Frontier! Vol 5 Issue II - Rural Problems Rural Solutions by The Australian Medical Students' Association

AMSA Rural Health Volume V Issue II 2020

Rural Problems Rural Solutions Rural Problems A Personal Call to Arms 06 Rural Solutions Lessons from the Aboriginal and Torres Strait Islander-led Response to Covid-19 14 Rural Stories Rural Medicine, More than an RMO 28

Contents Letter from the Editor ELLI IZRAILOV

Letter from the Chair SARAH CLARK

Rural Problems A Personal Call to Arms NICOLE MOON

Medical School Carrot vs BMP Stick SARAH CLARK

Rural Background Students - the Rural Workforce Solution?

Lessons from the Aboriginal and Torres Strait Islander -led Response to COVID-19 LORANE GABORIT

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The Missing Piece JASMINE ELLIOTT

Rural Stories The Water

River, Roads and Returning to Rural Roots

A Passion for Public Health in a Pandemic TIANNA GRAHAM

My Time in Cunnamulla

NICOLE MILANKO

Rural Medicine, More than an RMO KELLY BELL

COVID Problems Online Solutions: Running RHS in 2020 ELLI IZRAILOV

ERICA MUSGROVE

Rural Solutions

JASMINE DAVIS

Embracing Indigenous Wisdom in the Fight Against Fire

AMY THWAITES 10

Rural Opportunities

THIYASHA WANNIARACHCHI 16

GABRIELLE HAYMAN

Sexual and Reproductive Healthcare for Young Women Living in Rural Australia BELLE CULHANE

Health of Refugees in Rural Australia - How Can We Help?

How to Make the Most of Your Rural Placement BELLE CULHANE

Letter from the Editor Elli Izrailov Monash University (IV) Welcome one and all to Frontier! Edition 5, Issue 2: Rural Problems – Rural Solutions. I could not be more excited to reach each and every one of you reading this issue of Frontier!. Welcome to the lovely readers from the Sunshine State of Queensland, the Garden State of Victoria, the Festival State of South Australia and the Golden State of Western Australia. Welcome to everyone all the way up at the Top End in the NT, down to the Premier State of New South Wales, to Tasmania - our beautiful Apple Isle, and the Nation’s Capital the ACT! Hello! Welcome! I’m glad that you are reading this issue of Frontier!, an issue which is arguably the best yet to come from AMSA Rural Health. In the first issue of edition five, I was hoping to get a copy of Frontier! to every rural clinical school across the country, and amazingly, that’s actually happened! Now, more of you will be able to read what AMSA RH is about, and (hopefully) love what rural Australia has to offer. Rural Problems – Rural Solutions. It was nice that I actually came up with the name of this issue of Frontier! The idea came from a

meme to tell you the truth. You know, the one from the Chapelle Show going “Modern day problems require modern solutions”? That idea somehow led to the idea of how problems are being handled in the rural health space. And to tell you the truth, most rural problems are being dealt with a ‘metro’ lens. This issue of Frontier! is therefore divided into four segments. In ‘Rural Problems’ we have articles highlighting some of the key problems prevalent in rural and remote communities. In ‘Rural Solutions’ we have even more pieces illustrating how these problems can be solved with the ‘rural’ lens. From there we have a compilation of ‘Rural Stories’ and ‘Rural Opportunities’ which showcase our AMSA Rural Health community’s experiences and prospects. All in all, and I am biased, this issue is the best issue of Frontier!, both in terms of addressing key issues and in delving into the lives of rural medical students. I would like to personally thank first and foremost my wonderful Frontier! Editorial Team; Bri, Kisal, Peony, and Thedini. You have made my life so much easier and this magazine is a testament to your hard work. I would like to also thank my fellow members of the AMSA Rural Health Committee who have worked behind the scenes

to make this issue of Frontier! a reality. I also have to give a shoutout to chair Sarah Clark who dealt with me messaging her about every quirk and concern I had in the production of this magazine. Special thanks of course to all our writers and photographers for submitting their beautiful and thought-provoking pieces and Paul Michael’s beautiful aerial photo of Roebuck Bay, Broome, WA (purchased from Shutterstock). Before I forget, a big thank you to my mother Milla Izrailov and my close friends Cody, Elijah, and Melinda, whose help was invaluable in making the final product of this issue as aesthetically pleasing as possible. And last of all, but not least of all, thank you, yes you, the fantastic reader, for picking up this magazine in your homes or in your common rooms and letting yourself become more informed on rural problems and rural solutions. Yours truly, Elli Izrailov 2020 AMSA Rural Health Publications Officer. P.S. Andrew Baker, if you’re reading this, please don’t tell me where the single typo in this issue is - I’d rather live peacefully.

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Report from the Chair Sarah Clark University of New South Wales (VI) Hi everyone! Sarah here, UNSW Wagga Wagga final year medical student, and AMSA Rural Health Chair for 2020. Welcome to 2020’s second issue of Frontier!, ‘Rural Problems Rural Solutions’ - a magazine full of the ways in which the problems affecting the rural Australian landscape lie in the hands of rural people and rural perspective. Touching on topics ranging from rural background students, to bonding, to Indigenous Australians and rural refugees, this issue is certainly one to sink your teeth into! Being the Chair of AMSA Rural Health this year has been more challenging and yet more rewarding than I could have ever imagined. This year has thrown so many trials at rural Australians, from bushfires to floods to pandemics to second waves of pandemics - to advocate for rural health in this

The 2020 AMSA Rural Health Committee Back Row: Jasmine Davis, Ross Lomazov, Elli Izrailov, Isaac Wade Middle Row: Maushmi Udaya Kumar, Jasmine Elliott, Belle Culhane, Kira Muller, Eeleen Tey, Claudia Mallory Front Row: Sarah Clark Absent: Kelly Bell

