The World of Rural Family Medicine - address to WONCA World Rural Health conference, in Brazil

April 06, 2014

Bom dia. Good morning.

Thank you to the chair of our WONCA working party on rural practice, Dr John Wynn Jones and to all the members of the working party for your great work supporting rural family doctors right across the world, and for the success of this 12th WONCA International Conference on Rural Health.

And thank you to Dr Leonardo Vieira Targa and the members of your national committee, to the Brazilian Society of Family and Community Medicine, to the South Brazilian Congress on Family and Community Medicine, and to our conference organisers for bringing us all together here in Gramado in this beautiful mountain region in the south of Brazil.

It is timely that this conference is held in Brazil. Brazil is leading the world in family medicine-led primary care reforms to ensure universal health coverage for all people in this large, complex and populous nation. I will discuss some of Brazil’s reforms during this speech.

One privilege of being WONCA president is that I am invited to visit family doctors across the world to gain insights into the challenges that our colleagues face in providing the best possible care to the people of their local communities. During this presentation I will share with you stories from some of the remarkable rural family doctors I have met over the past year as WONCA president.

Colleagues like Dr James Heng-Chia Pen, a rural family doctor who works at the Jinshan District Public Health Center on the beautiful coast in the rural north of Chinese Taipei. As well as providing an excellent clinical service to the people of his community and surrounding district, James is a dedicated teacher of medical students and family medicine trainees.

I need to begin with a word about words. When I say rural family doctor, I mean you. Whether you call yourself a rural general practitioner, or a rural family physician, or a rural generalist, or a rural primary care doctor. Whatever you call yourself, and whatever your patients call you, when I say rural family doctor I mean you, my sisters and my brothers in family medicine. The language we use to describe who we are differs from place to place. What matters is the common work that we do, the vision that we share, the outcomes that we achieve for our patients and their families, and for our communities.

So why are we here at this conference on rural health in Gramado? And why is rural family medicine important? The answer is simple. Half the world’s population lives in rural areas. But half of the world’s doctors do not. As we all know, most of our colleagues in other specialties are based in cities or in large regional centres. It is the family doctors who are based in rural communities and provide medical care and advice to half the world’s population.

WONCA, our World Organization of Family Doctors, has a long tradition of supporting rural practice, through the activities and impressive achievements of our WONCA working party on rural practice. Our members work together to strengthen family medicine across the world to the benefit of our patients, our communities and humanity.

I pay tribute to our WONCA working party on rural practice which for the past 22 years has been such a strong and effective advocate for training and supporting sufficient numbers of skilled rural family doctors to meet the health care needs of the people living in rural areas in all nations of the world.

Our WONCA working party on rural practice was established in 1992 at the WONCA World Conference held that year in Vancouver and right from the outset comprised rural family doctors from both developed and developing countries; rural family doctors who shared a vision of health for all rural people around the world.

The WONCA working party on rural practice has been highly influential through close work with the World Health Organization, the WHO, in the development of global health policies on rural health and in the roll out of programs to support rural practice.

The working party has developed a number of important policies which have shaped global thinking on rural health care, including the 1997 WONCA Durban Declaration on the “Health for All Rural People”, the 1998 WONCA Policy on Rural Practice and Rural Health to assist governments around the world to better meet the health care needs of their rural populations, and the 2002 WONCA Melbourne Manifesto which is a code of practice for the international recruitment of health care professionals and which emphasises the responsibility of each country to ensure it is producing sufficient health care professionals to meet its own current and future needs. And that those countries that can afford to do so, train more health care professionals than they need and so help to redress the shortages in many parts of the world.

Our WONCA rural practice working party has also developed policies on women in rural practice, on the health care of Indigenous People, on the use of information technology to improve rural health care, and on quality and effectiveness issues in rural health care; policies which cover the breadth of the key issues affecting the provision of rural medical care.

And in 2012 our rural working party, at the last WONCA Rural Health Conference along with other global partner organisations and institutions, released the Thunder Bay Communique, calling for new ways of thinking to ensure equity in the delivery of health services to the people of the world living in rural areas.

Our rural working party has organized a series of 14 successful WONCA Rural Health Conferences on all continents, including two conferences in Africa, in South Africa in 1997 and in Nigeria in 2006. The very first WONCA Rural Health Conference was held in Shanghai in 1996, at a time when China was first discovering the potential of family medicine to transform health care delivery to the vast population of that country, half living in rural areas. And now we have our first conference in South America, here in Brazil.

