Trego's Mountain Ear

by Madeline de Figueiredo, The Daily Yonder
November 20, 2025

As rural areas across the country face worsening provider shortages and reductions in health care services, one community hospital in Billings, Montana, is celebrating the success of two new residency programs training the next generation of rural physicians. 

Roughly 65% of rural counties face a shortage of primary care physicians, according to a Centers for Disease Control and Prevention (CDC) report. In some states, like Montana, the crisis is particularly acute. Research shows that a rural background is one of the strongest predictors of becoming a rural physician, yet the number of medical students from those communities has declined steadily over the past fifteen years. Today, fewer than 5% of U.S. medical students come from rural areas, contributing to a widening gap in access to basic health services. 

But Billings Clinic has a different story to tell. 

Since launching its internal medicine residency program in 2014, Billings Clinic has graduated 75 physicians, with half now practicing in rural communities. The program’s outcomes stand out amid national trends, where only 11% of physicians work in rural areas.

“I’ve never seen as much interest as I have over the past year in our residents remaining in the area,” said Dr. Steven Gerstner, program director of the Internal Medicine Residency Program at Billings Clinic. “The residency program has maintained the internal medicine department at Billings Clinic. Without the residency and the faculty we have attracted, we would be in very dire straits.” 

That success sparked more growth. In 2023, Billings Clinic launched Montana’s first-ever psychiatry residency, welcoming its first cohort in 2024. 

In the last 30 years, Montana has ranked in the top five states for suicide rates across all age groups. Youth alcohol use in the state significantly outpaced the national average, alcohol-related deaths have nearly doubled in the state in the past decade, and over half of Montanans live in communities that do not have adequate access to mental health providers. 

“We have patients from eight hours away or six hours away who have to come [to Billings Clinic] because there are no other services for inpatient acute care in their communities,” said Dr. Mariela Herrera Rojas, the program director of the Billings Clinic Psychiatry Residency. 

“There is a very high need to address mental health issues, but we are very under-resourced and there are a lot of shortages,” Dr. Herrera Rojas said. “That’s what we want to address through the residency program. What is it that we can do to address these shortages of addiction psychiatrists, child psychiatrists, and other providers?” 

The psychiatry program was funded, in part, by The Leona M. and Harry B. Helmsley Charitable Trust, a global philanthropic organization, which has given over $23 million to the Billings Clinic, including funding the development of its residency programs. 

“In Montana, the need for psychiatrists is huge,” said Walter Panzirer, a trustee for the Helmsley Trust. “One of the worst disparities across the United States is in Montana, and you look at all the behavioral health problems. It just seemed like a natural fit to further expand Billings Clinic’s residency program into psychiatrics.” 

A Rural Health Success Story

Billings Clinic serves a large region that includes eastern Montana, the western edges of North Dakota and South Dakota, and northern Wyoming. Residents see patients from across rural communities both at Billings Clinic and in rural rotations they complete across Montana. 

Every resident completes at least two rural rotations in communities such as Lewistown, Livingston, or Hardin, a structure designed to both expose them to rural practice and encourage them to stay in the region long term.

Ashley Dennis, Ph.D., director of Billings Clinic’s Office of Medical Education, said that this immersive experience prepares residents for the realities of rural practice. 

“The more opportunities that residents have to get out into rural communities, the better for, ultimately, them practicing in those spaces,” Dennis said. 

That firsthand exposure to rural medicine teaches residents to think differently about everyday procedures and logistics.

“We did a study recently talking to rural providers who had just transitioned into rural practice about their experiences. Through that, we heard lots of stories, and it’s simple things, like realizing, ‘Hey, before I do this procedure, I need to call the blood bank and cross-check that they have enough blood,’” Dennis said. “That’s something you may not consider at all if you’re in a place where there are ample resources and opportunities. So, having that contextual awareness changes how you practice as a physician.”

Dr. Mette Strand graduated from the Billings Clinic residency program and now practices in Livingston, Montana, where there are only two internal medicine primary care providers. She said both the rural training rotations and the program’s teaching philosophy played a key role in preparing her for rural practice.

