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On the ground in rural NSW, what are the lessons for ‘living with COVID’?

The easing of public health restrictions has big implications for people in rural, regional and remote areas, and yet their voices are often least likely to be amplified by media coverage, not least because of the closure of many local newsrooms.

Mark Burdack, CEO of Rural and Remote Medical Services in NSW, lives in Orange in the Wiradjuri Nation, and has been speaking to a range of people about their reaction to the easing of lockdown in NSW, and lessons for ‘living with COVID’.


Mark Burdack writes:

Rural and remote residents are riding a roller-coaster of emotions from jubilation to trepidation as we move to the lifting of COVID lockdown in NSW.

It would be wrong to suggest that there is one unifying view across rural and remote NSW about the lifting of lockdowns. As the old saying goes, ‘if you have been to one rural town, you have been to one rural town’.

The truth of this saying has been reinforced as I talked to rural and remote people about the lifting of the COVID lockdowns.

Yuwaalaraay woman Roslyn Forrester is an Aboriginal Education Officer who lives in the tiny community of 240 people in Goodooga in north-western NSW. Seventy-five percent of the population are Aboriginal and/or Torres Strait Islander people.

As a member of the Goodooga Health Advisory Group, Ros has been a driving force in the response to COVID in her community.

When COVID first broke out in NSW, Forrester knew that local Elders were at high risk. She immediately brought together the community, Local Health District, Police, Shire Council and Rural and Remote Medical Services Ltd (RARMS) to plan a community-led response to help keep people safe.

The Goodooga COVID Action Plan, written by Forrester, would become a template for community-led action across the State.

The fear that drove Forrester to organise and write the COVID Action Plan remains to this day.

“People are still scared. I’m scared,” she said.

“Even though 93 percent of our people in Goodooga have had their first vaccination, we can still get COVID and we can still pass it on to others. We have high rates of chronic disease and a large number of elderly people. Vaccination will help, but it is not going to stop people from getting sick or dying if COVID gets into town.

“The further away you are, the less your voice gets heard.  The rules that apply in our town are those designed for Brewarrina Shire, not Goodooga.  What we have always wanted is the ability for communities like Goodooga to create their own special rules that reflect the risks of COVID to our old people.

“If the lockdown is lifted, we are going to get more people coming to our town, and more people from our town going to Dubbo for essentials and coming back.

“We are telling people that its really important that they keep using the QR codes so if someone visits a place of concern, they can be contacted and self-isolate.  We need to keep wearing masks and keep socialising to a minimum.”

Relief

The outlook from Goodooga is in contrast to views from the remote settlement of Collarenebri about two hours’ drive away. Around half the population of 420 residents are Aboriginal and/or Torres Strait Islander people.

The local GP, Dr Julian White, says there is “complete relief” in the community about the ending of lockdown.

“Collarenebri is a large agricultural community, but it’s heavily reliant on surrounding service towns for supplies and equipment,” he says.

“Being locked down has been really frustrating for locals. Many of our local businesses have not been able to trade as usual and we have not had many visitors. The economy is really struggling.

“Collarenebri was locked down because of the Delta outbreak in Walgett because it’s part of the same Shire.

“People were slow to take up vaccination due to the concerns about coming to town and getting infected.  And there was hesitancy about getting vaccinated because of all the misinformation flying around.

“We got together to work out how to address local concerns. We started using telehealth to encourage patients to keep up with their healthcare and to get information out about getting vaccinated. We set up NSW’s first drive-through COVID vaccination clinic in Collarenebri, weeks before anyone else was doing this.

“From that point, we saw vaccination rates increase rapidly. The benefit of living in Collarenebri as a GP is that you know your community and you are better able to design strategies with the community that you know will work.

“There was a sense of celebration at The Tattersalls, the local pub in town, when it reopened after restrictions were eased.

“Many people live on isolated properties, so coming together in towns like Collarenebri is absolutely essential to the mental health of locals. You could see how the lockdown was wearing people down psychologically.

“I think there is a sense that the lifting of restrictions is a good thing.  But people know that the risk is still there.

“We now need to learn how to live with COVID in our communities.  We’ve got to keep numbers at social gatherings reasonable, keep social distancing and wear a mask.