Over the past few weeks I have had the opportunity to read the new WONCA Rural Medical Education Guidebook, written by members of the WONCA working party on rural practice. One of the privileges of being WONCA president is that I get to see some things first. I am going to quote from some of the authors during this presentation.

The book is a wonderful contribution to the medical literature and captures the essence of rural medical practice around the world and the key principles that underpin the work we do as family doctors and medical educators and primary care researchers based in rural areas in each of our countries. My congratulations to the editorial team of Bruce Chater, Jim Rourke, Ian Couper and Roger Strasser who have done a marvellous job bringing together so many viewpoints from our colleagues from around the world.

As family doctors, we are all indebted to our teachers; our fellow family doctors who have taught us how to practice medicine in our communities using a combination of scientific knowledge and tender loving care.

Like many of you, I have been fortunate to have had some inspiring rural family doctors as my teachers and mentors during my medical career, and I want to pay tribute to my teachers and at the same time, to yours.

When I was a medical student at the University of Melbourne I spent my compulsory family medicine rotation with a rural doctor, Dr Don Cordner. Dr Don was an Australian football legend from the 1940s but when I was with him forty years later, he was approaching retirement and spent much of his day driving around his rural district north of Melbourne, mainly providing palliative care to a number of his patients who had grown old with him and who were being cared for by their family members during their final days in their own homes on their farms, with the support of Dr Don and a team of visiting palliative care nurses.

Dr Don’s kind, gentle manner, practical approach and unwavering commitment have been a lasting inspiration, and he opened my eyes to the privileged role family doctors can play in supporting our patients at the end of their lives and allowing them to die with dignity in their own homes, if that is their choice. This is our role in providing “last contact care” to our patients.

My experience with Dr Don has also driven my desire as a Professor of General Practice, and now as a medical school dean, to ensure that all my medical students gain some experience of rural family medicine, in the hope that some will take up the challenge of a career as a rural family doctor, and that the others will gain at least some understanding of life in a rural community and the challenges facing the patients they will inevitably treat from rural areas.

As a medical student I also had the opportunity to work with Australia’s Royal Flying Doctor Service, an amazing group of family doctors and primary care nurses who provide primary care and emergency medical care to people living in the most remote parts of our nation. I also discovered that I throw up on small planes when things get bumpy, so it was clear I wasn’t going to become a flying doctor after graduation.

After graduating from medical school I became a trainee in family medicine, and I spent part of my training working in a small Australian rural town called Dimboola with a solo rural family doctor, Dr John Pickering, who ran his practice with his wife, Annette. John was a classic rural family doctor, running his clinic and the adjacent small country hospital, delivering babies, performing surgery, managing emergencies, on call 24 hours a day, seven days a week, and practising medicine with care and genuine affection for his patients and his community. And his patients and his community loved him back. When John and Annette retired from practice, the township of Dimboola named the park in the middle of the town in their honour.

I also discovered the lengths rural communities will go to keep a doctor in their town. Each week I would be invited by one of the farmer’s wives to come and have dinner at their home. And each time they would sit me next to one of their unmarried daughters. In my case this strategy did not work.

Later in my training I had the opportunity to carry out my Doctor of Medicine research at Monash University under the supervision of one of the world’s best-known rural family doctors and medical authors, Professor John Murtagh.

And I had the opportunity to work with two family doctors who would go on to become world leaders in rural family medicine– Roger and Sarah Strasser at their clinic in Moe in rural Australia.

More recently I have been privileged to work as a family doctor with Indigenous people from desert communities attending the Aboriginal Medical Service in Alice Springs in Central Australia where I have been taught especially by the health workers from the local communities.

Our mentors during our medical training and subsequent careers influence the sort of doctors we become.

You may wonder why, with all this experience as a medical student and family medicine trainee and with wonderful mentors, I didn’t settle down and become a full-time rural family doctor for the rest of my career. The answer is a personal one. It was my sense of vocation. When I finished my family doctor training in the late 1980s, the HIV epidemic was at its peak in Australia with many people dying of AIDS. There was a lot of fear about AIDS and many people with HIV were experiencing discrimination from the medical profession and were finding it hard to find a compassionate doctor to take on their medical care. I felt I could do the most good as a family doctor by working with people with HIV and so I joined a community-controlled clinic providing care to people dying from AIDS.

