“Rural stoicism”: an excuse for poor health care access

AUSTRALIA’s National Rural Health Commissioner, Professor Ruth Stewart, is heartily sick of hearing the trope of the stoic country person who doesn’t turn up to a doctor until things are dire.

“When rural health care is taught explicitly, students are told things like ‘rural and remote people are stoic – they don’t turn up until they’re really sick’,” said Professor Stewart.

“That’s not because they’re able to put up with pain more, they do because they have to. They look at their local health service and go, ‘they’re really stretched, and they’re already overbooked; why would I go when I’m not really sure that this is a thing yet, it might just get better’.

“I am looking forward to a day when there is no longer this story that remote people are stoic. Remote people just do not have the access to health care that they deserve.”

In an editorial for the MJA, Professor Stewart laid out the harsh facts of health care in rural and remote areas.

“Australians living in remote areas are admitted to hospital at 1.3 times the rate of those living in urban and regional areas,” she wrote.

“For Australians living in very remote areas, the rate is nearly double the urban rate. Potentially preventable hospitalisations also increase steeply with remoteness. The difference is most marked for acute conditions where remote rates are almost 2.5 times those of urban areas. The median age at death in major cities in Australia is 82 years; in outer regional, remote and very remote areas it is 3, 9 and 18 years younger, respectively, and the statistics are much worse for First Nations Australians.”

Professor Stewart called for rural health researchers to live, work and report back to the communities they studied, rather than being “seagull researchers”.

“In the Torres Strait, people talk about researchers who come in, fly in, collect data and fly away and that’s the last we see of them. And that collection of data is experienced as a loss by the local community,” she told InSight+ in an exclusive podcast.

“The process of collecting the data can be uncomfortable – these strangers asking personal questions, taking blood maybe, doing examinations, it can be uncomfortable. Then the locals get nothing out of it apart from that discomfort and distress.

“They don’t hear the results of the study, and so they coined the term, they’re like seagulls, they fly in and steal your food, shit on you and go.”

Apart from giving back to the communities, local researchers can be part of retaining clinicians in rural areas.

“When we look at interventions that actually increase the retention [of doctors] in rural and remote communities, establishing a learning bond is a really strong one – giving clinicians a career advancement plan makes a big difference to retaining them,” said Professor Stewart.

“If we can have more support for resident rural and remote clinicians to conduct research, we will increase the retention of those clinicians in those communities.

“The conversations I have with clinicians about leaving [the country], it’s really rare for them to say, ‘I can’t wait to get back to the city’. What they most often say is ‘I wish I didn’t have to leave’.

“If we can increase the complexity of the educational and research environment in the rural and remote communities and health care systems, we will increase the chance of retention of those skilled workers in those communities.”

During her term as National Rural Health Commissioner Professor Stewart would like to see an increase in the number of rural generalists being trained.

“We’re not training enough,” she said.

“Australia has the highest per capita number of doctors in the OECD, and that has not solved the problem of distribution of doctors. And the maldistribution that we see in the medical workforce is nothing compared with the maldistribution in the allied health workforce.”

Professor Stewart’s editorial is a preview to a supplement being published by the MJA on 14 December from the Spinifex Network, which comprises community-based researchers.

“Within this network, researchers are able to find collegiate support and collaboration and conduct research that will lead to improved rural and remote health outcomes,” she wrote.

“The beautiful thing about Spinifex is that it’s formed of people who live and work in rural and remote Australia,” she told InSight+.

“They understand the clinical challenges and the health service challenges in rural and remote Australia, and they are doing research investigating the things that matter to rural and remote communities.

“There are so many questions that we have that haven’t been answered. And a lot of the research that was being done wasn’t answering the questions we had. That’s why Spinifex is so important.”