Rurality as an analytic category: implications for public health

Rurality as a concept was originated within the framework of the migration phenomena of the nineteenth century. During the post-war period, a dichotomic approach was established for this concept, along with the emerging notion of growth, which influenced the economic models of multiple countries worldwide. However, during the last 50 years, the rurality concept acquired a polysemic nature. Thus, the main objective of this article is analyzing several definitions of rurality from the perspective of some subdisciplines of the social sciences and their lines of thought to evaluate their implications for public health within different contexts.

During the 60s and 70s, with the adoption of an interrelational perspective from the urban-rural continuum (1), that emerged in 1929, from a proposal by Sorokin and Zimmerman (2).The concept of rurality became diffuse, which made necessary its adaptation to the category of territory.
D. In the early years of the twentieth century, the concept of hybridization of knowledge was adopted to describe spaces of tension, conflict relations and social forces of change (4,5).Within the context of a globalized society, it was oriented towards sustainable development, leading to a transdisciplinary approach.These characteristics have promoted the coexistence of rurality in the permeable limits between the disciplines that have included it as an object of study.This concept is particularly conflictive and heterogeneous for public health as an area of knowledge where several sciences and disciplines confluence, since there is no consensus, resulting in different approaches that depend on different epistemological and theoretical perspectives (6)(7)(8).Likewise, institutional technical criteria have been integrated to its definition.An evidence of this is the indistinctive use of dissimilar concepts such as rural, farmer, agriculture, population or rural community, and rurality observed in studies by Restrepo and Acuña (9), Dirven, et.al.(10), Pineda-Restrepo (11) and Chung (12).
As for the Colombian context, in order to understand rurality, it is necessary to acknowledge that this is a complex concept that extends beyond population aggregates or administrative structures because it constitutes the axis for identity establishment, reflecting the imposition of growth models and the diversity of conflicts that the country experiences as a nation.Consequently, for understanding rurality, public health needs to broaden the descriptive frameworks of the health-disease process; define dimensions for the interactions among environment, health and work; rebuild social protection policies and reformulate curricula and practices for the disciplines that are part of public health regarded as a field of knowledge and as a field of action; and determine its integration with socio-sanitary services.
Considering the previous rationale, this paper aims at analyzing several definitions of rurality from the point of view of some social sciences subdisciplines and their lines of thought, to determine their implications for public health.The scope was focused on: 1) identifying the conceptual elements guiding the making of governmental health policies and the adoption of strategies and models that are fundamental for the praxis of public health; and 2) promoting debate around the conceptual constructs of rurality which influence public health as a field of knowledge.

I. Geography: Between the classical view and the critical view
Geography's object of study is spaces, but it considers as essential concepts territories, places, and landscapes, among others.Rojas-Salazar (13) identified three lines of thought that move through the historic, quantitative, radical, systemic, social, ecological and landscape traditions: A. Determinism, whose main representative is the German geographer Friedrich Ratzel with his Anthropogeographie (1898), where he analyzed the life of populations and their activities from the individual and collective points of view (13).B. Possibilism had its more emblematic author in Paul Vidal de La Blache, who regarded people as geographical agents, based on the transformations they made to their environment (14,15).C. Positivism, which reunites the chorological, ecologic, spatial, physical and landscape traditions (16).
Possibilism is framed within rural geography as a branch describing the human and socio-economic aspects of this discipline, which highlights the importance of multiple factor analysis of geographic facts.García-Ramón (17) and Ávila-Sánchez (18) acknowledged Vidal de la Blache school as the precursor of rural geography.Within this setting, we must acknowledge the influence that English-speaking countries postulates had, which proposed spatial modelling (thus, getting closer to positivism).
In contrast with possibilism, the concept of rural metabolism has a wide resonance today, understood as a notion emerging from the Marxist category of capitalism analysis, which is related to the appropriation of nature observed from a deterministic position.At the same time, the appropriation of nature consists of an internalization or assimilation of natural elements by the social "organism" (19).
On the other hand, rising from the theory of interdependences, descriptive approaches of the concept of rural have emerged, based on the urban-rural continuum (grounded on Sorokin and Zimmerman's empiricist postulates), which highlight the benefits of adopting an integrated rural-urban approach for regional growth by focusing on interdependencies and common features, rather than differences (20).Additionally, and coming from the perspective of peri-urban territories, Ávila-Sánchez has proposed to incorporate to the analysis: Those transformations experienced by rural spaces that are in contact with urban areas, i.e., those areas absorbed by cities in their expansion; the socio-spatial situations derived from them and experienced by inhabitants at these settings (rural and urban) as mutational spaces (21)(22)(23).