But even then things looped back to rural medicine; I didn’t realize at that time that I would end up working later in my career in the Limpopo region in the rural north of South Africa, assisting with the establishment of primary care based HIV testing and treatment services and training a new generation of family doctors in the care of people with HIV.

If you wonder what an Australian family doctor looks like in the Limpopo, I wore a white coat at all times, so that people knew I was a doctor and would look after my welfare, and I wore a wide brimmed Akubra hat to keep the hot African sun off my head, and I carried a large stick, in case I was attacked by baboons.

All these experiences helped prepare me for my current role with WONCA. WONCA now has 118 Member Organisations representing over 500,000 family doctors in 130 countries around the world. The 500,000 family doctors represented by WONCA, and including all those of us here, each year have over 2 billion consultations with our patients. Two billion. That’s the scope of our current work and our influence.

But we need to do more. We need to work to ensure that every family doctor, every GP, every primary care doctor, joins us in our commitment to deliver high quality primary care to our patients and communities. And we need to expand our commitment to the education and training of family doctors and quality care and primary care research to the 80 nations of the world where WONCA does not yet have a presence.

In the words of our very first WONCA president, Dr Monty Kent Hughes, speaking to the first WONCA world council in 1972: “the future of our professional discipline will depend on our ability to work together in the service of humanity.”

WONCA provides the global voice of family medicine. We are also the eyes and the ears of global health care observing and listening to our individual patients and our communities and identifying their health care needs. And we are the head and the heart of global medicine – combining our scientific knowledge as medical practitioners with tender loving care. Indeed this is the Latin motto of several of the member organisations of WONCA: cum scientia caritas – “with scientific knowledge and tender loving care”.

WONCA represents you and your professional college or society at a global level. WONCA advocates for the important work you do every day in meeting the health care needs of your patients and your communities.

Why do we do this? Because family medicine is important.

Because the evidence is clear that health systems based on strong primary care, which includes strong family medicine, are the most efficient, equitable and cost-effective.

Because strong family medicine is the best way to improve the health of individuals, families and communities.

Because every family should have a family doctor who the members of each family can trust for their medical care and advice.

Because family doctors are part of the social fabric of our societies and we work to keep the fabric of health care together.

The family doctor has an important role to play in the life of every family in every community in every nation of the world.

In the opening chapter of the new WONCA Rural Medical Education Guidebook, Steve Reid from South Africa and his coauthors state, “The unique characteristic of rural medicine is the very wide scope of practice that is demanded of rural doctors.”

They reflect how “over and above the wide minimum scope of skills, rural practice in different places demands different skills sets for specific needs.”

And how “beyond the skills set, there is a choice of a long term commitment to a rural community, that develops into a sense of identity, which is linked to a working lifestyle, a network of relationships continued over time, and a particular landscape.”

In the words of Professor Ian McWhinney, one of the giants of our profession who passed away two years ago,“ideally, family doctors should share the same habitat as their patients.” This allows us to best understand the social context of our patients’ lives. This is, of course, especially true for rural family doctors.

Last August I visited rural family doctor, Dr Armine Tadevosyan, and her primary care team at their family medicine clinic in the rural village of Agarak in Armenia, about two hours from the national capital of Yerevan. Armenia lies between the Black Sea and the Caspian Sea at the crossroads of Europe and Asia. Dr Armine is a specialist in family medicine, and leads a team of four family medicine nurses and a midwife, and also supervises the work of two community nurses based in more remote villages, and a driver who is responsible for the clinic ambulance.

Together Dr Armine and her team provide comprehensive primary care to 3,500 people in their rural region. The gender of Dr Armine and her team reflects the dominance of women in community-based primary health care delivery in many of the countries of the former Soviet Union.

In a wonderful chapter in the new WONCA Rural Medical Education Guidebook Susan Phillips from Canada challenges the stereotype of the rural doctor as a “rugged male”. Susan did a search of Google images and described her findings.

Susan states, “The typical picture of the family physician and, the rural doctor in particular is the rugged male.” Susan goes on, “Although hardly scientific, a Google search of why doctors choose rural practice unearthed many images of male physicians hiking across fields and forests (often wearing stethoscopes), riding horses, or roasting pigs on a spit. On those rare occasions when women are pictured, they are at work, smiling at children, and wearing those white lab coats most of us abandoned years ago. A recurrent picture is what might be labelled ‘The Big Fish’, not because the doctor gets to be ‘a big fish in a small pond’ (a role some might seek) but because the man pictured (the rural doctor) is holding his catch of the day – a big fish!

