On the positive side, and focusing on the United States, rural areas feature much more open space and less crowding. Their violent and property crime rates are much lower than those in large cities, as we have seen. The air is cleaner because there is less traffic and fewer factories and other facilities that emit pollution. Life in rural areas is thought to be slower paced, resulting in lower levels of anxiety and a greater sense of relaxation. For these and other reasons, rural residents exhibit better mental health on the average than do urban residents.

On the negative side, rural areas are often poor and lack the services, employment opportunities, and leisure activities that cities have. Teens often complain of boredom, and drug and alcohol use can be high (Johnson et al., 2008).Johnson, A. O., Mink, M. D., Harun, N., Moore, C. G., Martin, A. B., & Bennett, K. J. (2008). Violence and drug use in rural teens: National prevalence estimates from the 2003 youth risk behavior survey. Journal of School Health, 78(10), 554–561. Public transportation is often lacking, making it difficult for people without motor vehicles, who tend to have low incomes, to get to workplaces, stores, and other venues (Brown, 2008).Brown, D. M. (2008). Public transportation on the move in rural America. Washington, DC: Economic Research Service. Rural residents with motor vehicles often must still travel long distances to shop, to visit a doctor, to go to work, and to do any number of other activities. Many rural areas in the United States lack high-speed broadband, a necessity in today’s economy. As a result, their economic development is impaired (Whitacre, 2010).Whitacre, B. E. (2010). The diffusion of Internet technologies to rural communities: A portrait of broadband supply and demand. American Behavioral Scientist, 53, 1283–1303. All these challenges contribute to special problems in rural areas. We now examine some of these problems.

Rural Health

As Chapter 13 "Health and Health Care" noted, rural areas often lack sufficient numbers of health care professionals, hospitals, and medical clinics. The National Rural Health Association (2012)National Rural Health Association. (2012). What’s different about rural health care? Retrieved from http://www.ruralhealthweb.org/go/left/about-rural-health. points out that although one-fourth of the US population is rural, only one-tenth of physicians practice in rural areas. Urban areas have 134 physician specialists for every 100,000 residents, but rural areas have less than one-third this number.

Compounding these shortages are other problems. The first is that the small hospitals typical of rural areas generally lack high-quality care and equipment. A patient who needs heart bypass surgery, brain surgery, or other types of complex medical care is likely to have travel to an urban hospital far away.

The second problem is the long distances that ambulances and patients must travel. Because ambulances and other emergency vehicles must travel so far, rural residents with emergencies receive medical attention more slowly than their urban counterparts. The long distances that people must travel make it more difficult for patients with health problems to receive medical care. For example, a rural cancer patient who needs chemotherapy or radiation might have to travel two to three hours in each direction to receive treatment. Travel distances in rural areas also mean that rural residents are less likely than urban residents to receive preventive services such as physical examinations; screenings for breast cancer, cervical cancer, and colorectal cancer; and vaccinations for various illnesses and diseases.

In yet another problem, rural areas are also much more likely than urban areas to lack mental health care, drug abuse counseling and programs, and other services related to physical and mental health.

For all these reasons, rural residents are more at risk than urban residents for certain health problems, including mortality. For example, only one-third of all motor vehicle accidents happen in rural areas, but two-thirds of all deaths from such accidents occur in rural areas. These problems help explain why rural residents are more likely than urban residents to report being in only fair or poor health in government surveys (Bennett, Olatosi, & Probst, 2009).Bennett, K. J., Olatosi, B., & Probst, J. C. (2009). Health disparities: A rural-urban chartbook. Columbia, SC: South Carolina Rural Health Research Center.

An additional health problem in rural areas arises from the age profile of their populations. Compared to urban areas, rural areas have an “aging population,” or a greater percentage of adults aged 65 and older. This fact adds to the health-care problems that rural areas must address.

Rural Schools and Education

The discussion of education in Chapter 11 "Schools and Education" focused mostly on urban schools. Many of the problems discussed there also apply to rural schools. However, rural schools often face hurdles that urban and suburban schools are much less likely to encounter (Center for Rural Policy and Development, 2009).Center for Rural Policy and Development. (2009). A region apart: A look at challenges and strategies for rural K–12 schools. Saint Peter, MN: Center for Rural Policy and Development.

First, because rural areas have been losing population, they have been experiencing declining school enrollment and school closings. When a school does close, teachers and other school employees have lost their jobs, and students have to rather suddenly attend a new school that is usually farther from their home than their former school.

Second, rural populations are generally older than urban populations, as mentioned earlier, and have a greater percentage of retired adults. Therefore, rural areas’ per-capita income and sales tax revenue are lower than that for urban and suburban areas, and this lower revenue makes the funding of public schools more challenging.

Third, rural families live relatively far from the public schools, and the schools are relatively far from each other. As a result, rural school districts have considerable expenses for transporting children to and from school, after-school athletic events, and other activities.

Finally, it is often difficult to recruit and retain quality teachers in rural areas. This problem has forced some rural school districts to offer hiring bonuses or housing assistance to staff their schools.

Rural Poverty

Although many US cities have high poverty rates, the poverty rate is actually somewhat higher overall in rural areas than in urban areas. In 2010, 16.5 percent of rural residents were classified as officially poor, compared to 14.9 percent of urban residents. However, the poverty rate in the nation’s largest cities was higher yet at 19.7 percent. The number of poor rural residents was almost 8 million, while the number of poor urban residents (reflecting the fact that most Americans live in urban areas) was almost 36 million (DeNavas-Walt, Proctor, & Smith, 2011).DeNavas-Walt, C., Proctor, B. D., & Smith, J. C. (2011). Income, poverty, and health insurance coverage in the United States: 2010 (Current Population Reports, P60–239). Washington, DC: US Census Bureau.

