Monday, February 14, 2011

Examining rural health disparity through the lens of communicative marginalization

Reading Dutta’s chapter on marginalization reinforced my views about the disenfranchisement of those living in particular rural communities and forced me to probe my understanding of the nature of their health disparity further than what I had before. In discussing the mechanisms that lead to marginalization, I was left questioning, in what ways are rural individuals cast towards the margins? Is the marginalized based on access to health information resources? Equitable health care? Resources for engaging in positive health behaviors (such as farmer’s markets or exercise facilities)? Educational avenues for furthering one’s ability to be employed and out of poverty? Or, is the marginalization more closely related to the inability of the rural citizen to participate in the discursive space where policy decisions are made?

Ultimately, all of these questions could be answer with the affirmative. Disentangling their individual impact, however, would be exponentially difficult. Broadly, many forms of structural inequity and the unequal distribution of resources contribute to the health disparity experienced by those living in rural areas. While my home community seems to possess a sufficient amount of social capital, furthered through the joining of all youth at one centralized middle/high school, a number of churches, and recognizable avenues for social interaction, there is a paucity of enacted social support networks or health information resources that serve the entire rural community rather than just one subset within. Because these smaller entities lack the resources (both materially and motivationally) to mobilize beyond their small realm and enact significant changes, the greater disparity of the community is masked by their presence.

There are few community-centralized entities set into place with the purpose of aiding all rurally disadvantaged citizens in this area. Dutta suggests that the marginalized are often spoken for by others, and that much of communication that does take place in context of marginalization is top-down, flowing from discursive spaces at the center to marginalized locales of underserved societies. Through my participation as a member in one of these entities, a health “coalition” aimed at addressing the health disparities experienced in my home rural community, I see this form of communicative marginalization occurring frequently. Individuals are selectively chosen to be a part of this coalition, including local health professionals, individuals associated with the Chamber of Commerce, local government officials, school employees, and those working at the community foundation. Not one member is a part of the general population of rural citizens actually experiencing the disparity. From the powerful, all-knowing perspective these individuals tout, they reinforce further marginalization of those without access. Policies and programs are crafted without the consideration of one marginalized voice (process-based marginalization), and the “general” community rural citizen is positioned as backwards, traditional, conservative, and unwilling to change, thus in need of intervention (message-based marginalization).

Basu and Dutta suggest that participation is not merely a matter of going to ready-made platforms that fit the dominant agenda, such as crafting a power-wielding “health coalition” for the betterment of a community’s health programs and services, but rather is embodied in creating alternative structures that challenge the basic inequities and injustices bred by the mainstream structures. Rather than relying on top-down structures as mechanism for enacting change, spaces must be opened for dialogue with, and not for, the marginalized.

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