Finding a doctor in rural America has never been easy. Even as more people were choosing physician and hospital care over traditional, “alternative” healing at the end of the 19th century, hospitals and physicians tended to locate in urban centers with a solid patient pool to keep beds filled. Today, still, the dearth of physicians in remote areas means hospitals are few and far between. And even should you find one, they may not be able to treat what ails you. Being a rural doctor often necessarily precludes specialization, so don’t expect a kidney transplant in Tonopah, Nevada.

Of course this is no new problem. Country folk have been bootstrapping their healthcare for generations through the use of hard to reach clinics, rural hospitals, and the traveling doctor. And even in the 1920s, when half of Americans still lived rural, 80 percent of doctors were in cities. The postwar shift from general practitioners to specialists didn’t help, either. Before WWII most physicians were still GPs. But specialization brought a higher potential income, and by 1960 85-90 percent of med school grads were choosing to specialize their practice. According to the Western Journal of Medicine, “nothing affects the location decision of physicians more than specialty. The more highly specialized the physician, the less likely he or she will settle in a rural area.”

A spread from Eugene Smith’s 1948 Life Magazine photo essay, “Country Doctor.” (Life)

With the rise of private “third party” health insurance beginning in the 1940s, doctors were no longer paid by their patients, and reimbursements for specialists were generally larger. Truth is, efficient healthcare and rustic living had never mixed very well—but the situation has worsened as medical careerism shifted from an emphasis on altruism to profit. Blame your orthopedist.

Some large government initiatives have attempted to alleviate the maldistribution of health care, between both urban and rural areas and across the income spectrum. The Hill–Burton Act of 1946 did much to pump hospital funding into middle class communities, but was plagued by accountability issues and accusations of ignoring stipulations aimed at enhancing care for poor patients. The Affordable Care Act, too, brought much needed funds to rural hospitals with its expansion of Medicaid coverage for some 9 million Americans—many of them the rural poor.