Rural poverty is thought to be more persistent than urban poverty because of the factors that contribute to its high rate. These factors include the out-migration of young, highly skilled workers; the lack of industrial jobs that typically have been higher paying than agricultural jobs; and limited opportunities for the high-paying jobs of the information age. Biotech companies, electronics companies, and other symbols of the information age are hardly ever found in the nation’s rural areas. Instead, they locate themselves in or near urban areas, in which are found the universities, masses of people, and other necessary aspects these companies need to succeed.

Compounding the general problem of poverty, rural areas are also more likely than nonrural areas to lack human services programs to help the poor, disabled, elderly, and other people in need of aid (National Advisory Committee on Rural Health and Human Services, 2011).National Advisory Committee on Rural Health and Human Services. (2011). The 2011 report to the secretary: Rural health and human services issues. Washington, DC: US Department of Health and Human Services.Because rural towns are so small, they often cannot afford services such as soup kitchens, homeless shelters, and Meals on Wheels, and thus must rely on services located in other towns. Yet rural towns are often far from each other, making it difficult and expensive for rural residents to obtain the services they need. For example, a Meals on Wheels program in an urban area may travel just a few miles and serve dozens of people, while it may have to travel more than one hundred miles in a rural area and serve only a few people. Adding to this problem is the strong sense in many rural areas that individuals should be strong enough to fend for themselves and not accept government help. Even when services are available, some people who need them decline to take advantage of them because of pride and shame.

Domestic Violence

One of the sad facts of rural life is domestic violence. This form of violence is certainly common in urban areas, but the defining feature of rural areas—a relatively low number of people living in a relatively broad area—creates several problems for victims of domestic violence, most of them women (DeKeseredy & Schwartz, 2009).DeKeseredy, W. S., & Schwartz, M. D. (2009). Dangerous exits: Escaping abusive relationships in rural America. New Brunswick, NJ: Rutgers University Press.

For example, these women often find it difficult to get help and/or to leave their abusers wherever they live. However, it is often even more difficult for rural women to do so. Rural police may be unenlightened about domestic violence and may even know the abuser; for either reason, they may not consider his violence a crime, and abused women may be that much more reluctant to tell the police about their abuse.

Another problem concerns the availability of battered women’s shelters, which provide invaluable services for abused women and any children they might have. These shelters tend to be found in cities, which still do not have nearly enough shelters. Rural areas generally lack shelters, and any shelters that exist are often long distances from the homes of abused women. In rural areas, abused women are also more likely than their urban counterparts to lack neighbors and friends to whom they can turn for support, or at least to live farther from these individuals. For all these reasons, rural women who experience domestic violence face a problem that has been called “dangerous exits” (DeKeseredy & Schwartz, 2009).DeKeseredy, W. S., & Schwartz, M. D. (2009). Dangerous exits: Escaping abusive relationships in rural America. New Brunswick, NJ: Rutgers University Press.

Cities are the great havens for knowledge, culture, and social life. Vibrant cultures are found in cities because it takes a large population to support museums, concert halls, sports teams, and night-life districts.

Cities also offer rich social opportunities. People in rural areas enjoy only limited social opportunities because of the small local population. City dwellers can choose their friends and mates from among a large number of people of similar interests and inclinations.

We are not likely to abandon the city as a cultural institution, but we need to make sure that our transport arrangements do not damage the city's other functions.

The Built Environment

It is only in America that cities are no longer regarded as the richest of man's built environments. Urban decay is as old as cities, but urban blight is something else again: it occurs when healthy city economies are undermined by the flight of the middle class to the suburbs. This process has gutted many American cities in the period since World War II. The suburbanites still depend on the city for their livelihood but no longer contribute much to its sustenance. The creation of metropolitan governmental authorities encompassing a city and its suburbs would do much to balance the economic inequities which have arisen and help to assure the financial health of cities.

Most great buildings and vibrant outdoor spaces are in cities. One has only to think of the great European capitals to find examples. New York, Boston, and San Francisco all have lively districts. St. Marks Square in Venice is perhaps the greatest example. Europe largely succeeded in preserving its cities during the past 50 years, while the hearts of many US cities became wastelands.

Three decades ago in a speech at Johns Hopkins University, Daniel P. Moynihan argued that one of the contributors to social malaise in the United States was the generally bad quality of public architecture since WW II. I believe now, although I did not at the time, that he is not only correct but too conservative in his views. In fact, the poor quality of virtually all the built environment in the United States causes a wide variety of social and psychological problems. A healthier society awaits the decision to construct buildings which respect the environments in which they are sited and which better serve basic human needs.

Transport and its Effects on Cities

The size of cities is limited by the availability of food that can be transported to the city and still sold cheaply. The explosive growth of London in the 19th century followed the development of canals and railroads. Today, the growth of cities such as Los Angeles, Bangkok, and Mexico City is limited by transport systems that have ceased to function at a tolerable cost (including the cost of travel time and indirect costs such as pollution).

Since the economic power of the city depends in part on bringing large numbers of people within close proximity to one another, it is important to encompass as many people as possible. This can be done either by increasing the population density or by increasing the average speed of the transportation system. The effectiveness of an urban transport system is therefore measured in time, not in distance. Public transport does not usually measure up very well - a competent bicyclist is usually faster door-to-door than the bus or even the subway. In many large cities, the car no longer delivers high door-to-door speeds, either. Even freight deliveries have become expensive due to the congestion of city streets and the resulting delays. Large cities based primarily on road transport are now choking on congestion, and these cities will face mounting difficulties unless they adopt a more effective transport system.