Health in Rural America: Remembering the Importance of Place

Historically, public health has been viewed through a variety of lenses. One lens focuses on the contrast between the science and the practice of public health.1 Another focuses on individual versus social responsibility for health.2 A third lens visualizes the contrast between an emphasis on disease categories and an emphasis on functional communities.3 A fourth focuses attention on the distinction between market forces and social justice.4 Of particular importance for public health professionals interested in rural health is that lens through which one sees an important part of the history of public health’s development as oscillation between a focus on health issues facing populations defined by their demographic characteristics and health issues in populations defined by their geographic location. Many of the early public health efforts in the United States focused on specific populations, such as merchant seamen and the urban poor,5 or specific outbreaks of disease, such as cholera, smallpox, tuberculosis, yellow fever, malaria, and typhoid.6 With the challenges created by the burgeoning industrial machine that dominated the late 19th and early 20th centuries, the roots of public health became deeply intertwined with the muck and mire of specific places—the urban slums that fed the industrial machine.7,8 This emphasis on poor populations in urban slums may have sprung from the self-interest of industrial and urban elites fearful about epidemics and their own physical health. It may also be attributed to the need for an adequate urban workforce that could be exploited for economic benefit or to a philanthropic ethos that required the more fortunate to assist those less fortunate than themselves. If nothing else, the consistent focus on simplistic causal explanations for the ill health of the urban poor probably indicates that public health’s focus on urban slums originated from some admixture of all these factors.9