What's it like to grow old in rural America? -- Millie Goolsby is a retired nurse, so when she experienced chest pain five years ago, she recognized the signs of a potential heart attack. But her family didn't call 911. The drive from her home to the hospital in Klamath Falls, Oregon, requires at least half an hour.
"It takes a while for an ambulance to get here, and then you hope the ambulance can find you" on an unpaved country road, said Goolsby, who is 83. Instead, her son-in-law drove her to the emergency room. (After three days in the hospital, she went home and resumed her 2-mile-a-day walks with her dog.)
-- Richard Howard, a 70-year-old cattle rancher who lives 17 miles from Chiloquin, Oregon (population: about 700), is considering how to reshingle part of his roof this spring. Professionals charge too much, he said. A friend who used to help with maintenance moved away. His wife's son is handy, but lives in Idaho and can visit only occasionally.
Young people tend to leave rural Oregon, Howard said, because "there's not the employment opportunities out here in the sticks." -- Through his 95th summer, Bill Kolacny was tending the tomato patch on the 400-acre Wyoming ranch where he and his wife, Beverly, had lived for 25 years. When he began to weaken from heart failure in December, all he wanted was to die in their log home on the Clark Fork River.
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But the nearest hospice organization, in Red Lodge, Montana, is not licensed to care for patients in Wyoming. And the closest Wyoming hospice said it couldn't afford to send staff members 60 miles to the Kolacny ranch.
So Bart Kolacny and his two sisters, who all live at least an hour away, took turns caring for their father at home with the help of their family physician, Dr. Bill George, also certified in palliative care. The family managed until Bill Kolacny died last month at 95, but "it wasn't easy," Bart Kolacny said.
When it comes to attention and medical resources, "we're kind of underrepresented," said George, who practices at Beartooth Billings Clinic in Red Lodge. "People sometimes feel forgotten." Aren't country folks supposed to be hardier and healthier, with all that fresh air and exercise, than their urban counterparts? "When you actually do the research, it's pretty much a myth," said Leah Goeres, a postdoctoral fellow at Oregon State University who led a research team comparing rural and urban dwellers' health.
The rural U.S. population is older: About 15 percent of residents are 65 or older, compared with 12 percent in urban areas, largely because many people have left in search of education and jobs.
"When young people leave, they take their fertility with them," said E. Helen Berry, past president of the Rural Sociological Society, which promotes the study of rural life, and co-editor of an essential 2013 book, "Rural Aging in 21st Century America." The remaining population gets older still.
Rural areas vary, of course. Some picturesque locales get infusions of capital and energy when younger retirees move in. In general, though, "people in rural areas tend to have lower incomes throughout people's lifetimes," Berry said, and thus lower retirement incomes, with greater reliance on Social Security.
Among those over 65, poverty rates run higher outside of metropolitan counties, the Department of Agriculture reports.
Because income level correlates with health, it is not surprising that Goeres found significant differences when her team analyzed five years of health data from people over 85: two groups in metropolitan Portland, Oregon, and one in the rural Klamath Basin.
The rural cohort had more chronic illnesses to start with, including higher rates of diabetes, stroke, cognitive impairment, heart arrhythmia and heart failure.
"The diseases got worse at a faster rate" in rural seniors, who also took more prescription drugs, Goeres said. They survived 3.5 years on average from the time the study began in 2000, compared with 7.1 years for urban dwellers.
Though the study looked at only one state, other studies have also found poorer health and higher mortality in rural areas. Yet because they struggle to attract and keep health professionals, it is harder for older residents there to get health care.
Louise Mohardt, 78, still working as a geriatric care manager in Lancaster, Virginia, needs to see an ophthalmologist for her glaucoma. "We had one here in town, but he retired," she said. So a friend drives her 85 miles to Fredericksburg, Virginia.
In Lancaster, "we don't have everything we need," Mohardt said. "We had a terrible time getting a psychiatrist." There is no local neurologist, pulmonologist or kidney specialist, either, and the nearest dialysis center is a 30- to 60-minute drive.
Few rural counties can offer much in the way of public transportation, so residents have to traverse these distances -- to supermarkets as well as clinics -- by car.
Nina Glasgow, a social gerontologist and co-editor of "Rural Aging in 21st Century America," recalls conducting a focus group in upstate New York. "One woman said, 'If I can't drive anymore, I'll just kill myself,'" Glasgow said. "I hope she didn't mean it."
Many seniors, wisely or not, fight to keep driving, but rural residents have fewer alternatives.
In most of the United States, families help with driving, shopping and activities of daily living as their relatives age. When adult children leave their rural homes, a key component of elder care goes missing.
"There's a question of whether people have to go into nursing homes prematurely" because they lack family caregivers, Glasgow said.
In their absence, neighbors and churches can play compensatory roles. Her research in rural areas has shown that older adults actually prefer to accept services from their churches rather than from government programs.
Satellite clinics and telemedicine can help bridge some of the health care gaps. For digitally adept older adults, the Internet already allows easier shopping, entertainment and social interaction.
Glasgow, among others, has called for better transportation options and for more senior housing, so that rural communities can bring services to clusters of people who need them.
The solution often suggested and generally rejected, however, is moving away. Sometimes that reflects the cold reality that would-be sellers cannot find buyers for homes in remote areas, but often it simply demonstrates the attachment older people have to their rural lives.
Since Bill Kolacny died, his children have taken turns spending the night with their mother, Beverly, 82. She has hypertension and uses a walker, so she no longer uses her second floor, and she has relinquished her flock of chickens. But she intends to stay put.
"I've seen so many old ranchers and farmers get to a point where they couldn't do it anymore, so they'd move to town -- and within a month, they'd be gone," Bart Kolacny said. "Staying on their place gives them that will to keep going." So he's not arguing with his mother. "If she wants to stay out there," he said, "I'll do everything I can to keep her there."