My Dad sang a song to me as I was growing up.

“It’s the same the whole world over, isn’t it a bloomin’ shame,
It’s the rich what gets the pleasure, and the poor what gets the blame.”

When you look at the state of healthcare around the world, it’s the poor what gets the blame alright, and the rural poor even more so.

Driven by the four horsemen of the rural apocalypse – distance, poverty, workforce statistics, and stoicism, rural health statistics across the globe are appalling.

Rural communities by definition are distant from the services available in urban areas, it takes longer for people to access care. Rural communities tend to be poor communities, people live a hand to mouth existence at the mercy of weather and crops. It can be hard to attract people with health care skills to work in rural places, and the “she’ll be right, mate” attitude of many people who live and work close the the land can add to delays in accessing healthcare.

Rural people, even in a sophisticated country like New Zealand, have worse expected outcomes for their health than people who live in an urban environment – worse suicide statistics, worse cancer statistics, worse heart disease statistics.

Rural communities and the governments that serve them would do well to listen to the voices of the health professionals who work in rural areas. Often the people who are living and working within a resource poor environment are the ones who have worked out the best, most pragmatic solutions to deal with the challenges they are facing.

Attending WONCA world rural health conferences has been a fantastic opportunity to listen to stories of rural practice from around the world.

Listen to the story of the Australian outback town where an aboriginal health worker, trained in a classical apprenticeship model, developed the skills to perform effective and safe general anaesthetics and surgery under supervision without ever seeing the inside of a surgical OSCE.

Listen to the story of the medical school that takes illiterate sons and daughters of fishermen and gradually trains them through midwifery, nursing and medicine into dedicated rural generalists capable of providing medical care in extremely resource poor environments.

Listen to the story of the medical students on elective charged with providing immunisations to a poor village, seeing the bigger picture and spending their time building boats to get the children from the village they lived in across the lake to the school, saving a two hour round trip through forests.

The Wonca Working Party for Rural Practice has over its 21 years of life developed an amazing resource of stories, pragmatic and evidence based solutions to the issues that face rural communities. Over the next year we will be revisiting many of these documents and thinking about what needs to be done to make sure that those stories are effectively heard.

Look at the Health for All Rural People statement, think about the role of women in a rural provider community, consider how best to support and develop effective teams of health care workers in rural communities.

We should all aspire to be like the WONCA expert “Five Star Doctor” – care providers, decision makers, communicators, managers and community leaders.

If you have an interest in rural communities, the documents available on the Wonca Working Party on Rural Practice page will help you.

NZ Doctor Column

Those of us that work in rural areas know the issues caused by our distance from medical support and social amenities and the challenges of working with rural people who are classically stoical, used to waiting,hard working or not working at all.

We know the need for us to develop extended skills to serve our communities, whether it be to help at the emergency on the roadside, or deal with a mental health issue when no-one else is available.

We know what we need to do to manage with limited resources and in situations of chronic workforce shortages. And we know how to do all this year in year out for many years.

Rural practitioners world wide are described by Prof.Roger Strasser as “extended generalists” – we provide a wide range of services, take high levels of clinical responsibility, for individuals and our communities at large in relative isolation. We know as rural nurses and rural doctors that we cannot perform in isolation, we work in inter-professional teams, sharing decision making and planning for the best possible care for patients, frequently working at the peak of our scope.

Rural communities that are lucky enough to have a small rural hospital available to them have the added advantage of being able to access hospital level services close to their home, but these services need to be staffed and supported by the health system in their region.

Rural practitioners are often instrumental in developing, driving and sustaining the services in their communities – they have developed skills in clinical governance, management and health service planning that are vital to the health service for their community.

Tudor Hart’s Inverse Care Law still applies – people who most need services are those least likely to be given access to them – and when the rural team stops working, services fail and communities suffer.

I was able this month to attend the WONCA world rural health conference, and heard how our experience in New Zealand is repeated world over.

What is exciting is that all over the world, and no less in New Zealand, the health and wellbeing of rural communities is vital for the health and wellbeing of nations.

There is nothing to be gained by setting rural and urban communities against each other, competing for resources for health services. It is mutually beneficial for us to aim for “equity” in health service provision across urban / rural boundaries.

Here we see ourselves as “number 8 wire” people, our heritage and national identity is embedded in the close community of our rural origins.Those of us that live in cities see rural areas as our place for leisure and a source of refreshment and vitality, we expect to be kept well when we are visiting them.

Perhaps even more importantly our country’s wealth relies on our primary industries, based in and reliant upon the health and wellbeing of the people who live and work in rural places.

One of the key international movements that was heralded at the Brazil Wonca conference was the development of “Rural Proofing” tools – our Ministry of Agriculture and Fisheries developed one 10 years ago – the NZRGPN adapted it to apply to the health sector 5 years ago.

The idea is to ensure that whenever any new policy is developed the impact on rural communities is considered and adaptions made if necessary so that unintended consequences do not follow.

Taking this step will have a slow but important effect on health and wellbeing in small isolated communities across the country. I am looking forward to advocating further for the development of “rural proofing’ in New Zealand, and to the support of the international family medicine community in seeing this become a reality here.

Attending in international conference is always a valuable experience for me personally and for the two sponsoring organizations who helped towards my costs (The RNZCGP and the NZRGPN) important in maintaining an international profile and being able to influence decision making at this level in WONCA.

The conference was attended by Michael Kidd and Amanda Howe (WONCA president and president elect) and both of these people acknowledged the Wonca Working Party on Rural Practice (WWPRP) as the most productive working party within WONCA and that the qualIty and breadth of work produced in the past has had international influence, in particular in WONCA’s work with the WHO and UN.

