to 225 agencies in rural areas outside of Oklahoma City. Gertie Cooper, who runs a soup kitchen in Carnegie, OK, reports, "the needs are great in western Oklahoma: flood victims, farm families, loss of cattle, farmhands. We need to reach out. Utility bills keep going up. The elderly have a hard time with medicine being so expensive." Food distribution is a major challenge in rural hunger relief efforts. Some food banks serve areas as large as 5,000 square miles and most do not have reliable vehicles that can reach remote rural areas.

Health care across the United States in rural areas has its own special problems. Take Medicare reimbursements to rural hospitals for example. Unlike our urban relatives and friends, most rural residents and Medicare and Medicaid beneficiaries do not have the option to choose another health care provider or to travel a short distance to seek health care services when those in their own community have been eliminated. Under the Balanced Budget Act of 1997, the amount of money that rural hospitals and other health care providers for their services to elderly and poor beneficiaries were reduced—the cost of equipment though, was the same, the reimbursements available were lessened. This had a chilling impact on the availability of resources and services. Legislators had the misconception that rural areas needed the services less, and the practice was that there were many that did not avail themselves of such services or did not know that they were available. What’s not used or known about was cut. But a lack of knowledge could be remedied by information. A lack of utilization could be overcome by adequate education and a provision of services customized to the culture of rural poor people. Rather than cut, what should have happened was more intense research to find ways to meet existent need, to supply transportation, information in community institutions.
For years rural hospitals have been confronted with one obstacle after another. Hundreds have closed. Rural health care is significantly at risk. Rural doctors derive a larger share of their gross practice income from Medicare and Medicaid patients than urban physicians. These public programs pay physicians at lower rates than private insurers. Rural hospitals have fewer opportunities to perform procedures that would be economically enhancing (obstetrical or surgical units, etc.) which further decreases relative reimbursement rates. Rural physicians on average work more and earn less than their urban counterparts. The needs of spouses and children factor into the recruitment process for doctors in rural areas. Professional isolation is often cited as a reason to leave rural areas.
Less than 11 percent of the nation’s physicians are practicing in rural areas. Providers in a small rural community usually do not have the option of refusing care to anyone, thus leading to potential bankruptcies. Where small hospitals are becoming linked to networks of hospitals and increasing managed care pressure to contain costs and achieve quality assurance standards, rural hospitals increasingly find themselves with less ability to provide uncompensated care.
Rural health care should be at the very top of the agenda for rural America. It is a social justice issue. Funding levels need to be increased to support rural health clinics, hospitals, and services for mental health. Medicare and Medicaid need to be organized with specific attention to rural conditions and rural culture. A one size fits all approach is not adequate. Our country has enough appreciation for diversity to recognize that rural cultures and communities are very diverse and need some tailor-made attentiveness.

The governor of Iowa organized an agriculture task force in the fall of 2000. The task force recognized the inadequate focus on farm health care in rural areas, I served on that task force, listen to it’s comment on health services for rural Iowa:

"In times of mild to severe rural economic conditions, service providers face a host of complications to providing adequate service. Unfortunately, many of these agencies and organizations have pre-determined limited funds devoted to assistance. As a result, in a severe farm economic crisis, funds are not available and potential clients may be turned away, placed on indefinite "waiting lists" or given minimal assistance. Some agencies and organizations are restricted by their grant guidelines or regulatory policies as to whom they can serve such that farmers have to meet income or net worth guidelines. Many organizations lack the capacity to respond to emergency needs, due to fixed budgets, and find themselves offering assistance on a "first-come, first-served" basis until the funds are quickly depleted, at which point, late-comers are turned away." (P.5, Task Force Report on Agricultural Issues, Iowa)

"With the removal of a "farm safety net" previously provided by the federal government’s farm program, new questions arise concerning how state government should respond to these changes. In general terms, none of Iowa’s service providers has as their primary, core mission to offer assistance to struggling farm families." (P. 5, Task Force Report)


"Additionally, there is not an organization or system that formally and strategically links service providers together to respond to farm family needs in a coordinated fashion." P.5, Task Force Report

"Mental health assistance includes services to assist families struggling with depression, stress or anxiety by phone consultations or referrals to local health experts. Mental health assistance may touch on rural families contemplating divorce, concerns about suicide, problems with children at school or elsewhere. In general, mental health assistance is an outlet for families searching for initial assistance in rural areas, where assistance may not be immediately available. Service providers estimate that there has been a 13.5% drop in direct service capacity with a 2 % increase in administrative costs. Under the current farm situation, there has been a 12% increase in service requests. Under the current farm situation, the number of emergency calls that are agriculturally or small business related have increased and account for 25% of the calls."

