Monday, March 27, 2017

Rural communities and renewable energies

"Small, remote, economically challenged communities have successfully integrated renewable energy into their existing, diesel-based power grids with more success than just about anywhere else in the world."

What? That's not possible.

Apparently it is.

Renewable Energy Alaska Project (REAP) is doing just what its name says, and seemingly with much success. Scientific American recently re-published an article by David W. Shaw from Ensia wherein Shaw describes the successes of "microgrids" in rural Alaska. Using hydro and wind energy sources, these microgrids created by REAP actually decrease costs of energy for communities in remote areas of Alaska. Let me say that again. Renewable energy is decreasing the cost of energy in rural Alaska.

According to Shaw, some of the more remote areas of Alaska pay up to $1 per kilowatt-hour for electricity. That is eight times the national average of just 12 cents. Safe to say we need more than just a few kilowatt hours of electricity to survive, especially in Alaska. That's expensive.

Here in Davis, CA, Pacific Gas & Electric charges me and my two roommates 18.3 cents per kilowatt hour for our electricity. After glimpsing at some past bills, it seems like we use about 210 kWh per month. That means that if we lived in one of these rural areas of Alaska, and used the same amount of electricity, we would be paying over $200 per month for electricity (plus whatever additional cost for gas). That's a very low estimate seeing as we live in a place where we rarely have to turn on the heat. Now, imagine a business owner, or a larger family, or someone with medical needs that require equipment that runs on electricity, or even one step further, a hospital. Energy costs are a huge concern.

One study, published by the UN Foundation, looked at 12  microgrids in three developing countries (India, Malaysian Borneo, and Haiti). The study examined factors that allow the energy models to "thrive or struggle." These factors are tariff design, tariff collection mechanisms, maintenance and contractor performance, theft management, demand growth, load limits, and local training and institutionalization. The study asserts that "microgrids – distributed systems of local energy generation, transmission, and use – are today technologically and operationally ready to provide communities with electricity services, particularly in rural and peri-urban areas of less developed countries." The success of the microgrids depends largely on the organizing body's ability to adapt to each individual community and also take into account the business model. That is, whether the project is for-profit or subsidized to some extent. Another more macro-breakdown of "best practices" for microgrid project planning in rural areas that the study provides is based on three areas: Social Context, Strategic Planning, and Operations.

The price benefits in rural areas of a developing country are even greater than in rural Alaska. According to the study, "Many households in rural areas of the developing world depend entirely on traditional fuels." The study reports that using wood or kerosene for a stove may cost $2/KWh hour while grid connection could reduce that cost to just 10 cents. Other benefits include "improved health, safety, productivity and education;" this is largely due to replacing kerosene with electricity.

Back in Alaska, REAP's model has successfully used microgrids to provide electricity for small geographical areas containing individual communities. Like the study discussed above suggests, Shaw describes these microgrids as "customized." That's exactly what they are. Piper Foster Wilder, deputy director of REAP, explains that they go into each community where a new microgrid will be built and figure out which resources are most abundant and how they should split up energy sourcing to be most efficient. She also notes that some of the Alaskan towns are primed for this project because of their topography, which has led to the great success of using wind and hydro power on a small scale. Each project is place and community specific.

Shaw's main point in his article is that these microgrid models are working. "Some 1.2 billion people on the planet do not currently have access to electricity. And there’s a lot these people can learn from Alaska." At least in rural Alaska, the microgrid model has saved families and businesses a lot of money through decreasing the cost of keeping the lights on.

For previous posts on renewable energy in rural areas, see herehere and here. And then read this previous post about legislation to help California farmers use easements for solar energy to offset land costs.

California: Potential sanctuary state?

A few weeks ago, UC Davis Law School alumni and Mayor Pro Tempore of the City of Woodland, Enrique Fernandez, visited our class to discuss the potential of Woodland joining the California trend and becoming a sanctuary city. While the term sanctuary city does not have a precise legal meaning, in the United States the term sanctuary city provides a loosely defined label for a city that welcomes refugees and illegal immigrants. For many undocumented immigrants, the term sanctuary city is a "shield from deportation."

However, there are often misconceptions about sanctuary cities. Marissa Montes, co-director of the Loyola Immigrant Justice Clinic at Loyola Marymount University Law School in Los Angeles, told USA Today:
The biggest misconception is that people think that when you declare yourself a sanctuary it means that there is absolutely no contact with ICE, and that is not true. If ICE wanted to have a raid in downtown LA and did everything procedurally correct, like get a warrant, the city would not be able to stop them.
This blog has recently discussed President Trump's immigration policies (see here, and here). In January, President Trump signed an executive order aimed at cracking down on sanctuary cities limiting cooperation between state and local law enforcement and federal immigration agents. According to the executive order, named "Enhancing Public Safety in the Interior of the United States," cities that do not comply with federal immigration enforcement agents per 8 U.S.C. 1373 “are not eligible to receive Federal grants, except as deemed necessary for law enforcement purposes by the Attorney General or the Secretary.”

Some of the largest cities in California–including Los Angeles, San Francisco, and Sacramento–have so-called sanctuary city policies prohibiting police from cooperating with immigration authorities. However, many cities and rural areas in the state do not.

Recently, Fresno Mayor Lee Brand, vowed that Fresno will not become a sanctuary city, bucking trend in large California cities. Fresno (my hometown) is the fifth biggest city in California by population, bigger than Sacramento–the state's capitol. Fresno county is home to million acres of the world’s most productive farmland, with agricultural operations covering nearly half of the county’s entire land base of 3.84 million acres. Farmers in Fresno raise more than 350 different crops, contributing directly more than $5.6 billion to the California economy and supporting 20 percent of jobs in the Fresno area. Because agriculture comprises such a significant portion of Fresno's economy, the city and county of Fresno–including small rural towns outside of Fresno–are heavily dependent on migrant farmworkers. This blog recently discussed how President Trump's immigration policies could kill the agricultural economy in California's Central Valley.

It seems inconsistent that areas like Fresno, which rely on immigrant and migrant labor, would not fight to protect against policies that could potentially strip the local and state economy. However, President Trump's threat to cut federal funding provides some explanation. Mayor Brand explained to the Fresno Bee: "I’m not going to make Fresno a sanctuary city because I don’t want to make Fresno ineligible from receiving potentially millions of dollars in infrastructure and other types of projects. My philosophy is to follow the law and to avoid these national culture-war questions." Yet, Californian government officials have vowed to fight back against President Trump and GOP proposals despite President Trump's threats.

In his State of the State address on January 24, 2017, California Governor Edmund (Jerry) G. Brown Jr. promised to continue forcefully defending those in the United States illegally against new proposals by President Donald Trump and national Republican leadership. Specifically, Governor Brown stated:
[I]n California, immigrants are an integral part of who we are and what we've become. They have helped create the wealth and dynamism of this state from the very beginning. I recognize that under the Constitution, federal law is supreme and that Washington determines immigration policy. But as a state we can and have had a role to play. California has enacted several protective measures for the undocumented: the Trust Act, lawful driver's licenses, basic employment rights and non-discriminatory access to higher education.
California is known to be one of the most progressive states, often setting trends for the rest of the country in terms of policy and regulation. In that vein, Governor Brown ended his address saying, "California is not turning back. Not now, not ever."