II. Rural sociology: Between Europe and America
Rural sociology started its development in the late nineteenth century, in Europe.However, its dissemination overseas was materialized in the United States until the second half of the twentieth century.We may differentiate three traditions around agricultural questions: the German, the Marxist, and the American traditions.
One of the most prominent authors in the German tradition was Ferdinand Tönnies, who proposed an important sociological distinction between community (Gemeinschaft) and society (Gesellschaft).This distinction contributed to shape the classical view of rurality, associated to a dichotomic vision (rural-urban; backwardness-progress).It is important to note that German sociology has closer links to Husserl's phenomenology and Neo-Kantianism regarding the inclusive and transcendental relation of agricultural matters to capitalism.Consequently, it seeks to place, within the wider context of society, the forms adopted by the economic, political, and cultural transformations experienced by rural areas due to the globalization of the capitalist organization of labor and production.The influence of the first works by Max Weber at the end of the nineteenth century should be highlighted, when the ideals of the German Nation-State materialized in the agrarian reform at the east of the country, through lands concession to German peasants (24).
The Marxist tradition emerged from questionings about land, before, during and after the social revolution.As a response, the Worker-Peasant Alliance was established during the nineteenth century, a common element of emancipation for Marx, Engels, Lenin, Trotsky, Mao Zedong and Rosa Luxemburg, who studied the conditions of the peasant class in countries such as England, France, Russia, China and Egypt.Meanwhile, Kautsky (25) analyzed the future of rural social sectors from the perspective of social actors, within the framework of the capitalist process and its laws, applied to the rural setting.
The American tradition originated after the end of the Civil War (1861-1865), that evidenced the rural poverty in the country.It emerged from a modernization process that was maintained until the Great Crash of 1929 and generated a mobilization of groups of farmers, such as The Grange, and the National Farmers Alliance, who sought grants from the government to solve their economic problems, caused by the Great Depression (26).
The decades of 1930 and 1950 saw the rise of rural sociology, which disseminated throughout Latin America, promoted by the progressive vision of the Organization of American States and based on Parsons and Merton's contributions to Structural-Functionalism, which were then transferred to Orlando Fals Borda's first works, who would subsequently move towards historical materialism, through the Participatory Action Research (27).
As constructs originated in the United Kingdom and France during the second half of the twentieth century and the first decades of the twenty-first century, the approaches from ethnography and symbolic interactionism were characterized as a criticism against American rural sociology (28).These approaches addressed topics such as the new geographies of the peasant agriculture; studies on rural youth population; the conceptualization of space through social representations of the rural (6,29); the "associations of age, the geography of diseases, gay and lesbian ghettos; the itinerant lifestyles of some communities (elder travellers, gypsies, etc.); social conflicts between non-agricultural populations within the rural setting; the division of public and private spaces in rural areas" (18) and gender constructs (30).With regards to gender constructs, works are focused on agricultural labor roles, post-colonialist forms of politic ecology and community forms of resistance, reflected through movements such as La Vía Campesina or Anti-GMOs Movements (18).
It is important to note that peasant movements, analyzed from the point of view of class conflicts in rural areas, are permeated by confrontations of several actors, which range from everyday forms of resistance to conflicts at a large scale, such as land conflicts.Also, there is a convergence of some movements that emerged due to problematics of land leasing, taxes, the deterioration of life conditions, social injustice and/or war.They often are part of greater movements for national liberation and social revolution, taking some evident historical and local specificities under consideration.As for counter-movements involved in agricultural matters, Bernstein (31) identifies them as an emergent field of analysis.
Regarding socio-cultural definitions, Halfacree (32) states that they vary according to the type of environment where people live; therefore, there is a correlation between the social and spatial features that influence studies on rural matters.

