People in rural America are five times as likely to live in so-called "ambulance deserts," areas far from an ambulance service or station, than those in urban areas.

In rural Iowa, ambulance service has declined as the population dwindles. The study, from the Maine Rural Health Research Center, said half of those living in ambulance deserts are in rural areas, more than 25 minutes from an ambulance station.

Keokuk, along the banks of the Mississippi in eastern Iowa, has seen its population shrink to fewer than 10,000, with a sharp decline in ambulance service.

Cole O'Donnell, city administrator, said the situation got worse when officials were forced to close the local hospital.

"It frightened a lot of people," O'Donnell recounted. "I know that we have older people that moved out of Keokuk to someplace closer to a hospital. You know, they had health problems and if something happened, they couldn't wait those extra minutes, or even the extra minutes of getting them from Keokuk to a hospital."

In addition to trying to bolster county ambulance service, O'Donnell noted Keokuk is working to help reopen the local hospital as a federally designated Rural Emergency Hospital, which requires the facility to provide emergency services and outpatient care 24 hours a day, 7 days a week.

Emergency medical service is not considered essential in rural America, and the federal government does not fund it. Volunteers form the backbone of E-M-S operations in many areas, including Iowa. But O'Donnell acknowledged in Keokuk, times have changed. It is hard to find paramedics and emergency medical technicians, let alone people who do not get paid to do those jobs.

"When I was growing up in the '70s and the '80s, my mom was even part of the first responders," O'Donnell explained. "You can't even get first responders now to set up a service where they respond before the ambulance gets there, because nobody wants to volunteer anymore."

While about 14% of Americans live in rural areas, the report shows they make up more than half the population living in ambulance deserts.

Groups from across Michigan are sounding the alarm on the effect Republican-backed policies would have on people in rural parts of the state.

In a recent webinar by the group Progress Michigan, leaders say policies laid out in Project 2025 are in stark opposition to the needs facing rural Michiganders. Representatives from Indigenous tribes, public school teachers and family farmers gave their views on the potential changes if the GOP regains power.

Dakota Shananaquet, member of the Little Traverse Bay Bands of Odawa, said she fears for her people's basic rights.

"The Project 2025 Agenda is a right-wing power grab that would harm Indigenous communities, our sovereignty and the ability for us to exercise our vote," Shananaquet asserted. "It would make outcomes worse by defunding health care and education programs."

Project 2025 is a 900-page document outlining plans for a conservative takeover of the federal government. Republican presidential candidate Donald Trump has disavowed any part in developing the document. However, dozens of former Trump administration officials contributed to the proposals.

Bob Thompson, president of the Michigan Farmers Union, which represents hundreds of small and medium-family farms, said the GOP plans to eliminate programs helping independent farmers implement conservation and clean energy goals, and most of the federal farm program's current financial safety net features.

"Family farmers operate on narrow margins and need the protection of many of the very programs that Project 2025 seeks to eliminate," Thompson explained. "Most elements stand against what rural folks want for our families and our future here in Michigan."

Gary Wellnitz, Northern Michigan field representative for the American Federation of Teachers-Michigan, said Project 2025 would have negative and destructive effects on public schools across the state.

"It's going to make the safety in our public schools far worse," Wellnitz contended. "We're going to see small schools closing down, We're going to see teachers losing jobs by the thousands if this were to take hold."


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With many rural hospitals on the financial critical list, Congress created a Rural Emergency Hospital model in 2021 to help deliver critical care to struggling communities in Nebraska and elsewhere.

Two years in, the Bipartisan Policy Center has issued a report which showed care is improving where the system has been implemented but more work is needed. Under the model, 32 Rural Emergency Hospitals in 14 states have been established.

Julia Harris, health program director at the center, said the plan is preserving health care options for rural residents.

"If you start seeing hospital closures go down, that's a success measure," Harris asserted. "Because this should be what helps them meet the needs of the community and stay open rather than being forced to close."

Harris pointed out under the Rural Emergency Hospital model, a rural facility can offer emergency department, observation, outpatient care and skilled nursing facility services in a distinct unit. Warren Memorial Hospital in the town of Friend is currently the only such facility in Nebraska.

Harris noted the growth of the model is reducing the number of rural hospital closures but acknowledged challenges remain in operational flexibility and the availability of financial assistance. She emphasized they studied states across the Midwest, looking for hospitals and communities which could benefit from a Rural Emergency Hospital.

"The reason we chose Kansas and Nebraska is because there was some modeling done to see which states would have the most hospitals eligible for this model," Harris explained. "Those were two states that had a lot of potential REHs. "

Other recommendations in the report included support for prescription drug discounts, more flexibility in converting to Rural Emergency Hospital status, timely payments to speed the process and more funding for providing technical and operational assistance, with what are called technical assistance centers.

