Issue 2 / 27 January 2015

THE largest migration in human history is underway as millions of people the world over move from rural origins into burgeoning cities.

Often the promise of prosperity is broken as living conditions and employment opportunities fail to live up to expectations. Witness the shanty towns, desperate in their poverty, in Africa and Asia that surround gleaming central districts of skyscrapers and opulence.

Yet a move to city living frequently confers a health advantage: many poor people do in fact make good and the next generation benefits immensely and does even better.

Life expectancy is going up almost everywhere. Access to sanitation and clean water, readily available food, transport and education make a huge difference and, of course, so does employment.

Health services including primary care are often more available in cities and specialised care is accessible to those who can pay. Think of the differences in care available in rural and remote parts of Australia for patients with cancer and heart disease compared to those available to people who live near major centres. Rural women have more mastectomies than city women because they cannot afford the time away from families for adjunctive therapy.

The consequences of these disparities in access have been well documented and are dismal. Occasionally service provision is organised to overcome these access problems with success for cancer patients in South Australia.

But the residual reality is that sophisticated health care — like opera and art galleries — does best in big cities. Workforce policies cannot overcome this problem. And no-one is going to pay for highly specialised radiotherapy programs in regional let alone remote areas.

We keep dodging this reality about the effect of remoteness on access.

Primary care is different, but not entirely so. New strategies, not old ones, are needed to meet the needs of people who live beyond big cities. The old strategies leave gaps.

Greatly enhanced transport and accommodation for patients receiving specialised elective care and their carers are two elements for these new strategies. The use of new technology, especially information and communication technology, is another.

But workforce shortages do also play their part. The lack of abortion services in Darwin because of the loss of a doctor creates big problems, as outlined in a letter published by the MJA. In an MJA InSight news story following up on this letter, one expert explains that enhanced means are available for medical abortion that can be managed by GPs as an alternative to surgical abortion, which necessitates long-distance travel for rural pregnant women seeking a termination.

But the big barriers to adequate care remain financial, worldwide.

In Australia, my research colleagues and I have shown that many people living with chronic illness do so close to or below the poverty line. The cost of services not covered by Medicare can be immense.

In Mt Druitt we found people who required allied health services to be delivered at home because they could not pay the bus fare to the community health centre. Fortunately these people are still bulk billed for general practice, but the current federal government has shown little sensitivity to the impact of its reduced welfare and social security support for disadvantaged, disabled, mentally ill and unemployed people.

So while distance matters in gaining access to health and health care, so does money! Money is fungible, by which the economists mean you can use it to pay for pills or pathologists. So a society that cuts its financial support to the sick will create barriers to health care.

Medicare is central to our social contract. Each time little bits are lost as the political mice nibble away at the cheese, access is diminished.

But we should count our blessings — in general it gives most of us (not all) a foot (not two feet) in the door when seeking care for our ills.

Professor Stephen Leeder is the editor-in-chief of the MJA and emeritus professor of public health and community medicine at the University of Sydney.

Dr Ruth Armstrong is on leave.

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