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space has been a very unique opportunity to be involved in. I just want to thank the amazing team of people I have worked alongside within AMSA Rural Health, within AMSA, and also to everyone I’ve had the pleasure of working with over my three years involved in the committee. I’m blessed to have worked with such determined and passionate advocates; it is people like you that shape the future of rural Australia, and I am so thankful it is in such great hands. COVID has thrown many spanners in everything, and AMSA Rural Health’s plans for the year were no exception! But we adapt and overcome, and I’m proud to share some of our achievements with you. The only rural health policy for us this year passed with flying colours at AMSA Council 1. We ran a breakout session at AMSA National eCouncil 2 educating

people on how to get the most out of a rural placement. We also ran a brilliant rural internships campaign in May, which saw some of our strongest social media engagement yet. In conjunction with AMSA Indigenous Health, we ran an online viewing of ‘In My Blood It Runs’. AND we produced TWO issues of Frontier! Not to mention the innumerable meetings attended with members of the Government and other external rural health stakeholders regarding our advocacy priorities for the year, where we continually put the student voice forward on these matters. None of these achievements would have been possible without the hard work of the people within the AMSA Rural Health Committee. It has been an honour to work alongside such a passionate, dedicated and hard-working group of people this year, and I congratulate you all on a wonderful year. I also want to offer a massive congratulations to Laura and Emma, our fearless RHS coconvenors for 2020. To turn an event around from in-person to online in the timeframe that you

and your team did without compromising quality is just incredible. We’re sad that you couldn’t show off your wonderful New England region, but that is all the more reason for everyone to attend RHS in person in 2021! I just want to take a paragraph to thank Elli and his wonderful Frontier! Editorial Team - Bri, Kisal, Peony and Thedini - for another fantastic publication. Issue 1 ‘Road to Recovery’ was a massive hit (take a look on our website www.amsarural.com if you haven’t seen it!), and in true AMSA Rural Health publications fashion, it’s just going to get better and better from here! Special mention to Elli as he brings to fruition his third (and final? Who knows, stay tuned!) publication with AMSA Rural Health. He continually pushes himself to be better and better for his team and his readers, and we all appreciate your continual hard work and dedication.

magazine; I just flip to the interesting content hidden inside. So, I hope you read the rest of Frontier! with the same enthusiasm, and I hope we continue to inspire you in your rural health journey! If you have any suggestions for how AMSA Rural Health can better represent,

connect or inform you, or if you’re interested in joining in on the fun in 2021 by applying for a role on our committee, please don’t hesitate to get in touch with us via our social media pages (Facebook, Twitter or Instagram), or email rural@amsa.org.au.

(Above) The 2019 AMSA Rural Health Executive: Sarah Clark (Secretary), Imogen Hines (Vice-Chair), Jacoba VanWees (Chair), Jessica Paynter (Treasurer)

After three years of learning the ropes of advocacy (side note: I’m still learning!), my time at AMSA Rural Health comes to a close as I graduate in October. As hard as it will be to finish up my time, I am thankful that the end of my AMSA Rural Health journey signifies the beginning of another one. I look forward to continuing to come up with rural solutions for rural problems as I advocate for and represent rural people as a junior doctor in a hospital in regional NSW. I look forward to my lifelong advocacy learning curve and continuing to contribute to the health and wellbeing of rural Australians. If you made it to the end of this well done! I never read the front introductory bits of the

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Rural Problems / Personal Experience

A Personal Call to Arms Nicole Moon Monash University (III) In 1955, a 26-year-old pregnant woman, Carmen, left her home country of Malta and boarded a ship with her three children in tow speaking only Maltese, emigrating to the country town of Newborough in the Gippsland region of Victoria, Australia. Here, she would meet with her husband of 10 years, Michael, who was awaiting their arrival while working a coal labour job. The 19,331km journey held hope for better working conditions, education and accessible healthcare for their growing family.

After settling down in Newborough Carmen would go on to have seven more babies. Unfortunately, not all their stories would have the happy endings sought when emigrating to Australia. Their youngest child, Mark, developed pneumonia and passed away before he was eight months old in 1968. The second-youngest child, Louise, was born with an intellectual disability and was a non-verbal child. In 1970, Carmen returned to Malta for six weeks when Louise was seven years old. Louise was sent to a short-term stay at Kew Cottages to provide respite for Michael while he looked after the other eight children and to ensure Louise received adequate care. Kew Cottages was a special development school and residential service in the eastern suburbs of Melbourne, roughly 140km from their Newborough home. Due to the distance, Michael and the children were not able to visit Louise. Tragically, Louise developed shigellosis shortly before Carmen came back to Australia and died alone in her room weeks before her eighth birthday.

1944: Carmen and Michael’s wedding

Between the ages of 16 and 25, Carmen had already endured one miscarriage along with the death of three babies while still living in Malta. In 1946, their 15-month-old son died of either pneumonia or Scarlett fever in the next room while Carmen was in labour with their second child. Her other two infants’ lives were cut short by what was described as a “blue baby” in 1947 and the measles in 1950.

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The eldest of the siblings, Tony, born in 1947, was diagnosed with an intellectual disability and epilepsy from a young age. He had extended stays in Sunbury Mental Hospital and a Kew mental health facility throughout his life. Tony was living in a unit in Fairfield when he passed away suddenly in his bathroom at the age of 42 – the autopsy reported pneumonia as the cause of death. Of Carmen’s 14 pregnancies, seven of her adult children live

across Victoria and Queensland today – one of whom is my mother. Although Australia’s rural healthcare has developed drastically since the death of my aunt and uncles between 1968 and 1990, many barriers still exist for people in country areas and for immigrants like my grandparents. With Carmen and Michael both having passed away, it is difficult to determine why Tony and Louise were required to spend time so far away from their family to receive care. However, it is fairly implicit that there would have been very few disability services available in Gippsland at the time and that being financially disadvantaged created a barrier to accessing what was available. In my grandparents’ case, poor health literacy combined with a language barrier would have delayed their seeking and receiving adequate healthcare. Perhaps I would have met Tony, Louise and Mark if my family had settled in Melbourne rather than country Victoria. My aunts and uncles wouldn’t have lost their brothers and sister, my grandparents wouldn’t have lost their children. It is critical that the healthcare workforce strive for accessible and quality services and facilities for the rural community of Australia. Whether this reflection on my family’s story highlights gaps in healthcare for immigrants and refugees, in obstetric and paediatric care, or for people with disabilities, I hope that you will translate your knowledge and skills into activism for the rural communities you will serve throughout your careers.

