A persistent, yet often overlooked, public health crisis continues to affect many rural communities across the United States (US), where residents struggling with deindustrialization, depopulation, hollowed out public services, and climate disasters face stark inequities in health. Despite voting in large numbers for a right-wing, populist president, rural residents are nevertheless unlikely to benefit from his changes to policy. To counter the corrosive effects of populist rhetoric, critical public health communities need to overcome the metrocentric and/or personal biases that shape research agendas and prioritize actively learning from and engaging with rural communities.
Half of the population of the USA, and indeed many around the world, are shocked (or perhaps numbed) by the results of the 2024 US presidential election. Many US residents are now soul searching, trying to make sense of an inexplicable second win for an authoritarian strongman, and now convicted felon, who is more articulate in his disdain for others than in his policy positions or goals for his presidency. Yet there remains a majority of voters who are celebrating the new administration, reassured by Trump’s promises to restore what they feel is a failing economy and a deteriorating nation. Even though traditional economic indicators have suggested a strong US economy, this strength is certainly not reflected in the experiences of working class voters, especially those living in rural areas who overwhelmingly supported Trump’s candidacy. The rising cost of rural living combined with wage stagnation, insufficient and prohibitively expensive rural health care, and growing inequality have created what some have called rural “landscapes of despair”(Monnat & Brown 2017):
These places have borne the brunt of declines in manufacturing, mining, and related industries and are now struggling with opioids, disability, and declining health (Monnat & Brown 2017, p. 232).
Perhaps this explains why so many rural residents responded to Trump’s populist rhetoric and promises (for the second time) to make America great again. Indeed, while a majority of voters in rural areas supported Trump’s 2016 election (61%), the proportion was even higher in 2024 (64%) (Montanaro et al. 2024).
And this reality shouldn’t come as a surprise. Evidence has accumulated on the persistent and pervasive “economic, social, and health declines that have transpired” in rural communities since the latter part of the 20th century (Monnat & Brown 2017, p. 229). Take one rural region where our Center for Critical Public Health has been conducting research since 2020: California’s rural North State. This area is not to be confused with ‘Northern California’ which refers to San Francisco and the wine regions of Napa and Sonoma which actually lie in the center of the state. Instead, the North State refers to the one third of California’s land mass that exists north of the San Francisco Bay Area and includes California’s overlooked north central and northeastern counties. Unfortunately, this region is defined less by its immense natural amenities, verdant valleys, and ecologically-rich forests and more by the material deprivations that face many of its rural residents. As for many rural communities throughout the USA and the Global North, deindustrialization and divestment have contributed to the higher rates of poverty experienced by North State residents (Gurley 2016, Sherman 2021). Tied to issues of poverty are high rates of un- and under-employment as well as wage stagnation, increases in the cost of living (especially pronounced in recent years due to unprecedented inflation), and a lack of available and affordable housing (Antin et al. 2024, Tickamyer et al. 2017). Compounding the consequences of rural poverty are underfunded and fractured social and health services that fail to meet local demands. Much of the North State region of California is in a Health Provider Shortage Area, a designation that refers to regions and populations with shortages in both primary and mental health care (Kirsch 2023). Inadequate mental and physical health care, coupled with the unique social disadvantages of rural life, create profound barriers to health and well-being.
Such cumulative rural disadvantages may explain why North State counties rank among the lowest in California on multiple measures of health. For example, data from 2019-2021 suggest that the region’s age adjusted rate of deaths from all causes was 819 deaths per 100,000 people, considerably higher than the rate for California as a whole, at 657 (California Health and Human Services Open Data Portal 2023). Deaths related to suicide, drug overdoses, and short- and long-term consequences of alcoholism, often referred to as “deaths of despair” (Case & Deaton 2020), are increasingly documented in studies of rural mortality (Potts 2023), including in California’s North State. For example, aggregated county level health data for the North State in 2023 show an age-adjusted death rate for chronic liver disease and cirrhosis of 21 deaths per 100,000 people compared to 14 in California generally. For suicide, the North State’s age adjusted death rate was 20 deaths per 100,000 people compared to California’s rate of 10. For unintentional injuries, of which poisonings account for approximately half and often include drug overdoses, the age adjusted death rate was 79 deaths per 100,000 people compared to 43 in California (California Health and Human Services Open Data Portal 2023). Such rural inequities are further exacerbated when socially marginalized, intersecting identities are taken into account (James 2017). Given these data emphasizing inequities in “deaths of despair,” the public health community can no longer afford inaction or indifference.
In light of this context, perhaps it is not a surprise that a majority of voters in California’s North State voted for Trump in 2024 (Politico 2025). Trump scapegoated immigrants to the USA for ‘stealing jobs’ and pledged to ‘drain the swamp’ to break the grip ‘corrupt elites’ hold on the nation. He campaigned on calls to end taxes on tips and overtime wages for hourly workers and expand the child tax credit. He controversially championed that his tariff program would strengthen US manufacturing, benefitting the everyday lives of US workers (Goba & Talcott 2025). And so on. Through a flurry of executive orders issued in the early days of his term, Trump wasted no time delivering on his promises.
