Danielle Christine Rhubart and Elyzabeth W. Engle
In the early 1980s, the people of Warren County, a rural, low-income area of North Carolina, learned that the state planned to put a hazardous waste landfill in their community. The landfill would become home to six thousand truckloads of toxic soil. In protest against the expected landfill and the health implications it would pose for the community, residents organized nonviolent protests against the state that garnered national media attention. In the end, approximately five hundred protesters were arrested, and the state moved forward with plans for the landfill. Although residents lost this battle, the grassroots organizing that occurred in Warren County to oppose an environmental hazard and its effects on human health is considered one of the first battles of what has become known as the environmental justice movement (Bullard 2000; Taylor 2014).
This chapter examines some of the environmental hazards facing rural areas of the United States and considers their impacts on the health status of rural communities and residents. The primary focus is on low-income rural communities that have borne a disproportionally large share of environmental burdens. These issues are linked to environmental justice literature, which helps to explain the historical, cultural, and socioeconomic processes that led to environmental and, subsequently, health inequities. This chapter draws on a concept developed by Michael Bell (2012) that he called invironment, which refers to the interconnectedness of the environment and individual health. Our bodies are, in fact, part of the invironment. This concept is a central tenant of the chapter because of its inherent acknowledgment of the interconnected relationship between our bodies and the environment. In this chapter, the word environment refers to the ecological, social, and economic processes that are removed from our individual lives. Figure 11.1 illustrates the distinction between the environment and the invironment.
Figure 11.1 The distinction between the environment and the invironment.
The chapter begins with a background on environmental justice and then explores the invironmental impacts of environmental hazards on the health and well-being of low-income rural communities across multiple issues, including energy resource development, agriculture, climate change, and waste facility siting. Then the context of health care and disparities in health outcomes in rural America are examined to explicate the dynamic relationship between environmental hazards and the health of low-income rural communities.
BACKGROUND
Since the late 1970s and early 1980s, the environmental justice movement has grown as a tool for grassroots advocacy as well as an area of study (Bullard 2000; Brulle and Pellow 2006). In the years that followed, hundreds of organized efforts against environmental hazards occurred across both rural and urban communities in the United States. What unites all of these efforts is the desire (1) to ensure that all voices are included in the decision-making processes about environmental hazards and benefits, (2) to reduce the incidence of environmental hazards, and (3) to ensure environmental hazards are not disproportionately experienced by low-income and vulnerable populations. More recently, the Environmental Protection Agency (EPA) has institutionalized the values of environmental justice in its policy and regulatory processes. The EPA (2016a) defines environmental justice as “the fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income, with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies.” This definition demonstrates the regulatory agency’s commitment to increasing inclusivity of all voices in the policy process, emphasizing two different dimensions of justice: distributive justice, or who receives or is exposed to environmental “goods” and “bads”; and procedural justice, or fair access to information, participation in decision-making processes, and access to legal procedures (Walker 2012). Gordon Walker (2012) recognizes a third dimension of justice, justice as recognition, which considers who is (or who is not) given respect or valued within environmental or social issues. Because this chapter focuses on the health dimensions of environmental justice among impoverished rural populations driven by exposure and proximity to environmental hazards, it primarily considers the first dimension of justice—distributive justice.
More than two decades of environmental justice studies in the United States have overwhelmingly shown that, in general, ethnic minorities, indigenous people, people of color, and low-income communities experience a larger burden of harmful environmental exposure from air, water, and soil pollution from industrialization, militarization, and consumer practices than other citizens do (Mohai, Pellow, and Roberts 2009). These vulnerable populations are overrepresented among the rural poor (see chapters 1 and 6), making environmental justice a pressing concern for rural scholars, practitioners, and policy makers. In many ways, rural America may be considered a “dumping ground” for locally undesirable land uses (LULUs) that have important implications for environmental and human health (Lichter and Brown 2011, 582). The siting of LULUs often takes advantage of low-income rural people and places that are fundamentally powerless due to their dire need for economic development and job creation as well as their exclusion from extra-local decision-making processes (Mohai and Saha 2006; Lichter and Brown 2011; Pellow 2016). Yet, as David Pellow (2016, 381) points out, “the rural dimensions of environmental justice studies have long been present, but generally only in the background, rarely foregrounded, centered, or taken seriously as a social, ecological, cultural, economic, and political category that shapes [environmental justice] struggles every day.”
