The Rural Monitor, Volume 10, No. 3, Winter 2004
In this issue:
- Cover Story
Linking Health and Social Services to Local Economies by Thomas D. Rowley
- Around the Country
Addressing the Nursing Shortage in Iowa; Community Leadership Training in Michigan; New Hampshire Public Health and Bioterrorism; Getting More Out of EMT's in Oklahoma; by Erica Hauck
- Research Roundup
Rural Poverty: New Looks at an Old Phenomenon by Thomas D. Rowley
This issue is also available in PDF.
Linking Health and Social Services to Local Economies
By Thomas D. Rowley
The link between health and human services and economic development
has long been neglected by both care providers and economic developers.
Yet in many small, rural communities, health care and social services
are major economic engines. A local hospital, for example, is often
one of the biggest employers in town, just behind the local school
district.
“Health care has never pushed it and economic development
has never had to think about it,” said Sam Tessen, director
of Texas’ Office of Rural Community Affairs (ORCA).
Tessen
said that he once told a local economic development official
from rural Texas that a major employer in the official’s
area was in danger of closing. The official was surprised, especially
after Tessen told him that the employer was the local hospital.
“It
was news to him,” Tessen said. “He was apoplectic.”
But
he’s not alone. Many rural business leaders and their health
care counterparts have not always seen the symbiotic link between
their two worlds.
“People traditionally have the mindset
that a hospital is a hospital and not a business,” said
Gentry Woodard, director of legislative affairs for St. Joseph
Health System in east Texas.
Hospitals, along with other health
care and social service providers, are businesses. They employ
people, pay wages, and buy supplies. They help keep a community’s
workforce healthy and productive. They help attract and retain
other businesses by providing services critical to those businesses’ employees
and their families.
And they help keep dollars in the community
that might otherwise have gone elsewhere—dollars for shopping,
lunch, and lodging that people typically spend on a trip to the
city for care when it is not available locally, or when local
care is thought to be of lesser quality.
All told, health and
human services play a huge role in any community’s
economy. They play an even larger role in small rural communities,
where any sector accounts for a larger share simply due to the
small size of the whole.
The flipside is, of course, also true.
Bringing or keeping people and income in a community adds to
the patient base of the community’s
health sector, thus helping it stay healthy.
Using Taxes in Texas
In Texas, the Office of Rural Community Affairs (ORCA) is itself
an attempt to, among other things, better link economic development
with health care. As such, the agency encourages communities
to not only utilize Rural Health Works (RHW) tools (see text
box on page two), but also to utilize other more traditional
economic development tools to bolster local health care and
thereby enhance economic development efforts.
One such tool is
the economic development sales tax created in 1989 to stimulate
the Texas economy and provide smaller communities with an optional
source of local revenue for economic development. By law, communities
may vote to adopt an economic development sales tax, the revenues
from which can finance a variety of economic development projects—from
industrial facilities to marketing to training and education. One
provision of the law (known as 4B) allows communities to use the
revenues to pay for “quality of life enhancements,” including
health care facilities.
Upon hearing Sam Tessen at a meeting
tout the use of 4B taxes for health care facilities, Gentry Woodard
went back to his non-profit hospital system and began looking
into the possibilities.
“We were a little creative in what
we did,” Woodard said.
What they did was secure some $47,000
dollars in 4B tax revenues to renovate their Navasota hospital
and make room for a CT scanner. How they did it was by showing
the Grimes County economic development agency, which oversees
the economic development sales tax in the county, just how important
health care is to the local economy.
According to Woodard, a
market analysis showed that people from Navasota were leaving town
to get nearly 400 CT scans each year. By renovating the hospital,
and purchasing and installing a CT scanner, many of those people
would stay and purchase their scans locally—to
the tune of about $1,000 per scan.
Those people would
also be spending money locally that would have been spent on
trips to get scans. The scanner operation would require additional
personnel and therefore create additional jobs. And by contracting
with local builders, plumbers, and electricians to
do the renovation, even more jobs and money would
be generated locally. Finally, the area would become
more attractive to prospective firms because of this
additional health care resource.
The economic development agency
agreed. The funds were made available. The scanner is going in.
“This
economic development tax is an example of how the government
is putting a carrot in front of the donkey to get businesses to go
to rural areas,” Woodard said.
Reaching
Out in Iowa
As in Texas, not having the facilities
to perform certain procedures meant that patients in tiny Clarion,
Iowa, had to go elsewhere, and take their dollars
with them. Rather than adding space and purchasing
the necessary equipment, however, Wright Medical
Center (WMC) has chosen a slightly different route:
contracting with mobile providers and circuit-riding
specialists.
Steve Simonin, administrator of WMC, said this approach allows
the hospital to do three things: avoid huge investments
in technology, get their patients access to the best technology
available, and keep patients in the community.
“As
a small hospital, we’re able to dart and
weave to provide services without the huge investments
in technology,” he
said. “They give us the best quality
technology that’s
out there. In a larger hospital, they have
to use up their resources before they upgrade.
Therefore, you’re actually getting
better quality in small rural hospitals.”
WMC
contracts with mobile providers of a variety
of services, including Magnetic Resonance
Imaging (MRI), nuclear medicine, and soon,
PET CT scans. A trailer truck pulls the self-contained
unit, employees and all, into the WMC parking
lot once or twice a week depending on the
service.
The specialty provider bills for the services, so it’s not
a direct source of revenue for the hospital.
Still, Simonin said, it keeps patients coming to WMC for other services. For
example, a patient with an orthopedic problem is more likely to get treatment
locally since he or she can get an MRI locally,
rather than driving to Fort Dodge 40 miles away, to help in the diagnosis.
“It’s
kind of like milk at the grocery store,” Simonin
said. “It’s not exactly a loss-leader,
but it brings people in and then they get
other things. We’re able to keep
them here in the community. That’s
huge.”
In addition, the center has
a specialty clinic that brings in health
care specialists from outside the community
on a regular basis to complement the local
medical staff. Again, this means patients
can stay in Clarion to get their care and
support the local economy by doing it.
Practitioners in 17 different specialties
provide care at the clinic.
WMC is also
involved in helping provide human or social services to those in
need. And that, too, helps economic development,
even though that is not the primary goal.
Several years ago,
the center began providing space to the Domestic/Sexual Assault
Outreach Center (D/SAOC) to run a satellite site in Clarion. Many,
though not all, of the people seeking help at the D/SAOC are Hispanic
women who work at large industrial hog and chicken
operations nearby.
“The work that we do is not optional,” said
Joyce DeHaan, executive director of D/SAOC.
Bringing in Human Services
Few look at or understand the economic
importance of human or social services.
DeHaan, however, does. The help the clinic
provides, she said, enables victims of
domestic and sexual abuse to find safety
and that enables them to become productive
individuals, support their families, and
contribute to society.
One reason the value of social services isn’t
recognized is due to the absence of numbers. While statistics are available
which show the economic impact
of certain kinds of social problems, such as alcohol-related illnesses,
there is little, if any, data showing the benefit of social services
that might address these problems. No models to measure the economic
impacts of the social services exist, though Gerald Doeksen wants
to move Rural Health Works in that direction and create such models.
Kathleen
Belanger will be glad when he does. Belanger is director
of child welfare professional development
at the School of Social Work at
Stephen F. Austin State University
in Nacogdoches, Texas. She is also
a leading advocate of rural social
services—a
long neglected sector, she
said.
“If you have the people who are the livelihood of the community
and they hit any problem
in their life, if they get into alcohol or substance abuse, they’re
much less likely to get treatment in a rural community,” Belanger said, “If
they can’t
get treatment, there is an
economic cost. If they can’t get
what they need, they can’t
work, they can’t get
a degree, their business
may fold.”
Indeed, social
services are part of making
a community whole. A thriving
Head Start program helps
ensure kids start out in
school with a leg up academically
and assists working parents.
A thriving Area Agency on
Aging can help the elderly
in a rural community live independently
longer. Mental health and substance abuse providers
also play a key role in helping keep needed services
in the community.
“Economic development folks think that social services
are a drain on the economy, but they’re wrong,” Belanger
said. “Social services
are the difference between
someone being a productive
member of society and a
total drain on society.”
Clearly,
rural communities benefit
when they have both a strong
health and human service
sector, as the folks at Wright
Medical Center have demonstrated.
“We truly believe that the more we can
do together, the better off we’ll all be,” Steve Simonin said.
Forging Links: Operation Rural Health Works
Recognizing the need to highlight the economic impact of
the health care sector and stress its critical role in rural
development, representatives from five states (Kentucky, Missouri,
Nevada, Oklahoma and Pennsylvania) met in June 1998 to initiate
a pilot project to do just that. Out of that meeting, Operation
Rural Health Works was born.