Christmas 1960 (left to right): Joe, Carmen, Michael, Tony, Mary, Connie, Michael Snr, Jane

1957 (left to right): Charlie, Mary, Tony, baby Joe, Connie

1970: Louise (7 years old)

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Rural Problems / Report

Photograph by Judah Grubb (Shutterstock) Great Ocean Road Victoria

Sexual and Reproductive Healthcare for Young Women Living in Rural Australia Belle Culhane Deakin University (IV) Health inequities in rural and regional areas have become obvious, and in some areas, deeply rooted. One disparity rarely addressed is that of sexual and reproductive health, particularly in the younger people of these communities. I would like to bring to attention the plight of this population group, namely surrounding inequities in the provision of contraception, especially Long-Acting Reversible Contraception (LARC), access to emergency contraception and termination of pregnancy. Although inroads are being made into these areas, I implore further support for vulnerable people living outside of our cities. Access to contraception Access to contraception is the cornerstone to sexual and reproductive health. And understandably so. Unfortunately, the further a female resides from our State capitals, the more challenging the access to reproductive health products, especially LARCs (1). A â&#x20AC;&#x2DC;first lineâ&#x20AC;&#x2122; option for young women, LARCs allow superior efficacy in reduction of unintended pregnancy (1). Despite having been available for many years, promotion and implementation of LARCs has been slow. Less than 6.1% of women have adopted the Implanon or intrauterine devices (IUDs), the two most common forms of LARCs (1). This has been further compounded within rural and remote townships, where both lack of access and inability to identify doctors trained in insertion of implants or IUDs impedes uptake.

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Provision has also suffered roadblocks in health professionals who are reluctant to provide LARCs. Limited training opportunities, minimal interprofessional support, low access to supervision/mentoring and concern regarding insertion and removal impede GP uptake (1). As a result, the community is unable to access yet another health promoting service readily available in most cities. Emergency contraception represents an important component in sexual and reproductive health. Unfortunately, proactive contraceptive methods may fail, be used incorrectly, or not at all, increasing risk of unintended pregnancy (2). An Australia-wide survey reported that just half of teenagers analysed had used condoms during all previous sexual encounters (3). It is therefore vital emergency contraception is available locally and in a timely manner, especially in populations at risk of unintended pregnancy. Detrimentally, women requiring this emergency contraception in rural communitiesâ&#x20AC;&#x2122; face barriers related to stigmatisation, discrimination and confidentiality (2). Currently, these factors are compounded when the same women are also confronted with travel and financial blockades. Access to abortion services Although not widely discussed, unintended pregnancies are experienced by 50% of Australian women, with 1 in 3 women electing for termination of pregnancy throughout their reproductive life (4). It must be highlighted that teenage pregnancies and fertility rates increase the further a woman is situated from their state capital. Teenage pregnancy in remote Australia outnumbers that in major

“IT MUST BE HIGHLIGHTED THAT TEENAGE PREGNANCIES AND FERTILITY RATES INCREASE THE FURTHER A WOMAN IS SITUATED FROM THEIR STATE CAPITAL.” cities by 8 to 1 (5). Within capital cities, high numbers of public and private abortion clinics exist. Unfortunately, this is not a privilege afforded to women outside of major metropolitan centres. Lack of both medical and surgical options for termination of pregnancy in these areas and the impacts on rural and regional health have been widely discussed in recent literature (6). Fortunately, decriminalisation in several states and territories in Australia have reduced the legal barriers for women seeking or doctors providing abortion services (7). Medical termination of pregnancy (MTOP) is a safe and effective method within the first trimester with General Practitioners (GPs) are well poised to deliver this form of termination to communities. Despite this, less than 1.5% of GPs are registered MTOP providers, this rate is lower still in rural townships. As a result, local women requiring this vital service often must travel further and pay more. These barriers can be almost insurmountable for many women who may be without adequate financial means or social support. Added costs associated with travel expenses, accommodation and time off work more significantly impacts the lives of rurally based women seeking abortion (6). Stigma Another issue jeopardising reproductive health care rights, including abortion, in rural Australia is the persistence of stigma. Stigma is an issue that continues to obscure the process of seeking and having an abortion in rural Australia, due to fear of judgement from doctors and medical staff (8). Doran and Hornibrook demonstrated that stigma perpetuates as shame and

secrecy felt by women seeking termination in rural Australia (8). Women seeking termination in rural Australia described judgemental attitudes exhibited by health professionals when discussing pregnancy options and felt fearful suggesting abortion (8). Stigma is exacerbated further when one must travel hundreds of kilometres, in some cases across state borders, to state capitals whilst keeping their termination secret (8). Solutions Australia’s current state of rural sexual and reproductive health care acts to disempower our most vulnerable, adding barriers based upon where they reside. Progress in rural reproductive health will come from models that promote women’s self-efficacy and self-determination. Complex and persisting barriers to equal sexual and reproductive health exist between Australia’s metropolitan and rural areas. However, recent advancements in implementation are providing some promise. Rural towns, such as those in North East Victoria, have established sexual health services, offering bulk billed access to contraception and termination. However, there are only two services situated in this very large rural and regional catchment area, for women not situated close to these services they still need to travel (10). The “Docs in Schools” program has proven merit in educating adolescents on sexual health and offering GP services (including provision of contraception). Conclusion I commend the GPs already facilitating LARCs and MTOP rurally. Normalisation of family planning for young people through increased implementation of LARCs and MTOP at the GP level will help ensure reproductive health care is managed in a timely and effective manner. I believe this represents effective and lifechanging primary care provision to young rural community members. Navigating sexual and reproductive health in rural Australia’s young