Susan says, “Such images deter young female doctors from rural practice. If learners do not see themselves in their preceptors or work mentors, they will avoid such practice settings. Yet while the icon of the rural physician is stereotypically male and not inviting for women, Canadian women are drawn to remote practice with the same frequency as men. Perhaps the survey identifying the attraction of the rural setting as ‘a place to make a difference’ has greater explanatory value than does ‘the big fish’ for why women physicians might choose to leave the big city.”

While our clinics may be different from country to country, what is important is the way we are the same – through our commitment to comprehensive, continuing, coordinated whole person care. Through care that is person-centred, and family and community-oriented. Through first-contact care, acute care, chronic disease management, prevention and health promotion. And through our understanding of the interplay between population health and the health of individuals in our communities.

The new WONCA Rural Medical Education Guidebook also highlights the work of Professor Barbara Starfield who showed through her research comparing health systems in many different countries, that comprehensive care by generalist doctors is not only more cost-effective, but also leads to better health outcomes at a population level than compartmentalized narrow specialist care.

Barbara provided us with the evidence of the benefits of primary care in lowering the cost of care, improving access to services, and reducing the inequities in a population’s health.

I last met with Barbara a few months before she died in 2011. Barbara was keen to talk about the biggest challenges she saw for family medicine in the future, and what WONCA, and what Michael Kidd as the incoming president, should be doing. I wrote it all down and here is Barbara’s last message for WONCA:

“Here are the three challenges I think you should focus on:
“How do we develop primary care research to address the challenges of care for people with comorbidities?
“How do we truly adopt patient-centredness into family medicine?
“How do we use the information from primary care to improve population health?”

There is enough in that simple statement for a dozen PhDs in family medicine.

Barbara recognised the failure of guidelines to accommodate comorbidity and multimorbidity and the need to turn our evidence-base upside down.

Barbara recognised that primary care is person-focused, rather than disease-focused and that our health systems need to be reformed to focus on person-centred care and to embrace our greatest allies in family medicine – our patients.

And Barbara recognized the power of the information that we are starting to collect through digital means in primary care and how this can be used to improve population health? We need to build our own evidence base from primary care. And where do we get this evidence from? The answer is right in front of us. It is from our encounters with our patients. In the words of immediate past WONCA president, Rich Roberts, “If we want evidence-base practice, we need practice-based evidence.”

Research like this is critical to family medicine. We all appreciate that research is a core component of family medicine training, scholarship and clinical practice in all our nations. Our WONCA working party on rural practice has recognised that we need research that is conducted in rural family medicine by rural family medicine researchers to identify the special challenges of rural family medicine.

Dr Yin Shoulong is a rural general practitioner in Tai Shitun Village in China, who hosted my visit to his clinic last month. Tai Shitun is in the Mi Yun District, two hours drive north of Beijing and a very different world from the densely populated metropolis to the south.

Dr Yin lives in a typical Chinese rural village house built around a central courtyard with his clinic occupying one side of his home. His patients are from his farming community and many are impoverished and elderly and frail.

Dr Yin has devoted his career to supporting the health and well being of the people of his village and the surrounding district. Recently he has become involved in providing experience in rural medicine to young family medicine trainees on rotation from the Capital Medical University in Beijing. He is part of the primary care revolution underway across China.

China has embarked on a massive drive to train and recruit up to 400,000 general practitioners in the next seven years in order to reform the country’s health system to meet the current and future needs of the population, especially the 800,000,000 people living in rural areas.

The reforms underway in China will have implications for the rest of the world, and especially for those countries where family medicine is not yet well established. The Chinese Government recognizes that one of the biggest challenges is training the family doctor workforce to meet the needs of rural China. If the rural challenges can be met with success, then this should provide lessons that will flow to many other parts of the world facing the challenge of providing universal health coverage. This bold initiative by China needs to be supported by solid research and evaluation.

Last October I was invited to another of the world’s most populous nations to speak at the 50th anniversary of the Indian Medical Association College of General Practitioners.

India, like many nations, has a focus on strengthening primary care and has recognized that universal coverage, especially in rural areas, will only succeed with strong teams of health practitioners working together with communities to provide high quality primary care and that family doctors are an important part of this solution.

