Taken out of context: academic rural health in Aotearoa New Zealand

Rural New Zealanders are more likely to die of a preventable cause than their urban peers.¹ One in four Māori live in rural areas compounding already stark health inequities.² The medical workforce remains geographically maldistributed, favouring large urban centres.³ Similar patterns are observed in comparable counties, but what is different, and unexplained in Aotearoa New Zealand (NZ), is that despite poorer health outcomes, rural dwellers have significantly lower hospitalisation rates than those living in urban areas.^4,5 Relative urban and rural primary care utilisation rates are unknown.

In 2002, a paper was published describing access to public hospitals.⁶ The methodology appeared rigorous, including the use of new GIS techniques. The paper was co-authored by a respected geographer and a member of the Ministry of Health Public Health Intelligence Team. It should have been an important rural health publication. Unfortunately, the southern rural hospitals had been relabelled as 'health facilities with beds' (each generation of health policy makers has an urge to apply an alternative label to these facilities), and consequently they were excluded from the analysis. Further north, tiny facilities that lacked acute beds and were closer to aged residential care facilities were included. Anyone with an understanding of the rural health context would have immediately spotted these anomalies and recognised the findings were seriously flawed. A similar approach to modelling access to rural primary care was suggested. The paper was published in a peer reviewed journal, has 271 citations and continues to be regularly cited, including by NZ authors.

The growth and recognition of academic Rural Health in NZ has been at best, sluggish. And the absence of lived rural experience amongst the authors of research and reports into the health of rural people, is considered normal. This may in part be because so many New Zealanders have rural connections and are therefore confident they have the understanding to conduct research and teach on the rural health context. These attitudes are further reinforced by the systematic bias that favours urban specialist expertise over rural experience and wisdom. Malin Fors a Norwegian rural academic has recently labelled this bias ‘geographic narcissism’.⁷ Those of us living and working in rural communities and our representative bodies are not immune to the geographical narcissist within and are just as likely to defer to urban expertise. Attendance at any rural health conference or CME activity will attest to this. The possibility that useful knowledge could flow in both directions is seldom imagined.

An even greater barrier to building academic capacity in rural areas is that in NZ resources must first flow through large urban institutions. Even with the best of intentions, the universities struggle to overcome the financial incentive to concentrate research and education on urban campuses. The rural context might be seen as a valuable source of clinical placements but seldom as home to the full range of academic activity in the way an urban surgical or medical department would be.

In spite of this, and with few exceptions, the initiatives that have in the end delivered insights into the health of rural New Zealanders, and grown the rural workforce, had their genesis in the rural context: day to day clinical practice, teaching and research at the coalface. This does not mean that close partnerships with those on the main campuses are not important, indeed they are as crucial in rural academic practice as they are in rural clinical practice. But to deliver what is desperately needed, rural academic activity needs to grow and remain firmly embedded in the rural context.

In Australia, three comprehensive government programmes have worked to ensure that health professional education and research are both well-resourced and embedded in rural and regional communities. These include the medical Rural Clinical Schools, the multidisciplinary University Departments of Rural Health and postgraduate Rural Training Hubs.^8,9 Although these programmes are delivered by the Universities, they are independent of their standard funding models, and must be delivered in rural and regional centres. As a consequence, academic activity in rural areas has flourished. In 2018, there were over 1300 rurally based clinician academics. We do not need to look far to find a template that could be adapted to suit the NZ context.

Currently, there is a great deal of discussion about ‘who’ amongst the universities is best placed to deliver academic rural health in NZ. A lot of promises are being made. More important questions might be exactly ‘where’ rural health research and education will have its home? By this I mean the full range of activity present in any other university department, not just undergraduate clinical placements. And whether it is possible to achieve this in the rural context, regardless of the institution involved, without first addressing the funding models in the way our Australian colleagues have done? Getting it wrong will widen the health, health service and health workforce disparities that exist in NZ for decades to come.