Rural Health Works (RHW) is sponsored by the Federal Office
of Rural Health Policy, the U.S. Department of Agriculture’s
Cooperative State Research, Education, and Extension Service, and
the Rural Policy Research Institute. Dr. Gerald Doeksen, professor
at Oklahoma State University, directs it.
According to Doeksen, RHW utilizes and has developed several
tools for helping local officials understand and improve the linkages
between the health sector and the economy. Chief among those tools
is an economic model known as IMPLAN (Impact Analysis for Planning),
developed by the U.S. Forest Service and adapted by RHW. The model
uses data at the county or zip-code level to measure the impacts of
changes to one or more sectors on a local economy. In this case, the
model measures the impact of hospitals, doctors’ offices, nursing
homes, pharmacies, and other medical services.
Armed with the data and the IMPLAN model, local planners
can determine, among other things, how many jobs in the community
depend on the health care sector.
Doeksen said the percentages vary from state to state and
community to community, but on average, between 10 and 15 percent
of the jobs (and income) in a community of 15,000 people depend on
the health care sector—directly and indirectly.
Some people work directly for a hospital or other facility.
Some people work at jobs made possible by a hospital purchasing goods
and services locally. And still other people work at jobs made possible
by hospital employees purchasing goods and services locally. In economic
parlance, those effects are known as direct, indirect, and induced.
Another way to look at it: every hospital job creates another .10
to one job in the community.
Another tool in RHW’s chest is its health care service feasibility
study. With that, health care providers can determine whether it makes
economic sense to add, say, kidney dialysis or outpatient rehabilitation
to the services they offer.
Using such a study, Doeksen said, helped one community in
Oklahoma avoid a costly error, when leaders realized that although
people wanted adult day service and the hospital was ready and willing
to add it, the numbers simply did not add up. Indeed, adding the service
would have meant losing $20,000 a year. Thus informed, the community
and hospital passed.
Another community, Stroud, Oklahoma, found by doing a feasibility
study that it could break even providing kidney dialysis. Breaking
even, however, was just the starting point. Adding dialysis would
mean adding some 10 jobs to operate the service—no small shot
in the arm to a small town economy. It also meant that people who
had been driving 50 miles to Oklahoma City for treatment and eating
and shopping while away, could get treatment, eat, and shop locally—another
shot in the arm.
Taking RHW to people around the country has been one of Doeksen’s
missions for the past five years. He, together with his associate
Cheryl St. Clair at OSU, has conducted workshops to train the trainers
in 45 states. Local communities in more than 30 of those states have
subsequently been introduced to RHW and its tools.
The goal of the workshops is simple. “You demonstrate to the
community how important the health sector is,” Doeksen said, “get
them all fired up, and hope that they expand it to help economic development.”
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Around the Country
by Erica Hauck
Iowa
Addressing the Nursing Shortage in Iowa
A new center is helping facilities throughout Iowa mentor and recruit
new nurses and nurses’ assistants.
The Iowa Department of Public Health established the Center for Health Workforce
Planning in 2002 to address the issues of health workforce supply and demand,
and worker recruitment and retention. The Center, which is staffed by two full-time
state employees, received $1.1 million from the U.S. Department of Health and
Human Services for its establishment and first year of operations. Congress later
authorized an additional $993,500 for its second fiscal year, ending July 31,
2004.
A large portion of the Center’s funding is awarded as grants to health
care facilities for recruitment and retention efforts. In its first year, the
Center awarded 44 grants, totaling $838,152, to health care facilities and training
institutions for mentoring programs for new nurses, and scholarships for nurses
or nursing assistive personnel wishing to advance their careers.
The mentoring programs, which provide intensive orientation and training to new
nurses, also have a benefit beyond recruitment and retention of new employees.
Because the mentors are nurses already working in the field, mentoring programs “have
done a lot for the professional image of the mentors,” said Jeneane Moody,
a Community Health Consultant with the Center. “It has added a new sense
of professionalism and responsibility” to the role of the existing health
care workers, contributing to the overall retention efforts of the Center, Moody
said.
