Rural Round up: It’s all about the people!

This month's Rural Round up is written by Prof Ian Couper of South Africa. He is Director, Centre for Rural Health and Academic Head, Department of Family Medicine, University of the Witwatersrand, South Africa. He is also Immediate past chairperson, WONCA Working Party on Rural Practice. Find out more about Ian Couper

During the second half of this year (2013), I have had the privilege of spending some sabbatical time in North America. I was based for three months at the University of Washington (UW) in Seattle, in the Department of Family Medicine, which is under the sterling leadership of fellow rural working party member Dr Tom Norris. It was encouraging to interact with folk from UW who are making a difference to the health care needs of the northwest of the USA, through two programs.

The WWAMI regional medical education network, which covers Washington, Wyoming, Alaska, Montana and Idaho (hence WWAMI), provides distributed and local MD training for and in the five states. WWAMI aims to meet the health care needs of the region, make public medical education accessible to residents of these five states, and encourage graduates to choose careers in primary care medicine and locate their practices in non-metropolitan areas of the Northwest. It has been going for over 40 years now (it celebrated its 40th anniversary in 2011), and continues to make an impact on the human resource needs of this largely rural region, which accounts for 28% of US land mass, but with only 3.5% of the population. Further decentralisation to regional campuses is part of current curriculum renewal.

UW’s MEDEX program has been training physician assistants for 44 years. MEDEX focuses on expanding access to healthcare for the medically underserved and in rural and remote settings throughout the five-state northwest service region. The program is committed to educating experienced health personnel from diverse backgrounds to practice medicine with physician supervision. The passion and enthusiasm of the faculty team for the mission of MEDEX was inspiring.

It was great to see how two programs that were pioneers have continued to be clear in their commitment to underserved, rural and remote people in need of health care, while at the same time innovating, adapting and renewing their programs continually. A key for me is the people who are part of these programs. I asked Terry Scott, PA program director, about this, and he said it is absolutely the people – people who have served over many years with dedication and new staff coming in because they are drawn by the vision of the program. This accords with what Jim Collins says in his book “Good to Great1 , that the starting point for going from good to great is to focus on the "who" not the "what"; that is, make sure you have the right people in place, and then develop your vision with them.

While in Seattle, I also visited Montana (I had previously visited Alaska), and was invited to spend time at the Northern Ontario School of Medicine and Memorial University of Newfoundland Medical School in Canada, both examples of socially accountable, rural-focused institutions. All over I found people engaged in exciting, innovative work. I met a particularly inspiring group of rural doctors in Labrador, a key leader amongst whom is Dr Michael Jong. (Michael let me have some fun on Rosie the Robot, to see how he and his colleagues can give support to remote health care centers through internet-based robotics!) Once again, there I saw young people being drawn in because they can see the commitment and enthusiasm of their mentors.

Through these experiences I was reminded again of two factors that I constantly return to in terms of understanding key issues in rural health care, globally and locally, and how we respond to them. Firstly, there is a significant degree of commonalty in the issues we face around the world. Yes, the resources to meet the needs are very different; I can only look at what rural folk in the US and even more in Canada have access to with a degree of envy and frustration – yet when I go to Mozambique and Malawi, I come back thankful for all that I have access to in South Africa, so it is all relative. Despite this, the challenges are essentially the same. There are fewer physicians (of all types) and health professionals in general in rural areas compared to urban areas – it is the degree of both the absolute numbers and the differentials that vary around the world – and rural people have poorer access to the range of health care services, and also to other social and educational services, usually associated with poorer health status. This is the major focus of advocacy for rural health.

Secondly, no matter what systems one puts in place, and how much money and technology one throws at the problem, the heart of the problem - and the solution - is people. We need dedicated and committed health professionals who are prepared to serve rural communities – for whatever reason and in whatever way. We know that the issues of selecting rural students and providing rural training are essential contributors in this process. However, there is a spark that I see all around the world in rural doctors that I meet, who are doing amazing things in challenging environments. That spark cannot be taught – hopefully though it can be caught, where there are role models and mentors. Can we choose to train people who already have that spark? That would be great, but the challenge is identifying them. Some of the graduate entry programs that select medical students with life experience may do that better than others; certainly the MEDEX PA program makes a point of doing that, with good effect.

As for me, all I want for Christmas is to see more and more sparks setting alight a fire of passion for making difference in the lives of rural people.
1. James Collins. Good to Great: Why Some Companies Make the Leap... and Others Don't. New York: HarperCollins, 2001