While driving home recently, I noticed some shadows in the twilight. On the road ahead, about half a dozen cattle were being herded from one field to another about quarter of a mile away, writes Muiris Houston.
Two teenagers were in charge of the animals. The driver ahead of me put on his hazard lights; however, an oncoming car did not see the cattle until quite late and skidded to a halt. Needless to say, the two boys had no torches or reflective jackets. The scene was an accident waiting to happen. And it reflects some of the findings of the Pfizer Rural and Agricultural Health Index, published last year, which found that farmers are more at risk of illness and workplace accidents than any other population group in the Republic.
According to the study, the fatality rate in agriculture rose sharply in 2005, when it increased by 25 per cent on the previous year. The second-largest cause of death involved animals being moved or released. I dare say if either of the teenagers I came across recently had been killed or injured, they would have been classified in this category in the statistics for 2007.
Although 91 per cent of those who live in rural areas consider themselves healthy, objective screening of people attending the National Ploughing Championship in 2005 resulted in 50 per cent requiring referral for elevated cholesterol and blood pressure. And almost a quarter of rural dwellers had a serious medical condition such as asthma, cancer or diabetes. The inescapable conclusion from the Rural Health Index is that those living and working in rural Ireland have a poorer-than-average health status.
Part of the problem may be poor access to healthcare. The index found that farmers and others living in rural areas reported medical conditions at a level well below those found by Central Statistics Office figures. This suggests that people are not reporting their conditions or are not presenting to their GPs for diagnosis and treatment.
Health resources available to the rural population in Britain are declining. This is despite the finding that death rates from road traffic accidents, asthma and cancer are worse in rural areas. In addition, cancer is diagnosed at a later stage and coronary disease is less aggressively treated in rural patients. Research has also found that rural patients are admitted to hospital less frequently than urban dwellers.
"Promoted as potentially higher quality, the centralisation of services distances care for rural patients," an editorial in the British Journal of General Practice argues. "The need to travel disproportionately affects the most vulnerable, the elderly, the infirm and those with socioeconomic disadvantage, particularly those without cars."
It is clear these issues are as relevant in the Republic as they are in Britain. The sorry saga of Monaghan hospital and the attempt to centralise hospital services in the northeast is testimony to how rural health deprivation can be worsened by poor access to care.
Speaking at last week's annual meeting of the Irish Medical Organisation, outgoing president Christine O'Malley said no elective surgery had been carried out in Cavan General Hospital for the previous two months, reflecting the pressure the hospital is under following the downgrading of services at Monaghan.
While general practice remains quite strong in rural Ireland, the problem becomes acute when a patient needs to access specialist services. Some new treatments, such as angioplasty for acute coronary blockages and clot-busting therapy for acute stroke, may well be outside the reach of many rural patients.
However, there is strong evidence that when specialist services reach a certain critical mass, the outcome for patients improves significantly. This is certainly true for cancer services and for highly specialised surgery. So, how can we reconcile the relative health deprivation for rural dwellers, driven by poor access, with the need to centralise specialist services so that those patients who can access the service have a better treatment outcome?
In Canada and other countries, community hospitals give chemotherapy safely under the treatment plans set out by regional specialists. Mobile X-ray units could be used to reduce travel for rural patients. And, if rural general practice was to be funded on the basis of a deprivation index and explicitly supported by secondary and tertiary services, then it could take on some of the workload.
The HSE has said it wants to develop primary care in the Republic. While welcome, the initiative will take time to implement. In the meantime people living in rural areas should remind politicians that they already endure poorer health outcomes and that a further rationalisation of rural hospitals, without an adequate alternative, is not acceptable.
Dr Houston is pleased to hear from readers at mhouston@irish-times.ie but regrets he is unable to reply to individual medical queries.
Medical Matters
Muiris Houston