Health-care choices - the right of all Australians

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People who live in rural and remote Australia have usually chosen to do so because it is a lifestyle they love, regardless of the challenges it presents. One of these challenges is in managing personal and family health issues with fewer services and less support available than for those who live in cities or large rural centres. Such disadvantages are likely to be accepted with little complaint as part and parcel of the remote lifestyle. The disadvantage of such stoicism is that these issues are rarely discussed-and therefore, rarely addressed. Gay Greenwood and Brian Cheers' research^1,2 recently published in Rural and Remote Health, have highlighted the health-care issues unique to women and their families who live in remote areas. This timely examination of the underdiscussed area of remote healthcare deserves our full attention, for only then will solutions be proposed and found.

Australians put a high priority on the maintenance of good health and access to quality healthcare when ill. For most women, these are guaranteed. Some of the issues that Greenwood and Cheers' participants identified and discussed, demonstrate that women in remote towns and stations lack access to even basic health services, or else obtain such services at a high personal cost, such as the separation of pregnant women from their partners and home in the perinatal period in order to obtain obstetric care.

Even if women in remote towns have access to basic health services, many options that urban women take for granted are a rarity. The opportunity or choice to consult a female general practitioner (GP) has rarely been an option in rural and remote areas. However, as Greenwood and Cheers found, Commonwealth funding for the 'fly-in fly-out' scheme, where female GPs travel to the location of isolated women, has made an incredible difference¹. Younger women in particular have a real need and desire to be able to sit down and 'let go' with their GP, but this letting go of emotional burdens can be inhibited if they are likely to meet up with the GP at a social function or in the main street. In a sense, the opportunity to share emotional and family issues is at least as important to remote women as are female health checks, such as Pap smears.

However it is not only women who may have difficulty coping with life's hardships. The increase in the number of young rural men who loose their life by suicide or in road trauma is a national scandal. Police stationed 'nearby' must often act as ambulance as well as investigators after a suicide or road death, adding to their emotional burden. A concern that preoccupied Greenwood and Cheers' participants was men's neglect of their own health. It was agreed that, in general, men do not seek help for a health problem until something is obviously wrong. By then the condition may be well advanced. It is hard for a man to confide in a GP or health professional who may be his partner on the golf course. Imagine trying to express your inner most feelings in that context - everyone has their pride. During periods of severe drought, when men are under financial and family pressure, they are even less likely to seek help. It could be suggested that the neglect by men of their own health is the male equivalent of the lack of services for women. A lateral approach to address the issue of rural men's neglect of their own health may be to present health promotional material in agricultural magazines. Because agricultural material is what a rural man is accustomed to reading, this offers a non-threatening forum. Men's regard for such publications may lend the message credibility.

Young people feel stressed when they hear their parents talking at night about the property, the bank manager and the future. There are no adolescent health services in remote areas. In fact, there are just not sufficient health professionals to meet even basic needs, and those who are available may be many kilometres away and quite impossible for a young person to access.

Domestic violence is not confined to cities. Imagine trying to escape from a homestead during a violent domestic episode. The nearest sheltered accommodation is not around the next corner, and there's rarely a bus or train that passes the property! There may be a 1800 number to call, but how can this be of any practical help when a someone in the home has become physically violent? Often women hide in a distant farm house and try to handle the problem themselves. Or a distressed family member must be taken to a large city for care. These factors increase the difficulty and heartbreak of the situation for all concerned.

At every stage of the lifespan, remote-area living compounds the difficulty of dealing with health problems or age-related disability. Parents of disabled children are doubly challenged by having to access appropriate services many kilometres away, sometimes in another state. Such stresses can place an intolerable burden on the parents' relationship. If the task becomes too hard, one parent may leave the family, so the other has the added burden of having to manage the situation alone. And at the other end of the lifespan, young and middle-aged women often carry the responsibility of caring for the older family members.

Regarding the provision of appropriate aged-care services in remote and rural areas, the funding bodies have just used 'Bandaids'. Like older, urban Australians, rural elderly people who need supported care have the right to be near their families and friends. However, when political elements enter the aged-care funding equation, the viability of an aged care service is judged in dollar terms, rather than being seen in terms of the need of an older person to be in a familiar environment. There are not enough facilities to care for our elderly in the areas where they have lived their lives. To expect elderly people to move, in some cases hundreds of kilometres, from the people and area they know and love is against the very policies that the funding bodies promote. This is unacceptable to rural people. Aged care experts have long reminded us that entering residential aged care is a complex issue and its management impacts on an elderly person's quality of life and health, yet this does not seem to apply to elderly people in rural areas. Solutions need to be found to the challenge of applying aged-care standards to all Australians.

Now that Greenwood and Cheers and their participants have spoken out about the health issues that concern rural and remote women, let us try to find solutions. As well as the strategies Greenwood and Cheers have suggested, we need to encourage and support rural school students intending to study health sciences to commit to returning to work in rural Australia. This applies particularly to those who train in medicine and choose general practice as their specialty. While it is understood that solo practice is not an acceptable proposition, new models are being tested in order to offer, for example, more flexible working hours. Commonwealth schemes such as Medical Rural Bonded Scholarships³ and programs to enhance rural health workers' education and training are just the beginning of the solution^4-6. The health concerns identified by Greenwood and Cheers are not just those of rural women, regional policy makers and government funding bodies-all Australians share the burden, and all of us are part of the solution.

Margaret Brown
Chairperson
Health Consumers of Rural and Remote Australia
Editorial Board Member
Rural and Remote Health

References

1. Greenwood G, Cheers B. Doctors and nurses in outback Australia: living with bush initiatives, Rural and Remote Health 2 (online), (accessed 2 Dec 02). Available from: http://rrh.org.au

2. Greenwood G, Cheers B. Women, isolation and bush babies. Rural and Remote Health 2 (on-line), (accessed 2 Dec 2002). Available from: http://rrh.org.au

3. Office of Rural Health, Australian Department of Health and Ageing. Medical Rural Bonded Scholarships. (On-line) 13 September 2002. Available from: http://www.health.gov.au/ruralhealth/students/bonded.htm (accessed 2 Dec 2002)

4. Office of Rural Health, Australian Department of Health and Ageing. Rural clinical schools. (On-line) 21 August 2002. Available from: http://www.health.gov.au/workforce/education/clinical.htm (accessed 2 Dec 2002).

5. Office of Rural Health, Australian Department of Health and Ageing. University Departments of Rural Health. (On-line) 13 September 2002. Available from: http://www.health.gov.au/ruralhealth/students/udrh.htm (accessed 2 Dec 2002).

6. Office of Rural Health, Australian Department of Health and Ageing. Rural health workers - support, education and training. (On-line) 24 October 2002. Available from: http://www.health.gov.au/ruralhealth/workers.htm (accessed 2 Dec 2002).