THE PHYSICAL ENVIRONMENT
The term environmental hazards brings many different ideas of pollution to mind. This section provides an overview of four physical environment issues—energy resource development, agriculture, climate change, and waste facility siting—that affect the invironmental conditions of vulnerable rural populations, including community and individual health. The industries discussed in this section are overwhelmingly located in rural places, meaning they affect rural residents not only through proximity and exposure but also through occupational conditions because a larger share of rural people are employed in mining and agriculture industries compared to urban residents (McGranahan 2003; Bureau of Labor Statistics [BLS] 2014).
ENERGY RESOURCE DEVELOPMENT
When considering the environmental and human health impacts of energy development, the extraction of fossil fuels has received the majority of attention from scholars and activists alike. Rural areas that have experienced a great deal of energy development—such as coal mining, natural gas extraction, and petroleum drilling—may be known as “energy sacrifice zones” or “places that are exploited for the purpose of supplying cheap fossil fuels and electricity to power the world’s growing energy demands” (Harlan et al. 2015, 137). From extraction to processing to handling waste by-products, different types of energy resource development are linked to negative environmental and human health consequences for residents and employees.
One particular type of energy resource development often connected to rural environmental (in)justice is mountaintop removal, a surface-level coal mining process by which coal seams running through the upper portion of a mountain are mined by blasting and removing all of the overlying rock and soil to create a level work surface (Bell 2016; U.S. Energy Information Administration 2015). This type of energy extraction is largely concentrated in the region of central Appalachia (West Virginia, southwest Virginia, and eastern Kentucky and Tennessee), which is predominantly rural and has high rates of poverty and unemployment (Partridge, Betz, and Lobao 2013; Tallichet 2014). Mountaintop removal, in addition to the traditional underground coal mining that also is concentrated in this region, has contributed to invironmental health degradation through increased instances of intense flood events, soil erosion and landslides, water contamination, and air and noise pollution (Bell 2016). When compared to the rest of the United States, the coal-mining subregions of Appalachia in particular are plagued by higher rates of chronic illness, birth defects, cancer, and mortality, even after controlling for the lower socioeconomic indicators of these subregions (Hendryx 2008, 2011; Ahern et al. 2011).
Coal production in central Appalachia is linked to negative invironmental consequences through waste impoundments in which hazardous wastewater and slurry are stored behind hazardous dams. These impoundments are more likely to be located near neighborhoods with higher rates of poverty and unemployment (Greenberg 2016). History has documented several instances of impoundment dam failure in which coal slurry floods have killed hundreds of people, left thousands more homeless, and utterly destroyed local ecosystems and drinking water sources (Erikson 1976; Morrone and Buckley 2011). In addition to the effects on general population health, coal extraction in this region is inextricably linked to particular occupational health issues, such as coal workers’ pneumoconiosis (CWP), commonly known as black lung. This is a chronic, and often fatal, lung disease caused by the long-term inhalation of dust generated in coal production, rates of which have unexpectedly risen in recent years among central Appalachian miners (Centers for Disease Control and Prevention [CDC] 2012b).
Other forms of energy development also have been linked to detrimental environmental and human health conditions. Several studies have found that residential proximity to natural gas wells may be associated with a heightened prevalence of skin, neurological, gastrointestinal, and respiratory conditions through exposures to air and water contaminants (Bamberger and Oswald 2012; Steinzor, Subra, and Sumi 2013; Rabinowitz et al. 2015). Fossil fuel extraction is not the only type of energy development with negative implications for vulnerable rural people and places. Proximity to nuclear power plants and uranium mining are associated with increased risk of cancer, birth defects, and hereditary illnesses in neighboring communities through environmental contamination and radiation exposure (Vakil and Harvey 2009; Malin 2015). Hydroelectric dams have been linked to compromised invironmental health through dam failure and flooding, loss of food security, increased exposure to vector-borne and water-related diseases, and reservoir-induced seismicity (Lerer and Scudder 1999). Several such dams are located throughout rural America, some in very close proximity to vulnerable areas such as Native American reservations and the controversial Grand Coulee Dam in Washington, the largest electric power-producing facility in the United States (U.S. Energy Information Administration 2016).
