Did you know that Maine is the most rural state in the United States? It doesn’t seem like it, when you consider the vast empty spaces in states like Wyoming and North Dakota.

The U.S. Census defines all areas with more than 2,500 people as urban. By that definition, I live in the most rural county (Lincoln) in the most rural state. Lincoln has four towns larger than 2,500 people, but it is considered 100 percent rural by the U.S. Census, as is Piscataquis County.

That rural character is what we most love about Maine: endless forests, remote lakes, snow-capped mountains, rolling hills of green farmland, wild coastal shores.

This comes with a price though. Maine is part of a very worrisome trend — the growing divide in health and mortality outcomes between rural and urban areas. Rural areas across the U.S. consistently experience higher rates of chronic disease, obesity, suicide, injuries and accidents, and in a newer development in Maine, increased opioid addiction and infant mortality.

The 2016 County Health Rankings (a joint effort of the Robert Wood Johnson Foundation and the University of Wisconsin) noted that rural counties have had the highest rates of premature death for many years. And while urban counties show improvement in death rates, rural counties keep getting worse.

We commonly think that people are healthy if they make good personal choices and see a doctor periodically. Good health is actually a complicated dance between personal health behaviors, accessible medical care, income and educational status, social stability, and community characteristics (housing, transportation, safety, environmental quality). Many of those factors weigh heavily in rural areas.

A recent report by the Maine Health Access Foundation and the Muskie School of Public Service looked at health and health care in this rural state and found similar disparities between our own rural and urban counties. Maine’s most rural counties are older, poorer, have lower education levels, and higher unemployment rates. Moreover, rural counties exhibit higher rates of chronic disease, disability, and reports of fair or poor health.

Maine’s rural counties are also whiter; even though increases in diversity are evident in Maine, those increases are largely in our urban areas. An article last August in The New York Times pointed out another disturbing trend with application to rural Maine — that death rates among white, lower-educated men have been climbing since 1999, while rates among people of color have been dropping. Primary reasons posed are alcoholism, drug addiction, and general despair about the future.

The health access foundation’s report looked at how health care systems can impact rural health, particularly if there are geographic and financial barriers to obtaining care. Again, rural areas lagged behind urban in mental health care, preventive checkups, access to regular primary care, and insurance coverage, to name a few indicators. In the latter case, the gradual decline of large employers in rural Maine has severely reduced access to employer-sponsored health insurance. That is a major reason why signups for Obamacare in Maine were very high and why Medicaid expansion remains an important issue for rural residents.

Socioeconomic issues continue to haunt rural Maine when compared to its urban areas: lower median incomes, more residents living below the federal poverty level, lower college degree attainment, and higher unemployment rates. All of these factors are associated with lower levels of health and well-being among rural residents.

So what is to be done? Do we yield to an overwhelming sense of hopelessness? Fortunately, there are effective interventions with evidence behind them described in a companion report to the County Health Rankings.

To improve health outcomes in rural areas, the most immediate issue is prevention and treatment of opioid addiction. In the longer term, evidence shows that unintended injuries can be prevented by seat belt enforcement, alcohol sobriety checkpoints, and fall prevention in the elderly. Chronic disease and obesity can be reduced by such proven strategies as increasing access to facilities for physical activity, increasing farm to school programs, and reducing screen time for children.

Rural areas also need health care system improvements tailored to their specific needs. Evidence shows that rural training in medical education is effective. Telemedicine is a promising practice. Increasing rural residents’ access to a medical home, self-management programs in chronic disease, and sealants and fluoride treatment in schools have all been shown to be evidence-based.

Addressing some of rural areas’ most persistent socio-economic issues can produce a more ready and adaptable workforce for the changing economy. Strategies with the most evidence behind them are early childhood education, universal pre-K classes, dropout prevention programs, career academies and internships, transitional jobs out of welfare, and housing rehabilitation.

Maine’s most rural populations face significant health challenges that threaten the future prosperity of well over half our state. There are roadmaps available to us, if only we take the first steps. If we do not, we risk further decline in the signature areas and communities that define our unique way of life.

Lisa Miller, of Somerville, is a former legislator who served on the Health and Human Services and Appropriations and Financial Affairs committees.

(Editor’s note: An earlier version of this post misstated the number of towns in Lincoln County with more than 2,500 people.)

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