In addition, the Center recently partnered with the University of Iowa’s
Office of Statewide Clinical Education Programs to implement the Regional RN
Tracking Pilot Project. The project tracks data on all registered nurses in a
13-county region, including demographics, education, and work settings, and studies
the supply and demand of nurses in the area. The Center hopes to eventually expand
the RN tracking project to the entire state in order to forecast and respond
to shortages in the health care professions.
The Center also engages in research and has published numerous reports, issue
briefs and white papers on topics such as health care trends and the supply and
demand of health professionals throughout the state. It also works to facilitate
communication and the sharing of information among various agencies that collect
data on health care professionals, serving as a central point of contact for
those seeking information about the health care workforce in Iowa.
For more information, contact Jeneane Moody, Community Health
Consultant, Center for Health Workforce Planning, at 515-281-6211,
or Eileen Gloor, Executive Officer, Center for Health Workforce
Planning at 515-281-8309. Internet: http://www.idph.state.ia.us/hpcdp/workforce_planning.asp
Michigan
Community Leadership Training
A new program in Michigan is providing rural residents with the
tools to make decisions based on consensus and the unique needs
of their communities.
The Michigan Center for Rural Health is offering training in the
Community Leadership Development Process (CLDP), a collaborative
process that brings together stakeholders from multiple sectors
in the community. The training is supported by funding from the
Robert Wood Johnson foundation.
The CLDP programs teach volunteers how to garner participants and
support in the community, and how to hold focus groups or meetings
with multiple stakeholders that can reach consensus on a particular
issue. All viewpoints are considered in the CLDP decision-making
process, including those from the health care, faith-based, law
enforcement and business sectors. It is an approach that can be
used to address a multitude of different community issues.
The state- and federally-funded center, located in East Lansing,
Michigan, had its first experience with CLDP during a demonstration
project it conducted last spring. Using funding from the National
Rural Health Association and the National Highway Traffic Safety
Administration, the Center helped communities with Critical Access
Hospitals develop educational campaigns for seat belt use. As part
of the project, community members participated in a one-day training
session on CLDP in order to learn effective strategies for implementing
campaigns that were tailored to their communities.
After their success with the training for the seat belt campaigns,
the Center’s Critical Access Hospital Program Administrator,
Angie Dietlein said,“We realized this process could be
applied to anything.”
Employees of the Center began going into rural communities in
October to train volunteers on how to apply the process to an
awareness campaign for MIChild (the state’s S-CHIP program).
They hope to reach more working poor families that are not eligible
for Medicaid. So far, they have completed training in two communities,
and based on their success, they plan to reach many more communities
in the future.
For more information, contact Angie Dietlein, Critical Access Hospital
Program Administrator, Michigan Center for Rural Health, at 517-355-7757,
or Marolee Neuberger, Rural Health Initiative Program Coordinator,
Michigan Center for Rural Health, at 517-355-8250.
New Hampshire
Public Health and Bioterrorism
The public health infrastructure in
twelve communities in central New Hampshire is getting a boost
thanks to the efforts of a regional coalition and a bioterrorism
grant it recently received.
The Caring Communities Network of the Twin Rivers (CCNTR) received
the $48,000 bioterrorism grant through the state from the Centers
for Disease Control and Prevention (CDC). The CCNTR is a broad-based
network of area agencies and organizations that works with the
region’s
twelve communities to identify regional problems and needs, and mobilizes
local resources to plan and implement solutions to those needs.
The CCNTR, comprising such organizations as the regional hospital,
local school districts and other service providers, was created
six and a half years ago to integrate services and planning and
improve the regional public health infrastructure. The network
also works in partnership with area municipalities, which have
no official health departments, to address the clinical and public
health care needs of the communities and to foster economic and
social capital development.
CCNTR is one of twelve regional groups that applied for and was
awarded funding from New Hampshire after the state received $8
million from the CDC to implement emergency preparedness programs
aimed at bioterrorism. The network is using the money to “beef up” its public
health infrastructure by taking a public health systems development
and all hazards approach, a rationale that assumes the same infrastructure
and system needed to respond to a bioterrorism threat can be used
for all types of public health emergencies.
The grant has enabled the network to expand its partners to include
the first responder community, and to conduct emergency training
sessions that bring together representatives from civic organizations
like schools, fire departments, local businesses, and area health
and human service agencies. The groups collaborate on planning
responses to hypothetical disaster scenarios, such as tornadoes,
earthquakes and disease outbreaks. These sessions achieve several
important goals for strengthening the public health infrastructure:
they help integrate individual towns’ emergency plans; identify areas that need
improvement; discover ways to engage civic and business groups; and
increase collaboration among all providers of health and human services
in the area.
According to Richard Silverberg, Managing Director of the CCNTR,
the network is working on the region’s public health infrastructure
at a very grass-roots level, through the collaboration and expertise
of members of the local community. “You’ve got to start
somewhere, and we’re starting at a very basic level,” Silverberg
said.
The network’s success has been recognized by other communities
in the state. It was recently asked by a neighboring region to provide
consultation and technical assistance on the creation of a public
health network similar to CCNTR so that it can apply for a bioterrorism
grant from the CDC as well.
For more information, contact Richard Silverberg, Managing Director,
Caring Communities Network of the Twin Rivers, at 603-934-0177.
Oklahoma
Getting More Out of EMT’s in Oklahoma
Emergency medical technicians
(EMTs) in Stroud, Oklahoma, are putting their “down time” to
good use by working in the emergency room and other patient care
areas of Stroud Hospital while they are not on emergency or transport
calls.
The eight EMS employees are included in the hospital’s regular
staffing schedule, and work their shifts at the hospital until an
emergency or transport call comes in. They do not require any extra
training for the work they do in the hospital. Anything they are
trained to do in the field they can perform in the hospital — this
includes checking patients into the emergency room (ER), administering
IV’s, drawing blood, and providing basic emergency care.
According to the hospital’s EMS manager, Scott Devers, the
EMTs participate in almost all forms of patient care within the hospital. “If
it happens in the hospital, we’re involved in it,” Devers
said.
Sharing the EMT’s time and skills with the hospital allows
for greater efficiency and cost-effectiveness. The EMS department,
which serves a rural area in central Oklahoma with a population of
roughly 3,500, had only about 450 calls last year. This would have
resulted in significant amounts of “down time” if the
EMT’s had not also worked in the hospital. The plan also saves
the EMS department a great deal of money, because for the time they
spend working in the ER, the EMT’s salaries are charged to
the ER budget. In general, about 45% of the funding for the EMT’s
salaries comes from the ER budget.
Since its inception in March 2001, when the hospital reopened
after a tornado destroyed it in 1999, the EMT staffing plan
has been very successful. In fact, in 2002, the EMS department
turned a profit, which according to Devers, is rather unusual
for emergency services departments. “It is getting harder and harder for [emergency]
services to earn a profit,” he said, “especially nowadays
with Medicare cuts.”
For more information, contact Scott Devers, Stroud Hospital EMS
Manager, at 918-968-3571.
CALL FOR INPUT
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Research Roundup
by Thomas D. Rowley
Rural Poverty: New Looks at an Old Phenomenon
Three recent studies in rural poverty expand the understanding of
that arena beyond the widely-known “poor folks live in the
country, too.” They do that by illustrating the variation of
poverty across space and place, the variation of the depth and severity
of poverty among the poor, and the unvarying toll it takes on the
most vulnerable among us: our children.
In How Do Persistent Poverty Dynamics and Demographic
Vary Across the Rural-Urban Continuum?, Kathleen Miller of the Rural Policy Research
Institute and Bruce Weber of Oregon State University show that poverty
rates vary across the rural-urban continuum: the smaller and more
remote the place, the more poverty you find. And in some of the smallest
and most remote places there are pockets of high and long-standing
poverty.
High poverty counties—those with 20 percent or more of their
population living below the federal poverty level—are geographically
concentrated in the South, Appalachia, the lower Rio Grande Valley,
and on Indian Reservations of the Southwest and Great Plains.
A subset of those high poverty counties are the 382 counties that
have had poverty rates of 20 percent or more in every decennial census
from 1960 on. These persistent poverty counties are the hardest of
the hardest hit. They are also overwhelmingly rural (95 percent of
persistent poverty counties are nonmetro). Again, persistent poverty
increases where county population centers are smaller and where places
are more remote from urban centers.
As one would expect, persistent poverty counties not only have lower
incomes, they have higher unemployment rates. They also tend to have
higher proportions of minority population and higher proportions
of people without high school diplomas than do non-persistent poverty
counties.
