By Taylor Knopf

When it comes to “rural” in North Carolina, there are at least a dozen definitions,” as defined by the U.S. Department of Agriculture.

About 40 percent of North Carolinians — approximately 4 million people — live in one of the state’s 80 rural counties. These are counties with a population density of 250 people per square mile or less, according to the North Carolina Department of Commerce.

There shouldn’t be a stark line drawn between rural and urban, said Mark Holmes, director of the Cecil G. Sheps Center for Health Services Research at UNC Chapel Hill. He claims it’s often  more of a continuum.

“In North Carolina, it works pretty well as a shorthand to say metropolitan areas have a Target, micropolitan areas have an Applebees,” Holmes joked during a rural health presentation to state lawmakers earlier this month.

shows darker green rural areas
The darker green areas are more rural according to most definitions. Courtesy of the Sheps Center for Health Services Research.

It’s commonly known that rural areas have a more difficult time accessing healthcare, with people, hospitals and physicians being scarce.

“Almost any measure you look at in terms of rural health, rural areas are doing poorer,” Holmes said. “They’re older. They’re poorer. They’re most isolated. They have persistently higher mortality on just about every indicator you look at… from the prevalence of diabetes to opioid use.”

shows the age adjusted mortality comparing urban and rural North Carolina to national statistics

While mortality rates have improved across all areas of the state, rural populations have held a higher mortality rate than metropolitan areas for more than a decade. Additionally, infant mortality is 16 percent higher in Appalachia than other areas of the U.S. This includes 29 western North Carolina counties.

this graph compares different health disparities such as drug/ alcohol use, suicide, injury, access to exercise, teen birth, uninsured, etc between urban and rural populations
The community type is more rural as you move from left to right on the graph, dark blue is urban and dark green represents the most rural areas of N.C. Data, graphic courtesy of the Sheps Center.

Rural areas of North Carolina have higher rates of drug and alcohol use, suicide, years in productive life lost, injury, teen births, uninsured patients and preventable hospitalizations.

These parts of the state also have fewer places to exercise, such as parks, greenways and gyms.

Rural areas have a shortage of almost every type of provider. In North Carolina, 20 counties do not have a pediatrician; 26 counties do not have an OB-GYN; and 32 are without a psychiatrist, according to the interactive North Carolina Health Professions Data System.

map indicates the average distance to care for each north Carolina county. Shows that residents in rural counties need to travel further to get care.
Sheps Center for Health Policy Research

“One exception is social association. This is a measure of social capital. How well do I know my neighbors? How well we get along? How many opportunities do we have to spend time together?” Holmes said.

He said social capital is one measure in which rural areas excel.


“When we talk about asset building from a rural area, we want to leverage the strengths that rural areas have,” Holmes said. “That is they get things done. They know their neighbors. They can be really resourceful.”

For example, one rural medical center in Madison County has creatively kept its patients out of emergency rooms by offering a plethora of services and extending its hours to nights and weekends.

Another strength for rural areas is the number of churches. Some rural health advocates in Halifax County are partnering with churches and their congregations to teach healthy cooking classes and build community gardens.

graphs show that rural hospitals are more likely to operate in the red than urban hospitals

On the other hand, rural hospitals are struggling to keep their doors open, and about a third are operating in the red.

There have been five rural hospital closures in North Carolina since 2010. Holmes said his organization defines a closure as a hospital that is not providing in-patient care anymore.

“The causes of a closure are multifactorial. It comes down to demographics, what’s happening in community, but also the economics and finances of the hospital,” Holmes said.

map shows five sites of hospitals that have closed in the past year, three in the west and two in the east
A map of the five rural hospital closure in NC since 2010. Courtesy of the Sheps Center.

“Surprisingly, there is not much evidence that [hospital closure] actually leads to poorer health. This is one of those things that drives academics and policymakers crazy because we would expect that but we cannot prove it,” Holmes said. “Sort of like no one has proven that a parachute saves your life in a randomized trial but we all know it works.”

When a hospital closes, at least 150 jobs are instantly gone, Holmes pointed out. There are also ripple effects within the community. He said other providers usually establish themselves around a hospital.

“What happens to home health? Hospice? All these other jobs dry up when the hospital closes,” he said.

And a closure results in a county-wide decrease in income.

“That’s all people in the county,” Holmes said. “When they lose their only hospital, they lose about $1,300 in permanent income. That’s a sizable economic effect.”

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Taylor Knopf writes about mental health, including addiction and harm reduction. She lives in Raleigh and previously wrote for The News & Observer. Knopf has a bachelor's degree in sociology with a...