people is extremely complex, but it is important to continue paving inroads into reducing this established disparity. Belle is the AMSA Rural Health General Officer for 2020 References 1. Mazza D, Bateson D, Frearson M, Goldstone P, Kovacs G, Baber R. Current barriers and potential strategies to increase the use of long-acting reversible contraception (LARC) to reduce the rate of unintended pregnancies in Australia: An expert roundtable discussion. Aust N Z J Obstet Gynaecol [Internet]. 2017;57(2):206-212. doi:10.1111/ajo.12587 2. Youth Affairs Council of Victoria. Young people and sexual health in rural and regional Victoria - A discussion [Internet] June 2013; Melbourne: Youth Affairs Council of Victoria. Available from: https://www.yacvic.org.au/ assets/Documents/Young-people-and-sexualhealth-in-rural-Victoria-VRYS-June-2013.pdf 3. Anne Mitchell, Kent Patrick, Wendy Heywood, Pamela Blackman and Marian Pitts. 5th National Survey of Australian Secondary Students and Sexual Health 2013 [Internet]. April 2014; Australian Research Centre in Sex, Health and Society Monograph Series No. 97. Melbourne: La Trobe University. Available from: https://yeah.org.au/wp-content/ uploads/2014/10/31631-ARCSHS_NSASSSH_FINAL-A-3.pdf 4. Kruss J, Gridley H. ‘Country women are resilient but. …’: Family planning access in rural Victoria. Aust J Rural Health [Internet]. 2014;22(6):300-305. doi:10.1111/ajr.12138 5. Australian institute of Health and Welfare. Teenage mothers in Australia 2015 [Internet] 2 May 2018; Infocus mothers and babies. Cat no:PER 93. Canberra: AIHW. Available from: https://www.aihw.gov.au/getmedia/6976ff0b4649-4e3f-918f-849fc29d538f/aihw-per-93. pdf.aspx?inline=true 6. Hulme-Chambers A, Temple-Smith M, Davidson A, Coelli L, Orr C, Tomnay JE. Australian women’s experiences of a rural medical termination of pregnancy service: A qualitative study. Sex Reprod Healthc [Internet]. 2018 Mar;15:23-7. Available from: 7. de Costa C, Douglas H, Hamblin J, Ramsay P, Shircore M. Abortion law across Australia--A review of nine jurisdictions. Aust N Z J Obstet Gynaecol [Internet]. 2015 Apr;55(2):10511. Available from: https://pubmed.ncbi.nlm.nih. gov/25871844/ 8. Doran FM, Hornibrook J. Barriers around access to abortion experienced by rural women in New South Wales, Australia. Rural Remote Health [Internet]. 2016 Jan-Mar;16(1):3538. Available from: https://www.ncbi.nlm.nih.gov/ pubmed/26987999 9. Hulme-Chambers A, Temple-Smith M, Davidson A, Coelli L, Orr C, Tomnay JE. Australian women’s experiences of a rural medical termination of pregnancy service: A qualitative study. Sex Reprod Healthc [Internet]. 2018 Mar;15:23-7. Available from: https://www.ncbi. nlm.nih.gov/pubmed/29389497

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Rural Problems / Opinion

Medical School Carrot vs BMP Stick A Student’s Perspective on Bonding during Medical School Sarah Clark University of New South Wales (VI) I was 18 when I signed my Medical Rural Bonded Scholarship (MRBS) paperwork, two months after I received my bonded medical offer at the University of New South Wales. Everything had worked out just as I wanted - dream university, dream course, dream college - I got everything I wanted, and with just one signature I also had the financial backing to have my proverbial cake and eat it too. I won’t pretend I was completely naive to the potential downfalls of an offer that seemed too good to be true. I even got one of my Mum’s friends with a law background to read over the contract (which I thought was impressive at the time - apparently a lot of people did that). Approximately $25,000 per year of medical school (it’s a six year undergraduate medical degree at UNSW, I’ll let you do the maths) for the same amount of years’ repayment of work in a rural or remote area once I was fully qualified. And that didn’t bother me. I have always wanted to work rurally anyway, so I basically just thought they were paying me throughout medical school to do my dream job when I got there. Piece of cake! It’s only really since I’ve neared the end of my degree where I’ve started to think more seriously about the implications of such a scholarship

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and the impacts it will have on my career. Was it fair to dangle the monetary carrot in an eighteenyear-old’s face only to follow with the stick about a decade and a half later (whether that stick came in the form of ‘doing time’ rurally or suffering the astronomical consequences of breaching the scheme - a restriction on providing services under Medicare)? While this is very clearly true for the MRBS, the same can also be said for ‘regular’ Bonded Medical Places (BMP) given to students when they begin medical school. The purpose of the MRBS and BMP initatives The aim of both schemes is to increase the number of qualified doctors working in regional, rural and remote areas (1), which in itself is a noble goal that is definitely worth striving towards. Rural Australians (which make up 29% of the Australian population) experience significantly poorer outcomes in all aspects of health when compared to their metropolitan counterparts* (2). In addition, the number of medical practitioners per person working in rural and remote areas was 2.5 per 1000, compared to 4.1 per 1000 in metropolitan areas. Furthermore, the number of specialists declines steadily with increasing rurality (3).

The problems of the MRBS and BMP initatives As I think a vast majority of people would agree - every Australian deserves equal access to healthcare regardless of their postcode. The Government has established programs and initiatives (such as MRBS and BMP) to improve access to health services and doctors (3). However since their inception, neither the MRBS or the BMP has actually been proven to successfully recruit or engage future rural health practitioners, and there is no evidence suggesting that bonded schemes result in longer term positive connection to rural life (4). Therefore, neither scheme is actually definitively working towards achieving that longterm sustainable rural medical workforce that rural communities need and deserve. I am now one of a dying breed 2015 was the last year of Medical Rural Bonded Scholars, with the last of us now finishing medical school. From 2016 onward, the 100 MRBS spots were added to the yearly cohort of Bonded Medical Places (5). While the cessation of MRBS was a step in the right direction, as are the other changes made to the contractual obligations as of the 1st of Jan 2020 that make them much more palatable, adding those places to the Bonded Medical Places is still a misallocation of Government resources into a program that lacks evidence proving its effectiveness. Further, evidence-based programs such as health education programs and recruitment and retention schemes, were discontinued. * This includes arthritis, back pain, asthma, COPD, blindness, deafness, diabetes, cardiovascular disease, cancer and mental health problems.