Populist rhetoric holds strong appeal for rural communities (Monnat & Brown 2017), especially in regions like the North State that have long been overlooked. Similar patterns of rural frustration and political discontent can be seen in other countries, likely contributing to the rise in right-wing populist movements worldwide. These movements blend a rhetoric of “anti-elite populism, exclusionary nationalism and authoritarianism” to address the concerns of the “common people”, including many rural residents who perceive themselves as “losers of globalization” who want to “revolt against the current system” (Stockemer & Arhin 2024, pp. 144–145). Though distinct in their ideologies, populist leaders such as Recep Tayyip Erdoğan in Turkey, Viktor Orban in Hungary, Narendra Modi in India, Nicolas Maduro in Venezuela, Daniel Ortego in Nicaragua, and perhaps soon Pierre Poilievre in Canada, have risen in popularity in recent years. We must ask ourselves whether the populist leaders rising within our corners of the globe are genuinely committed to addressing the issues they pledge to resolve. History tells us the economic promises of populism are likely too good to be true.
Between 2021 and 2023, our team interviewed over 150 North State young adults who graciously shared their time and stories with us (Antin et al. 2024, Lipperman-Kreda et al. 2025). As one participant, Lisa1, observed, “most people here grew up in hard times, and…Donald Trump fed into that, if that makes sense. That was his target audience”. While right-wing populism makes few promises beyond vilification and erasure to those who are among the most marginalized from society, paradoxically many of the people who cast their vote in support of Trump’s promises also have much to lose when they fall short. We think of our interview with Maggie1, who was living in a travel trailer after being displaced from her home due to a recent wildfire. The lack of livable wage jobs in her community and the meager government support following a natural disaster combined with the stress of parenting under these conditions left her struggling to make ends meet. “Around here lately…sometimes it makes for a bad day every day”, she told us. There was also our interview with Loki[1], a 33-year-old father and veteran who discussed being laid off after a traumatizing wildfire destroyed his workplace and much of the town, leaving him to scrape together odd jobs to support his family and navigate barriers to health care. “There’s a lot of hopelessness that goes along with the socioeconomic impact of living in a rural area that doesn’t have any industry… Rich people…have more to live for...the top is a lot prettier than the bottom”, he said. Another participant, Lana1, 25 years old, was working a minimum wage job while trying to build a new life, driving long distances to access addiction treatment services during a period of housing insecurity. She described drug crises in her community, and especially the spread of fentanyl, explaining that “every week, it’ll be someone new that’s passed away or overdosed”.
These are voices of those targeted by Trump’s rhetoric, yet likely to be left behind by its empty promises.
Like in politics, public health has failed rural communities where poverty and health inequities are persistent, pervasive, and severe (Tickamyer et al. 2017, p. 439, Ziller & Milkowski 2020). Despite evidence documenting longstanding concerns related to rural poverty and rural health, as Ann Tickamyer, a leading rural sociologist since the 1980s, said in an interview:
[R]ural poverty [has been] increasingly invisible and neglected, partially because everything rural is invisible and neglected (Gurley 2016, p. 597).
And this couldn’t be more true today. City dwellers have little awareness of the cumulative disadvantages facing the rural communities that they visit on vacation, where rose-colored glasses paint a romantic notion of the rural idyll. Metrocentrism continues to dominate mainstream research. And progressive researchers passionate about health equity may be less so when it involves poverty in rural, predominately white, America (Gurley 2016).
A critical public health approach is many things to many people. But one tenet that structures our research is a commitment to highlighting the voices of those disadvantaged within broader systems of power. They raise our attention to underappreciated and/or blatantly ignored social and health problems, often by challenging mainstream narratives. They contextualize, through their own lived experiences, the social and structural conditions that contribute to the extensive inequities observed within their communities. And they reveal overlooked, or sometimes silenced, sources of ingenuity and resilience that point to alternative strategies for building more equitable systems.
Rural residents may represent only 20% of the US population, but they wield an outsized influence in national politics in the United States (Wuthnow 2018). By listening to their experiences, we can shed light on the “sources of rural outrage” (Wuthnow 2018) that not only explain voting patterns but, perhaps more importantly, reveal the causes and consequences of rural poverty that are in dire need of attention and, as Wuthnow (2018) reminds us, “would have been evident had anyone bothered to look” (Wuthnow 2018, p. 12). This is something that a critical public health scholarship can and should do, both because it is a moral imperative and because we are well-positioned with the theories and methods to do so.
Our sincere appreciation is due to all North State participants who graciously shared their time and stories with us. Without them, our work is not possible. Thank you to CCPH staff for providing feedback on this editorial, especially in light of the chaos machine.
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[1] pseudonym
Journal of Critical Public Health, Volume 2 (2025), Issue 1