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How is rural Northland more vulnerable to Covid-19? – Expert Q&A

With part of Northland back in lockdown due to unlinked Covid cases, concerns have been raised about low vaccination rates and access to healthcare in the region.

The SMC asked experts to update their previous comments on healthcare in rural areas.

Fiona Doolan-Noble, Senior Research Fellow in Rural Health, University of Otago, comments:

How is rural Northland more vulnerable to Covid-19?

“There’s a high Māori population in Northland, and we know our Māori demographic is younger. Māori are more likely to be in low-paid jobs where it can be difficult to get away from work to get vaccinated. The age criteria of the rollout also meant that Māori, having a younger age structure, didn’t meet the criteria until later.

“I think it’s a very difficult situation in Northland and as a health service we look to ourselves around that. I think we need to look at the positives of what Māori communities have done for themselves. Just yesterday we saw John Tamihere’s win around getting access to data on unvaccinated Māori. The fact that this had to go to court highlights the barriers within the system which are stopping Māori healthcare providers from providing care for Māori. We do need to look at the system that’s set up for the majority and not necessarily the most vulnerable.

“Roading in rural areas can also be poor quality or gravel, which means it can take longer for people to get to vaccination clinics. It also costs more in fuel as the distances to travel are longer, further disadvantaging the population. This emphasises how important it is to take vaccine services to whanau.”

Abridged comments from 14 Oct:

“The Covid-19 pandemic has repeatedly exposed fault lines within society and a health system based on the value that public services are available to everyone. Culturally-based health inequalities being a clear example. Rural is potentially another. The questions asked here are focused on deficits rather than strengths – however, the multiple assets within rural communities and how these are activated during a pandemic is worthy of consideration.”

How does access to health services differ from urban areas?

“Specialist services are much harder to access. In May last year the Ministry of Health assessed the capacity of ventilators and ICU beds, which shows the lack of access to specialist care in rural regions. Rural areas have both lower access to timely specialist care, and fewer intensive care beds per capita.

“The rural GP shortage is serious, but it isn’t just the shortage – it is the increase in workload and complexity linked to the older rural population, and their associated multi-morbidity. Nurses are very much at the frontline and therefore at high risk.”

No conflict of interest.

Dr Jesse Whitehead, Research Fellow, Te Rūnanga Tātari Tatauranga – National Institute of Demographic and Economic Analysis, University of Waikato, comments:

How is rural Northland more vulnerable to Covid-19?

“The low rates of vaccination coverage in northern Northland, particularly among Māori, are obviously a concern regarding the latest outbreak. It’s essential to get vaccination rates up as soon as possible in order to protect communities, but barriers to accessing the Covid-19 vaccination continue to be an issue.”

Dr Mataroria Lyndon (Ngāti Hine, Ngāti Whatua, Waikato), Equity Lead, Mahitahi Hauora Primary Health Organisation, Northland; and Senior Lecturer in Medical Education, University of Auckland, comments:

Abridged comments from 14 Oct:

How does access to health services differ from urban areas?

“There are differences in access to health services in some rural communities like the Far North where there are shortages of health professionals or ability to enrol with a GP. Geographic barriers or the distance needed to travel to health services is also a burden for rural communities. Outreach/mobile services for testing and vaccination is an important strategy in addressing some of the barriers rural communities face.”

Katharina Blattner, Senior Lecturer, Rural Section, Department GP and Rural Health, and Pacific Island Nation Liaison, Va’a o Tautai, Division Health Sciences, University of Otago, and Rural Hospital Medicine and General Practice, Hauora Hokianga, Rawene Hospital, Northland, comments:

Is the healthcare system in rural Northland equipped to handle increasing Covid-19 cases?

“For communities based rurally, the patient journey into Whangārei hospital has generally already involved health providers both in primary care (eg GP clinics, Māori health providers), and at the primary-secondary care interface at Northland’s rural hospitals (Rawene, Dargaville, Kaitaia, Bay of Islands). While rural hospitals can manage around 70% of their community’s care, when their limited resources are exhausted (eg limited diagnostics) and the patient needs specialist care, they are transferred  to specialist care at Whangarei base hospital, involving St Johns ambulance transfer or, if urgent, retrieval by helicopter.

“A deteriorating patient with Covid needs access to advanced respiratory care. In Northland this means Whangārei hospital.

“Failure of investment in primary care and rural hospital care as well as failure of cohesive transfer systems for shifting patients in Northland’s rural areas over decades, is now contributing to the pressures on Whangārei hospital. Rural healthcare remains largely invisible – the end of the drip-line at central MOH levels. Resourcing of rural primary care and rural hospitals was inadequate even before Covid hit. Rural health and rural Māori health leadership voices are urgently needed early in the conversation (not when it’s too late). Resource needs to go in to primary care end not just the ambulance at bottom of the cliff.”

Abridged comments from 14 Oct:

Why are rural communities more vulnerable to Covid-19?

“There is often higher socioeconomic deprivation (poorer, less education), poor housing, poorer health including co-morbidities, long distances to access health care especially advanced or tertiary hospital care, limited health services in rural areas including very limited ambulance services, diagnostics, and limited connectivity. Also, there can often be a generally negative discourse from the rest of the country regarding rural communities – viewing rural areas as less of a priority. Only a limited body of research is available on rural health, it is a small new academic field – more research is needed.”

Why are vaccination rates lower in rural communities?

“A combination of: distance, being treated as the lowest priority – last in line, and access times for immunisation are often limited. For example, small local health teams are often providing the service along with all the other health services 24/7.

What kinds of distances are some rural people needing to travel to get the vaccine?

“There is a long distance to services, the state of rural roads are very poor (in many places, including the Far North) so it takes longer. There is poor or no public transport in rural areas, as well as a higher cost of travel. Some people have no registered vehicle and no money for petrol.”

How does access to health services differ from urban areas?

“The rural context is all important in understanding that rural health services are not simply a ‘mini-version’ of the city health services set-up. Geographical distance and smallness demands different approach – small teams of clinicians (medical, nursing, allied health)  work closely covering very broad scopes of practice at the primary-secondary interface, in community and rural hospital settings – over 24/7, 7 days a week.

“The more rural-remote, the further from big-city services, the more blurred is the boundary between primary care and secondary care. Rural clinicians have to manage anything that comes through the door 24/7 at least initially and with small spaces, limited assistance and limited diagnostics (eg they may not have an on-site lab or X-ray), plus there is not easy access to ambulance or retrieval services.

“The situation is worsened by the erosion of rural health services over decades. Rural health services are the end of the drip line. The rural GP shortage is serious. With respect to medical services, in general only 2 specialties work in rural areas:  General Practitioners and Rural Hospital Medicine specialists. Shortages in both areas have been well-documented over decades. The rural nursing shortage is even worse.”

What will be the issues when someone living rurally needs more specialised Covid-19 hospital care?

“The absence of access to advanced respiratory care in rural health centres and rural hospitals – except for immediate emergency treatment – is a problem. As above, there are no anaesthetists, anaesthetic nurses, or ICU specialists in rural areas. There is no equipment, and only limited diagnostics, eg no lab, no X-ray.

No conflict of interest declared.