Agricultural production processes also pose consequences for the invironmental conditions of rural populations. One prominent focus of research has been on the impacts of pesticide use in industrial agriculture on farmworkers and surrounding agricultural communities. Although pesticides vary widely in their human toxicity, many used in U.S.-based agriculture contribute to both acute short-term illnesses and chronic long-lasting illnesses, such as cancer, reproductive and developmental problems, endocrine disruption, respiratory disorders, and immune system depression (Harrison 2011, 31). The estimated number of total pesticide poisonings annually in the United States is around 300,000, with Latino populations being more commonly affected (Carolan 2016). Farmworkers, predominantly those who are low-wage, nonwhite, and without access to health care, are exposed to pesticides routinely through mixing and applying pesticides to crops and during ongoing planting, maintenance, and harvesting of crops (Carolan 2016). Due to job insecurity and financial pressures to work rapidly, farmworkers also tend to underreport exposure-related illnesses, delay decontamination and treatment practices, and only selectively use protective equipment in the field (Snipes et al. 2009; Thierry and Snipes 2015).
The issue of exposure to toxic pesticides does not stop at the edge of the field; exposure continues for farmworkers and their families as they eat pesticide-contaminated foods from their place of work and carry home pesticides on their clothing (Carolan 2016). Exposure is also an issue for communities neighboring industrial agriculture operations by way of pesticide drift, which occurs when pesticides move (via wind or water) from the area in which they were applied to nearby localities and people (Harrison 2011; Guthman and Brown 2016). Just like the issue of farmworker exposure, the communities that fall victim to pesticide drift are often impoverished, nonwhite, immigrant populations, largely in California where industrial production of fruits and vegetables still relies heavily on the use of pesticide additives (Harrison 2008). In addition to pesticides, other agricultural contaminants can affect environmental and human health. Fertilizer runoff results in nutrient pollution of surface and ground water, which is connected to skin irritation, stomach or liver illness, respiratory problems, and neurological effects (EPA 2016b). Drinking water containing nitrates, a particular compound found in fertilizers, is linked to a serious and often fatal health condition in infants known as blue baby syndrome (EPA 2016b).
Another agricultural issue that negatively affects the invironmental conditions of low-income, rural communities is concentrated animal feeding operations (CAFOs), which are a specific type of large-scale industrial agriculture facility that raises animals in very dense populations for the human consumption of meat, eggs, or milk and whose waste comes into contact with the local water supply (Hribar 2010). The invironmental issues associated with CAFOs concern the amount of manure they produce, which is known to contain a variety of contaminants that negatively affect water and air quality, and consequently nearby residents. These contaminants include excessive nutrients (e.g., nitrogen and phosphorus), animal-borne pathogens such as E. coli, growth hormones, antibiotics, and chemical additives (Hribar 2010). They have been connected to a variety of chronic respiratory, gastrointestinal, and neurological illnesses, as well as to more acute conditions of skin/eye irritation and joint/muscle pain (Wing and Wolf 2000). Several studies have shown that CAFOs (and their ill effects) are more likely to be concentrated near rural communities with a higher prevalence of low-income and racial/ethnic minority populations (Wing and Wolf 2000; Wing, Cole, and Grant 2000; Donham et al. 2007). CAFO workers, who are even more drastically exposed to these invironmental hazards, are also made up primarily of low-income and racial/ethnic minority workers, who are predominantly Hispanic and foreign-born (Mitloehner and Calvo 2008). More than 25 percent of CAFO workers develop a range of respiratory diseases, and exposure to high concentrations of bioaerosols has been linked to organic dust toxic syndrome, a condition that affects more than 30 percent of workers in the swine industry alone (Donham et al. 2007).