“This is the ‘new normal’.  It is not an open invitation to go back to ‘business as usual’.  I think the government needs to invest in a public education program to tell people how we need to behave in a post-lockdown world. We need a new approach to ‘business as usual’.”

Worries aplenty

Professor Amanda Barnard is a GP in Braidwood, and Professor of Rural and Indigenous Health at ANU. As an asthma specialist she fully understands the risks to rural and remote people with respiratory diseases from COVID.

“In the Southern Highlands and South Coast of NSW, many people and clinicians people are worried about the lifting of the lockdown,” she says.

“These are popular tourist spots so there is concern in these communities that they will get large numbers of people from Sydney and Canberra travelling for holidays and spreading COVID into the community.

“People just don’t know whether the local hospital system will cope with a major outbreak of COVID, and whether we have the systems in place to manage large numbers of people with COVID isolating and being managed at home.

“This has been exercising me a lot as a clinician.

“There are clinical models of virtual care or hospital in the home that are run by the LHDs [Local Health Districts], but the concern is what happens if numbers increase, and how patients may be managed by GPs in the community.  How can we provide integrated care in a way that supports patients in their community?

“Many people who are going to be adversely affected by COVID post-lockdown will have other chronic diseases like asthma or drug addiction.

“For example, for asthma sufferers we need to be thinking about some of the challenges around managing people in the home as we move into the asthma season and people’s respiratory conditions flare up.

“For people dealing with drug addiction, self-isolation will be a serious challenge particularly if they go through withdrawals.

“My concern is that we are treating COVID like a process designed to address a single isolated disease. This is not how primary care clinicians think.

“COVID is just one health issue we need to address and this means we need to shift from a disease-centred model to a patient-centred model of care.

“We know from Wilcannia that getting people to isolate at home, where there might be eight people living in the same house, is simply going to increase infections. We know that mental health conditions can be compounded for people being required to isolate. What this tells us is that we need to think about the patient in context.

“We need to rapidly shift from an exclusive focus on COVID back to a focus on human health or we are just going to be creating a new set of problems down the track.

“The problems will be further compounded because rural and regional GPs will not just be dealing with their own local patients. As people travel to a rural or regional area we need to think about how we are going to support those who contract COVID away from their own homes and have to self-isolate. I’m not sure how the system is set up to respond to this.”

Lessons for the future

Two important lessons from rural and remote communities that we need to take forward as we lift the COVID lockdown are:

  • No two rural and remote towns are alike, and one-size-fits-all solutions are inadequate in dealing with the needs of these communities.
  • In a crisis, we need to guard against the policy risk that we retreat from our focus on individualised patient-centred care towards an organisational-driven disease focus.

Rural and remote GPs don’t just provide high quality local healthcare and vaccinations, they have the local knowledge and relationships that help to bring community voices into the design of population health strategies that are more effective in achieving change at a local level.

GPs have a key role as community advocates that help to inform and improve policy responses. For example, during COVID, RARMS commissioned two surveys of rural and remote people to build our understanding of the views and attitudes of local communities to inform our health response. These surveys ended up being used to inform Government planning for COVID because there were no comparable insights available.

Cases such as the Ruby Princess, Newmarch House, the Wilcannia outbreak and the Towers in Melbourne demonstrate that successfully dealing with pandemics, and the delivery of healthcare more generally, is about more than addressing a disease.

Healthcare is about people in all their diversity and complexity, and successful health responses need to engage with this reality.

While all rural and remote towns are different, a common theme from the people I spoke with is the importance of a patient-centred approach and the role of place-based planning in addressing the unique circumstances and needs of different communities as we move forward to ‘living with COVID’.

Mark Burdack is the CEO of Rural and Remote Medical Services Ltd (RARMS). He lives in Orange in the Wiradjuri Nation. During his career he has worked with the NSW Government to design and implement services to improve access for rural, remote and other vulnerable communities, including LawAccess NSW.  He has worked with various universities to design and implement strategies to build workforce capacity in rural medicine, health and other fields. Today, RARMS is the largest charitable provider of on-the-ground primary healthcare in rural and remote NSW.


From Twitter

During the week of 16 August, Mark Burdack was guest tweeter for @WePublicHealth. Below is a selection of his tweets, providing a snapshot from a critical period for the transmission of COVID to regional NSW.

 


See our archive of stories from @WePublicHealth guest tweeters.

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