There has been a recent commitment by the Indian Government to ensure every medical student has experience in family medicine and to support postgraduate training in family medicine. It is recognized that these are important reforms that have delivered great improvements in the quality and availability of well trained family doctors in other parts of the world.

The Indian Government recognizes the need to continue to grow family medicine, the need for qualified family doctors to serve the needs of both urban and rural communities, and the need for “the medical students and young doctors of India to enter family medicine by choice, and not by chance”.

One of the leaders in the establishment of WONCA, and the first person ever to be awarded WONCA Fellowship, was Dr Prakash Chand Bhatla from the Indian Medical Association who once wrote that “Education and motivation of the community has to be done on a personal basis. And who is nearer to the community than the family doctor?”

Who is nearer to the community than the family doctor? As family doctors we need to be engaged by our governments and international health organisations in the planning and delivery of national and local health programs. Family doctors are part of their local community and have the trust of their local community and can be part of ensuring the successful delivery of health programs, especially to the most vulnerable members of our populations.

WONCA calls for a family doctor for every family. This means that every family has access to a caring committed family doctor working with other primary health care providers, including dedicated nurses and midwives and community health workers, to provide comprehensive continuing care to all people.

And by family I mean family in its broadest context. Not just families with a mum and a dad and 2.3 kids and a dog. We provide care for every member of every family in the global family. As family doctors, we don't discriminate. We care for all families - nuclear families, extended families, rich families, poor families, gay families, sad families, and families of just one person.

Family is also important for rural family doctors. As Steve Reid and his colleagues remind us “Family issues hold particular value, and the spouse of the rural medical practitioner is often a crucial partner in the sustainability of rural practice. Bringing up children in a rural environment is an enormous benefit when they are young but becomes more challenging the older they get. The lack of high quality education is a deterrent to health professionals with families living in more isolated areas and thus has an effect on health care delivery.”

Last April I visited Indonesia and this rural family medicine clinic, called a puskesmas, or Primary Health Center, on the island of Timor, about an hour north of the city of Kupang. This clinic delivers primary care services to the members of the local community and also includes a birthing centre which has led to a substantial reduction in the rate of infant and maternal mortality in the region.

But this clinic has serious challenges due to its isolation. The electricity supply is patchy at best and blackouts are frequent. There is no running water. Water for the clinic is drawn from a well. I had never drawn water from a well before and enjoyed the novelty of hauling up buckets of fresh clear water from deep below the earth’s surface. My hosts informed me that the novelty wears off very quickly.

As Steve Reid reminds us “Working in a rural community where resources and technology are not immediately accessible requires practitioners to make the most of whatever is available, often under challenging circumstances. The unique preserve of the rural practitioners is the flexibility demanded by the principle of “any patient with any problem, anytime and anywhere”. Dealing with uncertainty and balancing relative risks is a central part of the job.”

There are those who say that family medicine has no real role to play in low and middle-income countries. Well we have blown that theory out of the water. Last year the Director-General of the World Health Organization, Dr Margaret Chan, launched WONCA’s new guidebook on the contribution of family medicine to improving health systems. The guidebook includes the chapter from the WHO showcasing the research into the impact family medicine is having in improving health outcomes in many middle income nations including Brazil, China, Thailand and countries of the Eastern Mediterranean region. And there is a chapter outlining the remarkable work that is underway across Africa to strengthen family medicine, especially involving WONCA member organisations within Africa supporting developments in neighbouring nations.

What these developments demonstrate is the need to strengthen the whole health care workforce, including family doctors, community nurses, community health workers, and traditional birthing assistants, and support working together to deliver appropriate care to all people. People in low income countries still want and deserve access to health care, access to caring clinicians, access to life saving medications.

But serious health care delivery challenges can occur in any country. Last month I was invited by rural family doctor and Professor of Family Medicine, Ryuji Kassai, to visit communities in the Fukushima region of Japan affected by the 2011 tsunami and the nuclear reactor disaster.

We all remember the tragedy of the March 2011 tsunami that hit the Pacific coastline of Japan following an earthquake, killing thousands of people and destroying coastal towns and villages. And the global fears that followed when the damaged Fukushima nuclear power plant exploded releasing radiation into the atmosphere. The radioactive contamination resulted in over 100,000 people being evacuated from their homes and a 50 kilometre exclusion zone was established around the damaged nuclear plant and the path of the radiation fallout. Ryuki shared his experiences at that time through a widely-read blog published on the website of the British Medical Journal.