CLIMATE CHANGE
Climate change and human health are intrinsically linked in the invironment. Human-induced climate change is associated with increases in extreme temperatures and precipitation (Fischer and Knutti 2015). The National Institute of Environmental Health has issued concerns about a number of health illnesses that could increase as a result of extreme temperatures and precipitation. These include asthma, allergies, cancers (via increased ultraviolet radiation), cardiovascular issues (via heat stress and air quality), water-borne disease, and weather/heat related morbidity and mortality (Berko 2014; Portier et al. 2010). Similar findings are reported by the Intergovernmental Panel on Climate Change (IPCC). The IPCC’s 2014 report links climate change to negative health effects via extreme temperatures, flooding and storms, and ultraviolet radiation. These weather changes lead to increased heat-induced illness and death, air pollutant–induced illness, as well as increases in morbidity and mortality due to food- and waterborne diseases.
These invironmental impacts are not evenly distributed across the United States. For instance, rural counties experienced the highest rates of cold-related mortality and flood-storm-lightning-related mortality from 2006 to 2010 (Berko 2014). This may be the product of the types of occupations and recreational activities available in rural counties as well as distance to trauma centers. In addition, severe weather changes affect rural livelihoods because unpredictable growing seasons raise issues of food and occupational insecurity, especially for those employed in the agricultural sector. Invironmental risks are not determined by climate alone, but also by a rural community’s ability to adapt (Gutierrez and LePrevost 2016; Davidson, Williamson, and Parkins 2003). Rural communities that experience increases in severe weather are dependent on fire departments and emergency medical services teams that are volunteer-based. Depressed places have weaker safety nets and deteriorating infrastructure and may be unable to meet the needs of people during natural disasters.
Finally, many rural communities are centered around tourism, which is being affected by climate change. Rural communities are already disproportionally more vulnerable due to a lack of occupational diversity (EPA 2011; Adger, Lorenzoni, and O’Brien 2009), and depressed or unstable economic conditions will undoubtedly affect rural people’s health and well-being by restricting their access to positive health behaviors (e.g., healthy foods) as well as access to health care. These challenges in tourism-based communities are exacerbated by the affects of climate change. For example, estimates show that unstable snowfalls and increased overall temperatures will negatively affect winter sport tourism in the decades ahead unless communities actively use adaptation strategies (Scott, McBoyle, and Mills 2003). Adaptation and mitigation policies and strategies are needed to prepare rural communities (Jensen 2009) for invironmental changes. Coupled with climate change mitigation, this will be essential in supporting the environmental and human health of low-income rural communities.
The 1980s and 1990s were a period of realization of the invironmental inequalities associated with hazardous waste and dumping. This was also the era when environmental justice literature began substantiating the gross inequalities of hazardous waste dumping. The EPA (2016c) defines hazardous waste as “a waste with properties that make it dangerous or capable of having a harmful effect on human health or the environment. Hazardous waste is generated from many sources, ranging from industrial manufacturing process wastes to batteries and may come in many forms, including liquids, solids, gases, and sludges.” Facilities that produce, store, or dispose of hazardous waste are more likely to be located in low-income and rural areas. Research suggests that rural America has become a dumping ground for urban America (Lichter and Brown 2011). For example, Bullard (2000) found that hazardous waste facilities were disproportionately located in rural minority communities in the South. Similar studies on other types of waste facilities have found waste sites are more likely to be located in working-class communities, in communities with larger shares of minorities, and in low population density areas (Davidson and Anderton 2000; Kearney and Kiros 2009; Atlas 2002). Public and private agencies have targeted Native American reservations as well—populations plagued by generations of socioeconomic vulnerability and lagging improvements in disease treatment—to act as sites for the storage and disposal of hazardous nuclear waste (Randel 2001; Brook 1998). The unequitable distribution of these facilities is a manifestation of decades of distributive injustices when inclusivity of all voices in the policy process was not prioritized.
