*Names changed for privacy

“The South. They’re all addicted to drugs,” said physician assistant Jane.*

A shrill tune pierced the air – almost as striking as her words. It was a nurse calling Jane’s phone. This was the third time she received a call from work during our thirty-minute conversation. It was Jane’s day off, but as one of the two physician assistants at the only clinic within a fifty-mile radius, “free time” wasn’t in her job description.

I was interviewing Jane about the difficulties she faced working at a rural clinic in Missouri. I expected her to discuss issues regarding poverty, education, transportation – and she did. But I didn’t expect substance abuse to connect all of these topics.

“[Patients] come in for normal blood pressure medicine, diabetes, indigestion, a cold, whatever. We run a blood test or a urine test and they’re addicted – we know it. Sometimes, they’re on the drug while they’re sitting there.”

Rates of drug overdose have been rising nationwide, especially in rural areas. In the CDC’s most recent analysis, drug overdose in rural areas is 17.0 per 100,000, surpassing the urban rate of 16.2 per 100,000. Jane thinks the statistic is actually higher: people don’t come, count, and care about people in the rural South, she says. In fact, that is the very reason she thinks drug overuse is so common where she works. The county where she works has a poverty rate of 30% – the highest in the state. 

I ask, “What do you do?”

“Nothing. What can we do? They’re all people with jobs, families, and children. We treat that sickness, and we let them go.”

There are no initiatives to educate, rehabilitate, or address drug misuse in the town. Drug possession in her state would lead to imprisonment and a fine of at least $500, a cost these families can not afford.

“90% of my patients are on Medicare or Medicaid. They’re poor. They walk to the clinic or come in rundown cars. Others will use an ambulance through Medicare. Sometimes we just have to telehealth because the distance is too long,” Jane said. “They’ll ask me, ‘Are these my stomach meds? Are these my anxiety meds?’ I’ll have to label the medicine bottles with “PAIN” or “STOMACH” in different colors. Many can’t even sign their own names – I don’t think they can read.”

Educational inequality has been linked to drug use and abuse across the world. The town Jane works in only has a single middle school. This lack of education combined with substance abuse makes connecting to patients difficult.

“Everyone is fluent in English – that really isn’t an issue. But compliance is difficult for us. Especially when they’re on a lot of drugs,” Jane said. “Like, explaining a diabetic diet? They don’t believe us and they don’t do it.”

Jane says she often hears people call those in the rural South “backward.” But she disagrees. To Jane, the word “backward” is a personal insult – the “backward” people are not only her patients but also her coworkers.

“We have Padma.* She was in grade eight. She left school, and she’s been working with us for 20 years. She was a drug addict for four years and then she got clean. Doc [the doctor who owns the clinic] found her. We have Shayla,* and Doc employed her and all of her sisters. They’ve all been with Doc for decades,” said Jane.

Framing individuals suffering from drug addiction as “backward” blames the structural issues of a lack of economic opportunities, education, and drug use awareness on people instead of the policymakers that have the power to change these circumstances. It’s a fundamental issue that is prevalent throughout American welfare politics, and it ultimately hampers many reforms from being implemented. This mentality ignores the fact that solutions to America’s drug addiction and rural health issues must work upstream, addressing deep-rooted social determinants of health. As long as health policy continues to fail to address these complex shortcomings, healthcare workers like Jane will continue to feel helpless, and Jane’s patients will remain unjustly underserved.