Senate Bill 54, introduced by Senate President Pro Tem De León, fights to make California a sanctuary state. The Bill, officially titled the California Values Act, would prohibit local and state agencies from using state resources to communicate with federal agents, with a few exceptions (such as task forces involving federal and local agencies). With minor changes to win over moderates, the Bill–perhaps the Legislature’s highest-profile act of defiance against the Trump administration–cleared a key hurdle Monday, March 13th and will head to the full Senate for a vote.

California cannot stop federal immigration agents from conducting raids within the state, but that is not stopping the state from fighting back against President Trump's policies. It will be interesting to see how the Trump administration will respond to California's defiance and how rural communities and the state economy will (hopefully) benefit from new state-wide sanctuary policies.

The rural health landscape (Part III): Interview with a midwife

Parts I and II of this series discussed, respectively, women’s health in rural America (generally) and the history of midwifery in rural America (specifically). This post provides a glimpse into modern midwifery.

Eva Warner is a Certified Nurse Midwife (CNM). She completed her undergraduate degree at the University of Colorado–Boulder. As an undergrad, she lived abroad in India, where she collaborated with the Institute of Health Management (IHMP) to study the socio-cultural determinants of maternal health in Pune, India. After graduating with honors in Sociology, Eva worked as a case manager at Clinica Family Health, a full-service medical provider serving disadvantaged and low-income patients in south Boulder, Broomfield and west Adams counties. In addition to receiving her Master’s from Columbia University’s Nurse Midwifery Program, Eva is also the recipient of the National Health Service Corps (NHSC) Scholarship. When she graduated from Columbia, Eva was offered positions in both Chicago (serving an underserved urban community) and New Mexico (serving an underserved rural community). She recently accepted the offer from New Mexico, and will spend the next two years serving rural and underserved women in and around Los Lunas and Belen.

The following transcribes my interview with Eva. Editorial additions and asides are bracketed and indicated with italics.

Hi Eva! Thank you so much for agreeing to share your thoughts and experiences. To start, please tell us a bit about your personal background. Who are you? Where are you from? Do you have any previous experience with rural communities?

I grew up in Colorado Springs, Colorado in a multiracial and multicultural family. Dinner table conversations navigated topics of social justice and politics, floating between English and Spanish. My worldview was shaped by trips to Mexico for Christmas and living in Chile in elementary school and high school. I come from a big family, full of cousins (mostly boys), teasing uncles and aunts in eclectic southwestern attire. We were all raised harmonizing around a campfire in the mountains of Colorado or under the stars in Mexico.

I was always interested in anatomy and physiology of the human body, but I knew that I wanted to pick a career where I was working with people and giving back. I entered undergrad with the intention of becoming a nurse. I felt that as a nurse I could care for the patient as a whole, their social context and their physical ailments. I knew that nurses were able to spend more time with patients, I liked that. During my first spring break, I shadowed doctors at a local hospital. I was fascinated by their ability to problem-solve and create solutions for patient care. I changed my trajectory to medical school, hoping to keep my nursing spirit as a doctor. After my sophomore year, I had an internship with midwives in Aurora. I was completely enamored with the profession. It was an integration of nursing philosophy and medical problem-solving. It was the marriage between social justice (the essence of “giving back,” feminism, fighting the patriarchy, serving the underserved) and reproductive medicine.

After working at a FQHC [Federally Qualified Health Center] as a case manager [referring to her work at Clinica Family Health], I moved to New York City to attend Columbia University for both nursing and midwifery school. I chose Columbia because I was interested in learning from the urban underserved patient population. For my Master’s degree, I was awarded the National Health Service Corps Scholarship [NHSC], a very competitive, full-ride scholarship from the U.S. government.

[The NHSC program is housed within Health and Human Services, and is specifically directed at addressing health professional shortages. In addition to certified nurse-midwives, eligible disciplines also include: physicians, nurses, dentists, psychiatrists and psychologists, family therapists, and professional counselors.]

In exchange for tuition and living expenses, I have a contract to work for two years in an underserved community. The NHSC rates hospitals and clinics based on many factors and gives them a score for how underserved the community is. I was required to find a job [in a community] with a certain score to satisfy my scholarship contract requirements.

[To become NHSC-approved, a site must serve populations in areas designated Health Professional Shortage Areas (HPSAs). Once approved via an application process, sites must recertify every three years. NHSC-approved sites may offer primary care, outpatient, or ambulatory services, and may not discriminate in the provision of services because of income level or because payments would be made under Medicare, Medicaid, of the Children’s Health Insurance Plan (CHIP).]

Tell us a bit about your job as a midwife. What do you do? What type of training and certification is required to do what you do? Have you received any rural-specific training?

A midwife is trained in the same way as a nurse practitioner. In most of the country, in order to be a midwife, you must first become a Registered Nurse and then receive your Master’s in Nursing with a specialty in midwifery. We are mid-level providers who care for women throughout the lifespan. This means that I am trained to care for well women, pregnant women, women with health conditions, and menopausal women. My scope of practice includes all primary care health screenings, including pap smears, breast exams, and full body physicals; birth control, including IUD and Implanon insertion; gynecological care, including treatment of sexually-transmitted and vaginal infections; prenatal care, including all necessary screenings and management of abnormal conditions (e.g., gestational diabetes, thyroid conditions and anemia); intrapartum care, including managing normal and abnormal labor with pain management (including epidurals) and delivering the baby; postpartum care, including evaluating for abnormalities, caring for the newborn, and assisting with breastfeeding; peri-menopausal care, including hormone replacement therapy.

I can make decisions about patients’ care and prescribe medication on my own, without a doctor’s approval. However, I am trained to know when something is beyond my scope of practice. I care for low and medium-risk women. If I think that a patient may be high risk, then I transfer care to a physician (this includes C-sections). More important than what I can and cannot do: everything I do is done with the utmost respect for the patient. We are trained in patient-centered, evidence-based care. Midwifery operates under the philosophy that women are wise; midwives are guides but our patients are the leaders. In birth specifically, midwives bring a reproductive justice angle to care. We push for policies that minimize unnecessary interventions and honor the idea that there are many variants of “normal.”

Unlike medical school, midwifery does not have government funding for residency programs. While we have complete hands-on training during school (for example, I have delivered 39 babies with my own hands and inserted more than 10 IUDs by myself), we are still nascent providers in our first jobs. Because of this, many employers have six-month orientation periods where a new midwife works with a “senior” midwife one-to-one. During my orientation, I will be practicing under my own license, but will work with a senior midwife, who will double-check my work and give me guidance if necessary.

Tell us a bit about the community you will be serving. Where is it located? What are the population demographics? Did you visit the community in advance of accepting your position? If yes, what were your impressions?

A midwife’s work has two parts. The first, clinic work, includes primary care, prenatal care and well women care. The second is hospital work, which is where we deliver babies and care for women postpartum. I will be doing my clinic work (three days a week) at two clinics south of Albuquerque, in cities called Los Lunas and Belen.