The strategic placement of waste facilities in low-income, minority, and indigenous rural communities can have profound invironmental affects on health disparities. The health implications of living or working around hazardous waste sites are extensive (Brender, Maantay, and Chakraborty 2011). For example, risk of brain cancer among children is higher for those whose mothers lived within one mile of industries that were listed on the Toxic Release Inventory during pregnancy (Choi, Shim, Kaye, and Ryan 2006). Reproductive outcomes and, in particular, chromosomal abnormalities, including neural tube defects and heart defects, have been linked to a mother’s residential proximity to hazardous waste landfill sites (Vrijheid et al. 2002; Croen et al. 1997). Residence near waste sites has been linked to higher rates of diabetes in New York State (Kouznetsova et al. 2007) even after controlling for other determinants of diabetes including smoking status, diet, exercise, and income. For the Native American tribes’ land targeted for nuclear and hazardous waste storage and disposal, the physical environmental risks to the health of these populations exacerbates their already elevated risks of certain types of cancers, which have been found in regional analyses (Weaver 2010; White et al. 2014; Hoffman et al. 2014). The health implications of living or working near hazardous waste, coupled with the fact that these waste sites are disproportionality located in rural and low-income communities, require a new approach to determining where and how waste is disposed as well as investment in mitigating the current environmental and human health consequences of hazardous waste.
THE HEALTH CARE ENVIRONMENT
The invironmental relationships between environmental hazards and the health of low-income populations in rural America is mediated by the level of access to quality health care. Lack of access to care can be explained by many factors, including financial and geographic barriers (Comber, Brunsdon, and Radburn 2011). This section discusses the state of rural health care, including how and to what extent federal health care reform has improved access to quality care in low-income rural America to be able to treat the health consequences of environmental hazards.
The financial barriers to accessing health care have been at the center of national discourse in the past decade. The Patient Protection and Affordable Care Act (ACA) sought to expand access to insurance to low-income populations to rid economically vulnerable populations of this barrier. The Medicaid expansion component of the ACA was a key part of the health care reform package. It sought to create equal access to Medicaid—including among childless adults. Prior to expansion, eligibility for Medicaid varied drastically by state, both in terms of income eligibility thresholds and whether childless adults were eligible. The Supreme Court’s 2012 ruling on the National Federation of Independent Business v. Sebelius resulted in states having the ability to refuse to expand Medicaid. Nearly half of states opted out of Medicaid expansion in 2014. In these states, there is what is called a “coverage gap.” The coverage gap represents those individuals who make too much to qualify for Medicaid but too little to afford insurance through the newly created health insurance marketplaces, even with federal tax credits. According to the Kaiser Family Foundation, “nearly two-thirds of uninsured people in rural areas live in a state that is not currently implementing the Medicaid expansion” (Newkirk and Damico 2014).
The county-level health insurance coverage rate for rural and urban counties in states that did and did not expand Medicaid is presented in table 11.1. In 2013, before Medicaid expansion, counties in states that would eventually choose not to expand Medicaid already lagged behind in terms of county-level health insurance coverage rates. On January 1, 2014, when Medicaid expansion was rolled out, nearly half of state leaders chose not to participate. Although nearly all counties in all states experienced increases in coverage rates from 2013 to 2014, the disparity between counties in states that did or did not expand Medicaid has increased. Other state and county-level factors explain why states that would eventually opt out of Medicaid had lower rates of county-level coverage to begin with, but Medicaid expansion exacerbated these disparities, leaving behind states whose leaders had chosen not to expand. Moreover, across both years and among both counties in states that did and did not expand Medicaid, the coverage rates in nonmetro and rural counties continue to lag behind those of metro counties. Therefore, we can expect that rural and nonmetro counties will continue to lag behind but even more so in states that did not expand. Vulnerable residents in these counties who potentially face the health consequences of more prevalent environmental hazards will continue to face financial barriers in accessing care.
Table 11.1 Average County-Level Percent Insured by Metropolitan Status and Whether the County Is in a State That Expanded Medicaid, 2013–2014
| Types of counties |
Average county-level percent insured, 2013 |
Average county-level percent insured, 2014 |
| Expanded Medicaid |
Did not expand Medicaid |
Expanded Medicaid |
Did not expand Medicaid |
| Completely rural |
80.00 |
75.96 |
86.55 |
79.37 |
| Medium nonmetro |
81.22 |
75.88 |
86.78 |
78.73 |
| Large nonmetro |
81.75 |
77.47 |
86.86 |
80.28 |
| Medium metro |
82.32 |
78.37 |
87.50 |
81.29 |
| Large metro |
84.88 |
79.64 |
89.03 |
82.57 |
Source: Author’s analysis of Small Area Health Insurance Estimates for 2013–2014 from U.S. Census Bureau (2015).