If the Government is going to continue to give funding to programs like the BMP, then there are certain elements that need to be addressed. MRBS-or-bust If I didn’t sign my MRBS contract, I had no guarantee that I would have received a non-bonded medical school offer. At that point, it was MRBS or bust for me in terms of going to UNSW like I wanted that year. This approach is quite coercive and can easily result in negative sentiment around rural experience, leading to a reluctant rural workforce with high turnover rates. Further, there is the potential for stigmatisation against students under these schemes, as they may be perceived as lacking sufficient merit to qualify for a non-bonded Commonwealth Supported Place in medical school. This then continues to have broader implications as the negative associations of rurally-bonded students may fuel negative preconceived ideas and attitudes towards undertaking placements or working in rural areas (4). Minimising coercion and stigmatisation is paramount to raising a medical workforce with a genuine interest in rural health. The consequences of withdrawing your place Another coercive element of these contracts can be seen in the conditions of withdrawing from medical school if you hold one of these bonded places. If a bonded student withdraws from medicine after the census date of their second year, they must pay the equivalent of a full fee-paying place (which at the University of Melbourne in 2019, was $71,296/year (6)). This cut-off date quite often falls before any student has had extensive clinical placement to determine if medicine

is the career for them, meaning that students either have to stick it out in a degree they don’t like for a career they no longer want, OR pay exorbitant fees, neither of which is the ideal outcome. I mentioned earlier that I sought legal advice for my contract, and I’m glad I did. However, coming from a non-medical family, I really had no idea the long haul I was signing myself up for when I decided to pursue medicine. I needed greater awareness and legal support regarding my contractual obligations and what they meant, in plain English. Given that not everyone has a family friend with a legal background, there is also scope for these programs to encompass free and easily accessible legal advice when it comes to signing these contracts, so we can truly appreciate what we’re signing ourselves up for (4). The perks of the MRBS and BMP This all sounds awful and doomand-gloom, and for many people it is - and that’s why it’s important that evidence-based alternatives are put in place instead of these schemes to make sure: that rural Australians get the healthcare they deserve, and; that medical students and doctors are truly invested in their rural careers. But if I’m completely honest, I can’t say I wish I’d never signed it. Having the financial backing of such a generous scholarship has significantly eased the burden of university on myself and my parents. I didn’t need to work to support myself throughout my degree, I didn’t need to scrimp and save to get by, I didn’t need to rely on my parents for financial support and they didn’t need to worry about me and could instead focus on saving for my sister to go to university (to study a degree with far less generous scholarship

opportunities). I am certainly grateful for all of the opportunities my scholarship has afforded me. But that doesn’t mean I don’t have a perpetual buzz of anxiety hanging around my future and what that might look like, while I complete my return of service (hopefully in a lovely rural GP practice), or if I accidentally or intentionally breach my contract and find myself suffering those consequences. For more information on AMSA’s stance regarding bonded medical places, see their Bonded Medical Policy at https://www.amsa.org.au/ sites/amsa.org.au/files/Bonded%20 Medical%20Scheme.pdf Sarah is the AMSA Rural Health Chair for 2020 References 1. Department of Health. Bonded Medical Places Scheme [Internet]. 2018 [cited 1 July 2020]. Available from: http://www.hpv.health. gov.au/internet/main/publishing.nsf/Content/09699C23B61BBE3DCA257EF80079B8F6/$File/BMP-information-booklet-2018.pdf 2. Australian Institute of Health and Welfare. Rural and Remote Populations [Internet]. Australia’s Health 2018. 2018 [cited 1 July 2020]. Available from: https://www.aihw.gov.au/ getmedia/0c0bc98b-5e4d-4826-af7f-b300731 fb447/aihw-aus-221-chapter-5-2.pdf.aspx 3. Australian Institute of Health and Welfare. Medical practitioners workforce 2015 [Internet]. 2015 [cited 1 July 2020]. Available from: https://www.aihw.gov.au/reports/workforce/ medical-practitioners-workforce-2015/contents/ how-many-medical-practitioners-are-there 4. Mason J. Review of Australian Government Health Workforce Programs [Internet]. Department of Health. 2013 [cited 1 July 2020]. Available from: https://www1.health.gov. au/internet/main/publishing.nsf/Content/ review-australian-government-health-workforce-programs 5. Commonwealth of Australia. Budget 2015-16, Budget Measures, Budget Paper No. 2 [Internet]. 2015 [cited 1 July 2020]. Available from: https://archive.budget.gov.au/2015-16/ bp2/BP2_consolidated.pdf 6. Australian Medical Association. Regional/ Rural Workforce Initiatives 2005 [Internet]. AMA Position Statement. 2005 [cited 1 July 2020]. Available from: https://ama.com.au/sites/ default/files/documents/AMA_Position_Statement_on_Regional_Rural_Workforce_ Initiatives.pdf

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Rural Solutions / Opinion

Rural Background Students – the Rural Workforce Solution? Jasmine Davis University of Melbourne (III) Coming from a rural beachside town, I was no stranger to the knowledge that there is a rural workforce shortage. Growing up rural no doubt contributed to my aspirations to pursue a career in medicine and instilled in me a desire to reduce rural and remote health inequity. I always thought rural medicine to be an exciting and important career. However, the first few weeks into my medical degree and up until now, I have noticed a negative discourse about rural medicine from my city-based colleagues, which is exemplary of an underlying cultural belief that rural students and clinical schools are of lesser priority. It all started with the common false perception that rural background students only get into medicine due to their rural upbringing. These are the common responses I’ve received when telling people I got into medicine; ‘Being rural helps you get in yeah?’ ‘Some of the best schools are in rural areas it’s not even relevant anymore’ ‘I’m guessing you got a bonded medical place then’

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‘I had to go to boarding school away from the city, why didn’t that count’ ‘I’m going to live rural for 5 years so my kids can get into med easier then’. Negative discourse about rural medicine continued in discussions regarding allocation to the rural clinical school (RCS). As Melbourne University allocates students to clinical zones with your offer to medical school, meeting other first years usually includes a discussion of what clinical zone you were in. Having been allocated to the RCS, I started to notice a difference in the response I received upon my reply to that question, compared with my friends who were placed in the inner-Melbourne zones. The common responses my citybased friends received included; ‘Awesome!’ ‘You’re so lucky’ ‘Which hospital are you thinking of preferencing?’ The common responses I received included (and I am not joking); ‘Oh you poor thing’ ‘I’m guessing you’re from the country then’ ‘F*** that’ ‘I wouldn’t have accepted my place if I got given rural’ Having been excited to start medical school, and honestly enthralled to be part of the RCS; this sort of response confused and upset me.