My hospital work will be in Albuquerque at University of New Mexico Hospital. The pregnant patients that I serve in Los Lunas and Belen will travel to Albuquerque when they are in labor. About 75% of my patients are on Medicaid, which can be a proxy for lower-class. I do not know the exact percentages, but most of the patients are a combination of Hispanic and White, and some of the patients are Native Americans.

[Los Lunas (population 14,835) and Belen (population 7,152) are the first and second most populous cities in Valencia County, which gives you a feel for the population densities in the surrounding areas. Though both communities are named in homage of their Spanish ancestries, today their populations are predominantly white, at 72.1 percent and 67.5 percent, respectively. Obviously, both qualify as NHSC-approved sites.]

I spent an afternoon in the clinic during my interview. First, I was impressed with how well-resourced the clinic seemed. Most of my rotations in midwifery school at Columbia were in underserved public hospital settings where paint was chipping, wait times were astonishingly long, and supplies were limited. The clinic in New Mexico seems like a well-oiled machine—it even had a great microscope, which is unheard of in the city hospitals! My impressions of the community itself were as I expected. The patients came in for routine care, a pap smear or a check-up. But by the end of the appointments, the midwife was counseling the patient about the domestic violence resources in the community or validating the woman’s fear about being an alcoholic and watching her dad die of liver cancer. Physical ailments were present, but the social ailments were staggering and center stage. I was also impressed with the relationship between the midwife and the patients. As the only prenatal provider (there is only one midwife in both clinics) in both cities, the midwife cares for the women with every subsequent pregnancy. Even more, the midwife cares for the patients’ mothers and sisters and daughters. There is trust and respect between patient and provider that you don’t see when there is less continuity of care.

What were the critical factors you considered when you were deciding on a geographic practice location? Were you specifically hoping to serve a rural community?

My job search was limited by the restrictions of my scholarship. You could say that serving the underserved was the most critical factor because it was my personal goal and a requirement of the scholarship. The next most important factor was the way that the practice provided maternal care. Some of the considerations that I used to evaluate clinics and hospitals during my job search were: C-section rates, availability of birth control, and pharmacy formularies for pain management during labor; midwife autonomy, and the professional relationship between doctors, midwives and nurses; how healthcare teams evaluate evidence-based care and how quickly clinical protocols are adopted; hospital set up (e.g., do the doctors, midwives and nurses all sit together? Or is a hierarchy apparent even in the structure of the seating arrangement?); resources for new midwives; and length of the orientation period.

My intention was always to serve the underserved, but as a NHSC scholar, I am required to work two years in a location that has a specific “underserved” score. I did not have a specific desire to work in either a rural or urban community; they represent different manifestations of underserved, and I was interested in both. But for rural work specifically, I was interested in the availability of a support system. When I do not know what dose of drug to prescribe, who do I call? University of New Mexico has a well-established call system for all rural providers. Their phone banks are staffed with providers 24/7 to help rural providers problem-solve if necessary.

What are your fears—and conversely, your hopes—moving from an urban metropolis to a rural area?

My fears, which I share with many of my new grad peers, is: “I AM GOING TO KILL SOMEBODY.” Of course, I, personally, am not going to kill anybody—I know that. But people do die, even in the world of birth. Statistically, it will happen within my first five years of practicing as a midwife. I think that this fear is amplified in the rural setting. For example, when I was shadowing at the clinic during my interview, the midwife noted that the baby’s heart rate was on the lower end. This could mean two things: (1) the baby has a normal low heart rate and is totally healthy, or (2) the baby’s heart rate is having a deceleration, meaning that it is dropping 15 beats per minute for 15 seconds or more. Decelerations can be a sign that something is not going well. When this happens in a hospital, we can hook the mother up to a machine that tracks the baby’s heart rate for 20 minutes, and we can see if the pattern of the heart rate is normal or if it is a deceleration. The rural clinic does not have this machine. If you think that it is a deceleration, then you send the woman to the hospital. But the hospital is 45 minutes away. Some women do not have cars. Or, they may be able to get a ride to the hospital, but have no ride home from Albuquerque if the test comes out normal. That puts a lot of responsibility on the midwife to make sure that you send the right people to the hospital. As a new midwife, I am sure that I will send many more people to the hospital than necessary. But I will practice under the “I would rather be safe than sorry” philosophy until my clinical intuition sharpens.

My hope is that I can make connections with my patients that empower them. Being a mirror of a woman’s own strength is my favorite thing about being a midwife. We have the opportunity, in a small room as a woman sits on crinkly paper, to validate women’s fears, to listen to their concerns, to provide care that will make them healthier individuals, and to celebrate their existence.

[There are two methods monitoring a fetal heart rate: external and internal. External monitoring is accomplished most often with a Doppler ultrasound device. The process involves attachment of an ultrasound probe (transducer) to the mother’s belly. The transducer sends the rate and pattern of the baby’s heart to a computer. Internal fetal monitoring is accomplished by running a thin wire (electrode) from the baby’s scalp through the cervix. Internal monitoring is more accurate, but it can only be done if the amniotic sac has broken and the cervix is open.]

[Access to healthcare equipment, particularly with respect to perinatal care, is a continuing problem in rural America, but the rise of new technologies, including portable devices and distance-based care, is offering promising steps forward.]

What types of special challenges do you think you might face delivering care in a rural community? 
  • I’m particularly interested in some of the issues recently raised in a Scientific American article—e.g., high rates of maternal mortality in rural areas, scarcity of resources and professional providers, access issues, etc.

Great article! I think it sums up the main concerns:
  1. Getting to the hospital with enough time. This not only means everything you think it means, but also requires enough clinic time for the provider to educate the woman about when is the right time. The article focuses on women getting to the hospital too late, but I think getting there too early can be harmful also. Most studies suggest that laboring at home until you are in active labor (6 cm) is best. When we admit patients too early, unnecessary interventions are more likely, which can also lead to increased C-section rates.
  2. Unhealthier populations in rural settings. I am eager to explore this issue in my work. In New York City, I worked with a lot of black and Hispanic communities. These communities are also more likely to have health concerns, some due to genetic predispositions and others due to public health or social concerns. I am interested to explore the differences in the cascade of causal factors for health concerns between the rural and urban communities.
  3. Lack of providers. This is exactly what my scholarship is trying to address! There is a bill in the works that suggests a new algorithm to assess the “underserved” score of hospitals and clinics with respect to maternal health. I have only seen headlines about this so I do not know much more about it, but the idea is that the algorithms we use now do not accurately evaluate maternal health in underserved communities. Maternal health is a different hue of primary care, so we can’t use the same proxies. My guess is that [a maternal health-specific algorithm] would reach more communities and expand the definition of underserved.
[For more discussion on maternal health-related bills currently before Congress, see this previous post, discussing the Improving Access to Maternity Care Act.]

Sunday, March 26, 2017

Rural masculinity, work, and media representation

Philip Morris retired their iconic "Marlboro Man" in 1999. Projecting an image of masculine strength in untamed nature, the smoking cowboy was an image of a ruggedly physical rural laborer that sold millions of filtered cigarettes. Indeed, when devising the character, the broadest consensus around a signifier of masculinity in focus groups was the cowboy figure. The Marlboro Man is gone now-- Philip Morris discontinued the ad campaign as cigarette advertising was largely regulated away in the late 90s, and plenty of former Marlboro Men died of smoking-related illnesses. But more broadly-- does the cowboy do the same kind of cultural work in conflating rural lifestyles and livelihoods with masculinity as it used to?