Rural residents also face geographic barriers in accessing health care, and this also is tied to state Medicaid expansion decisions. Residents in rural areas face longer distances to primary care physicians (Chan, Hart, and Goodman 2006). This is the result not only of the wider disbursement of the rural population but also due to lower per capita levels of physicians and surgeons in rural areas (Rosenblatt 2000; Thompson et al. 2005). Exacerbating this issue is the accelerating rate of hospital closures in rural America (Hsia and Shen 2011), which leads to greater travel distances for rural residents seeking care. The rate of rural hospital closures has been higher in states that did not expand Medicaid (Kaufman et al. 2015). In part, this is explained by the fact that in states that did not expand Medicaid, hospitals are experiencing a higher rate of uncompensated care costs. Uncompensated care costs are accrued by hospitals and physicians when caring for uninsured patients or patients who are not able to pay their bills. Uncompensated care costs reached $50 billion in 2013 (Assistant Secretary for Planning and Evaluation [ASPE] 2015). Costs have begun to decline, but the decline is significantly larger in states that expanded Medicaid (ASPE 2015). In rural areas, where hospitals struggle with lower profitability, revenue, and utilization, high rates of uncompensated care can increase their risk of closure (Kaufman et al. 2015). Rural hospital closure rates exacerbated by state decisions not to expand Medicaid leave many rural residents with larger geographic barriers when deciding whether to seek care. The low-income rural populations in the states that did not expand Medicaid continue to struggle in accessing quality health care due to financial and distance barriers. The risk these barriers pose is that rural residents will receive less preventive and primary care, which is essential for improved community health and reduced health care spending (Institute of Medicine [IOM] 2003, 2009). Together, as part of the invironment, environmental risks, geography, and socioeconomic indicators help to explain the degree to which these rural residents can access care and live a healthy life (McMichael 2013).
Environmental hazards and lower access to care in rural communities are related to and compounded by poor health outcomes for rural residents. For example, not having health insurance is associated with not receiving primary and preventive care (CDC 2012a; Tejada et al. 2013) and thus being diagnosed at later stages of illnesses, which is more costly and more likely to be terminal (Wilper et al. 2009; IOM 2009). In addition, socioeconomic, demographic, and geographic characteristics of rural areas put residents at greater health disadvantages. For example, research demonstrates that rural health behaviors (e.g., smoking, diet, activity levels) are associated with elevated risks of chronic health illnesses such as diabetes, obesity, cancer, and chronic obstructive pulmonary disease (COPD) in rural communities (Eberhardt and Panuk 2004; Hartley 2004; Meit et al. 2014). These factors, added to the elevated health risks associated with environmental hazards discussed earlier, are evidence of the invironmental disadvantage rural communities and people face.
LOOKING FORWARD
Strategic action and planning is taking place at the federal level to address the invironmental concerns raised in this chapter. The EPA is currently the chair of an Interagency Working Group on Environmental Justice (EJ IWG), which facilitates Executive Order 12898: Federal Actions to Address Environmental Justice in Minority Populations and Low-Income Populations (EPA 2016d). Federal agencies involved in this working group are attempting to address issues that affect the invironmental well-being of vulnerable communities, including low-income and rural communities. In addition, the EPA is crafting a 2020 Action Agenda: a five-year strategy for “deepening environmental justice progress in the EPA’s programs to improve the health and environment of overburdened communities; working with partners to expand [their] positive impact in overburdened communities; [and] demonstrating progress on significant national environmental justice challenges” (EPA 2016e).
