The state of rural public health: Enduring needs in a new decade

Public health in the rural United States is a complex and underfunded enterprise. While urban- rural disparities have been a focus for researchers and policymakers alike for decades, inequalities continue to grow. Life expectancy at birth is now 1 to 2 years greater between wealthier urban and rural counties, and is as much as 5 years, on average, between wealthy and poor counties. This article explores the growth in these disparities over the past 40 years, with roots in structural, economic, and social spending differentials that have emerged or persisted over the same time period. Importantly, a focus on place-based disparities recognizes that the rural United States is not a monolith, with important geographic and cultural differences present regionally.We also focus on the challenges the rural governmental public health enterprise faces, the so-called "double disparity" ofworse health outcomes and behaviors alongside modest investment in health departments comparedwith their nonrural peers. Finally, we offer 5 populationbased "prescriptions" for supporting rural public health in the United States. These relate to greater investment and supporting rural advocacy to better address the needs of the rural United States in this new decade.