Elevating the Voices of Rural Minority Women

Abstract

In May 2001, a national conference was convened in Galveston, Tex, with support from the newly created National Center for Minority Health and Health Disparities, National Institutes of Health. At this conference, approximately 250 representatives of the public health and medical communities, along with applied researchers from academia and the private sector, were joined by members of local communities to discuss the health and health care needs of minority women living in small towns and rural areas of the United States. These women represent an often invisible and silent subpopulation of a subpopulation. The US decennial census for 2000 reports that the US population of approximately 281 million is 51% female and 49% male. Of the females, approximately 20% live in rural areas (i.e., outside metropolitan areas). Sixteen percent of the total rural population is composed of racial and ethnic minority groups.1 Of women living in rural areas, approximately 10% are from such groups. In this issue of the Journal, several reports by noted researchers seek to disentangle the maze of fragmented and incomplete data about rural and other women of color. Rural women have the following in common: geographic and informational isolation, fragmentation of services, limitations regarding transportation, gender biases and inequalities, educational limitations, and disproportionate poverty. Women of color experience all of the above conditions in addition to the following: cultural differences; differences regarding health beliefs; racism; political, economic, and access inequalities; language barriers; migratory patterns that further fragment services and health care; and abject poverty. These conditions unique to women of color, coupled with the limitations of life in small towns and rural communities, leave them with feelings of hopelessness and disempowerment, and they are less understood by the institutions responsible for serving them. Their already difficult situation is further exacerbated by the deterioration of the health care safety net and a strong tradition in rural America of self-sufficiency. In general, rural women are more likely to be married, to live in larger, extended families, and to have strongly enforced gender roles.2–4 They work for lower salaries than urban-based women, and their jobs usually do not provide adequate health insurance, if any. Women of color experience these conditions at twice the rate of their White counterparts, thereby increasing their overall vulnerability.5 The health problems of racial/ethnic minority women living in rural areas include the same health disparities experienced by urban minorities, but with greater severity. They include cardiovascular disease and its risk factors; diabetes (largely among Mexican Americans but increasing exponentially among African Americans); increasing violence, mostly domestic; HIV/AIDS, the fastest-growing problem among African American women; breast and ovarian cancers; and the staggering increased rates of cervical cancer among Asian women. Infant mortality, one of the longest-standing health and medical care problems among African Americans for over a century, continues to challenge us. The cumulative effects of these factors experienced by women of color, and the health conditions from which they suffer, require further research. However, research must be carried out in partnership with women of color and followed by the needed policy responses. Consideration of concepts such as “weathering,”6 put forth by Geronimus, and the sustained impact of lower socioeconomic status and systemic racism and discrimination as posited by Williams7 may further inform our understanding of the complex nature of the problems faced by women of color living in rural America. While the disparities discussed in the reports that follow are important, grounding them in the everyday lives of women provides the evidence we need to tailor appropriate remedies. In our dialogue at the Galveston conference with women of color from local communities, we validated their need to be included in the decisions and options made available to them. They expressed a desire to include the whole community in which they lived. They do not live separately from their neighbors, families, or churches, and by including the “whole community,” women meant that they wanted their communities to “know”and that their ways of “knowing” may be different from those of other groups. How and what they do is reinforced by the culture and belief systems of which they are a part, and they want to understand their options and participate in decisions that affect them and their communities. Unfortunately, our conference did not address the special needs and vulnerabilities of elderly woman of color per se, but their situation is an example of what happens when social and medical systems fail to consider the needs of women in general. Elderly women of color are an ever-growing population in rural America, with 43.9% living in the South, 32.6% in the Midwest, and 23.5% in the remainder of the United States.3 They experience multiple chronic conditions, disabilities, and comorbidity within a social and medical system in which there is no coordination between the organizing, delivery, and financing of health care. These burdens are further exacerbated by the fact that most elderly women of color are socially and economically disadvantaged.8 If we are to turn the tide for women of color living in rural America, we must do the following: Give voice to those affected by the problem. Work with women—in their communities, on their own terms—to acquire the data and information needed to create new policies that better serve their needs or to change current ones. Expand the curricula of health professionals to include early exposures to minorities at the community level through a multidisciplinary approach to health and medical care. This exposure would serve to enhance the understanding of vulnerable groups' day-to-day lives, cultural traditions, belief systems, and the challenges they face. These experiences will yield a better-prepared professional. Upgrade our regionalized medical care systems to include better linkages with providers at the local level while expanding partnerships with other care-giving organizations and locally based infrastructures. This effort would foster continuity and comprehensiveness of care for vulnerable populations. Contextualize our research and educational programs to create models that can be evaluated and replicated within minority populations. This approach may yield new measures to better inform our knowledge and value their differences. Muster the political will needed to change public policies that inhibit our success and design new ones to enable our success. If we fail to make a measurable difference toward the elimination of health disparities among the most vulnerable in our small towns and rural communities, we most assuredly will not make the needed progress required by our urban neighbors.

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