While several other rural health issues have been receiving greater attention, deaths due to chronic lower respiratory diseases (CLRD) have been increasing dramatically in Alabama’s rural areas. CLRD includes bronchitis, emphysema, asthma, and other or incompletely specified respiratory diseases. The vast majority (96 percent) of all CLRD deaths in Alabama, as well as the nation and all 50 states, are classified as other or incompletely specified respiratory diseases as specified on death certificates.

Between 2000 and 2016, Alabama’s age-adjusted death or mortality rate from all causes of death has decreased by over 8 percent. During these same years, Alabama’s death rate from CLRD increased by nearly 24 percent, the second highest increase among all 50 states.

In 2000, there were 2,057 deaths to Alabama residents from CLRD for an age-adjusted death rate of 45.4 deaths per 100,000 standardized population. This was the 27th highest rate among all 50 states and was slightly higher than the national rate of 44.2. By 2016, the number of deaths from CLRD increased to 3,326 in Alabama and the rate increased to 56.2. This was the 7th highest rate among all 50 states and was significantly higher than the national rate which had declined to 40.6.

While this dramatic increase of 24 percent statewide is concerning, the highly disproportionate increase in our rural areas and the tremendous increase among rural females demands attention. The death rate from CLRD among Alabama’s rural residents increased from 43.7 in 2000 to 66.4 in 2016, a 50 percent increase. The death rate from CLRD among Alabama’s urban residents increased from 46.8 in 2000 to 49.0 in 2016, a 5 percent increase.

The table below presents CLRD death rates for several demographic components of Alabama’s rural and urban residents. The following observations from this data are of special interest:

In 2000, the CLRD death rate was greater among Alabama’s urban residents. By 2016, this rate was considerably higher among our rural residents.

This rate tends to be significantly higher among white Alabamians than among African Alabamians.

There was an increase of 53 percent between 2000 and 2016 among rural white Alabamians compared to only 6 percent among urban white Alabamians. This same disparity is seen when comparing rural African Alabamians and urban African Alabamians.

The CLRD death rate is significantly higher among males than females. However, the rate for rural females increased by over 94 percent between 2000 and 2016, from 30.4 to 59.1.

The death rates for the elderly (age 65 years or more) were higher for urban residents in 2000. By 2016, these rates reflected dramatic increases among rural residents which were considerably higher than the rates for urban residents.

Rural Alabama Counties Urban Alabama Counties
Deaths Rate Deaths Rate
Year 2000 861 43.7 1,196 46.8
Year 2016 1,642 66.4 1,684 49.0
White Alabamians
2000 783 48.7 1,049 52.2
2016 1,507 74.4 1,456 55.1
African Alabamians
2000 77 22.1 146 27.1
2016 133 31.7 220 28.3
2000 501 65.5 625 65.2
2016 818 77.0 813 57.7
2000 360 30.4 571 36.7
2016 824 59.1 871 43.7
2000 – Age Groups
35-44 years 0 N.A. 13 N.A.
45-54 years 38 15.5 29 8.2
55-64 years 108 58.9 129 55.6
65-74 years 254 184.5 357 199.4
75-84 years 315 375.8 433 386.8
85 or more years 142 466.7 229 621.1
2016 – Age Groups
35-44 years 12 N.A. 0 N.A.
45-54 years 59 23.1 55 14.2
55-64 years 234 91.4 209 53.7
65-74 years 488 247.7 441 164.8
75-84 years 542 538.5 585 441.6
85 or more years 300 877.1 379 721.2

SOURCE: CDC Wonder, Detailed Mortality Database, accessed on April 24, 2018.

(Dale Quinney, April 26, 2018)

More in-depth research is needed on this disturbing trend to better identify what is causing this increase in CLRD deaths and what intervention(s) are possible to disrupt this trend.


Alabama’s rural health crisis is well documented and shows little sign of improvement without effective assistance.  Alabama has the second or fourth highest number of rural hospital closings among all 50 states, according to when the count is started.  We have the fourth highest death rate among all 50 states, even when removing the age differences between state populations and this rate is nearly 12 percent higher among Alabama’s rural residents compared to our urban residents.  We have 38 counties (all rural) that do not have a hospital providing obstetrical services.  The listing of rural health concerns could go on and on but this is not the subject of this article.

