Rural health – the continuing challenge
Rural health is frequently inferior to city health. This old generalisation covers much contradictory detail, and exceptions abound: according to the Australian Institute of Health and Welfare, the life expectancy of non-Indigenous women in 2002-04 was much the same – 84 – whether they lived in big cities or very remote areas. For men, the difference is a matter of six months or so. And it is not a rigid generalisation: increasingly sophisticated broadband-enabled communications and ever-more efficient transport have reduced the gap between city and country.
Nevertheless, the numbers and the facts suggest that the accumulation of wealth, talent and many other features of contemporary city life confer a small advantage in life expectancy and wellbeing on city-dwellers. This disparity challenges those who hold the value that one of our social duties is to ensure, as far as possible, equality of opportunity to health and health care to all Australians. What should we do?
Two pathways to action present themselves for our consideration.
The first, and the one most easily grasped by the medical profession, concerns access to medical care in the rural setting. Massive technologically-based services can only be provided in large cities, and lesser technology-dependent services need at least strong regional bases.
We are getting better at finding ways to make these technologies available in relation to services such as radiotherapy, relieving the pressure on country women to favour radical breast surgery because they cannot afford the time and separation for chemo and radiotherapy.
But as we concentrate on providing rapid care for people with acute coronary syndrome and stroke (an increasing possibility in cities), the challenge of providing similar care in remote parts of the country may be beyond us at present.
The attitude of some to this problem – that those who live in remote parts of the country do so entirely by choice – is similar to saying that drowning people should be left, as they chose to swim or go boating.
But with telehealth, and many large city medical services increasingly interested in providing networked services to places that lack them, the problem is being partially addressed.
The search for equality of access may well require affirmative funding, and this has been recognised to some extent in fee structures and remuneration.
Equality does not mean paying the same for the care of people in different places: we need to accept that services provided beyond cities will cost more, and ensure that we finance them accordingly.
There are also concerns, raised most recently by Max Kamien, Emeritus Professor of General Practice at the University of Western Australia in Medical Observer, that the relaxation of hiring rules in many rural areas will “open the floodgates” to corporate practices.
While on the surface of it, a boost to the number of doctors working in rural areas would be welcome, this is not the case if they are being employed on short-term contracts to simply churn through large numbers of patients, and leave more challenging and time-consuming cases to existing practices. The focus needs to be on quality of care, not just quantity.
The extent to which the learned colleges have recognised the need for greater action on behalf of their rural members has been variable.
A framework for rural health developed by representatives of all Australian states, territories and the Commonwealth in 2011, recognised the need to be sensitive to the special needs of older people, babies and children, Aboriginal and Torres Strait Islander people, people with chronic disease, refugees and people from culturally and linguistically diverse backgrounds.
The second approach to rural health disparities takes us well beyond the surgery.
Even with networked services, e-health, and affirmative funding, we are faced with residual differences in health status that are attributable to the social and economic context of rural and remote life.
Medicine cannot, for example, diminish the vast distances many country people have to drive, every kilometre increasing their risk of a serious accident. At best, it can be sensitive to distance when arranging care of patients with continuing problems.
Medicine cannot do much to promote high-quality educational opportunity, although the development of regional universities and technical education capacity has been impressive in the past three decades.
Rural clinical schools have done a remarkable job in acquainting future medical practitioners and other health professionals with the challenges and opportunities of rural practice, and the long-term effects of this intervention will be seen in the next 20 years.
Medicine, though, has no influence over agricultural and extractive industry policies, all of which have great significance for employment and economic sustainability in rural communities.
These environmental factors – the social determinants of health – set the health agenda.
Some fall within the sphere of influence of public health, but many are well beyond even its wide reach.
Their importance was reviewed in a paper by Jane Dixon, from the ANU, and Nicky Welch, from Waikato University, in The Australian Journal of Rural Health in 2000. ‘What is it about rural places or the rural experience that contributes to different health outcomes?’ they ask.
The broad-spectrum advocacy of the Rural Doctors Association of Australia and the Rural Health Alliance contribute to the wider political and policy agenda that may help us to answer this question and to make serious progress.
It is vital for medicine to respond to the needs of rural communities as they are, not as they might be in a reimagined ideal world.
My sense is that we are making steady progress. The indicators that we have favour an optimistic view.