Amid the unending stream of COVID-19 news (see the 17 March statement from the Australian Health Protection Principal Committee), it’s easy for the voices of rural, regional and remote communities to be drowned out.
Marie McInerney investigates a range of ways the pandemic is already affecting people living outside of the metropolitan centres.
Marie McInerney writes:
Australian rural and regional health professionals are sounding an urgent warning that they are at the “tail end” of the supply chain for staff and resources in national pandemic planning and risk “catastrophic scenarios” from outbreaks of the coronavirus.
Doctors told Croakey that general practices were being “overwhelmed” by anxious people wanting tests or saying employers required them to be tested, were running out of personal protective equipment (PPE) and desperately trying to manage risks for the limited health workforce so they didn’t get sick or have to self-isolate.
Pharmacies were running out of essential medications, including for diabetes, asthma and hypertension, because of supply issues, panic buying and upstream hoarding, and one local hospital at least was preparing significant bed numbers for “palliation”, they said.
Cases of coronavirus in rural and regional Australia have been reported in Orange in western New South Wales and Launceston in Tasmania, which have prompted immediate warnings that an outbreak of the virus will only amplify existing shortages, including of health professionals.
While people living in more crowded urban environments may have a higher likelihood of being exposed to COVID-19, they may also have better access to care, said Alison Verhoeven, chief executive of the Australian Healthcare and Hospitals Association.
“At a state level, there is connection across all the regional hospitals and health services, but their access to testing, protective equipment, ICU beds, specialist workforce etc will likely be as limited as it is in normal circumstances,” she said.
And there is a new threat, with reports that supermarkets in country towns have been raided and depleted by city residents, arriving by the busloads and stocking up on groceries that are hard to find in metropolitan stores (see responses to the tweet below here).
Stakes high for Indigenous communities
There are also big concerns for at-risk groups and regions, particularly Aboriginal and Torres Strait Islander communities who were hit disproportionately hard during the H1N1 virus outbreak in 2009.
The Anangu Pitjantjatjara Yankunytjatjara (APY) Executive Board on Wednesday encouraged all Anangu to stay at home until further notice and not be encouraged to attend large gatherings, including funerals. It said access to outside agencies would be restricted to essential only.
The Aboriginal Medical Services Alliance of the NT (AMSANT) has called for much stronger government measures to reduce the risk of the spread of COVID 19 into Aboriginal communities by providers of non-essential programs and services.
AMSANT also wants the Federal Government to suspend the participation requirements for the Community Development Program (CDP), saying they represent “a recipe for disaster”.
“The stakes could not be higher,“ said AMSANT CEO John Paterson in a statement. He said the risk factors for COVID-19 are greater than the H1N1 virus in 2009, which resulted in death rates among the Aboriginal and Torres Strait Islander population six times higher than the non-Indigenous community and the need for ICU admissions 8.5 times higher.
This week the Lowitja Institute, the national institute for Aboriginal and Torres Strait Islander research, warned that the systemic failure to ensure appropriate environmental health and safety within Indigenous communities, such as adequate housing and clean water, presents a particular risk in the face of the coronavirus epidemic.
Calling for any responses to the coronavirus to include engagement with — and resourcing of — community controlled health services, and respite for the Aboriginal and Torres Strait Islander workforce in remote communities, it also reminded mainstream services that “cultural safety is not an afterthought” at a time of crisis. It said:
“Past poor experiences in the health system have left many Aboriginal and Torres Strait Islander people feeling unheard and unwelcome. Unchecked biases, our own and that of others, can prevent care and treatment for Aboriginal and Torres Strait Islander people.”
National Rural Health Alliance CEO Dr Gabrielle O’Kane told Croakey that the coronavirus poses “unique challenges” for rural Australia and called for proper workforce planning by federal, state and territory governments to ensure that rural doctors’ surgeries and hospitals don’t become even more overwhelmed than they already.
“We know workforce shortages and poor access to health care are already some of the biggest health issues in rural Australia,” O’Kane said. “A coronavirus outbreak in a rural area will only make matters worse.”
On Wednesday, the Rural Doctors Association of Australia (RDAA) and Australian College of Rural and Remote Medicine (ACRRM) welcomed the Federal Government’s expansion of bulk-billed telehealth consultations by additional health professionals and distribution of more P2 masks to GPs and pathologists taking samples and conducting tests.
Under the changes, eligible patients who may not have access to video-conferencing at home will now be able to have a phone consultation instead, and previous limitations of needing to live at least 15 kilometres away from a specialist have been lifted. Bulk-billed telehealth consultations will now also be available with midwives for eligible patients.
There are also new bulk-billed telehealth items for GPs to continue to provide certain health services to their patients if they are required to self-isolate.
However, the groups said many more masks and other PPE, as well as test kits, are needed urgently in rural and remote communities and that, during the COVID-19 emergency, the wider general public should be able to access phone and video-consults.
“It is imperative that the needs of rural and remote communities during this emergency are not overshadowed by those of the cities,” they said in a statement. “The impact of coronavirus in smaller populations has the potential to be just as pronounced as in urban centres, especially given the poorer health profile of those living in rural Australia.”
Speaking in the midst of another 14-hour day at his GP practice in Emerald, 900 kilometres northwest of Brisbane, ACRRM President Dr Ewen McPhee said the biggest need is strong public health messaging “because at the moment we’ve got people panicking left, right and centre, getting stressed and distressed”.
Earlier this week his practice had about 30 people ringing in just one day to demand work certificates because a local mine site was taking all employees’ temperatures and telling them to get COVID-19 testing done to demonstrate they were fit to work, he said.
“It’s overwhelming small rural practices, because we’re trying to deal with not only the ‘worried well’, but sick people too. Employers are panicking, the community is panicking.”
That’s also contributing to shortages of medications and medical equipment for pharmacies that don’t have the buying power of larger pharmacy chains and where some doctors have ceded to pressure from patients for six month’s supplies of essential medications.
McPhee says his practice is down to its last PPE gown and running out of masks. “There’s been a run on the pharmacies, a run on the shopping centres, the employers are getting angry because we’re telling (unwell) people to stay home and rest…”
Unlike some others in the health sector, McPhee praised the work of Health Minister Greg Hunt and Chief Medical Officer Professor Brendan Murphy, saying they had “done a wonderful job in trying to deliver consistent messages”.
Murphy’s work had been “exemplary”, he said, and had included contacting him personally regarding policy changes.
But he said federal and state governments were relying too much on “talking heads” when robust and consistent public communications were needed where people could access them, including for people in rural areas who may not be able to access online sources.
That lack of clear communication to the public and employers was adding to the already stressful load on doctors like him. On top of trying to cope with big patient loads, they are also having to be involved in multiple meetings for disaster planning, and expending a lot of energy talking via social and mainstream media to the community about what they should do.
Pressure on rural hospitals, which are “at the end of the supply chain” on beds, staff and equipment meant it was likely that the army might have to step in with field hospitals.
“If we get a surge of patients, we’re likely to overwhelm both general practice and hospitals pretty quickly,” he said.
McPhee said a big risk and pressure for rural and regional health professionals, even beyond that experienced by their metropolitan peers, was keeping themselves well and at work.
He admitted the risk of infection was putting many “on edge”.
“If I go down, there’s no one to pick up my work,” he said.
That’s also been a big issue in proper planning, including at the national level, with the Health Department having insisted for too long on face-to-face meetings, he said.
McPhee said he had to opt not to attend a critical meeting for primary care pandemic planning in Canberra recently, because he could not afford to be away from his practice for the two and half days of travel that would have been involved, and its attendant risk.
One of his colleagues represented him and was now in two weeks of isolation, having come into contact with people on the plane who had later tested positive for COVID-19.
“There needs to be common sense about reducing exposure of frontline clinicians to non-essential travel,” he said.
What McPhee wanted those planning meetings to do is to “make sure rural health is not forgotten, that they understand we have limited resources both in manpower and equipment and we need to be in their thoughts and minds when they’re looking at planning to make sure we get adequate resourcing if we get overrun and overwhelmed”.
Feeling the pressure
Western Australia GP Dr Michael Livingston is also feeling the pressure, this week joining the Facebook support group ‘Adopt a healthcare worker’.
He is a solo rural generalist covering the communities of Ravensthorpe and Hopetoun, about 550 kilometres south-east of Perth, including two active mines, with FIFO (fly in fly out) and DIDO (drive in drive out) staff.
The only doctor on call for emergencies between Esperance and Albany, he is supported by a St John’s Ambulance service staffed by older volunteers.
But with more than 20 percent of the local community in Ravensthorpe over 65 years of age, one of the greatest concentrations of this age group in Australia, and just a single ventilator in the local Emergency Department, he says the risk of coronavirus to the region is potentially “disastrous”.
Earlier this week he locked the practice door and is screening patients through the glass, given the high rate of transit visitors to the area, from tourists to mine workers and others.
“It only takes one ‘super spreader’ to come into the community,” he said. “The undertaking is massive and the next few weeks will see me pushed beyond what anyone can reasonably expect when our remote health services fail (which they will).”
In his four years in the region, Livingston said he has not had an Emergency patient die, but at the local hospital now, the six beds have all been earmarked for palliative care in a coronavirus outbreak.
“The potential for this to devastate and decimate remote communities is frightening,” he said.
In crisis again
A major concern for psychiatrist Dr Skye Kinder, a member of the Board of the Rural Doctors Association of Victoria, is the impact of coronavirus in communities recently affected by the devastating 2019-2020 bushfires.
This could manifest “both in terms of practicalities of social distancing for communities that have lost homes and infrastructure but also psychological impact of surviving one crisis then being thrust into a second – and possibly losing loved ones across either or both”, she said.
Her other concerns include difficulties associated with patient transport in rural regions, the increased risks associated with home-based isolation for people experiencing family violence, and how to provide essential services for other chronic diseases (which disproportionately affect rural communities), given finite healthcare resources will likely be redirected to managing any coronavirus risk and outbreak.
For Jessica Stokes-Parish, a registered ICU nurse at John Hunter Hospital in Newcastle, New South Wales, there is a need for more consultation and communication around the critical care response, having observed staff relying on personal connections or Twitter to gauge how to manage an intensive care unit surge.
While she welcomed the newly released Australian and New Zealand Intensive Care Society guide, it does not appear to have strong rural/regional input.
“If we in Newcastle are feeling left out of the loop, then I can only imagine how truly rural and remote locations are feeling,” she told Croakey.
But there is a potential bright side. While the AHHA’s Alison Verhoeven has concerns that rural and regional areas have poorer access to health care, she said there may also be strengths inherent in regions that have experienced disasters such as bushfires, droughts, water and food insecurity, and the loss of local business and services.
“The ability of communities to manage extended periods of isolation or lockdown may be greater in communities where people are more accustomed to having to work together in adverse circumstances and I suspect those in rural communities may be more resourceful than many city dwellers in this regard,” she said.
See Twitter thread responding to Dr Jane Munro’s tweet above here.
See this Twitter thread by Dr Louis Peachey.