I was keen to learn about the role local rural family doctors and their teams are continuing to play in assisting in the recovery of the surviving members of the devastated communities. It was a sobering week.

Three years later, the evidence of the damage caused on that terrible day remains. Many people still live in temporary housing and are prohibited from returning to their abandoned homes. Many people, especially young families, have moved away to other parts of Japan. Many elderly people left behind grieve for their missing families, their lost homes and their lost way of life. 200,000 affected people are being followed up regularly in special clinics set up to screen for problems related to radiation exposure.

The coastline is desolate, having been cleared of the ruins and debris that was all that remained of coastal cities and rural communities and the surrounding forests destroyed by the tsunami. The villages have gone, the farms have gone, the forests have gone. It is like there has never been anything there. The exception is the exclusion zone around the nuclear reactor where the damage from the tsunami is still visible with damaged buildings, upturned cars and fallen trees. Whole villages that survived the tsunami but were subjected to radioactive fall out are now ghost towns with deserted homes and shops with empty windows and no sign of life. The local rural family doctors tell me that, for many elderly survivors, the impact of lifestyle risks may be worse than the radiation risks, due to increased alcohol use, poor diet and obesity, and related mental health problems and risk of self-harm and suicide

This visit was a stark reminder of the challenges people face in rebuilding their lives and their communities following catastrophic events. And the huge impact such events have on the physical and mental health of each affected person. But I also had the privilege to visit rural family doctors of this region and discuss the roles that family doctors and the members of our teams can play in supporting our communities during and after such devastating events.

I met young rural family doctor, Dr Hiroshi Takayanagi, who is based at the Kitakata Centre for Family Medicine in Fukushima Prefecture.

Hiroshi works with his elderly patients to seek to reduce the impact of the forced relocation and social isolation. He has seen many of his patients experience worsening of dementia and development of depression and anxiety. Others have sought to find solace in overuse of alcohol or in poor nutritional choices leading to a rise in liver disease and obesity. Some public health experts believe the health impacts on many elderly people would have been less if they had been left to live in their own homes, regardless of the nuclear contamination.

It is in times of community peril that family doctors often rise to the challenge and often do so brilliantly. Bruce and Anne Chater hit the headlines in Australia in 2010 when their hometown of Theodore was threatened by serious flooding. Bruce and Anne and their family made sure all the people of the town, including the elderly and the frail and their beloved pets, were all evacuated safely before the flood waters arrived. Bruce was the last person to leave before the floodwaters engulfed their town and destroyed their clinic. And Bruce and Anne were the first ones back, setting up a makeshift clinic where Bruce looked after his patients for many months before a new clinic was available. Bruce and Anne are true heros of rural medicine. They demonstrated their care for every single member of their community. This is universal health coverage in action.

Universal health coverage has been part of the charter of the United Nations since 1948. Universal coverage does not mean meeting the needs of 80% of the population – it means ensuring that health care is available to everybody.

One of the countries leading the world in strengthening family medicine to ensure that health care is available to all people is Brazil. Brazil is the global leader in addressing universal health coverage through family health teams of doctors, nurses and community health workers. In November, in one of the favelas, or shanty towns, of Rio de Janeiro, I had the opportunity to visit one of the primary care clinics established to meet the health care needs of the poorest people of that great city. I was accompanied by Inez Padula, our WONCA president for the Iberoamericana Region.

At this family medicine clinic I met with young family doctor Euclides Colaço and his colleagues. Euclides works with a family medicine resident, two nurses and six community agents, or community health workers, providing comprehensive clinic-based and home-based care as a team to a defined population of 4,500 people.

This visit allowed me to see the renowned “Family Health Team” model of Brazil in action. Euclides and his team are expected to know about the health status of every single person living in their area. The community health agents have a key role to play; they go out into the community and visit everybody and bring those in need of assessment and assistance to the clinic, or the community health agents escort the doctor or one of the nurses on a home visit. This is true comprehensive primary care delivered to an entire community. And there are over 33,000 such teams in operation across the entirety of Brazil. It is a very impressive model.

The government of Brazil is seeking to expand the model further through its Mais Médicos (More Doctors) scheme to ensure that everyone of this country’s 200,000,000 citizens, and especially those based in rural areas, will have access to the high quality primary care provided through a well-trained and well-supported family health team. Part of this initiative involves improving the postgraduate training of family medicine doctors. Another part involves the upskilling of the existing doctors working in the community across Brazil.