Attendance at the WWPRP meeting on April 2nd was as usual very open and inclusive, this has been the philosophy of the working party, which has run on the basis of a core of dedicated and recurrently attending members who support a small executive. The whole working party meets face to face once a year at each rural or world WONCA conference, and these meetings take the form of a “council” made up by the people who attend.

I am an executive member (I was appointed as “public relations officer” in 2013 )

Present at this meeting were people from Alaska, Usa, Canada, Columbia, South Africa, Croatia, Serbia, Brazil, Australia, New Zealand, Nigeria, Germany, Norway and the UK.

Membership of the organisation was discussed and it was generally agreed that the WWPRP would remain open to all who come to the meetings, with an executive, a core of active members and a network of other interested people.
It was hoped that the working party will achieve a balance of gender, and more younger people, over the next 3 years.

Questions were raised about how to engage with “3rd world” countries especially when income is limited, and language a barrier. The executive will work on this but has in the past year established an active “google list server” creating email linkage between interested members (this has over 300 rural doctors linked currently and is still rising,) we have had a monthly “rural round up” in WONCA news, and have an active “twitter” presence @ruralwonca.

The group asked the executive to look at a regional structure for membership of the WWPRP whilst retaining the current open membership. Whilst applying some structure to membership of the WWPRP associated with WONCA regions the group suggested the executive use other working party policies to identify gaps, for example in the Working party for women, each region has an older and a younger member.

Social media links are an opportunity we need to build on – the group suggested the executive build and administer a “facebook” or “google hangouts” social presence as members of the list server seem to need a social outlet as well as discussion forum.

Funding was discussed as a perennial problem and some ideas as to how to raise money discussed.

The WWPRP has developed over time a number of influential policies, statements and declarations, these are being reviewed and people were allocated a responsibility. I will be looking at the policy on Information Technology and its use to improve rural health outcomes.

The main work undertaken by the Working Party over the past 7 years apart from the regular conferences has been the development of the Rural Medical Education Guidebook launched at this conference and the Melbourne Manifesto statement around ethical international recruitment.

Other issues to be discussed in workshops in this conference include the future role of rural hospitals, and rural proofing of policy. The WWPRP spent some time discussing these workshops and organizing the role of WWPRP members over the next few days.

The Dubrovnic conference in 2015 was discussed, and the organizing team, have decided to build in a nursing stream to be added to the conference, previous conferences I have attended have had a strong inter-professional education flavour to them, reflecting this.

The conference itself started the following day and although it is usual to find the main benefit from attending a conference like this is in the out of session networking and connections, all the keynote and individual workshop sessions were both useful and engaging.

Highlights of the conference programme included Michael Kidd’s presentation, inspired by the WWPRP guidebook and previous work, in which amongst other things, he quoted from the chapter of the Guidebook written by NZ’s Campbell Murdoch where he paraphrases Tudor Hart’s Inverse care law, claiming that quality of care is thought by some specialists to be inversely proportional to the distance from a teaching hospital.

Amanda Howe talked mainly about the role WONCA has in the international sector and how important it is for member organizations, through bodies like the WWPRP and the Working party of indigenous people, headed by Tane Taylor from New Zealand to be engaged in its work.

Roger Strasser gave the second John MacLeod address, succinctly detailing a lifetime’s worth of research and practice around rural medical education into a fascinating forty minutes. Along with John Wynn Jones’s keynote on Rural Proofing, these two orations emphasized the importance of rural communities to their countries, and of rural health workforce to those communities. They showed ways of addressing the issues raised by distance, lack of amenities, extended community expectations and workforce retention, recruitment and training.

I am very much looking forward to these speeches being available on line through the post conference website.

One of the changes implemented in Brazil compared to recent other WWPRP conferences was a “rural skills” stream, I ran a workshop focussing on or hospital assessment of trauma and pre hospital analgesia which was attended by around 15 Brazilian delegates and through the excellent “real time” translation worked well.

I also contributed to the workshop on small rural hospitals, sharing data from the DivRHM training scheme and emphasizing the NZ philosophy of including the Division within the RNZCGP. I also highlighted the joint training (around PRIME and APLS / ATLS) for example and extended responsibility of nurses in rural New Zealand.

I presented at the workshop on Rural Proofing and will continue to contribute to the work that is to be undertaken over the next 12 months leading to a larger presentation from the WWPRP on this issue in Dubrovnic in 2015. Amanda Howe took on board the message about rural proofing and committed to ensuring WONCA the executive considered “rural proofing” WONCA policy.

I also attended talks and workshops around concerning “rural stories”, innovation in rural practice, community engagement in rural areas, disaster management and rural family medicine, small group training “clinical jazz.”

I was also able to have NZ students highlight in the conference photographic exhibition.

The conference was personally very interesting and I learnt a lot. I consolidated relationships with other members of the WWPRP and made new connections with researchers in the USA (David Schmitz and Randall Longenecker) and the UK (Philip Wilson). I shared several conversations with Amanda Howe who is coming to the RNZCGP conference in July, and through conversations with Tanja (Croatia) expect to be invited to join the Dubrovnic organizing committee, along with a NZ rural nurse.

CONCLUSION

Rural health issues remain very important in the NZ context. Attending this conference and being part of the WWPRP help us to influence our own communities through the international influence it exhorts. We are strengthened by association with others dealing with similar issues.

The fact of being there indicates to our own Universities, members and Government that we do not suffer from what the Brazilians call “Stray Dog Syndrome” – the self doubt that arises from isolation.

I used the social network “twitter” (@RNZCGP1, @ruralwonca and #nzrgpn) to disseminate information about the conference as it happened, and will now undertake to disseminate further some of the learning from the conference through press releases, through this wordpress blog “Don’t shoot..” and facebook.