Although the cowboy is still an instantly recognizable image for many Americans that signifies hard physical labor in rural places, and the attendant masculine associations, real cowboys are few and far between in 2017. Some trace the end of the cowboy era to the invention of barbed wire, which happened in the 1870s. The cowboy is not the only association with rural livelihoods and masculinity-- loggers, miners, and oilfield workers have all been theorized as archetypes of rural masculinity. The key component? Work as the defining component of masculinity. 

I. Work and rural men

What is "masculine" about rural work? Jobs in extractive industries require a high degree of skill and mastery to avoid serious injury or death on the job. They necessitate physical strength, resilience, and stamina. Although these defining traits are by no means "essentially" masculine, American culture genders them that way. 

In addition to the on-the-job masculine traits, extractive industry was the driver for the strongly gendered narrative of the white man "conquering the wilderness" in the West. The men engaged in such work were heirs to the dual goals of establishing white hegemony in the West and bringing its bounty into the dominion of the United States. 

Rural livelihoods outside of extractive industry also display these traits- such as a high degree of serious danger in the grain farming industry. Farming, too, has historically been a way for rural men to display traditionally masculine traits like strong work ethic, tolerance for danger, and physical strength. 

II. Media representation and the post-work rural man

What happens to rural men's sense of self when jobs leave town? Although rural economies were once heavily dependent on traditionally masculine jobs, many rural economies have shifted from these industries to a more diverse spate of jobs, not all of which are "masculine" in the traditional sense (see, for example, hospital work or tourist re-enactments of extractive industry). How are men in these areas developing masculine identities without masculine work to perform?

Rural men are not forging their identities in a vacuum-- there is an enormous media apparatus designed to observe, repackage, and resell 'rural lifestyles' to rural people. Through media representation, one can track a changing culture of rural masculinity. Although hard work is still valorized in country music, big ticket consumer goods and pleasure-seeking consumption are increasingly ways to express a manly identity. See, for example, the transition from songs glorifying blue collar work like "East Bound and Down" and "Six Days on the Road", to songs like "Truck Yeah"-- glorifying the high dollar commodity of a truck.

Similarly, see the commodification of hunting-- once a male-gendered method of obtaining sustenance for the family unit, now the touchstone for a dizzying array of camouflage products for both men and women as a signifier of rurality. Again, the emphasis on work for the development of rural identity has been supplanted by consumption.

The rural lifestyle media also depicts toughness to the point of pugnacity as a masculine value. Readiness to fight has always been part of country culture (and not limited to men). Recent developments in country culture have included an amplification of this vein. Mixed martial arts has enjoyed a boom of popularity in rural places, following after the perennially popular professional wrestling that emerged from rural carnival sideshows in the 1930s. Manly posturing by rural men around fighting and physical conflict has always existed-- but now it is commodified and resold to rural viewers.

Rural masculinities are shaped and refined by media representation. In the absence of the structuring force of work, the media of "country culture" packages and redistributes an image of the rural man as a consumer and flaunter of masculine products and a self-assured, sometimes pugnacious figure, but less and less as a worker. This new rural masculinity may unfortunately be a fragile self-image to maintain without a paycheck. The result is bad for family structures and may cause mental illness among those unable to sustain job-centered self concepts. It may be possible to frame these issues as symptoms of toxic masculinity and not rural problems. However, the rhetorics of toxic masculinity are sold to rural men by the bushelful in political discourse, and maybe that alone is cause to take a closer look at how rural men are constructing their self-image. 

Budgeting for failure: Trump's proposed budget will hit ruralities hardest

We know now that white rural America was a massive factor in Donald Trump's November 2016 victory over Hillary Clinton. Rural voters turned out for Trump over Clinton at a ratio of 3 to 1, an unexpected boon for the GOP that the Dems seemingly weren't prepared for. To secure that oft-overlooked portion of the voting population, Trump made frequent references to "taking care" of the rural population, including focusing on the opioid epidemic and building the infamous border wall, to stem the alleged tide of "job-takers."

After the election, rural voters maintained their faith in Trump, citing their satisfaction with his "quick" movements to shake up institutional norms. Anecdotally, my own family members, hailing from small farming towns in the Central Valley, appeared to be pleased with his efforts, and were prepared to quickly overlook any minor misgivings. 

It wasn't until the recent release of the federal budget outline proposal that we got a glimpse of just how Trump plans to "take care" of those communities. The new budget makes cuts to 19 separate agencies that exist to provide services to the rural poor, including job training for seniors and after-school programs in high-poverty areas. The federal budget proposes a steep 21% cut to the Departmet of Labor's budget alone, which houses many programs that typically garner bipartisan support, like job skills training. Rural regions depend heavily on federal dollars, and pulling this funding seems a harbinger of even further problems for already-plagued rural communities. 

Other areas of the budget cuts that will negatively impact rural voters include things as far-ranging as public access television and access to rural transportation. For instance, under the budget proposal the Essential Air Service would be eliminated; the program currently subsidizes flights for rural passengers that allow those small regional airports to remain operational. Without those federal dollars, the airports will likely close in a matter of years, or even months. The budget also proposes to eliminate the Amtrak Southwest Chief line, which moves many members of small rural communities, and would be a huge loss to those who rely on it. 

The budget also aims to cut funding to the Legal Services Corporation, despite it taking up a meager one ten-thousandth of the federal budget. LSC is the single-largest funding source of civil legal aid for low-income individuals in the nation. Don Saunders, Vice President of Civil Legal Services at the National Legal Aid and Defender Association, said: 
"We’ve had urban legal aid programs for over a century. But it was the federal support that created the capacity to expand out into rural areas. So you will see a great retrenchment in that regard without federal support."
Despite these clearly troubling hard-number statistics that show a disproportionate impact to ruralities, at least some of those who voted for Trump still seem to support his actions. The question necessarily arises, is this an inherent danger of a strictly two-party system? Do rural voters feel adrift without an option, with no single candidate ever truly looking out for their own best interest? Surely there are some who voted for Trump genuinely believing he was a great candidate for the job, but just as surely some voted for Trump as a "best of the worst" option. One thing is certain: rural voters are seeing no greater success in fighting their unique battles under Trump's presidency thus far, and in fact seem to be the most negatively impacted of all in terms of hard steps taken by the administration. Whether this fact impacts the next election, or has the possibility to shake our current political two-party system at its core, remains to be seen.

Saturday, March 25, 2017

Small states' outsized political power (Part III-A: The case for reform and proposals)

This is the third part of a series exploring the political heft of the least populous states in the country. The first part explored the history of several constitutional features, and the second part probed the empirical realities of small states' power in the U.S. Senate as well as in the House of Representatives and Electoral College. This phase pivots from the descriptive to the prescriptive, asking why small states retain such power, how they might be stripped of it, and what the implications of doing so would be.