"There is a federal TA center to help hospitals that are trying to consider their pros and cons," Harris observed. "We advocate for continued funding for that TA center to be able to continue to do this sort of advising and help states make these choices."

By Claire Carlson and Anya Petrone Slepyan for The Daily Yonder.
Broadcast version by Suzanne Potter for California News Service for the Public News Service/Daily Yonder Collaboration

After being incarcerated for 19 years, most people would be happy to never step foot in a prison again. But Jesse Vasquez returns week after week, flashing his state-wide security clearance to guards who know him by name. 

Vasquez leads the Pollen Initiative, a non-profit organization that supports the development of media centers and newspapers in prisons. When he was incarcerated, he was sent to 12 different prisons before ending up at San Quentin Rehabilitation Center, located just north of San Francisco. There, he got involved with the prison’s long-running newspaper, San Quentin News. He served as the paper’s editor-in-chief before he was paroled in 2019. 

Now, he’s working to bring similar media projects to other prisons in California, especially more rural ones that don’t have the same programming opportunities as San Quentin.

“It’s not necessarily that people don’t want to provide the programs, it’s proximity [to the prison],” Vasquez said.

Vasquez’s sights are currently set on the Central California Women’s Facility (CCWF), one of California’s two women’s prisons located just outside of Chowchilla, a small city in the Central Valley. Since March of 2024, Vasquez and his colleague Kate McQueen have made the two-and-a-half-hour drive from the Bay Area to Chowchilla to teach a journalism class to CCWF’s incarcerated residents. 

In mid-September, they printed the first edition of the Paper Trail, a monthly newspaper written and edited by incarcerated journalists at CCWF. 

“We want to have media centers and newsrooms flourish inside these institutions primarily because for the longest time they’ve been closed institutions with no transparency, no accountability, and no exposure,” Vasquez said. 

Geography Matters

For those incarcerated at the Central California Women’s Facility, San Quentin News has long been a source of both awe and exasperation. 

Megan Hogg is a regular reader of San Quentin News and a member of CCWF’s inaugural journalism class. Though she looks forward to reading the newspaper every month, she said she can’t help but notice the difference between the opportunities available to her at CCWF compared to those at San Quentin.

California’s Department of Corrections and Rehabilitation “has provided so much for San Quentin, but they just ignore us,” Hogg said. “It’s frustrating to open the San Quentin News and see that they have athletes, musicians, and artists coming in. There are no resources like that for the women.”

CCWF is one of the largest women’s prisons in the world, with a population of over 2,100 incarcerated residents. It is one of two facilities for women in California, though it also houses trans men and nonbinary people. 

The nearby city of Chowchilla has a population of 19,000 and is in Madera County. Madera County comprises a small, single-county metropolitan area. 

Although certain programs like Alcoholics Anonymous, Narcotics Anonymous, and basic education are available across all of California’s prisons – rural and urban – access to other educational, vocational, and therapeutic resources varies across institutions. 

Many of these programs rely on support from local volunteers and nearby organizations. For example, San Quentin, which is located in the Bay Area, benefits from 500 active monthly volunteers who implement 160 different programs in the prison, according to the California Department of Corrections and Rehabilitation (CDCR). 

In comparison, CCWF has 100 monthly volunteers who come in at least once a month.

In more rural prisons like High Desert State Prison, located in Lassen County, a nonmetropolitan county with a population of 32,700, just 36 “long-term program providers and religious volunteers” provide programming to the incarcerated, according to the CDCR. Approximately 10 providers with statewide prison clearance provide services to High Desert “a few times throughout the year,” the corrections department said. 

These differences are not lost on Vasquez. While he’s extremely proud of San Quentin News, he said, he’s also “ashamed that we’re not representing the 32 other [California] prisons, many of which are in rural areas and have fewer resources and programming.” 

The Fourth Estate Behind Bars

The Pollen Initiative’s effort to support prison newspapers builds on a long history of prison publications in the United States. 

The first prison newspaper was published from a debtors’ prison in New York in the year 1800, according to archives from the American Prison Newspapers collection. Printing presses were commonly used for vocational training in prisons during the early and mid-20th century, which allowed for a vibrant prison press to flourish.

Since 1800, more than 700 different newspapers have been published at prisons across the country, with the number of publications peaking in the middle of the 20th century. 

But in the 1970s, attitudes towards incarceration began to shift. Punitive, tough-on-crime policies replaced efforts at rehabilitation, and the prison population exploded from 200,000 in 1973 to 2.2 million in 2009, according to a report from the National Resource Council. 

This change in attitude also affected educational and vocational opportunities within prisons. For example, the 1994 Crime Bill excluded incarcerated people from using federal Pell Grants, which had previously helped them access college education. Without funding, few prison college programs survived. 

Most prison newspapers met a similar fate. Punitive attitudes and legal challenges over censorship and the first amendment rights of the incarcerated caused the majority of prison newspapers to disappear by the end of the 20th century. 