Discrimination toward RCS students continued throughout my first year of university. We were denied the opportunity to visit our clinical sites prior to preferencing, when all city-based students were given tours. When searching ‘rural’ in my lecture notes from pre-clinical years, I receive the result of 3 sets of lecture slides. Case-based learning of rural medicine is often fraught with stereotypes of middle-aged Caucasian truck drivers who are racist and don’t care for themselves. Cases discussing rural hospitals portray them all as run down, with no staff and no technology. University organised lectures from rural-based clinicians, and promotion of diverse rural careers are non-existent pre-clinically, the organisation of such promotion often falling on rural health clubs. Three years down the track, and I am starting to face a new bias and pressure related to being rural. This is surrounding the idea of rural background students being portrayed as the only solution to the current rural workforce shortage. Study after study has shown that students from a rural background are more likely to return to work in the country than people raised in the city. I love rural medicine, and I likely see myself working rurally in the future, however, this kind of discourse makes me feel as though I would be abandoning my community and contributing

Photograph by Milla Izrailov Kimba South Australia

to the health inequity of rural and remote Australians if I decide to consider a city-based career. Instilling all hope into rural background students will not solve the issue and placing too much pressure on this group may alienate them. A broader approach needs to be taken to encourage a more diverse group of students to go rural; including students who grew up in the city, and international students. This includes the fantastic #destinationrural campaign which is targeting pre-vocational junior doctors. However, for junior doctors to value rural medicine as a potential

career, we need to enact a cultural shift in the way RCS and rural careers are portrayed and valued by city-based universities, starting preclinically. From day one, universities need to be calling out behaviour that discriminates against rural background students and those allocated to the RCS. They need to be placing equal value on RCS and city clinical schools so that students donâ&#x20AC;&#x2122;t believe there is a disparity in quality or future opportunity. Rural careers should be promoted from day one of medical school. The teaching of rural medicine should be embedded into the pre-clinical program, with the consultation

of rural clinicians in its creation to reduce stereotypes and negative framing of rural practice. Students from a rural background should be encouraged to pursue any career path they are passionate about. Students interested in rural medicine (despite their background) should be supported and nurtured from pre-clinical years to see all of the incredible and diverse opportunities a future in rural medicine can include. Jasmine is the AMSA Rural Health Events Officer for 2020

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Rural Solutions / Opinion

Lessons from the Aboriginal and Torres Strait Islander-led Response to COVID-19 Lorane Gaborit Australian National University (II) As of June 25th Aboriginal and Torres Strait Islander COVID-19 statistics are staggering. Since January, only 60 cases of COVID-19 have been reported in Aboriginal and Torres Strait Islander patients, with 0 cases in remote or very remote communities. Only 15% of these cases have required hospitalisation, resulting in 0 ICU admissions and 0 deaths (1). This is a fraction of what might have been expected, with Indigenous Australians experiencing 72% lower rates of COVID-19 than non-Indigenous Australians, an outcome even more impressive when considered in the context of the higher rates of comorbidities, barriers to health care, and socio-economic factors (1,2). The numbers speak for themselves, with the Indigenous health response not only outperforming the nonIndigenous population but also leading to some of the best outcomes documented in Indigenous populations internationally (I). What can we learn from this as a nation? Without oversimplifying the complexity of the response,

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Aboriginal land councils, health services, and representative bodies such as the National Aboriginal Community Controlled Health Organisation (NACCHO) have been widely credited with this success, showing incredible leadership and collaboration in the face of the crisis (1, 3, 4). The National Aboriginal and Torres Strait Islander advisory group on COVID-19 fast-tracked an emergency response plan and continues to provide leadership and culturally appropriate advice to the Department of Health. The advisory group is itself made up ofleaders from Indigenous organisations and government, operating on principles of shared decision-making and selfdetermination (5). Indigenous rural and remote communities responded quickly and decisively to the first signs of an impending pandemic. Numerous land councils such as the Anangu Pitjantjatjara Yankunytjatjara (APY) Lands Traditional Owners began restricting access to their regions from early March, preempting official lockdown and travel ban orders (2), and the Tangentyre Council and Larrakia Nation implemented â&#x20AC;&#x153;Return to Countryâ&#x20AC;? programs to cover the cost of people wishing to return to their communities (6).

Community groups also acted early and effectively to support their members and communicate information. Many communities produced their own educational material in multiple formats and even multiple languages to ensure clear, consistent and culturally appropriate messaging around social distancing and hygiene (I). Notably the Northern Land Council produced YouTube videos in 17 languages outlining information about Covid-19 and how to slow the spread (3). Aboriginal Community Controlled Health Organisations (ACCHOs) have also demonstrated their capacity to deliver scientifically valid, evidence-based and culturally translated COVID-19 prevention messages in innovative ways. For instance, Apunipima, a Cape York ACCHO in Queensland, has also been communicating with Aboriginal and Torres Strait Islander people about how to protect themselves from COVID-19 via Facebook and TikTok in addition to printed resources (2). Critically, the Aboriginal community-controlled health sector reacted swiftly and effectively to the COVID-19 outbreak despite funding and staffing pressures (4). Aboriginal medical services have worked tirelessly to deliver services and

Photograph by Kevin Mitchell Newman Western Australia

support throughout the pandemic, including a massive uptake of phone and telehealth consultations (1). Access to culturally safe and trusted services has been essential to the management of the pandemic and provision of continuity of care, an outcome only possible due to prioritisation of Indigenous leadership and expertise (1,2). Commenting on the success of community controlled health organisations in responding to the pandemic, Angela Young, general manager of the Queensland Aboriginal and Islander Health Council (QAIHC), said (4): “The reason the community-controlled health sector is doing so well in responding to Covid-19 is because we know our patients and we know our community.” It is well established that trusted Aboriginal leadership and selfdetermination is essential to successful outcomes for Aboriginal communities. We know the critical importance of the Aboriginal communitycontrolled health sector for improving the health and wellbeing of mob (2). Structural change and funding allocation on a needs-based model is essential to empower

“Examining the lessons learned in the COVID-19 response begs the question; how many more health, justice, education and social issues could be better addressed by being Aboriginal and Torres Strait Islander-led?” the sector to continue to deliver positive outcomes not only in relation to COVID-19, but all aspects of Indigenous health (4). Examining the lessons learned in the COVID-19 response begs the question; how many more health, justice, education and social issues could be better addressed by being Aboriginal and Torres Strait Islander-led? This article was written in partnership with AMSA Indigenous. AMSA Indigenous is an AMSA special interest group, providing support and opportunities to Aboriginal and Torres Strait Islander medical students, and representing AMSA in Indigenous health advocacy, education and policy. Follow us on Instagram @amsa_indigenous for more information. References

pandemic’, webinar, hosted online, June 25 2020, accessed at https://nb.tai.org.au/ webinar_series?utm_campaign=aboriginal_health_video&utm_medium=email&utm_ source=theausinstitute#previous 2. Finlay, Summer & Wenitong, Mark, ‘Aboriginal Community Controlled Health Organisations are taking a leading role in COVID-19 health communication’, Australian and New Zealand Journal of Public Health, June 24 2010, accessed at https://doi.org/10.1111/17536405.13010 3. Marwung Walsh, Aileen & Rademaker, Laura, ‘Why self-determination is vital for Indigenous communities to beat coronavirus’, The Conversation, published online, May 6 2020, accessed at https://theconversation. com/why-self-determination-is-vital-for-indigenous-communities-to-beat-coronavirus-137611 4. McQuire, Amy, ‘Aboriginal community health’s success with Covid-19’, The Saturday Paper, published in print, April 25 2020, accessed at https://www.thesaturdaypaper. com.au/news/health/2020/04/25/aboriginal-community-healths-success-with-cov id-19/15877368009740 5. Department of Health, ‘Aboriginal and Torres Strait Islander Advisory Group on COVID-19’, webpage, accessed at https:// www.health.gov.au/committees-and-groups/ aboriginal-and-torres-strait-islander-advisory-group-on-covid-19 6. Fredericks, Bronwyn, Holcombe, Sarah & Bradfield, Abraham, ‘Reconciliation Week: a time to reflect on strong Indigenous leadership and resilience in the face of a pandemic’, published online, May 29 2020, accessed at https://theconversation.com/reconciliationweek-a-time-to-reflect-on-strong-indigenousleadership-and-resilience-in-the-face-of-apandemic-139311

1. The Australia Institute, ‘The success of Aboriginal-led health responses to the

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Rural Solutions / Opinion

Health of Refugees in Rural Australia â&#x20AC;&#x201C; How Can We Help? Thiyasha Wanniarachchi University of New South Wales (V) Australia resettles approximately 19,000 refugees annually (1). While most refugees settle in major cities, federal government policy has resulted in an increasing number of refugees being settled in rural and regional Australia (2). Although such settlements offer affordable housing and greater employment opportunities for refugees, it may have compromised their access to education and healthcare. Refugees arriving in Australia are from diverse cultural and racial backgrounds, and therefore their health may differ greatly from that of the general Australian population. For example, intercountry differences in nutritional status and infectious diseases such as schistosomiasis, hepatitis B, and malaria contribute to the differences in health status (1, 3). In addition to variations in physical health, refugees are also more likely to encounter challenges in their mental health from their experiences pre-arrival, and during the integration into new environments (1, 3). Therefore, refugees have complex physical and mental health needs. Refugees, however, are less likely to access healthcare due to reasons including unfamiliarity with the healthcare system, cultural and language barriers,

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differences in expectations of health service delivery, resilient attitudes, distrust in government services, and financial constraints (1, 4), and thus can present late in their disease progression - more likely to experience complications. Therefore, they remain a vulnerable population in Australia. The vulnerability of refugee populations in Australia has reinforced the significance of addressing key areas of refugee healthcare including: infectious diseases, nutritional deficiencies, suboptimal immunisation status, dental diseases, chronic pain conditions, and reproductive health (5-7), particularly during the early resettlement period where their health needs are greater than those of the general community. Unfortunately, the limited healthcare infrastructure such as bulkbilling GPs, mental health services, and dental services in rural and regional areas of Australia (8) have made access to medical services challenging. Even when accessed, GPs feel that they do not have the necessary systems and support staff to confidently screen for and manage the unique and complex disease profiles that refugees can present with (9). Furthermore, communication with refugees using interpreter services, including telephone interpreter services, have also been found to

be time-consuming and difficult to organise and use, particularly when managing mental health problems (9). As a result, interpreter services continue to be underused in rural Australia (8). Strategies which overcome barriers to healthcare for refugees in rural and regional settings need to be well designed and implemented. For example, clearer health information being provided to refugees by settlement services on arrival can aid them to navigate Australian healthcare services better (9). Regional GPs believe that education and cross-cultural awareness training would improve patient communication and understanding of cultural challenges such as cultural appropriateness of physical examinations (10). Similarly, support from specialised refugee or community health services and participation in networks of service providers (8, 10) can help GPs care for refugee populations better. Expanding funding for healthcare infrastructure in rural and regional Australia such as specialist refugee counselling services can help address issues of access. However, implementation of these improvements is resource-heavy and/or requires support from beyond rural and regional communities, thus, taking time before it is available. Rural and regional communities can ask themselves â&#x20AC;&#x2DC;what can we do in the meantime to contribute to the betterment of health of these new settlers?â&#x20AC;&#x2122;. Joyce and Liamputtong (11) found that welcoming nature of rural towns provide settlers with a sense of belonging and thus greatly help their mental health and wellbeing; therefore, development of refugee

communities or volunteer groups from the host communities in rural and regional areas can provide social support for newcomers and thus ease some psychological stressors of resettling. The importance of forming a sense of community was reinforced in findings by University of Technology Sydney (12) where one refugee who was included in the local youth group “found so many friends” as a result of it, and another refugee who identified members of a local refugee community as “sister(s) and brother(s)”. Further to social support, these volunteer groups can also help refugees learn the English language as it is a frustrating barrier to employment, education, healthcare, and social support which can make refugees feel as though people “don’t like me” and “depressed of life” (12); helping refugees with English has the potential to greatly improve their quality of life. In conclusion, the challenges experienced by rural Australia in accessing equitable healthcare are augmented for refugees. Although

resettling refugees in rural and regional Australia may be economically beneficial, the limited health services in these areas coupled with the heightened healthcare needs of refugees call for further advancement in and diversity of rural healthcare to address minority populations. While a multipronged approach addressing issues at individual, interpersonal, organisation, community, and public policy levels would be ideal to improve the overall health of refugees, rural communities can begin to take steps in the right direction with a heartfelt smile at a newcomer. References 1. NSW Government. NSW Refugee Health Service: Factsheet No. 1: An overview. 2018 (cited 2020 27 June); Available from: https:// www.swslhd.health.nsw.gov.au/refugee/pdf/ Resource/FactSheet/FactSheet_01.pdf. 2. McDonald‐Wilmsen, B., et al., Resettling refugees in rural and regional Australia: Learning from recent policy and program initiatives. Australian Journal of Public Administration, 2009. 68(1): p. 97-111. 3. Jackson-Bowers, E. and I.-H. Cheng, Meeting the Primary Health Care nNeds of Refugees and Asylum Seekers. Primary Health Care Research and Information Service, 2010(16). 4. Nyagua, J. and A. Harris, West African

