Engaging Remote and Underserved Populations

The meaning of “remote” has changed. Once, destinations such as Kathmandu, Patagonia, and the Galapagos Islands were considered remote because of the distance and difficulty of transportation. Today, inexpensive global travel has made these once-exotic destinations so accessible that they are threatened by the volume of vacationing tourists. Now, remote means “off the grid,” set apart from mainstream society; isolated by gaps in language, culture, or social exclusion due to political or socioeconomic status— no matter how physically proximate. From my office in Washington, D.C., our city’s Wards 7 and 8, with their “food deserts,” are only 3 miles away but are considered remote, as are the towns of Appalachia 90 miles to the west.

Engaging remote populations requires skill for crossing gaps of language, culture, and social exclusion and thus is often a challenge. Such populations often have had painful histories in their relationships to mainstream society. Sometimes, they simply have been viewed as odd or “different.” Sometimes, there has been stigmatization or exploitation by the dominant culture. More is required than the simple delivery of expert knowledge, skills, or material resources. Well-intentioned health care professionals have sometimes found their humanitarian efforts rebuffed or ignored, because the well-resourced professionals were perceived as “outsiders.”

The first task of engagement is to build a trustworthy relationship, despite one’s outsiderness, before teaching, providing services, or otherwise “doing good” as an expert. This is a challenge when the relationship is asymmetric with regard to power (e.g., resources, funding, skills, political influence) or burdened with a history of injustices that cannot be erased. Second, building a trustworthy relationship means listening and learning about the history and physical setting of the population and understanding the adversities they have faced. Third, engagement is strengthened by keeping a steady focus, not only on problems but also on the resilience of the individuals, families, communities, and culture, despite their problems (1, 2). Focusing on resilience conveys the respect that is needed to create a collaborative, trustworthy relationship.

From these three principles come locally applicable best practices, some of which can be illustrated by the current American Psychiatric Association’s (APA’s) Mental Health Disparities Program in Central Appalachia (3–5). The Appalachian regions of Tennessee, Virginia, Kentucky, and West Virginia have struggled with the “diseases of despair”—such as alcohol abuse, prescription and illegal drug overdoses, suicides, and alcohol liver disease—as primary causes of declining physical and mental health. These remote, traditionally insular communities have had high levels of stigma against mental health services and difficulties in recruiting and retaining mental health professionals (3–5). Best practices that have facilitated engagement have included the following.