“I think it was very valuable for the Billings [Clinic] residency to emphasize rural health during our training,” Dr. Strand said. “They would always give us scenarios, asking what if you didn’t have that consult service available? Or, what if you are on your own? They were always prompting us to think about how it would be to practice in a rural setting without the resources that we had.”

As a rural internist, Dr. Strand can care locally for patients that might otherwise have to travel far distances to see specialists. She now manages diabetes for patients who previously had to see endocrinologists, treats advanced chronic obstructive pulmonary disease (COPD) cases typically referred to pulmonologists, and cares for patients with liver disease once handled by gastroenterology. In some cases, she can manage these conditions locally right up to the point of transplant referral.

“The trip from Livingston to Bozeman or Billings can be hazardous, especially in the wintertime. And many of our elderly patients do not take that trip all winter. We also have patients struggling to afford gas or have help to go back and forth to those places,” Dr. Strand said. “By being able to offer internal medicine here in Livingston we are able to ensure better follow-up and treatment for these patients.”

Dr. Elizabeth Schiedermayer also graduated from the Billings Clinic internal medicine residency program and now practices in Anaconda, Montana. 

Dr. Schiedermayer said that while she came into residency already committed to practicing outpatient care in a rural setting, the Billings Clinic residency program offered her the opportunity to anchor her career in rural primary care. 

“They actually give you a primary care clinic. The rural rotation was really excellent, and they made space in our busy schedule to do that and value that,” Dr. Schiedermayer said. 

“I really like blue collar, rural people, and I like taking care of them,”  Dr. Schiedermayer said. “It’s a privilege to take care of my neighbors.” 

In a sea of stories about geographic disparities in medicine, Billings Clinic is forging a path to train and retain rural providers. Already, three of the upcoming Billings Clinic graduates have signed on to stay with Billings Clinic. 

“Our hope in building residency programs is to keep people in the community,” Dennis said. 

For Dr. Strand, that mission is coming full circle as she prepares to train future rural doctors. 

“I have my first resident coming after the new year,” Dr. Strand said. “I’m really excited about that opportunity.”

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This article first appeared on The Daily Yonder and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.

This is one of the most common systems used today. The council makes decisions, and a manager runs the town.

In a place like Eureka, this is where things can get tricky.

With only 8 to 24 people attending meetings, the council can operate with very little public pressure. If a few council members agree with each other, they can control what moves forward and what doesn’t.

At the same time, the manager controls:

• What information gets shared
• How fast things move
• What options are presented

This combination makes it very easy to:

• Block ideas without clear explanation
• Move things forward quietly
• Keep decisions inside a small circle

Nothing looks wrong on the surface. Meetings happen, votes are taken. But most of the real decision-making can happen before the public ever sees it.

This is the system where people often feel like:
“Everything is decided before we even get there.”

Bottom line: Efficient, but with low public turnout, it can become one of the easiest systems to control quietly.

by Sarah Melotte, The Daily Yonder
January 7, 2026

Editor’s Note: This post is from our data newsletter, the Rural Index, headed by Sarah Melotte, the Daily Yonder’s data reporter. Subscribe to get a weekly map or graph straight to your inbox.

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Last August fellow Daily Yonder reporter Ilana Newman and I visited a 1,500 square-mile lead cleanup site in the Coeur d’Alene mountains of North Idaho, a region nicknamed the Silver Valley because of its international reputation for high-production silver mines. Industrial mining has more than a century-long history in this region, and lead is one of the byproducts of the silver mining and refining process. 

For almost a century, mining companies dumped tailings, or waste, directly into the Coeur d’Alene River and its tributaries, eventually leading to one of the worst lead poisoning events in United States history. By the early 1970s, the Silver Valley had some of the highest blood lead levels ever recorded in children. 