The Case for Reform

As explained in Part I, the thirteen colonies that formed the United States varied widely in geographic scope and population scale. The Senate's guarantee of equal representation addressed small states' concerns that by ceding their sovereignty they would not entirely forfeit their voice. In the 1780s, distinct legal regimes and diversity of industry from one state to the next gave states good reasons to resist the homogenizing effect of laws imposed by a majoritarian Congress. But by the mid-1900s states were willingly adopting synchronized laws promulgated by groups like the Uniform Law Commission and the U.S. Supreme Court had embraced a view of the Commerce Clause that empowered Congress to regulate virtually the entire national economy. By the late 1800s, the country had both a railroad network and a thriving cluster of big businesses with national footprints; a century later these were supplemented by an interstate highway system and trans-national corporations. Even the legislative lubricant of the "pork barrel" project, previously a boon for small states, has fallen prey to the modern angst over government spending.

Thus, a combination of economic destiny and legal-political assimilation resulted in a national economy that cares little for state borders. The exceptions that prove the rule are a handful of industries still subject to heavy state-based regulation such as financial services and insurance, but nonetheless these sectors exist across the country. In recent decades, California has leveraged its population heft against the slim profit margins of global commerce to force products distributed throughout the country to conform to its regulatory predilections (a phenomenon dubbed the "California effect").

As this blog has explored time and again (and again, again, and again), the rural/urban divide is a more meaningful border than those among the states. Small states (those with low total populations) are distinct from rural states (those with a relatively large share of their population in rural areas), though there is overlap. According to 2010 Census data, the ten largest states had an average of 23 percent of their population in rural areas, compared to 39 percent for the ten smallest states..

To this extent, the eighteenth-century vestige of state primacy functions to preserve the rural voice today. But should it be so? The justification for preserving small-state power within a project of confederation is different from the justification of preserving rural power in a vastly urban country. Rural people make up less than one-fifth of the population; people who are categorized as "Hispanic or Latino" make up a similar share of the electorate. Should the latter also benefit from systemic protections?

Yes. This blog has repeatedly shown how rurality functions as a dimension of identity akin to those of race, gender, and sexual orientation. Ours is a majoritarian society that -- if more often in word than in deed -- strives to protect the rights and ensure the prosperity of its marginalized groups. But it is a suspect notion that the best way to achieve those ends is through the means of inflating these groups' political power. The conclusion of this series will argue that the best policy prescriptions for rural America are those which are anathema to the political sensibilities of rural people. First, however, comes a summary of the proposals for shifting the balance of power.

Proposals for Reform

The case for reform in the Senate is weakest. First, Article V of the Constitution prohibits any amendment which would impair a state's "equal suffrage" in the Senate unless the state agrees. Second, there are good reasons to think that federal resources would not flow equitably to small states if Congress were a purely majoritarian institution. Third, senators must sit for election on a statewide basis, and most states' populations are split between dense urban cores and sparse rural areas in ways that generally force candidates to balance those disparate political outlooks. As explored earlier in this series, Republicans gain only a modest edge in Senate politics due to small states' power. Reforms to the Senate rules, such as those affecting the filibuster, seem better avenues toward change. (For encouragement, look to the successful push to end secret holds in 2011.)

In the House of Representatives, the methods of gerrymandering, packing, and cracking all skew political power away from the representative ideal. Additionally, the combination of a century-old cap on the size of the House and a requirement that each state have one member means that large states hit a kind of ceiling. California's 38.8M people are more than 66 times more numerous than Wyoming's 584,000, but California only gets 53 House seats to Wyoming's one. Because the size of the House remains fixed no matter how the population changes, California is underrepresented in Congress by nearly 25 percent. An easy solution, known as the Wyoming Rule, would be to use the population of the smallest state's population as a baseline and then scale-up the House membership accordingly. (Note: since no one wants a fractional member of Congress, we would still have to utilize one of the various mathematical fixes to allocate seats across states.) Adopting the Wyoming Rule would increase Congress to a body of about 550 members: still a small body compared to other countries. While few states would lose representatives, many would suffer a dilution of power. More importantly, the enacting Congress would be voting to erode its own members' power: a formidable barrier to reform. Additionally, interest groups want fewer votes to whip, not more, and they would likely oppose the effort. Then again, proponents of reform might utilize enemy-of-my-enemy logic to convince voters that a change opposed by sitting politicians and special interests is worth fighting for.

The "fix" in the Electoral College is the easiest to implement, the most defensible, and the most likely to occur. Surely, the Constitution could be amended to rejigger or even abolish the Electoral College. But a more attainable goal is the National Popular Vote Interstate Compact (NPVIC), which is a coalition of states that have adopted legislation pledging their Electoral College votes to the winner of the national popular vote. The compact does not take effect until the states' votes constitute a majority (currently 270). At present, 11 states totaling 161 votes have joined. Defenders of the Electoral College generally make squishy arguments about campaign visits or some kind of "mandate" that cannot come from the popular vote alone. These arguments are easily debunked, and Donald Trump's coronation amidst ongoing controversy about foreign electioneering belies the claim that electors will deny the White House to a dangerous candidate. While the NPVIC has new life after the 2016 election, observers have noted that it is unlikely to take effect without adoption by "red states." Given that the current system has twice in the last five contests delivered the presidency to a Republican who lost the popular vote, the project's prospects can appear dim.

Whatever their merits, efforts to re-calibrate small states' power face an uphill climb over rocky political terrain. Yet even with this parliamentary boost, rural places have continued to struggle as the country's population and economy have coalesced in urban areas. The next section explores the potential for policy interventions to aid rural communities where "big government" is anathema.

Thursday, March 23, 2017

Observations from a hometown coffeeshop

Is Chico,CA rural? A morning spent at a local coffeeshop reveals that it feels like it to some people.

With a population of almost 90,000, the urban epicenter of northern California hardly teeters on the edge of being "rural" by population measures. The strong farming communityhigh poverty rate (almost twice the national average), low sense of anonymity between two high schools, and lack of neighboring communities all argue that it may be.

Stu stands to look out the window 
It is 6am but they were probably here when the coffeeshop opened at 5am. This group of white-haired farmers has been coming to Mondo's Cafe since I was in High School down the street. A few members have switched out, moved closer to their grandkids, or passed on but the aura remains intact. Talking over each other while ping-ponging through subjects, sizing up other early morning guests to the coffeeshop, and turning multiple tables worth of chairs towards each other are no surprises to the early shift employees.

Water in Northern California 
Stu looks out the window. "We were irrigating by this time last year." Someone responds, "shit, I started in December last year." Water is the theme of the morning for a minute. This spins off onto conversations speckled with proper irrigation techniques, water costs per acre-foot, and finally, what should and should not be done with Oroville Dam.

"They're dumping water now," someone chimes in. This verb choice may not be coincidental as many northern Californian farmers were angry with water contracts in the drought years that sent Sacramento River water to southern municipalities. To keep the scarce resource, some northerners revived the call for the State of Jefferson. When the Dam filled to capacity last month, the emergency spillways were opened to relieve water from the reservoir and prevent uncontrolled release. There were a handful of commenters to a live stream angry that the water was being released. While some comments may be accredited to a misunderstanding of why it was being released onto an eroding spillway, others were genuine.

