Apocalypse no. 2

 Part of a semi-regular series. The first part is here.

Albrecht Dürer
The Four Horsemen, from The Apocalypse
via Wikimedia

You've probably encountered people saying we don't need vaccines because "who gets measles now anyway?" and "when was the last time smallpox was an issue?".

You get why that's a problem, right?

We don't see measles moving through our population because almost everyone has been vaccinated against it, and we're in the middle of getting to see what happens when you drop that rate from 95% to 80%.

This is the paradox of vaccine success. They work so well, we forget that they do anything at all.

What if we had this attitude towards the way society as a whole works?

Government is a convenient whipping boy: a target for our frustrations with how our lives are going. And it's easy to find things that government does wrong, could do better, or makes worse.

Unfortunately, it's even easier to overlook the basic things that government does well which enable the day to day lives we've come to expect.

For a quick and morbid example, it's illegal to sell baby cribs with bars too far apart. If you're a manufacturer of baby cribs, you might find this annoying. If you're a parent of an infant, you might appreciate that the government has made it impossible for your baby to get its head stuck between the bars of its crib and strangle itself. But you also might be unaware that such a rule exists. All babies - including yours - are now safe from getting their heads stuck between crib bars and strangling themselves to death, and people don't realize that it was government action that removed that risk.

For a longer example, and one that hits home given where I live, we need an outline understanding of how a rural economy works.

The one economic field in which rural areas have a natural advantage is resource extraction.

Cities need copious food, wood, fish, oil, etc., but don't have the space to produce those things themselves. So rural areas collect resources and send them to urban areas where they are processed into the finished goods we all use, city and country folk alike.

Cities are also the natural hubs of services, which rely on concentrations of people to be offered efficiently.

Of course, rural areas have more than just farmers and loggers.

In the villages, towns, and small cities that are part of the rural fabric, you find service industries ranging from convenience stores through Walmarts, locally owned shops, beauty salons, car-repair places, restaurants, and medical facilities.

In some rural communities, such as mine, you have a college or two, and in some (mine again) you have tourism.

But the economic activity that has to be rural is resource extraction.

And for deep economic reasons, there's a 200 year pattern in which the prices of the things that rural areas produce go down relative to the cost of things that cities provide. Compounding this, the work done in rural areas has turned out to be relatively easy to automate.

So we need fewer and fewer people doing the type of work that can only be done in rural areas. The natural consequence of these forces is that wages for rural occupations stay low, and thus rural populations stagnate or shrink as younger people disproportionately move away seeking the expanded opportunities in urban areas. The remaining populations are poorer and older than the national average.

Now look at how Medicaid, Medicare, and Social Security work. They collect taxes from all over the country and state, and spend them wherever the recipients are. Being poorer and older than average, rural areas pay into these programs at below average rates while receiving benefits at above that same average.

To be clear, I have no problem with that. As I said above, the economy needs what both types of areas provide. Social insurance programs like these are one way of returning to rural areas some of the wealth they helped create, doing work for which they got paid very little.

But their effects on rural areas extend far beyond the direct beneficiaries (the people getting a retirement check from Social Security, the people having access to medical care only because of Medicare and Medicaid).

After the Affordable Care Act was passed, the Supreme Court let states opt out of the Medicaid expansion that was a key part of how the bill was meant to function. As a result, we got a natural experiment, where some states expanded the program while others didn't.

And the results were pretty clear: states that opted not to expand Medicaid saw a disproportionate number of rural hospital closures.

Now play that out on a national scale, and more thoroughly. The experiment we ran involved some places not expanding Medicaid. Now take both Medicaid and Medicare and reduce or eliminate them, and do it everywhere. Run that experiment and see how many rural hospitals close up shop.

Your doctors mostly leave the area. They may have grown attached to the place, but they're generally from somewhere else, and if there's no job for them, they're not sticking around.

A lot of nurses are originally from the local population, so maybe a fair portion of them stay. But those who do no longer have their good-paying nursing jobs at the local hospital or clinic. And others move away.

If your area has a college, good luck recruiting people to move to an area that doesn't have a hospital anywhere nearby. And existing faculty staff will be looking for ways to get out as well.

With the extinction of many high-paying jobs in the region and a reduction in population, the housing market sags, particularly at the upper end, putting a hole in property-tax revenues. There goes your budget for the local schools, cutting into additional decently-paid jobs.

As for all those local businesses - the convenience stores, retail outlets, beauty salons, car-repair shops, restaurants - they're either down, or they're out. There are a few establishments that mostly serve people with low incomes, and I suppose they'll do fine. But lots of places serve a mix of incomes - repair garages, for example - and they'll lose a lot of revenue. Others, like fancy-ish restaurants, are entirely dependent on people with money to throw around, and they're just gone.

Don't worry, I haven't forgotten Social Security, which is also being targeted. There's another tranche of income for area residents that indirectly supports a range of local businesses.

In a rural area, the direct beneficiaries of these social insurance programs are the older people and lower-income people who depend on them for their retirement checks and medical care.

But the indirect beneficiaries are pretty much everyone, from a public-school teacher, through a doctor, to the president of the local chamber of commerce.

And yet we have the spectacle of congressional representatives from rural areas like my own voting for massive cuts to Medicaid and Medicare. (As it happens, not my own representative, Josh Riley, but a majority of House members representing rural areas.)

These examples could be multiplied, not endlessly but longer than you want to read or I want to type. Still, they are perhaps enough to illustrate the chasm between what the median voter thinks the government does and the actual role it plays in making our day to day lives function, especially in rural areas.

Until 2025, our government - imperfect as it is - functioned well enough that we could ignore how well it worked.

Now we're experimenting with a social version of vaccine hesitancy, and it may be that more people have been infected with this particular cultural virus than with the one that makes people refuse vaccines.

Before long, we may look back at the current expanding measles outbreak as the good old days, in rural areas most of all.