» Back to Table of Contents

Director's Letter

The problems of rural America are high in the minds of politicians and policy makers these days. Part of this is due to the role of rural voters in electing Donald Trump, but an even bigger role is the explosion of problems such as opiate abuse and suicide which have been especially devastating in rural areas and smaller towns.¹ The way we think about the health problems of rural Veterans has changed as well. Previously, much of the focus has been on problems of access for Veterans who live farther from major VA medical centers. In response, VA has made great strides in expanding programs to serve distant Veterans, as described in some of the articles in this issue: expansion of community-based outpatient clinics, major investments in telehealth, increasing virtual communication such as secure messaging, and programs like SCAN-ECHO which help train up the abilities of rural and other primary care providers. As VA expands into a world of "Choice" and community partnerships, providing access will increasingly draw on community providers. But truly supporting the needs of rural Veterans must go beyond providing health care access—recent reports from the Centers for Disease Control and Prevention indicate that rural Americans have higher mortality from each of the five leading causes of death—heart disease, cancer, accidental injury, lung disease and stroke.² Especially worrisome are the recent rises in what have been termed "deaths from despair"—suicide, drug overdose, and alcoholism. Although rural communities can be tight-knit communities, isolation can also be a problem, especially for individuals struggling with unemployment, mental health issues, or substance abuse. As we take a population health approach, and especially as we tackle suicide, VA will need to focus on how we can more effectively reach out to our Veterans outside of their health encounters—to promote prevention, provide better social support, and to promote connectedness. This will involve partnering with community groups, faith organizations, and other social services, much like what has been done so successfully with homelessness. The solution isn't simple, but the need is compelling.

David Atkins, MD, MPH, Director, HSR&D

1. Alex Berezow, "Suicides in Rural America Increased More Than 40 Percent in 16 Years," American Council on Science and Health, March 2017.
2. Moy E, Garcia MC, Bastian B, et al. "Leading Causes of Death in Non-metropolitan and Metropolitan Areas - United States, 1999–2014." MMWR Surveillance Summaries 2017; 66 (No.SS-1): 1-8.