Reframing rural health inequities: a norm-critical approach

Over the course of the last 3 years there has been a wealth of research highlighting rural health inequities within Aotearoa New Zealand (NZ). This research has demonstrated increased mortality for rural people,¹ increased mortality for rural Māori,² educational disadvantage experienced by rural students³ and poorer access to the social determinants of health for rural people.⁴ Media representations of rural health have raised concerns about a rural workforce crisis, burnt out rural doctors and unsafe practices. The picture, that rural research and media representations paint, is of an unhealthy rural population and an unhealthy rural health system. This problematic framing of rural health and associated discourse can imply a rural deficit and lead to unhelpful assumptions and generalisations about rural populations and health professionals.

The operationalisation of a rural deficit lies in the discourse and rhetoric used. For example, Fors⁵ describes a geographical narcissism in which urban is seen as the norm and geographical maps reflect an urban centrality. Within NZ the Geographical Classification of Health categorises the country along a continuum from major urban areas to remote.⁶ While this classification is helpful for highlighting differences, the definitions of rural areas are based predominately on conceptualisation of urbanism and travel time from urban centres. Remoteness is viewed as distance from a city, but in reality it is the city that is remote from the people that live within these areas.⁷

Metro-normativity, that is implicitly and explicitly expressed within rural-urban discourse, can result in rural othering, whereby rural is perceived as different or not normal or exotic. This rural othering can have racialised, colonial, ableist and gendered aspects. An example is seen in hegemonic rural masculinity where the urban gaze perceives ‘typical’ rural occupations, such as the stoical farmer, the rugged hunter and the Swanndri© clad forester, as strong males.⁷ Similarly, the discourse of settlers breaking-in rural land predominately invokes images of bearded white males chopping down trees. The ontological perception of rural land as a resource to extract wealth from contrasts with decolonised views of land having deep connections to tangata whenua and spirituality.

This homogenisation of rural people and communities, and the binary labelling of rural and urban, ignores the diversity within all communities. In part, this homogenisation arises because of the challenges in defining rurality. The NZ approach to defining rurality draws predominately on structural and demographic approaches, in which rural is constituted as measurable variables that are compared and contrasted.⁷ A structural and demographic approach is understandable when data and figures are required to shape policy and practice. However, numbering and categorising can condense and collapse diversity and risks feeding into negative portrayals of rurality.

The presentation of rural deficits is also reinforced in the other ways in which data are presented. Relative risks, incident rate ratios and odds ratios where the reference value is taken as urban highlight rural disadvantage. In contrast, if a rural reference value is used, then the lens is placed on urban advantage. Taking a norm critical approach to rural issues requires a reframing of how data are used, knowledge of how discourse creates othering and a conceptualisation of racialised, colonial, ableist and gendered urban power.

While norm criticism draws from educational theory and queer theory⁸ a rurally located theory of power exists that could disrupt the gaze of urban privilege. Gaventa’s⁹ theory of power, drawn from his studies of rural Appalachian coal miners, proposes that power holds three forms. These forms, when applied to a rural health setting, are:

Similarly to norm-criticism theory, Gaventa¹⁰ proposed that the discursive nature of symbolic power can mold a social reality by shaping its depiction or characterisation. It is this depiction and characterisation of rural health issues that I suggest is challenged. Rural researchers, educationists and health providers should adopt an agenda of disruptive discursive practice. The elements required in this agenda, drawn from Gaventa’s theories^9,10 are three-fold:

Converting a rhetoric of rural deficits to a critique of urban privilege focuses attention on where power is located and who holds power. It creates opportunities to disrupt this power and concentrate on rural solutions and control of health. If an agenda of reframing of rural inequities does not occur then a risk of equity fatigue can occur where the dialectic resistance encountered simply results in maintenance of rural-urban differences.⁸