III. Economic thinking: From peasant economy to the notion of growth
An epistemological approach of economic thinking was born in the nineteenth and twentieth centuries.According to García & Montiel (33), this discipline moves through approaches from realism to constructivism.On economy branches, particularly peasant economy, Alexander Chayanov was one of the first authors to mention this concept in the first half of the twentieth century, since he stated that the farmer's system of production is an independent system of production, with a different rationality to that of the capitalist system (34).Currently, Bernestein's (31) postulates, which establish the concept of peasant class, and Van der Ploeg's (35) notion of food empires are the most widespread alternatives for the analysis of globalization at localized ruralities in Latin America.
Another alternative with an empirical and descriptive character is the index of rurality, aimed at creating gradients by using the contrast of two or more indicators, such as the place of residence, and the level of income or the economic activities, as well as the number of inhabitants, among others (36); it becomes a comparative or relative measure of a community (37).In Colombia, the recommendation of the Organization for Economic Co-operation and Development (OECD) was adopted; the National Planning Department, through the mission for rural transformation, directed by Jose Antonio Ocampo, established the index of rurality, based on the rurality criteria of urban systems, population density and population relations (38,39).
Additionally, the analysis of social capital and the configuration of social networks and relationships contribute to the evaluation of rurality dynamics (40), as well as its political processes and identities (41).Likewise, rurality is integrated to the analysis of economic relations: political economy, the Actor-Networks theory and the theories of innovation and learning processes (42).
In view of the above, the economic thinking generated the idea of rural growth, which emerged after the end of World War II and reached its peak in the first decade of the twentieth century.According to Pachón, et.al. (43), two approaches are involved in the debate about rural growth: a technocratic one (focused on food production through the Green Revolution) and a contemporary one (centered on people and the social inclusion of the rural population).For the latter, particularly in Latin America, a perspective of new rurality was proposed, which constitutes a new conception on the multidimensionality of globalization from the point of view of sustainability (44).Additionally, it is important to highlight the debate about land distribution and the agrarian structure and reform that has taken place during the twentieth century in Colombia, which has been promoted by authors such as Absalón Machado, Jesús Antonio Bejarano, Orlando Fals Borda and Darío Fajardo.This debate has discussed issues on rural poverty and land tenure within the complex Colombian context, in relation with social inequalities and conflicts.

IV. Demography
Demography describes the distribution of populations with statistical purposes.It is generally used as a criterion to evaluate rurality by entities such as the National Center for Health Statistics in the United States (NCHS) (45), the Canadian Statistical Agency (6), or the Rural Urban Classification of rural settlements in the United Kingdom (37).In Colombia, the National Department of Statistics adopted census distributions and established the categories of major municipality, center of population and dispersed rural settlements (46).Some authors identify as main limitations (45,47,48) the assumption of a false dichotomy between urban and rural areas that underlies population distribution classifications, which makes them insufficient.Additionally, this ignores the variability in important characteristics of the communities who live outside large urban centers or in what could be called the commuting factor, which defines territories that can be regarded as urban, but that may include extremely rural regions lacking the services available in the metropolitan region (6).Also, Burawoy, as cited by Johansen and Nielsen (47) identifies three contextual fallacies (ignoring, reifying and homogenizing the world beyond the field site) and three dynamic fallacies (viewing the field site as eternal, treating the present as a point of arrival rather than a point of departure and, wishful).