In 1983, the EPA added the Silver Valley to the National Priorities List (NPL), a list of communities prioritized for federal assistance with hazardous waste mitigation. The site itself engulfs surrounding small towns and both active and inactive mines that comprise the Historic Coeur d’Alene Mining District.

Congress created the NPL on December 11, 1980, through the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), also known as Superfund, which established a trust fund for cleaning up hazardous waste.

In this edition of the Rural Index, I mapped the hundreds of Superfund sites that are scattered across rural America. While Superfund sites may appear evenly distributed overall, research shows that the most hazardous types of sites are more likely to be located near disadvantaged communities.

The National Priorities List

Today, 1,340 active sites make up the NPL all across America – in rural and urban communities alike. The following map displays all of the nonmetropolitan, or rural, Superfund sites. Click on the interactive version of the map and zoom in to your own state or county. (Keep in mind that some sites may be divided into multiple points depending on the size and the complexity of the cleanup area.) 

Most of the communities included in the NPL have been polluted by industrial operations like oil refining, metal smelting, or manufacturing, among many others.

The historic industrial corridors in Pennsylvania and New York are home to a concentration of rural Superfund sites. In the small town of Frackville, Pennsylvania, for example, a glass company dumped hazardous waste into lagoons which seeped into the soil and contaminated groundwater. 

At a Superfund site in South Cairo, New York, public health officials discovered that employees of American Thermostat improperly disposed of volatile organic compounds into the nearby area, which polluted private wells. The EPA added the several acres surrounding the American Thermostat facility to the NPL in the 1980s. 

Superfund sites are not evenly distributed across the country. A 2025 research paper from the Journal of Environmental Epidemiology found that Superfund sites related to industries like lumber, scrap metal, metal processing, and battery production, which have the highest risks to human health, are near communities that had lower incomes and educational attainment compared to the general American population. 

The geography of Superfund sites also exhibits racial disparities. Compared to Americans at large, Black residents are more likely to live near Superfund sites, according to Shannon Z. Jones, a biology professor at the University of Richmond who studies environmental racism. 

The EPA is establishing a new waste repository in the Lower Burke Canyon located in the town of Wallace, Idaho. (Photos by Ilana Newman)

Environmental health activist Barbara Miller took me and Ilana on a tour of the Superfund site in her North Idaho community. One of the many EPA-managed waste repositories we visited that day was in the small town of Wallace at a repository called Lower Burke Canyon. 

As we turned off the main highway, a straight, gravel road passed under a metal fence flanked by pine trees. A neon yellow sign explained that, beyond the woven wire fence, a toxic waste repository stored lead-contaminated soils from the area’s Superfund site. The EPA monitors all waste going into and out of the Superfund waste repositories on a recurring basis, collecting data on things like water pollution and air quality. This monitoring program is meant to ensure that the waste repositories themselves do not pose risks to humans and the environment. 

But despite EPA procedures, Miller told the Daily Yonder she is still concerned about negative health outcomes in the communities where these repositories are located. Directly across the street from the Lower Burke Canyon repository is an affordable housing development for low income families. Although we can’t say anything definitive about the residents of this particular housing development, government agencies do often fail to disclose when affordable housing units are polluted with contaminants like lead.

And despite reassurance from environmental engineers that the waste repositories aren’t doing any additional harm, Miller’s worry is understandable. When she was younger, Miller saw concerns about how the mining companies were dumping waste into the environment being disregarded. “And now, there’s documentation that it was … harming. It did harm,” Miller said.

A long-form story detailing the history of the Silver Valley will appear in the Daily Yonder later this month. Stay tuned.

UPDATE: A public health professional from the Panhandle Health District clarified that residents of the public housing development across the street from the Superfund site did receive disclosures about the presence of the site in their neighborhood. The health district regularly engages with residents to provide public health guidance to the community, according to the health professional.

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This article first appeared on The Daily Yonder and is republished here under a Creative Commons Attribution-NoDerivatives 4.0 International License.

This Venn diagram has a certain appeal – at several times in my life I have dealt with Marxists, Mountain Lions, and Toddlers: