Health Cover

A Two-tier System

Rural Canadians have less access to health care

Chris Wood June 7 1999
Health Cover

A Two-tier System

Rural Canadians have less access to health care

Chris Wood June 7 1999

A Two-tier System

Rural Canadians have less access to health care

Chris Wood

in Port McNeil

The small Bell JetRanger B206 helicopter bucked gently in the wind and put its nose down into the oncoming cloud. Through scattered holes in the curtain of white, the pilot and two passengers caught glimpses of rugged wooded slopes below, rising rapidly. Suddenly, a bank of heavy cloud seemed to thin and treetops abrupdy appeared, barely 10 m beneath the choppers twin skids. Then, the ridge fell away, opening up a spectacular view of Nasparti Inlet on Vancouver Islands remote and lovely northwest coast. Fifteen minutes later, the helicopter settled onto a baseball diamond in the isolated logging community of Zeballos, B.C., and Dr. Bob Taylor strode across the wet grass to begin his clinic.

Wednesday is doctor day in Zeballos: the one day a week when Taylor or a colleague from Port McNeill, on Vancouver Islands more populous east coast, flies out to the hamlet of 450. One Wednesday in late May, a handful of people were already waiting in the community’s neat new grey and white clinic to see Taylor. Nuu-chah-nulth First Nation elder Arnold John had travelled half an hour by open boat from his home at Queens Cove, almost 30 km away by sea, to consult the doctor about his diabetes. Patricia John was there with her daughter Desiree, an active two-year-old who gives no sign she underwent open-heart surgery last August. This was their only chance to see a doctor without braving a lV2-hour drive over tire-shredding logging roads to Port McNeill, or an even longer trek to the bigger centres of Port Hardy or Campbell River.

Zeballos is one of Canada’s more remote settlements, but its residents are far from alone in having little access to the kind of health care taken for granted in the cities included in the Macleans ranking. In every province, rural doctors are becoming increasingly vocal, pointing to shocking declines in their numbers, an erosion in morale resulting from overwork, isolation and burnout, and vanishing access to their patients’ needed secondary and specialist care. Doctor-patient ratios tell part of the story. One doctor serves every 200 people in urban Canada. In rural areas, that ratio slides to one for every

800 people. The nine million Canadians living outside major centres also have shorter life expectancies and higher mortality rates than their urban cousins. Max Blouw, a geneticist at the University of Northern British Columbia in Prince George, who will host a national conference on rural health this autumn, reaches a pointed conclusion. “From the perspective of people who live in rural areas,” he says, “there is already a two-tier health system: rural and urban.”

The physician shortage is the easiest disparity to identify. Across the country, rural populations have stopped falling and even begun rising as aging boomers discover retired life can often be cheaper and more pleasant in the country. But Canada-wide, the number of doctors serving that population is dropping—by 15 per cent between 1994 and 1998,

Continued after advertising supplement

according to a study published last year. The decline continues: British Columbia alone lost an average of more than two country doctors each month between last June and the middle of March (329 remain out of 349 a year earlier). “Some provinces,” concluded the national study’s author, Dr. Peter HuttenCzapski of Haileybury, Ont., “have undergone a physician attrition rate that spells rural extinction by 2006 if it continues.”

Those who remain have begun to fight back. After 22 beleaguered doctors in five small northern B.C. communities withdrew emergency services last year, the province accepted a consultant’s recommendation to pay them extra for being on call. It also agreed to pay their bonus temporarily to other physicians, allowing rural doctors much-needed time off to upgrade skills or recharge batteries.

More quietly, small-town physicians across Canada are embracing the Internet to end their isolation, creating a surprisingly effective new national voice for rural health care. “I have more in common with a doctor in Port McNeill than I do with people in city practice in Ontario,” says Dr. Patricia Vann, who works in Dryden, Ont., 300 km northwest of Thunder Bay. Vann is president of the Society of Rural Physicians of Canada, founded in 1993. With more than 800 members, it has flourished in cyberspace, sponsoring online discussion groups and a professional journal that lets rural physicians exchange ideas. The ability of country doctors to get together on the Internet, says Vann, has encouraged them to act on their shared sense of being under threat. “Things have gotten so bad,” Vann says. “We’re in rural practice because we enjoy what we’re doing, and we enjoy the communities we’re part of. We see things starting to crumble around us.”

The rural doctors have plainly caught at least one ear that matters. Last August, the society Vann heads urged Health Minister Allan Rock to name a senior adviser on rural health. Acting the following month, Rock named Shawville, Que., physician John Wootton as the first executive director of a new national Office of Rural Health. The veteran country doctor says his appointment was “a recognition that there is a real rural-urban disparity in access to services. It is a national problem.” As well, February’s federal budget dedicated $50 million to rural health care over the next three years.

Vann’s group is also pushing for change on other fronts. It has secured the College of Family Physicians of Canada’s approval of a model curriculum for medical schools to use to turn out more qualified country doctors. The group is also putting pressure on licensing boards to relax the profession’s prevailing province-by-province licence system. Instead, it wants doctors with rural medicine skills to be able to provide relief for colleagues in more than one province.

But beefing up the number of physicians alone will not reverse the erosion of rural health care. When even the largest urban centres are feeling the stresses of long waiting lists and

overloaded hospitals, the cascading pressures are felt most acutely at the margins: in the small communities that are constantly at the losing end of one centralization scheme after another. In rural Ontario, as the number of hospitals delivering babies dropped by 20 per cent between 1988 and 1995, residents increasingly found the procedure available only in larger and more distant centres. And those centres can be overwhelmed. In mid-May, the regional hospital in Campbell River—where Port McNeill is supposed to direct cases it cannot handle— advised the five smaller hospitals that depend upon it that it had no free beds for any medical category other than obstetrics. Four days later, obstetrics, too, was closed to admissions. “It happens two or three times a month” says the hospital director of acute services, Linda Latham, “usually for 16 to 24 hours.”

Nor will more doctors ease the load on front lines that are often staffed by other overworked, overstressed practitioners. At Holberg, another stop on the Port McNeill clinic’s flying circuit, nurse Elizabeth Frost provides the local medical care for 200 people. “I have no replacement here,” says Frost, who is on call 24 hours a day. “I get very stressed having no professional colleague to talk to.”

Technology may provide a partial answer. Several provinces

have experimented with tele-medicine—linking patients in smaller hospitals or clinics to specialists in larger centres through data lines and videoconferencing. Nova Scotia has gone furthest: its $8-million network to link 42 hospitals, including the region’s major medical centres in Halifax, was completed at the end of March. Among other capabilities, it allows a doctor in Halifax to examine patients in outlying communities by remotely controlling a video camera mounted in an examination room. The technology promises to save patients and their families coundess hours travelling to and from Halifax to see specialists.

But sometimes only a face-to-face meeting will do. While a troubling number of communities struggle to retain or attract physicians, Port McNeill is holding its own better than most. As well as their flying doctor service, its five physicians conduct research on rural medical practice and teach outpost skills to University of British Columbia medical students. And just about every Wednesday, depending on the weather and the winds in the misty ranges of the wild west coast, a doctor flies to Zeballos.

Doctors in distant settlements are fighting their isolation by embracing the Internet and tele-medicine