Public health in the rural United States is a complex and underfunded enterprise. While urban-rural disparities have been a focus for researchers and policymakers alike for decades, inequalities ...continue to grow. Life expectancy at birth is now 1 to 2 years greater between wealthier urban and rural counties, and is as much as 5 years, on average, between wealthy and poor counties.This article explores the growth in these disparities over the past 40 years, with roots in structural, economic, and social spending differentials that have emerged or persisted over the same time period. Importantly, a focus on place-based disparities recognizes that the rural United States is not a monolith, with important geographic and cultural differences present regionally. We also focus on the challenges the rural governmental public health enterprise faces, the so-called "double disparity" of worse health outcomes and behaviors alongside modest investment in health departments compared with their nonrural peers.Finally, we offer 5 population-based "prescriptions" for supporting rural public health in the United States. These relate to greater investment and supporting rural advocacy to better address the needs of the rural United States in this new decade.
I appreciate the invitation to comment on the article by Brownson et al. (p. 1605). The recent events in our country have affected me as a person, as a seasoned physician, and as a former public ...health official (administrator of the Health Resources and Services Administration and executive director of the Utah Department ofHealth). I am aggrieved by the confluence of the COVID-19 pandemic and the problems that have arisen owing to disagreement on how to respond to the current Black Lives Matter-related protests, which began in large part as a consequence of the murder of George Floyd by police in Minneapolis, Minnesota. Both have exposed serious fault lines- in our criminal justice system and our public health system. At the same time they have provided opportunities for working together across the political spectrum to achieve consensus on what needs fixing in the United States. Unfortunately, both issues have been politicized: they have been used by politicians and activists on the left and right to further their agendas. I am not an expert or experienced on matters of policing policy, but I feel that whatever changes are sought we need to continue to protect the public and maintain the rule of law. So, I will limit my comments to the great challenges we must address to improve and strengthen public health practice in our country.
Policies facilitating integration of public health programs can improve the public health response, but the literature on approaches to integration across multiple system levels is limited. We ...describe the efforts of the Massachusetts Department of Public Health to integrate its HIV, viral hepatitis, sexually transmitted infection (STI), and tuberculosis response through policies that mandated contracted organizations to submit specimens for testing to the Massachusetts State Public Health Laboratory; co-test blood specimens for HIV, hepatitis C virus (HCV), and syphilis; integrate HIV, viral hepatitis, and STI disease surveillance and case management in a single data system; and implement an integrated infectious disease drug assistance program. From 2014 through 2018, the number of tests performed by the Massachusetts State Public Health Laboratory increased from 16 321 to 33 674 for HIV, from 11 054 to 33 670 for HCV, and from 19 169 to 30830 for syphilis. Service contracts enabled rapid response to outbreaks of HIV, hepatitis A, and hepatitis B. Key challenges included lack of a billing infrastructure at the Massachusetts State Public Health Laboratory; the need to complete negotiations with insurers and to establish a retained revenue account to receive health insurance reimbursements for testing services; and time to train testing providers in phlebotomy for required testing. Investing in laboratory infrastructure; creating billing mechanisms to maximize health insurance reimbursement; proactively engaging providers, community members, and other stakeholders; and building capacity to transform practices are needed. Using multilevel policy approaches to integrate the public health response to HIV, STI, viral hepatitis, and tuberculosis is feasible and adaptable to other public health programs.
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