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Know the West

Stopping the downward spiral


While the factors Elizabeth Zach cites  —  low reimbursement by public insurers, reduced inpatient services, hospital mergers and others  —  have historically impacted the ability of rural communities to sustain viable health services, this litany of forces reflects incomplete knowledge of research dating back 30 years (“A Rural Health Care Checkup: Lessons from the Central Valley,” HCN, 9/5/16). For decades, rural health professionals and leaders relentlessly pointed the finger at forces external to their communities that threatened hospitals and other services, including small populations and weak economies. Then a solid body of research emerged demonstrating that in most rural communities, the primary reason for the demise of health services, including hospitals, was the failure of communities to meet their residents’ needs and expectations. Our research at the University of Washington Medical School, Department of Family Medicine, documented massive outflows of patients to larger communities for hospital and other services, even services available locally. Unacceptable quality of care, across a wide spectrum of experiences, drove residents elsewhere, but community health-care leaders typically either denied this or failed to come to grips with the problem. Other issues are common: chronic conflict among clinicians, inadequate engagement by community leaders in the downward spiral of services, and continued externalizing of the blame. Our research documented that the primary dynamic in the deterioration of rural health services was factors within our communities, even as the external forces of course aggravated the situation. But communities that stepped up and took control, engaged in honest and comprehensive analysis, and accepted responsibility for the internal decay, showed again and again that an appropriate range of quality health services could be sustained. 

Bruce Amundson 
Shoreline, Washington