Programs are beginning to address the health care needs of low-income rural populations. Broadly speaking, Medicaid and the Children’s Health Insurance Program (CHIP) provide health insurance to low-income adults and children in the United States, although, as previously stated, the degree to which Medicaid is available varies by state. Several programs specifically target underserved regions, including rural areas, with an increased supply of health care professionals. The National Health Service Corps (NHSC) places thousands of primary health care providers in underserved communities each year and provides scholarships and loan repayment programs to physicians who join. This and other programs, such as the United States Public Health Service Commissioned Corps (PHSCC), are beginning to fill some of the health care access gaps in rural America. Yet thousands of underserved communities and frontier areas, many of which are rural, fall within the health professional shortage areas or medically underserved areas (U.S. Department of Health and Human Services 2016).
CONCLUSION AND IMPLICATIONS
This chapter has examined some of the environmental hazards facing low-income rural communities in the United States and considered the implications on the health status of those rural communities and residents. Low-income rural communities have borne a disproportionally large share of environmental burdens. An invironmental approach acknowledges the consequences of environmental hazards that lead to socioeconomic, environmental, and biological instability in low-income rural communities—particularly in communities that lack a health environment that is accessible to all. Unstable occupational and physical environments, met with unstable or incomplete social and health infrastructures, create a recipe for higher risks of morbidity and mortality for vulnerable populations.
It is important to acknowledge the rural environmental hazards that have not been discussed in this chapter, such as forestry and deforestation, lead and other heavy metal exposure, petrochemical factories, and food deserts (see chapter 10). These environmental hazards also pose significant consequences for rural communities. This chapter focused on four realms of hazards at the forefront of rural environmental justice literature and particularly on distributive justice and the distribution of environmental “bads.” Just as the distribution of environmental bads is inequitable, so is the distribution of environmental “goods.” A great deal of research has focused on what is called environmental privilege (Pellow and Brehm 2013), an area that can equally inform future efforts toward justice. Rural populations are more likely to be exposed to environmental hazards, but they are also less able to address or alleviate these situations procedurally or politically because of a lack of financial resources and education, language barriers, and legal status (Walker 2012; Taylor 2014; Pellow 2016). Moreover, low-income rural populations often lack the resources and capital to escape residential or occupational environmental hazards. Together these limitations leave rural populations as sitting ducks, unable to affect or change their invironmental situation.
Researchers studying environmental injustices continue to face methodological challenges. In particular, data limitations affect our knowledge—and therefore policy and practice—around rural environmental justice. The lack of data and the challenges to collecting data on both rural health and the environment make it difficult to substantiate the invironmental links between environmental hazards and health outcomes. Linking chemicals to individual and community health is extremely difficult. Chemicals can be transmitted through soil, water, and air and can take decades, if not centuries, to decompose. Humans are exposed to chemicals in many ways, and in most cases people are more likely to be exposed to a mixture of chemicals than to just one chemical, making it difficult to narrow down a “who done it” for chemicals (De Rosa et al. 1996). Missing data in many federal data sets further exacerbates the ability of researchers to substantiate relationships. As a result, most of the rural environmental justice studies that do exist are regional or community case studies, making it difficult to compare, validate, and draw wider conclusions.
Despite recent advancements to incorporate environmental justice values in policy and regulatory processes, rural America continues to bear the invironmental consequences of these environmental hazards amidst a health care context that lags behind in accessibility. Rural residents face greater financial and geographic barriers in accessing primary and emergency care due to lower levels of physicians, accelerated rates of hospital closures and consolidations, and lower rates of insurance coverage. Interdisciplinary research is needed to better understand the connections between health status and environmental hazards, as well as how the rural health care context mediates or exacerbates that relationship. The environmental justice movement first began nearly three decades ago in Warren County, North Carolina, and it has made monumental strides in shedding light on and advocating for environmental justice. It is the responsibility of current and future generations to continue that work. For low-income rural American communities to no longer be treated as the dumping ground for America, all voices—low-income, minority, and indigenous—must be part of the solution toward equitable burdens and benefits in the interconnected and interdependent relationship between our environment and our individual lives.
Michael Hendryx
Appalachia is a forested, mountainous region of the eastern United States extending from southern New York to northern Mississippi. It is home to about 25 million people, about 52 percent of whom live in rural settings. Within Appalachia are three subregions: northern, central, and southern Appalachia. To some degree each region has had its own history and its own developmental successes and struggles. This case study focuses on central Appalachia and addresses the complex interplay between rural poverty in this subregion and the environmental affects of its long-standing dependence on coal.