Last century, the United Nations had a target of ensuring health for all people by the year 2000. Clearly we did not meet that goal.

Last September I attended the United Nations General Assembly in New York, representing WONCA at a summit called to examine progress in meeting the Millennium Development Goals (MDGs), and to discuss what happens beyond the end of 2015 when the current MDGs conclude.

You may be aware of the MDGs. They are eight aspirational goals, agreed by all the world’s countries in 2000, which aim to halve extreme poverty rates by 2015, provide primary school education to all children, empower women, reduce infant and maternal mortality, combat HIV, tuberculosis and malaria, and ensure the sustainability of our environment.

The MDGs have galvanized unprecedented efforts across the globe to meet the needs of the world’s poorest people. And progress has been impressive with rates of extreme poverty halved ahead of schedule, and significant reductions in infant and maternal mortality and HIV infection rates in many countries, with millions of lives saved through reductions in preventable deaths.

Among the key messages that I took away from the United Nations summit was how success has occurred only when there has been both national and local ownership to give the MDGs traction, and the importance of allowing the local adaptation of the MDGs to target local conditions. And it was no surprise to be reminded that developing countries want capacity, not charity – and that building self-reliance is critical; this is a key role for WONCA in our support through our member organisations for education and training for the members of the family medicine workforce in every nation.

The MDGs have also come in for criticism because of what is missing. They don’t have a specific focus on rural communities, they don’t tackle the need to strengthen the primary care basis of each country’s health system, or to tackle chronic disease or mental health, or to address the social determinants of health, or to ensure universal health care access for all people in both rural and urban areas. This is part of the challenge looking beyond 2015. What should be the focus of the next set of global challenges?

As the world debates what happens next, with the clamour of thousands of interest groups and self-interested industries, WONCA needs to ensure the clear voice of family medicine on behalf of our patients and communities continues to be heard during these debates. 
We need to be clear about our role as family doctors in working with our patients and communities to increase life expectancy and achieve equitable outcomes. 

And we need to support the focus on the social determinants of health and how we ensure marginalized populations, those groups of people in our communities most at risk of poor health, are not excluded from health care.

People-centred care is a core component of universal health coverage, and there will be an increasing role for family medicine over the coming few years in many countries to ensure this happens.

So how do we as family doctors meet the challenge of meeting the health and wellbeing needs of the many diverse communities around the world? We do so by continuing to adapt to changing health needs and expectations.

Fortunately one of the greatest strengths of the people working in family medicine is our diversity, our community leadership, our resilience and our unwavering commitment to our patients and our communities. These are qualities that we need to reinforce and cherish.

This is the chart of life expectancy in the nations of the world – as you can see there is significant disparity in life expectancy based on the accident of where you are born. A difference of more than half a century between the highest and the lowest. Two and a half times the life expectancy for one over the other, all based on the accident of where a child happens to be born. In 2014, we have to do better than this.

Family medicine, as a component of primary care, has the power to play a transformative role in the shaping of societies. We have the power to tackle this disparity and transform the world we live in but we’ve got a lot to do.

WHO Director General Dr Margaret Chan has become a staunch supporter of family medicine. At a meeting in Hong Kong last December she stood up and proclaimed, “I love family medicine”, which didn’t please some of our colleagues from other medical specialties in the audience.

Dr Chan has recognised the value of family medicine and our contribution to primary health care. Dr Chan has also recognised that primary care is not cheap and must not be a “B-team” version of health care delivery.

In order to provide universal coverage, our countries need to stem the costs of health care, and can do so through increasing investment in community-based health services. And at the same time there must be a movement of funding from hospitals to the community, and especially to rural communities, rather then expecting more community-based care to be delivered with no increase in resources.

We need to work with our global partners, the WHO, the World Bank and others to bring high quality primary care to the one billion people on this planet who currently have no access to any health care at all, many of course living in rural areas.

The same model of care is not going to work for each community. Which is why family medicine is so important. We have the capacity to adapt to our community needs.

We know that those at the greatest distance from health facilities often receive the least care, as reflected by UK family doctor Julian Tudor-Hart’s in his concept of the ‘Inverse Care Law’ first described in 1971.