Perhaps the most important single office supporting rural health in Alabama should be our State Office of Rural Health.  The purpose of this office, as described by the federal Office of Rural Health Policy, is to assist states in strengthening rural health care delivery systems by maintaining a focal point for rural health within each state.  This office is to provide an institutional framework that links small rural communities with state and federal resources to develop long term solutions to rural health problems.

The State Office of Rural Health program is funded through a federal grant program with only one State Office of Rural Health being located in each state.  This office in Alabama has been located in the Alabama Department of Public Health in the Office of Primary Care and Rural Health going back to the program’s inception in 1991.  This office can be and is located outside of state government in some states.

Having an office and staff dedicated to developing long term solutions to rural health problems should be given a high priority in a state with Alabama’s rural health needs.  This was true through the service of Claude Earl Fox, M.D. as the director of the Alabama Department of Public Health, also called our State Health Officer.  Dr. Fox’s service as Alabama’s State Health Officer ended in the early 1990s and the emphasis on rural health in this department has decreased since that time.

Under Dr. Fox’s leadership, the Alabama Department of Public Health established the Alabama Rural Health Association in 1991 to assist rural health in this state.  This non-profit association now operates independently.

When Dr. Fox’s service as Alabama’s State Health Officer ended, the director of Alabama’s State Office of Rural Health answered directly to the State Health Officer in the Alabama Department of Public Health organizational chart.  Now the director of this office is under the supervision of a bureau director who is under the supervision of an assistant state health officer who is under the supervision of the State Health Officer.

In addition to what must be considered a demotion in the emphasis given to this office and rural health in Alabama, this office is now so critically understaffed that it has been forced to contract with other entities for the completion of some of its grant obligations.  Not being able to meet some of these obligations recently resulted in delays in getting new Rural Health Clinics certified to open their doors to serve patients.

Additional evidence of the lack of emphasis being given to rural health needs by the Alabama Department of Public Health was recently experienced.  Several rural hospital administrators want to consider the authorization of a new type of hospital in Alabama that can have fewer than the currently required 15 beds.  They would also like to have consideration given to removing the requirement that a licensed hospital must have an emergency department.  There are many hospitals in other states, including some of our neighboring states, which have fewer than 15 beds and/or do not have an emergency department.

Changes in the rules and regulations of health care facilities in Alabama must be approved by a special committee located within the Alabama Department of Public Health.  Efforts to hold a brief meeting with Alabama Department of Public Health officials to discuss how such changes would have to be made have been unsuccessful.  An Assistant State Health Officer did call back leaving a message indicating that they were aware of this issue and the Alabama Department of Public Health had no interest in pursuing such changes in the definition of a hospital at this time.

A lack of communication on such important issues increases the risk of those serving the public in leadership positions only hearing about the desires of those who may have personal or organizational agendas and failing to act in accordance with what may be best for everyone.  The national trend is for rural hospitals to have fewer beds to better meet the needs of today rather than the needs of years gone by.

Many people consider public health and rural health to have considerable overlap.  This relationship has been restricted in Alabama and needs to be restored.  The Alabama Department of Public Health has a newly appointed State Health Officer.  There is no better time for this important department to send a powerful message by again establishing strong support for rural health in Alabama.   (Dale E. Quinney, April 22, 2018)

1. Alabama’s new State Health Officer should remove the Alabama State Office of Rural Health from organizational obscurity and have this important office again placed under the direct supervision of the State Health Officer.  
2. This office, that provides critical rural health services, must be adequately staffed with qualified professionals.  
3. Alabama Department of Public Health leadership should be informed of the commitment that this department has made to rural health in Alabama by seeking the role as Alabama’s State Office of Rural Health.
4. Consideration should be given to establishing a special advisory group, consisting of rural health care administrators, practitioners, and other stakeholders, to advise the State Health Officer and other Alabama Department of Public Health staff about rural health issues, needs, and possible solutions.