Attorneys and Federal Regulation 
Talking of water contracts, lawyers naturally come up next. "You know the Conquistadors had some faults but they didn't allow any lawyers to come and I like that." This comment is followed by a group chant, "Here, here!" A single voice adds, "I heard that lawyers chartered a bus on the way to a convention, blew a tire and went over a cliff. A bystander walks up and says 'it's a tragedy...that the bus wasn't full.'" Needless to say, everyone laughs. No mention of the lack of access to justice is made.

To them, it sounds, attorneys signify regulations. Each member has something to say on the ins and outs of running a business. Disdain for ADA accommodations and establishing handicapped parking spaces are discussed ad nauseam. "It's no surprise why it's so expensive to run a business these days." Interestingly, each volunteers that they have a friend or family member that needs an accommodation. In true red-county fashion, they seem to be suggesting that business owners should accommodate those with needs but do not need the government to tell them to do it in a specific way.

Localness for Explanation
Familiarity with the area and community members is used to orient the conversation a number of times. To give directions, "you know that shop, down there on the midway, is the place Tom Chambers bought." To describe the recently deceased, "Bob Bailey... he had the place across from Bonderson's there... Bob Bailey did." To position a story, "Jack Lucas' place, where the water pools, I was driving out there."

This sort of familiarity and lack of anonymity is nothing new to rural scholars. Indeed, this characteristic of small towns is both for better and for worse to the people that live there.

Oppositely, lack of localness is mentioned to describe a new neighbor. "We bought a bunch of walnut trees from some guy that used to come up from Sacramento, he worked on the hill, in the assembly, or something. He didn't let us into his shop right away... it took about 6months you know" Everyone nods in understanding.

Women
Attitudes towards women and the need for them in their lives are twofold. On one side, there is an air of coddling and care for them. "I did everything my wife asked before this rain came but then I said no more housing projects for a while." There were a round of nods to this.

On the other side, there is loving reverence and mysticism. Joking about experiences from a younger age, "I learned to appreciate good living with middle aged women...that was back in the day when I could take my shirt off without scaring everybody." Talking about a young grandson's inability to mature, "he just needs to be looking for a cute girl."

This daydreaming is interrupted by Stu standing up to leave at 7:30am. Someone exclaims "where are you going?!" Suggesting that it is his habit and within his schedule to stay longer. He leaves without explanation, likely to be questioned at tomorrow's coffee meeting.

Trucks line the Mondo's Cafe parking lot
Mondo's Cafe
Mondo's Cafe is a community stalwart. When it first opened as Cafe Mondo, it was at a more visible venue to the University students. When a Starbucks opened three doors down, the pressure was too much for the ownership to cope with. It changed hands and reopened as Mondo's Cafe. The Starbuck's eventually closed for whatever conglomerate reason. In a cruel twist of fate for Starbucks, Mondo's Cafe inhabits that space now.

Mondo's is a work training cafe. This means that they employ individuals with developmental disabilities and provide them a competitive wage. This also means that it takes a minute or two longer to get your coffee order. It is not an ideal place for a swift morning caffeine-aholic.

What it is is hometown. Mondo's moved twice and this pack of white-topped farmers followed. They carry Chico Chai, the local spicy chai blend that is only available in a handful of places outside the local Saturday farmer's market. They make their own muffins each morning. Conversations on diesel trucks, family farms, and livestock prices overshadow any mention of international events, technology, or travel. Sitting in Mondo's cafe there is no doubt that Chico feels like a rural town.

Indeed, as I get up to leave, my dad mentions that he knows a few of the guys.

Wednesday, March 22, 2017

The farmer's fight for the "right to repair"

Corporate giants like Apple, AT&T, and John Deere are up in arms about proposed legislation in eight states this year - legislation commonly known as the "Right to Repair" or "Fair Repair" bills. If passed, these laws will allow consumers and independent repair shops to fix equipment, like iPhones, without being forced to go through the manufacturer. It will also make the diagnostic and service manuals available to the public. And farmers are leading the charge. 

When I think about a farmer, I envision a self-sufficient businessman (or woman) who leads a rural lifestyle. Someone who will find a way to make ends meet using the resources at their disposal and fixing things when they are broken - like their own farm equipment. But thanks to intellectual property law, there is at least one piece of equipment a farmer can't fix...a tractor. 


If you are not mechanically inclined, or even if you are, you might assume that today's tractors can be fixed by using the correct combination of wrenches and screwdrivers. But actually they can't. Today's tractors are filled with sensors, wires, and complex computer software (some even have satellite radio!) that require factory passwords and special diagnostic tools to repair them.

Because of the Digital Millennium Copyright Act (DMCA), farmers cannot access these passwords or tools without the manufacturer's permission. The DMCA, which is designed to prevent digital piracy, classifies breaking a technological protection on a device's programming as a copyright breach. So if a person changed or modified that programming to fix the equipment, they would be in violation of the DMCA. 

Kyle Wiens has written about the difficulties of modern tractor repair and its effect on farming. Wiens is a strong voice for the "Right to Repair" movement and self-identifies as a "computer programmer by training and repairman by trade." In a Wired article, he recounts the experience of trying to help his farmer friend repair a tractor. 
Over my left shoulder a massive John Deere tractor loomed . . . Repair is what I do . . . being rebuffed by a tractor was incredibly frustrating. 
Wiens continues:
I tossed my wrenches and screwdrivers. The conventional tools of my trade had no power here. . . . Armed with wire, alligator clips, a handful of connectors, and a CANbus reader, I launched myself back into the cab. . . . One hour later, I hopped back out . . . Defeated . . . I couldn’t even connect to the computer. Because John Deere says I can't. 
Even with this knowledge, you might think, so what? I would never attempt to fix my car, my computer, or my iPhone for that matter, on my own. Those repairs should be left to a professional - someone who has training in complex electronic systems. This is the type of argument that manufacturers hope will persuade politicians as they prepare to fight in the Nebraska, Minnesota, New York, Massachusetts, Illinois, Wyoming, Tennessee and Kansas legislatures. 

Before "Right to Repair" bills were introduced, activist farmers and repairmen like Wiens worked with nonprofit legal groups like the Electronic Frontier Foundation to get a DMCA exemption from the U.S. Copyright Office for agricultural machinery owners. The limited exemption grants owners access to the software to assess, repair, or modify tractor systems. But there is a catch: the exemption only lasts until the next rule-making in two years. 

The main thrust of John Deere's argument is that people who buy tractors do not actually own them. Instead, they are buying an "implied license ... to operate the vehicle[.]" (see their opposition letter to a Kansas bill here). Apple and AT&T's arguments list the myriad of safety risks to consumers if they are allowed to fix their own devices. It will be a difficult fight: last year a similar New York bill was killed by Apple and IBM's aggressive lobbying. 

But farmers are not giving up easily. The farming community has been making, building, repairing and tinkering with their equipment for centuries and they would like to keep it that way. Farming equipment is extremely expensive (a new tractor might cost $100,000 to $250,000 or more), and unlike tractors of the past, when a modern tractor breaks down farmers are dependent on dealers and technicians to repair them. The added costs of hiring a technician, as well as the time lost waiting for the repairs, can have a real economic impact on a farmer's livelihood. 