The good news in Miller and Weber’s report is that the 2000
Census shows a dramatic decline in the number of persistent poverty
counties, down from 571 in 1990 to 382 in 2000. Not surprisingly,
the 189 counties that left the persistent poverty designation were
those counties that hovered near the threshold—that is, for
example, a county with 21 percent poverty was more likely to leave
than one with, say, 30 percent. The “leavers” also tended
to be metro, or, if nonmetro, at least adjacent to metro; on the
geographic edge of the poverty pockets; and have significantly lower
shares of minority populations.
The bad news and the conclusion of the report is that persistent
poverty—already a predominantly rural problem—is becoming
evermore so, hitting remote rural areas the hardest.
From that, one might conclude that poverty is worse in rural America.
That conclusion, however, is a bit oversimplified. It depends upon
one’s definition of “worse.”
In Comparisons of Metropolitan-Nonmetropolitan
Poverty During the 1990s, Dean Jolliffe of USDA’s Economic Research Service uses
measures that go beyond the widely used rate-of-incidence method
to look at the depth and severity of poverty. Jolliffe measures depth
by using a poverty-gap index to show how far below the poverty line,
on average, a population is and measures severity by calculating
the square of that index to get at the extreme cases or unequal distribution
of people below the poverty line. By doing so, he goes beyond mere
headcounts of the poor to answer the question “just how poor
are the poor?
According to Jolliffe, the usefulness of these measures is illustrated
by looking at a transfer of money from a rich person to a poor person.
If the transfer is insufficient to lift the poor person out of poverty,
it has no effect on the headcount index. It has, however, raised
the income of the poor person, and this improvement in well-being
is reflected in a reduction of both the poverty gap (depth) and the
squared poverty gap (severity) indexes. Similarly, a transfer of
income from a poor person to a poorer person does not change either
the headcount or the poverty gap index, but it does improve the distribution
of income among the poor and reduces the squared poverty gap index.
Using the measures, Jolliffe finds that while rural America clearly
has a greater incidence of poverty, depth and severity of poverty
are only slightly greater in rural than urban America. Indeed, the
depth of poverty in nonmetro was statistically higher at the five
percent level in only six of the ten years in the 1990s. The severity
of poverty was statistically higher in only three of the 10 years.
As for the causes of these differences, Jolliffe offers several contributing
factors: on average, the nonmetro poor are older and less likely
to work because of illness, disability, or retirement. The metro
poor are more likely to be in school. He does not find evidence to
support the common assertions that higher nonmetro poverty is a result
of working less or working at lower wage jobs.
All of which has implications for policy. The bottom line is that
the best approach to addressing poverty depends upon how you measure
that poverty. Metro poverty could best be helped by focusing on job
training, while nonmetro poor might benefit more from focusing on
supplemental income assistance for the elderly and disabled.
All these variations aside, what does not vary is the consistent
impact of poverty on children. In Dimensions
of Child Poverty in Rural Areas, Carolyn Rodgers of ERS finds that child poverty rates—urban
and rural—continue to be much higher than those of the general
population. The share of rural children in poverty did decline from
22 percent in 1990 down to 19 percent in 2000, but the fact remains
that nearly one-fifth of rural children are still mired in poverty.
A slightly lower number—15 percent—of urban children
are in those straits. In all, some 11.3 million U.S. children under
18 were poor in 2000.
As Rodgers points out, child poverty is closely linked to poorer
health, difficulty in school and low educational attainment, behavioral
and emotional problems, and delinquency. Poor children are also more
likely to need public assistance and, as adults, to earn less and
be unemployed more frequently.
Chilling as that is, Rodgers concludes on an even colder note: “…child
poverty rates could climb higher in the future unless more targeted
efforts are made by Federal, State, and local agencies to reach these
groups [minority children and mother-only families], especially in
more remote and very poor rural areas.”
Reports available at:
http://srdc.msstate.edu/measuring/series/miller_weber.pdf
http://www.ers.usda.gov/publications/rdrr96/
http://www.ers.usda.gov/Briefing/IncomePovertyWelfare/ChildPoverty/
For more information on rural poverty, please see the Rural Poverty
Research Center at: http://www.rprconline.org.
The Rural Monitor is published by the Rural
Assistance Center.
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Internet: http://www.raconline.org
© 2006. Rural Assistance Center. All Rights Reserved
Reprint Policy: Articles, photos, and charts appearing in the Rural Monitor may be reprinted with the permission of the Rural Assistance Center and proper citation. For permission, please contact ksande@raconline.org
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