As a way of responding to this lack of adequate attention to rural and farm healthcare, the National Catholic Rural Life Conference (NCRLC) has done several things. We have worked with the faith community and state organizations in the program called: "Sow Seeds of Connection, Harvest Fields of Hope."

NCRLC assisted organizing "Seeds of Connection" meetings held at 20 sites around the state during the month of May 2000. This was a wonderful first opportunity for professionals who work in rural areas of Iowa to come together and share programs, insights and experiences.

It is evident from the evaluations that participants were encouraged by the opportunities to network. At every meeting, people were excited to hear about programs offered by other agencies and the opportunity to dialogue about rural issues from many different perspectives. The case study format proved to be a useful tool for focusing the conversation. Nearly all of the 300+ participants commented on the need to do this kind of networking more often.

Another frequently heard comment, however, was disappointment with the low turnout among clergy and other religious professionals. This illustrates the need for more networking and more communication between agency professionals and clergy. Both congregations and communities are focused on survival in the face of low farm prices, increasing out-migration and low levels of morale rather than on creative efforts to partner in building a network responsive to the changing rural culture and economy. Rural professionals need to work together in order to help communities move beyond this survival mentality.

In order to build a more responsive rural network, Ecumenical Ministries of Iowa, the National Catholic Rural Life Conference, the USDA, ISU Extension, and Legal Services are committed to the long range development of listening and networking skills in rural areas. Specifically, these partners hope to provide opportunities to train professionals and nonprofessionals in peer listening as well as regular regional opportunities for rural service providers to come together to share programs, skills and perspectives.

The challenge will be to continue at the local level the dialogue and partnership efforts that were begun and to identify additional rural professionals with a passion for creative collaboration on rural issues. Specific steps include expanding the database of engaged professionals, the distribution of Seeds of Connection packets to those who weren't able to attend the earlier meetings, continued conversation at the state level on how best to build a more responsive rural network, and a quarterly newsletter providing additional case studies.

I am the chair of the Board of Directors of the SHAUN, a nonprofit organization committed to assisting farm families who have suffered from an accident or disability. We have done training of volunteers to assist in counseling and related support services for such families. SHAUN has helped to make more visible the distinct needs of such farm families. SHAUN’s collaborative partners include Easter Seals, Farm Safety for Just Kids, the Iowa Center for Agricultural Safety and Health at the University of Iowa, the Department of Agriculture of the state of Iowa and many others.

In addition, the National Catholic Rural Life Conference has developed an outreach program named after one of our esteemed past Executive Directors, the late Monsignor Luigi Ligutti in our Ligutti Rural Community Support Program. We have developed this program with private funding to reach out to Iowa farm families suffering from a lack of adequate support as identified in the Iowa task force report. We have two aspects to this program, a mental health component which we call Passages and a resource linkage, retraining component we call Directions, both of these components we see as necessary for our farm crisis response: to provide a structure of emotional support at a time of transition and to provide a range of training opportunities for persons needing that as well. Our first year of operation has involved considerable infra-structure development, in the near future we hope to move to direct service. In any case, as a faith based organization concerned about rural America, its needs, its future, we believe that social justice dictates that rural communities, farm communities deserve their fair share of appropriate health care services, sensitive to the cultural contours of these farm communities and families. In addition to trying to fill a void at the service level, we also believe we have a strong need to advocate at the local and national level for better policy for rural America. In Iowa we have convened a group called Rural Advocacy, where we bring to the surface the ongoing health needs of rural Iowa in order that persons engaged in more direct legislative efforts have good date from which to make their case. We have done the same at the federal level, speaking to policy makers about the date we’re finding on the ground. Our work with the health care community, including parish nurses and community enablers such as cooperative extension give us new partnerships for crucial future efforts for a more socially just system of service delivery for rural America.