According to the Appalachian Regional Commission (ARC), Appalachia has a poverty rate of about 17 percent compared to 15.4 percent for the nation at large. Of the region’s 420 counties, 203 (48 percent) are classified into lower levels of economic development (what ARC calls either “at-risk” or “distressed”) based on measures of income, employment, and poverty relative to the United States as a whole. Within central Appalachia, which includes the Appalachian counties of Kentucky, North Carolina, Tennessee, Virginia, southern Ohio, and most of West Virginia, this figure rises from 48 percent to 66 percent.
Central Appalachia also has a long-standing economic dependence on coal, in particular a form of surface coal mining called mountaintop removal. Mountaintop removal takes place in the steep terrain of central Appalachia in eastern Kentucky, southern West Virginia, western Virginia, and northern Tennessee. It involves clear-cutting forests and using explosives and heavy machinery to remove up to hundreds of feet of rock and soil to reach coal seams. This activity occurs in proximity to populated communities. The rock and soil, called overburden, is dumped into adjacent valleys, permanently burying headwater streams. Research has shown that the quality of surface waters emerging from mountaintop mining areas is severely impaired. The use of explosives and machinery for coal extraction, processing, and transportation also has raised concerns among local residents about air quality affects.
Epidemiological investigations have documented that the people of Appalachia who live where coal mining takes place are at elevated risk for a variety of health problems. Among these health problems are higher rates of total mortality, cancer, cardiovascular and respiratory illness, and poor birth outcomes including birth defects. To some extent these health problems result from poor socioeconomic conditions in the region and to behavioral problems that often coincide with low socioeconomic status. Smoking rates in mining communities are higher than regional averages, for example, as are obesity rates. However, the published studies show that people in communities where mountaintop removal is practiced have significantly elevated risks for these poor health outcomes even after statistical adjustment for other risks including smoking, poverty, obesity, educational attainment, age, and sex.
Another set of studies has begun to document that environmental quality in rural mountaintop mining communities is impaired compared to rural control communities that don’t have mining. Significantly higher levels of ultrafine particulate matter is in the ambient air in mining versus control communities, with evidence that particulate matter in mining communities contains silica, organic compounds, and other chemicals that are known to be harmful to health. One laboratory study demonstrated that dust collected from the ambient air in rural mining communities, but not dust from rural nonmining communities, caused changes to human lung cells indicative of cancer development and progression. These studies illustrate that environmental health issues are not confined to urban environments, and that rural populations also face environmental threats from human activities.
In one sense, studies on mining’s public health affects have treated poverty and other traditional socioeconomic and behavioral risks almost as “nuisance” variables, as confounds to be measured and controlled in statistical models. Once this is done, we see that people in mountaintop mining communities still have poorer health outcomes that cannot be explained by the traditional indicators. At least some of this disparity seems to be environmentally related. But in another sense, it is important to understand that poverty and mountaintop removal are connected, and that poverty is not simply a variable to be set aside or controlled. When data on where mountaintop removal takes place is combined with the most recent poverty data from the Appalachian Regional Commission for the years 2009–2013, the poverty rate is 22.1 percent in the counties within the four states where mountaintop removal takes place, compared to 18.8 percent for other Appalachian areas in those same four states. Mountaintop removal uses explosives and machinery to efficiently extract large amounts of coal without the need for extensive manual labor, and the number of miners needed per ton of coal extracted is less for this method than for others. The practice of mountaintop removal also comes with opportunity costs; it destroys the landscape, degrades roads, pollutes air and water, contributes to poor public health, and therefore discourages alternative economic development. If a worker isn’t fortunate enough to have one of the few relatively well-paying mining jobs, there isn’t much else to choose from.
To address the problem of poverty in rural central Appalachia, it is apparent that economic diversification is needed that reduces the area’s coal dependence. This would have benefits both in terms of improved environmental conditions and, over time, improved economic conditions. To paraphrase Einstein, “Insanity is doing the same thing over and over and expecting a different result.” More coal mining will not change the economic conditions that it created in the first place. Deliberate investments in education, adult retraining, and alternative business development are urgently needed.
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