Recently, in a class called “Health and Healthcare Systems in East Asia,” we read Doctor Stories by Dr. Kenjiro Setoue. I strongly recommend both the class and the book, but right now I would like to focus on an issue the book raises: Should governments devote disproportionate resources to providing public goods to people living in remote communities?

Setoue is a Japanese doctor who moved to Koshiki Island in 1978. Originally, he planned to stay for six months, but he ended up staying there for more than 30 years. When he arrived, Setoue was the only doctor on an island of 4,000 people. By the time the book was published, Setoue was no longer the only doctor on the island, but the island’s population had dwindled to less than 3,500.

The vast majority of the people left on the island are retirees whose children have moved to the mainland for educational and work opportunities. The island no longer has a high school, so the few children born on the island are forced to go to the mainland relatively early in their lives.

Setoue’s book focuses on the challenges of providing healthcare in such an environment. When Setoue arrived in 1978, the island had a single medical clinic with an operating room but no general anaesthesia. Any emergency surgery or surgery on patients who could not be moved to the mainland was performed without anaesthesia. Even once Setoue was able to to get access to better facilities and equipment, the island’s geography presented serious challenges. Even now, helicopter evacuations can only be conducted if the weather is favorable and often take a long time. Setoue must therefore handle a wide range of surgeries, often while under immense pressure.

Setoue is under pressure even when no one is injured; he explains his tradition of checking in with vulnerable residents before leaving the island and occasionally canceling a family visit or visit to a medical conference because he didn’t want to leave someone on the island without a doctor. One elderly resident habitually called Setoue before public holidays to ask if he would be leaving the island.

For Koshiki Island, maintaining doctors in every specialty or enough doctors for Dr. Setoue to leave the island without fear isn’t entirely feasible. Most of Koshiki’s residents are retirees, so the island’s tax base isn’t exactly limitless.

This restrains other public services as well; the island has already lost its high school, and if current trends continue it may no longer be feasible to have a middle school. This is a self-perpetuating cycle; the lack of a high school likely dissuades young families from moving to or staying on Koshiki, which causes the island to have fewer children, which makes it harder to maintain educational services.

This problem doesn’t just apply to Japanese islands. Small rural towns in America are also struggling with decreasing access to healthcare and education.

Communities around the world do not have enough people or enough tax revenue to justify maintaining hospitals or public schools — from a strictly economic point of view. But what about an ethical point of view? Is it the responsibility of the state or national government to support these communities even once doing so requires spending far more per resident than is spent on urban or suburban residents? Is it the responsibility of residents to accept that their choice of location causes them to have less access to certain services?

This is complicated in part by traditional ideas about certain lifestyles and services. America has a strong tradition of revering farmers, small towns and “traditional” ways of life. For many people, rural small towns, despite their shrinking population, represent the “real” America. Furthermore, many people view access to healthcare and education as human rights or at least more morally important than other services. Very few people think the government should ensure access to shopping malls, but hospitals and schools are different.

As so often happens, I don’t actually know what the right answer is here. I think that some towns, towns located in especially remote areas or with especially small populations, probably will experience more difficulty getting healthcare and education. But I don’t think that we should write off towns simply because they no longer break even from a strictly economic point of view. Deep down, I hope that changes like online physician consultations and virtual schools will relieve some of this pressure. But I suspect that there are limits on this; online doctor’s visits cannot eliminate the need for emergency surgery, and virtual schools make it hard for children to learn social skills.

Contact Sarah Myers at smyers3 ‘at’ stanford.edu.