Even in these divisive times, virtually everyone in America can agree on one thing: Our health-care system is sick.

Nowhere is this problem more evident than in rural America. For all five leading causes of death in the United States — heart disease, stroke, cancer, unintentional injury and chronic lower respiratory disease — rural areas have higher mortality rates than cities and suburbs.

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The mortality gap in cancer is especially stark — people in nonmetropolitan counties are more likely to die from cancer than their urban and suburban counterparts even though they have lower rates of diagnosis, the Centers for Disease Control and Prevention recently reported. And that gap is widening.

It’s true that lifestyle variables like cigarette smoking, physical activity and seatbelt use contribute to some of these differences. But behind it all lies a combination of poverty and geographic isolation that puts quality medical care out of reach for millions of rural Americans.

In 2015, 15 percent of rural Americans living in states that did not expand Medicaid under the Affordable Care Act remained uninsured. More than 80 rural hospitals have closed since 2010. And although 20 percent of the U.S. lives in a nonmetropolitan county, fewer than 10 percent of physicians practice in one.

Understandably, some people have begun using terms like “the forgotten America.” Policy, funding and economic forces have all contributed to this failure, but I propose that knowledge is the root of the problem.

Rural Americans lack access to a tsunami of knowledge that is coming out of rapid advances in science and technology. In urban and suburban America, patients with sufficient means enjoy the fruits of that new knowledge. Some are even lucky enough to receive the latest treatments in the same institutions where they were developed.

But that wave of innovation is not reaching towns like Mocksville, North Carolina or Trinity, Texas, which lost their hospitals last year. In Lamar, Colorado, the local hospital remains open, but has struggled for years to fill two positions even though they pay more than $200,000 a year.

It’s not hard to see why. Even with scholarships, loan forgiveness programs and generous salaries, newly minted doctors are reluctant to practice in rural America. The standard explanation is that they value the amenities of the big cities where they typically train.

But there is a more nuanced reason for young physicians to gravitate toward urban environments. In an age of breathtaking medical advances, even the most talented young physicians who practice in rural areas face the prospect of being disconnected. Confronted daily with problems they lack the resources to address, their job satisfaction and confidence wane.

The result is a vacuum of medical knowledge. In 2003, only two clinics in New Mexico treated the state’s 30,000 hepatitis C patients. People routinely travelled long distances, with wait times of up to eight months and advanced conditions that sometimes resulted in liver failure, cancer and other serious problems that never would have existed if patients had been able to get care sooner. Clinics in New Mexico had the tools to treat hepatitis C; what they lacked was enough providers around the state who were equipped to use them.

My organization, Project ECHO emerged from a motivation to better serve the needs of rural and underserved patients. It addressed this shortage by connecting providers around the state to specialists in Albuquerque through teleconferencing.

Treated in their own communities, patients were more likely to keep their appointments and adhere to treatment. Today more than 3,000 doctors, nurses and community health workers in New Mexico participate in programs. In fact, 103 medical centers and other sites around the U.S. have adopted the model.

Although facilities, funding and physicians are all vital, the process to start reconnecting “forgotten America” to the latest treatments and preventive measures for cancer, heart disease and other serious ailments begins by simply putting the right knowledge in the right place at the right time.



Dr. Sanjeev Arora is a liver disease doctor and the founder and director of Project ECHO, a global nonprofit organization that helps primary care clinicians treat hepatitis C in their own communities.