In his chapter in the guidebook, my old friend Campbell Murdoch twists the Inverse Care Law a little. “It was said in my home town of Glasgow that the quality of care in general practice was inversely proportional to the distance to the nearest teaching hospital. Certainly it has always been noted that practitioners who work in rural and remote areas develop knowledge and skills which are widely admired. However it was only when shortages of such skilled physicians began to appear that such people and places became regarded as a source of medical education. “

Many of our countries are responding to the global impact of health system reform that is shaking up the delivery of primary medical care around the world and this brings about challenges for the training of family doctors.

Many of us are linked to medical schools and universities that have a strong focus on social accountability and preparing our medical students to work where they are most needed. My own university, Flinders University in Australia, is no exception.

Charles Boelen and Bob Woollard in their work developing global consensus on the social accountability of medical schools have reminded us that “A medical school has a mandate to be socially accountable to the funders and the population where it is located, and to the nation. Medical training can be successful if it is associated with an effective health care system - and an effective health system is dependent on successful medical training program.”

Many countries have large numbers of general doctors, especially in rural areas, who have received no postgraduate training but who wish to be recognized as specialist family doctors. We need to embrace all our colleagues in primary care. We need to find innovative ways that work in each of our countries to upskill and support the professional development of our peers. We can’t afford to disregard the contributions of all doctors working in primary care.

At the same time we need to develop greater clarity around how we educate our future family medicine workforce to ensure we meet the future health care needs of the people of each of our nations.

We need to better support our rural family doctor trainers and teaching practices and provide incentives and motivation for those who don’t teach at present to join us. After all teaching the next generation is a fundamental responsibility of each medical professional as part of our Hippocratic tradition.

And the training we provide to our rural family medicine trainees must be based in rural primary care. Effective training for family medicine does not take place on the medical and surgical wards of major teaching hospitals in big cities. Our trainees are not fodder to carry out the menial tasks of other specialists. The training of our future family doctors needs to be based in our communities working as members of primary care teams.

As Michael Jong from Canada reminds us in his chapter in the guidebook, “Training of the medical workforce is best done in the setting that best approximates their future practice. Training rural doctors is best done in rural communities.”

And do not underestimate the opportunities for our medical students and family medicine trainees to make a difference to health care and to outcomes while they are students and trainees. The key is to give our learners enough space to be the amazing creative individuals they are.

In 2003 the WONCA Working Party on Rural Practice released a policy in 2003 on the Health of Indigenous Peoples, which recommends that health professionals receive education and training in cultural awareness so that we are competent in the care we provide to our Indigenous patients. It is important that all those involved in educating health professionals are trained in diversity and cultural awareness. This is some of my colleagues working in Indigenous Health in Central Australia. Last year, in a historic move, WONCA has established a new working party on health issues for Indigenous people and minority groups, led by Tane Taylor from New Zealand.

The paramount responsibility of WONCA, and of each of our member organisations, is to our patients and our communities. Family doctors, no matter where we work, ensure that health is affordable, safe, appropriate and equitable.

Something Iona Heath, former president of the Royal College of General Practitioners in the United Kingdom, said a few years ago really struck a chord with me, “I believe that general practice/family medicine is a force for good throughout the world.”

I am impressed with the commitment of family doctors to human rights issues. I am convinced that family doctors right around the world care about human rights. The basic expectations we all have about how we and our families and all people should be treated.

As family doctors we have social responsibilities. Each of us needs to be an advocate for social justice and human rights.

We need to speak out for what is right, to say “this is not OK”, and in so doing contribute to social change.

We need to contribute towards ensuring equity of access to health care – “a fair go for everyone”

And we need to care for the health of our planet as well as the health of our patients. What is good for the climate is also good for our patient’s health – reducing obesity, increasing physical activity and healthy improvements in diet.

After all if we, as family doctors, with our privileged position in society, and our access to pretty much the entire population in our communities, don’t stand up for these things, who will?

As family doctors we all work hard. I know that many of you work under very difficult conditions, that the resources that you need to do your job are often not available, that the hours you work and the demands on your time can be arduous, that your resilience is tested regularly. And we often feel unappreciated. And don't often hear the words thank you. It is why WONCA has established World Family Doctor Day, held on May 19 each year, to acknowledge the important work that we do.

So today, on behalf of the 2 billion people around the world who benefited from your care and support over the past year I say thank you. Thank you for your commitment to being a great rural family doctor. And thank you all for the important work that every single one of you does every day providing health care to the people living in the rural areas of our world.

I hope to see you all back here in Brazil in 2016 at WONCA’s next world conference.

Thank you. Obrigado.