For the past year and a half I have been fortunate to serve as a Dartmouth Center for Social Impact Class of ‘82 Fellow, working alongside the Public Health Council of the Upper Valley, town leaders, policymakers, and community partners to better understand what rural public health really looks like.
As I write this having worked with the PHC for over a year, I am grateful that I can continue collaborating with Alice Ely, the PHC’s Executive Director, over the coming months. Working with her and with the organization has shown me that public health is never just a set of policies or statistics. In rural communities it lives in the everyday. It appears in the driveways that freeze over all winter, in the waiting rooms people never enter because they cannot afford the bill, and in the neighbors who step in when systems fall short.
The stories are countless, and they stay with me long after the meetings or interviews end. Many parts of this region are aging, and that creates layers of vulnerability that do not appear clearly in datasets. I think of older residents who did not know how to book a vaccine appointment online during COVID. The process assumed comfort with technology and broadband access they never had. I think of individuals who distrust vaccines entirely, mistrust that grows not from malice but from isolation, fear, and years of feeling overlooked by the healthcare system.
And I think of the blind veteran in a small New Hampshire town. His story is the one that sits with me most heavily. He lived alone in a mobile home, unable to take out his trash, waiting month after month for a VA appointment that never seemed to come. His social security checks barely covered his needs and slowly his home filled with garbage. Eventually the smell drifted into the road. Neighbors called the town clerk, who then called the town health officer. When they entered the home they found a man barely holding on, furious at a system that had failed him at every turn. His story was not only about one man’s struggles. It revealed how fragile the safety net can be in rural places and how quickly people fall through when there is no one nearby to catch them.
There are other stories too. Families who choose not to vaccinate, not because they do not care, but because they distrust institutions they feel have ignored them. Elderly residents with long, steep driveways who become trapped inside for weeks after winter storms. People who cannot rely on consistent transportation, for whom an appointment thirty miles away might as well be across the country. Residents skip dentist visits until infections spread because insurance does not cover oral health. Others with no insurance at all who must choose between groceries and care.
Then there are the barriers that are harder to name. People of color who feel invisible in a region where diversity is limited and systems are not built with them in mind. New immigrant families trying to navigate unfamiliar services, working through language barriers, or facing subtle forms of exclusion. In a place that prides itself on being close knit, too many still find themselves left outside the circle.
Geography shapes these challenges as well. The Upper Valley straddles Vermont and New Hampshire. This creates opportunities for collaboration, but it also introduces mismatched rules and priorities. Insurance programs, social service structures, and legislative agendas differ across the river. A program that works smoothly in one state may stall in the other. The PHC sits at the center of this tension, helping local leaders piece together a system that is coherent enough to meet real needs across both states.
Yet for all the challenges, I have also seen resilience. I have worked with Town Health Officers who show up at doorsteps not simply to enforce rules but to perform welfare checks. I have met nonprofit staff who stretch every dollar to support food access, addiction recovery, or mobile clinics. I have seen legislators listen closely when local stories are translated into briefs and policy asks. And I have watched neighbors clear each other’s driveways after storms or check in on those who live alone. These quiet acts of care do not erase structural inequities. They do, however, show the humanity that underpins rural public health.
For me, the Upper Valley has become a home not because it is perfect but because I have seen how deeply people care for one another despite imperfection. Public health here is raw and real. It includes the grandmother at the end of a snowy driveway, the farmer who cannot afford to see a doctor, the teenager struggling with addiction, and the family balancing trust and fear around vaccines. It includes the blind veteran left behind by bureaucracy and the immigrant family learning to navigate systems that do not always see them clearly.
My time with the PHC has been an immersion into what rural public health actually looks like. Over the past year I have spoken with Town Health Officers, selectboard members, nonprofit partners, and fire chiefs to understand the realities of housing, sanitation, and community health. I have written blogs and reports that translate those realities into stories and policy recommendations that local residents and legislators can access. I have attended board meetings, written grants to support community health events, and helped shape legislative briefs that connect local experiences to state level decision making. Through it all I have been reminded that public health is not only about systems. It is about showing up where people are and making sure they are heard.
The state of rural health in the Upper Valley is complicated. It is full of inequities, resource gaps, and systemic barriers. It is also full of extraordinary resilience. Working here has reminded me why I care so deeply about this field and why I will carry these lessons with me as I move forward. I owe a special thank you to Alice Ely, whose leadership and mentorship have been a model of how to build trust, create connections, and make rural health more visible and more equitable.
Health is not only a matter of access or policy. It is the measure of how a community cares for its people. And here, even in the midst of struggle, I have witnessed a profound capacity for care.
Vismaya Gopalan is the Dartmouth Center for Social Impact Class of ’82 fellow with the Public Health Council of the Upper Valley.