Now, it seems a revitalization of the American prison press is underway. At least 25 prison newspapers in 12 states are currently published, and incarcerated journalists are increasingly collaborating with outside publications.

The presence of electronic tablets in prisons and jails across America has also drastically increased the distribution of prison newspapers among incarcerated people. For example, the San Quentin News – and now CCWF’s Paper Trail – are available in print at every California prison, as well as digitally in 950 prisons and jails around the country. Both papers have websites that outside audiences can access. 

This reemergence of the prison press could itself be an indication of shifting attitudes toward criminal justice. In combination with state-level reform, federal policies and legislation have reduced prison populations and expanded rehabilitative opportunities over the past 15 years.

While these reforms are promising for the Pollen Initiative’s work, Vasquez says there is no guarantee that such support for prison reform will continue. 

“When you look at the pendulum of criminal justice reform, it shifts so slowly in the way of progress and so quickly in the way of ‘tough on crime,’” he said. “So when you have a prison administration open its doors to you, you have to strike while the iron is hot because you don’t know when that door is going to close.”

At CCWF, it took nine months of meetings with prison officials before they began working inside the prison. That’s because starting a media center requires approval from the prison’s administration and buy-in from the incarcerated population – a trust-building process that takes time. 

In the spring of 2024, McQueen began teaching a weekly journalism class to the first cohort of students. The program held a celebration for the 19 graduates in mid-September, the same day the first edition of the Paper Trail was published. The Paper Trail’s editorial board was selected from members of this class and has directed both the content and vision of the new publication.

McQueen and Vasquez said the enthusiasm of the prison’s warden, Anissa De La Cruz, has made all of this possible. 

“I have made it my mission to give the population of the women’s prison a voice,” De La Cruz wrote in the first print edition of the Paper Trail, which was published September 16, 2024. “Part of that means making space for a newspaper at CCWF, its own newspaper.” 

The Paper Trail in Print

In late August, CCWF’s inaugural journalism class laid eyes on the first physical printing of their newspaper – a mockup that Vasquez and McQueen brought in so the editorial board could finalize the design and layout of the first edition. 

Though it was just a sample draft on regular printer paper, this first look at their newspaper was emotional for many of the writers. Sagal Sadiq, features editor for the Paper Trail, said seeing his first byline was “surreal.” 

“I don’t even know what to say,” Sadiq said, shaking his head. 

The writers hope that in addition to providing information and building community among the incarcerated at CCWF, it will also lead to more attention – and therefore more resources – for the prison. 

One article in the paper’s first edition highlights a peer support program at CCWF for incarcerated people, the first of its kind in the country. The program, which involves 82 hours of training, equips its participants to help new arrivals as they adapt to life in the prison. They’re also trained to facilitate support groups focused on things like personal health and reentry.

Paper Trail contributors say the newspaper is one way to highlight the innovation happening at this rural prison. “We’re doing things that are groundbreaking here, but we don’t have the same coverage as San Quentin,” said Amber Bray, the Paper Trail’s first editor-in-chief. “So we’re leveling the playing field.” 

Bray believes the newspaper can strengthen CCWF’s programming by helping Chowchilla residents see the incarcerated residents as part of their community, which could encourage more volunteers to get involved. 

Everyone incarcerated at CCWF is counted as a Madera County resident in the U.S. Census, Bray pointed out. And the first edition of the Paper Trail includes coverage of one of the many fundraisers put on by CCWF that directly benefits the outside community. Some local publications have shown interest in republishing articles from the Paper Trail, which would further expand the newspaper’s audience and influence.

“Hopefully the newspaper will motivate people to ask questions, and think about how they can help our community by volunteering and getting engaged,” Bray said. 

Nora Igova is the Paper Trail’s art and layout designer. She shares Bray’s hope that the newspaper will bring the inside and outside communities closer together. 

“The Paper Trail will humanize us, humanize this community,” Igova told the Daily Yonder. “There is still an instilled fear in the outside community around prisons. We want people to not be afraid to believe in transformation and rehabilitation, and to see us as potential neighbors.”

For Vasquez, the Paper Trail is an example of something he’s always known: every incarcerated person has a story to tell. 

“There are thousands inside the prison system who are brilliant thinkers, writers, artists,” he said. 

Vasquez knows he was lucky – when he ended up at San Quentin, the resources that were already there allowed him the opportunity to flex his own writing muscle. “I just happened to be at the prison with the most exposure, with the most proximity,” he said. 

No matter where a person is incarcerated, he wants them to have similar access to this opportunity. Vasquez and McQueen hope the Paper Trail can serve as a model for what could be possible at other prisons, rural and urban alike. 

“We want to show people that it is possible, and this is how you can do it,” Vasquez said.


Claire Carlson and Anya Petrone Slepyan wrote this article for The Daily Yonder.


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