The realities of a rural lifestyle exacerbate this problem. As I speculated earlier, farmers value their ability to fix things themselves without relying on or paying for outside assistance. But the repairs can be costly and most American farms are quite small. According to the Census of Agriculture, in 2012, 75% of American farms grossed less than $50,000. 

Additionally, many farmers live in small communities where the nearest dealer or technician may be hours away. It could take days for a technician to order the part, get out to the farm, and make the necessary repairs. Some farmers are so fed up with the hassle of repairing modern tractors that they are turning back to older models. 

The biggest issue with the legal restriction is probably the effect it can have on a farmer's crops. A crop's viability depends on the weather. Farmers work when the weather conditions are right, so an equipment malfunction during a crucial time, like planting or harvest, could be disastrous. 

Farmers also argue that tractors are being treated differently from cars and trucks. In 2012, Massachusetts passed a law guaranteeing the right to repair automobiles and trucks, which became national legislation after manufacturers gave up the fight in other states. 

Nebraska activist Kevin Kenny makes a compelling argument from a different lens. He argues that allowing farmers to repair this equipment will promote ag-tech innovation in "Silicon Prairie," a term used to describe the growing tech industry in the Midwest. 

I argue that farmers and mechanics who enjoy "tinkering" and fixing their own equipment should have the right to modify their property as they see fit. The agricultural industry faces unique challenges, as I mentioned earlier, and laws like the DMCA only frustrate a farmer's ability to do their job and maintain their independence - something that is highly valued in the profession. 

Nebraska is the first state to consider the bill this year and the outcome is especially important because they have a unicameral legislature, which makes it easier for proposed legislation to move quickly. Hearings have already begun, but whether the farmers will prevail remains to be seen. 

Tuesday, March 21, 2017

The "neo-rural" Part I: the new generation moving into the hinterlands

I have a person very near and dear to me. Let's call him my kin. He is a prime example of what can be called the "neo-rural". A few have made attempts at defining the neo-rural, but I'd like to broaden the scope of those definitions a bit. I think we are on the cusp of a whole new generation of folks who are moving to rurality. I'd love to know exactly who these people are, and what inspires their love of the country. This post is a modest beginning to this inquiry.

One of the groups of people who fit into the "neo-rural" are "modern homesteaders," which my kin most certainly is. I recently interviewed him, during which he decided to go by the pseudonym Bill (or, sardonically, "Bill Damn", when he has to throw down). He wants to keep his rural home and his name unpublicized because there are some grey areas with regard to legality where he lives, and honestly, he'd like to keep it that way. Bill's rural reflections on the law will be the majority of Part II of this post.

To get to where Bill lives, you drive a few miles out of a lovely small town with a population less than 6,000. The town is a tourist destination, but remains remote. Then, you go over a bridge, take a sharp turn and brace yourself for more than six miles of dirt roads that are unmaintained with the exception of the maintenance that local homesteaders do. Bill doesn't feel that far out. He told me:
Where I’m at is kind of a nice position to be in because it’s extremely rural and out miles of dirt roads and beyond the reach of the power lines but I’m still only, like 30 minutes from a grocery store, which is nice.
Thirty minutes from the grocery store sounds pretty far-flung, in my opinion. I asked Bill if he lacked services way out there, and he said that was definitely a factor of his life. When a friend got injured once on his property, Bill had to lift her into his truck and haul-ass over the dirt and gravel out to the paved road - the ambulance wasn't coming anywhere near the acres he owns. It sounded harrowing.

However, that bit about the land is one that deserves some underscoring: Bill owns land. Acres of it. He owns several parcels around where he built his house (with his own hands), and several parcels in various other places down the dirt road where he lives. Bill is just 31, and he owns more land than I will likely ever own in my life. He is part of a movement around sustainable off-the-grid houses. He built his house (and many others) from the ground up. House-building is both Bill's passion and his livelihood. He flies all over the world building sustainable housing, and has built houses and structures in Thailand, Cambodia, Australia, South America, Canada, and more.

The desire to move out into rurality isn't new, but living and building like Bill --i.e.off-the-grid "homesteading"-- has been gaining traction in pop-culture circles lately. For two examples, check out recent books "The Unsettlers" and "Modern Homesteading". People who have gotten tired of relying on corporations and government entities for services can find a myriad of articles that offer "21 Tips For Quitting Your Job, Going Off Grid and Living The Dream""The Secrets of Living with No Money""Lessons from Off-Grid Living" and more.

There is a lot of overlap with Bill's work and the tiny house movement, and he's also involved in the straw-bale house and pounded-tire construction communities. The electricity at his own house comes from his solar panels, which give him what he considers "oodles of power" to run his wifi, laptop, lamps, blender and bass-amplifier-doubling-as-sound-system. However, his solar panel-and-battery setup slightly limit his ability to live a "modern" technological lifestyle. No hairdryers allowed at Bill's, and you can't use all of the above at once. Bill Damn's house has a composting toilet, makes its own heat through passive solar heating, and all the water is harvested rain from the house's ingenious roof. Thus, the house entirely takes care of itself.

With the rise of AirBnB in rural places and the concept of "glamping," Bill's house now also pays for itself. If you ask him, Bill'd tell you that he feels his house actually takes care of him better than many humans in his life have. He says this with love in his heart, and when you listen to him, you realize how much of a modern cowboy he is: in his solitude, in his love of the land, and in his powerful self-sufficiency. This romanticism might seem a little gauche (especially since some urban circles have "practically fetishized the idea of building humble rural retreats"), but you can't argue that it is a remarkable life he leads.


Of course there are tough aspects about living as far out as Bill lives. As indicated above, getting services is a struggle: ambulance service has been a challenge for several small towns across the nation recently (examples here and here). In addition, the struggles of community-building in rurality and the dangers of substance abuse have become sticks in Bill's craw, so-to-speak. I asked him about this, to which he responded:
I sort of struggle sometimes because I feel like I’m one of the only ones out there who really wants [community] and wants to make it a better place, and a lot of people kind of go out there and settle for less. They’re comfortable being more cutoff and reclusive and, you know, there’s a lot of alcoholism, and some . . . heavier stuff as well.
The "heavier stuff" that Bill mentions might be a reference to rising methamphetamine use in rural communities (noted on this blog here, and here). He might also be intimating the rural opioid epidemic, which has recently been called "this generation's AIDS crisis." Fellow bloggers have also drawn attention to this heartbreaking issue's impact on rurality here and here. This upsets Bill, but the best he can do is look for other folk who are not part of that lifestyle -- who are more onboard with his goals for country living. The struggle of building community in rurality is an age-old one, but Bill has begun to discover new ways to create a network due to the house-building and subsistence-living communities that he has developed. He says that in recent years, community is improving out where he lives. He notes that "there’s starting to be some more younger folk coming out and building structures instead of dragging out trailers and starting junk yards."

Despite all the challenges of living in rurality, Bill Damn represents a growing contingent of Americans who find it to be the only way to live. Indeed, as of 2013, over 180,000 families lived off the grid in the US, and it appears that due to revolutions in battery technology and solar energy, it will only get easier to do so in the next quarter-century.