Contributions from the Colombian context
There are two epistemological concepts that are transverse to the study of ruralities: time and space.Therefore, the multiple theoretical approaches allow us to elucidate the relevance of rurality as a historical, social, economic, political, and cultural phenomenon that goes beyond territorial or population disaggregation.
The identification of the terms rural, agrarian, and agricultural was a result of the industrial revolution, due to the functional specialization of the rural setting for supplying food within the urban-industrial society.Among our complex and globalized societies, the terms rural, agrarian and agricultural need to be clearly distinguished, as rurality refers to a wider lens, based on the construction of identities, representations, imaginaries, territories and lifestyles that are geopolitically localized; it is precisely in this last setting where the term agrarian is established, meaning the economic production model that seeks to change surplus value to a lifestyle that is closely related to production and sustainability.Therefore, at the heart of rural societies, as Van der Ploeg proposes, there are different agrarian classes that depend on the economic model that has been established: the peasant classes and the industrial or capitalist classes.It is in these types of settings where we should consider the interconnections with the environment, culture, and society.Finally, the term agricultural refers to the associations with land use and, more precisely, to the activities that are specific of cultivation, which are not linked to forestry.
In view of the above, rurality is not a diaphanous analytic category that can be distilled from a single discipline.Therefore, a transdisciplinary analysis is needed, which can evidence its complexity in our societies nowadays, as rurality has been used as an adjective (rural health, rural economy, rural sociology, rural geography), due to the influence of hegemonic and sectorial factors.Within the Colombian context, the dilemmatic nature of rurality definitions has generated a dramatic impact in agrarian reform processes, a lack of preciseness in approaches to corporate and peasant agriculture, and a poor contribution to governmental policy making for peasantry (35).
In public health, rurality as an analytic category requires an acknowledgement of the post-conflict scenario (49), not only to overcome the barriers to healthcare access in rural areas, but to reconsider the goals of the health system in order to identify individuals' particularities, financing alternatives and the role of both healthcare professionals and non-medical personnel.It is also necessary to formulate new approaches to community participation that eliminate the restrictions imposed by current regulations and incorporate community as an essential element of the health system.Other fundamental aspects involve the mental health of victims and ex-combatants, policies for social protection in rural areas of the country and the conservation of the practices and knowledge of peasant women.
The acknowledgement of the importance or rurality for resources, regulations, political and personal decision-taking, the world vision, and interaction patterns with other people implies that education programs in public health must incorporate the study of ruralities and lore in their curricular plans.
In this view, establishing the euphemism "rural health" within the Colombian context implies persisting in a perspective that denies the vindications of territory and territorialities that are emerging in Latin America and Colombia, and which advocate for the character of social construct that rurality has as an analytical category for public health.
The following points was identified as emergent topics throughout this essay: A. There are opportunities for research in the functional diversity of the health system, disabilities, ethnicities, rural-urban interactions, and food sovereignty that require an understanding of the notion of rights as a fundamental element of ruralities, taking into account that they represent a political approach to the role of people beyond production (43).
B. The perspective of gender constitutes a fertile field for the study of rurality, which originates five relevant interrelated topics: identity, sexuality, power, environment, and work.C. It is necessary to understand government policy-making from a multi-scalar and multidimensional point of view, within a logic of totality (50).D. With regards to the analysis of inequalities in healthcare it is necessary to set aside the dichotomic vision of the place of residence, because, as Cummins, et.al. say, this analytic approach has resulted in an undesirable construction of places and persons (or the "context" and "composition") as mutually excluding and competitive descriptions (51).If we maintain this approach, the standardization of populations will only contribute to the masking of particularities, hindering the recognition of intra-and international dispariries.
A further aspect to integrate is the concept of agrarian structure, which influences the notion of rurality, as it is a synergy of the economic and sociological postulates.Likewise, we still must examine the epistemological view of the relation among ecology, economy and geography (19,52), in terms of the positions and ruptures that nature requires.
To conclude, considering rurality as an analytical category within the field of public health requires to understand the new political orders of our society, which originate from the existence of narratives that diverge from those that have been already stablished and demand new dialogs and the recognition of the socio-territorial diversity of rurality (53).The consistent talk about "rural" matters implies a conceptual distortion inherited from the imposition of growth and/or the westernization of territory as a construct ♣