I asked Bill exactly what kept him out in the "hinterlands," and he said that rurality is where he feels closest to home. He observed that in the beginning, striving for his rural life was a reaction against some aspects of modern urban life that he felt were unhealthy:
We’re constantly surrounded with a whole lot of distractions these days that kind of keep us separated from nature – speaking in a cliché, but it’s true, you know? Our existence is extremely disconnected from nature and from the natural phenomenon of the earth. We’re constantly sheltering ourselves from it and finding other things to look at, and even just finding things that keep us from connecting with one another.
Instead, Bill Damn lives deeply rooted in the earth, and he constantly strives to find new ways to connect to his rural livelihood and to reduce distraction. His life is built on finding more peace and harmony despite the craziness that he sees in modern society. "I guess I just feel more at peace when there’s less going on around me", he mused. It seems to me that he represents thousands of others in our nation who live by exactly the same sentiment.

The rural health landscape (Part II): Rural midwifery—Origins

Recently, during a dinnertime discussion punctuated by a phone call from my mother—“Call the Midwife is airing on April 2nd! What is the Netflix password?”—my boyfriend raised a bemused eyebrow and commented, “Aren’t midwives like witch doctors?”

No, no they are not—but surprisingly, my boyfriend is apparently not alone in his misconception. According to a 2015 article published by NPR, many people continue to imagine midwives as, at worst, “old ladies with potions and herbs,” and, at best, as “untrained labour coach[es]” adverse to modern medicine. Indeed, the prevailing myths about midwifery (see below) seem to position midwives as anti-establishment, anti-western and anti-modernity. It is possible these misconceptions are rooted in the profession’s historical underpinnings.

The midwifery origins story is steeped in rurality. In the late 19th century, two concerns preoccupied physicians: overcrowding and competition. An influx of practitioners into the medical market in the 1820s and 1830s prompted a new professional self-consciousness and a desire on the part of “learned gentlemen” to distinguish themselves from the “quacks.” In the Age of Reform that followed, qualified practitioners increasingly relied on “appeals to science as the justification for professional prerogative”—though, it must be noted, such appeals “took place well before medicine could demonstrate the efficacy of its science.” In obstetrics, especially, the effects of medical professionalization were severe. Before 1900, midwives and physicians attended births in roughly equal proportions, and less than five percent of women gave birth in hospitals. Then, in the first decades of the new century, Dr. Joseph DeLee, now considered the father of modern obstetrics, published a series of influential articles and textbooks on the practice of obstetrics. In The Prophylactic Forceps Operation, Dr. DeLee described labor as “a painful and terrifying experience,” resulting in “much morbidity that leaves permanent invalidism.” He concluded that professional medical intervention was the means by which to protect mothers from Nature’s pathogenic process. In 1915, Dr. DeLee spoke at the Sixth Annual Meeting of the American Association for the Study and Prevention of Infant Mortality. According to Volume 88 of the Medical Record:
Dr. Joseph B. DeLee of Chicago asserted his opposition to every movement to perpetuate the midwife, declaring her to be a relic of barbarism . . . He regarded her as a drag upon the progress of the science and art of obstetrics, her existence stunting the one and degrading the other. . . . In educating the midwife he felt that the profession assumed the responsibility for her, lowered the standards and compromised with wrong, and personally he refused to be particeps criminis.
Dr. DeLee was not alone in his opinion; even those “who had favored the midwife now admitted that she must be eliminated,” and that “she should never be regarded as a practitioner.” Notably, even amidst these avowed renunciations of midwifery as a professional practice, numerous physicians acknowledged that “in rural districts there was no demand for obstetric hospitals and dispensaries, but that there was a demand for good midwives.” Dr. J. Whitridge Williams of Baltimore voiced his belief that absent midwives, the “farmer’s wife” would have only the “neighboring farmer’s wife to look after her confinement.”

The obstetrical restructuring sought by Dr. DeLee and his contemporaries had a disparate impact. “For example, as physicians became the provider of choice for the affluent woman, midwives cared for an increasing number of poor women. These midwifery clients usually lived in either rural areas of the country, or in immigrant areas of large urban cities[.]

By 1935, midwives attended less than 15 percent of births. By 1939, over 50 percent of all women and 75 percent of all urban women gave birth in hospitals; by 1950, the percentage was 88; by 1960, it was 97. By the 1960s, fewer than 70 midwives were practicing in the United States, and the infant mortality rate had increased by 41 percent.

Today, many of the myths perpetuated during the period of medical professionalization remain entrenched in the popular imagination. Many Americans continue to believe that delivering with an obstetrician is safer than delivering with a midwife. In reality, studies show that “mothers whose care was led by a nurse-midwife had lower rates of episiotomies, drug-induced labor, and vaginal tearing during delivery.” Many Americans think that opting for midwifery care precludes a woman from giving birth in a hospital. In reality, “[m]ost births with midwives occur in hospitals, with relatively small percentages at free-standing birth centers or at home.” Many Americans continue to typecast midwives as naturopathic providers who lack formal training. In reality, “[t]he vast majority of midwives in the United States are certified nurse-midwives (CNMs) and certified midwives (CMs).” Typically, CNMs have earned at least a master’s degree from an accredited college, in addition to clinical training and certification from a national board. They have prescriptive authority in every state. Perhaps the most common myth is that midwives provide only maternal care. In fact, “CNMs and CMs provide health care services to women in all stages of life, from the teenage years through menopause, including general health check-ups, screenings and vaccinations; pregnancy, birth, and postpartum care; well woman gynecologic care; treatment of sexually transmitted infections; and prescribing medications, including all forms of pain control medications and birth control.

That said, some of the midwifery stereotypes ring true. Historically, midwifery shared a special affinity with rural America. Around the same time obstetrical medicine was organizing, Mary Breckinridge founded the Frontier Nursing Service (FNS) in Kentucky’s Appalachian Mountains. According to the National Museum of American History:
Serving families in a 700-mile area extending into four southeastern Kentucky counties, FNS had, by 1930, six outpost centers, with two nurse-midwives at each responsible for both the general health of all of the families as well as prenatal, labor and delivery, and postnatal care for women in their district.

The narrow winding roads of Appalachia meant that nurse-midwives might have to ride for up to an hour on horseback to help a woman in labor. Though supervised by physicians, the isolated nature of rural Kentucky meant that these midwives often worked independently, carrying supplies with them.
Today, FNS remains a bastion of midwifery. Today, many educational programs continue to emphasize rural outreach. For example, the stated mission of Frontier Nursing University (FNU), originally established as a part of FNS' demonstration project, is "to educate nurses to become competent, entrepreneurial, ethical and compassionate nurse-midwives and nurse practitioners who are leaders in the primary care of women and families with an emphasis on underserved and rural populations.” Over 80 percent of FNU graduates work in areas HRSA has designated as rural or underserved, and the program currently has nearly 2000 students enrolled across the United States.

Part I of this series provided a snapshot of women's health in rural areas.  In the interview that follows in Part III, a recent graduate of Columbia University’s Nurse Midwifery Program gives us a glimpse of modern midwifery and its intersection with rural populations.