Refugee Health in Rural Australia: Complex Cultural Factors that Influence Mental Health. Rural and Remote Health, 2008. 8(1). 5. Tiong, A.C., et al., Health Issues in Newly Arrived African Refugees Attending General Practice Clinics in Melbourne. Medical Journal of Australia, 2006. 185(11-12): p. 602-6. 6. Martin, J.A. and D.B. Mak, Changing faces: A review of infectious disease screening of refugees by the Migrant Health Unit, Western Australia in 2003 and 2004. Medical Journal of Australia, 2006. 185(11-12): p. 607-10. 7. Neale, A., et al., Health Services Utilisation and Barriers for Settlers from the Horn of Africa. Australian and New Zealand Journal of Public Health, 2007. 31(4): p. 333-5. 8. Sypek, S., G. Clugston, and C. Phillips, Critical Health Infrastructure for Refugee Resettlement in Rural Australia: Case Study of Four Rural Towns. Australian Journal of Rural Health, 2008. 16(6): p. 349-354. 9. Johnson, D.R., T. Burgess, and A.M. Ziersch, I don’t think general practice should be the front line: Experiences of general practitioners working with refugees in South Australia. Australia and New Zealand Health Policy, 2008. 5(1). 10. Duncan, G., et al., GP and Registrar Involvement in Refugee Health: a Needs Assessment. Australian Family Physician, 2013. 42(6): p. 405. 11. Joyce, L. and P. Liamputtong, Acculturation Stress and Social Support for Young Refugees in Regional Areas. Children and Youth Services Review, 2017. 77: p. 18-26. 12. University of Technology Sydney. Refugee Settlement Snapshot 2018: Toowoomba, QLD. Settlement Outcomes of Refugee Families in Australia 2018 (cited 2020 27 June); Available from: https://www.uts.edu.au/sites/default/ files/2019-04/Toowoomba%20Snapshot%20 -English%20final%20formatted.pdf.

Photograph by Jess Yu (Shutterstock) Alice Springs Northern Territory

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Rural Solutions / Report

Embracing Indigenous Wisdom in the Fight Against Fire Gabrielle Hayman University of Melbourne (II) The past summer saw bushfires Australia-wide that were unprecedented in intensity, scale and duration. Extreme heat, dry conditions, high fuel load, and an unfavourable meteorological pattern combined to create formidable circumstances ripe for the most intense fire season in recent memory. Thirty three people and hundreds of millions of animals perished, and 12.6 million hectares of land burned (1). These bushfires devastated rural communities – families lost loved ones and property, and witnessed the decimation of the local agricultural and tourism industries. In addition to the emotional and financial toll, bushfires widen the existing health disparities between Australians living rurally and their metropolitan counterparts (2). Wildfire smoke can cause difficulty breathing, exacerbations of respiratory conditions, acute cardiovascular events, and increased risk of pregnancy complications. In addition, natural disasters such as bushfires increase the risk of anxiety, distress and post-traumatic stress disorder (3). Bushfires also exert an indirect influence on health in a myriad of ways, ranging from loss of health services due to damaged infrastructure, to limitations on outdoor exercise during periods of poor air quality. These tangible, measurable impacts of bushfire events represent only a fraction of the damage, since many effects such as disruption to normal routines and loss of the natural landscape are difficult to quantify. Such costs take a significant toll on the health and wellbeing of individuals living in bushfire-affected areas, and increasingly long and intense bushfire seasons are decreasing the ability of affected communities to cope and recover. Numerous approaches to tackling the bushfire crisis have been proposed. These include emissions policy reform, additional research funding, enhanced response capacity, and investment in emergency services personnel, infrastructure and recovery efforts. One approach that has garnered significant public attention since the fires is fuel load reduction. In many regions, current practice is a Western-style hazard reduction burn. These burns are conducted on large areas of land and involve high intensity, high temperature fires. Unfortunately, the result of these types of burns tends to be the regrowth of highly flammable material that provides a substantial fuel load for bushfires when the hotter months arrive. This practice was recently called into question when, in December 2019,

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it was announced that the Committee on Environment and Energy would conduct an inquiry into the efficacy of past and current vegetation and land management policy, practice and legislation and their effect on the intensity and frequency of bushfires and subsequent risk to property, life and the environment. The inquiry has since ceased, to make way for the National Royal Commission into the bushfires, the results of which are due to be published by the end of August this year (4). A promising modification to our current fuel load strategy is the greater adoption of Indigenous land management techniques. The skilful use of fire by Indigenous Australians to care for country has been employed for thousands of years, but has gained awareness in the public conscience following the recent summer’s bushfires given its potential to prevent large, uncontrolled fires. Cultural burns, as they are often called, involve the lighting of ‘cool’ fires to reduce fuel load, rejuvenate flora and protect fauna. The latter of these is achieved by preservation of canopies in order to protect native animals living in the trees. Cultural burns are best performed early in the dry season, the timing of which is signalled by biocultural markers. Exactly when and how these burns are performed is determined by expert knowledge of country. They differ from Western-style hazard reduction burns in their holistic consideration of the ecosystem, the timing and intensity of the fires, and the substantially lower fuel load of the plants that regrow after the burns. Indigenous land management practices are implemented in some regions of Australia, but in others, uptake is slow. At a federal level, there exists policy to ‘promote Indigenous Australians’ use of fire’ – this is one of the fourteen goals specified in the National Bushfire Management Policy Statement for Forests and Rangelands (5). In practice, however, implementation is variable. In the tropical savannas of northern Australia, for example, collaboration with Indigenous land managers in fire suppression activities has contributed to a reduction in the total land area affected by bushfires in recent years (6). In Victoria, progress towards incorporation of Indigenous land management practices has been made through The Victorian Traditional Owner Cultural Fire Strategy, a project partnership including the Country Fire Authority and the Victorian State Government. However, despite being awarded funding in 2017, the project was only launched in 2019 and is still awaiting finalisation before it can be presented to a wider audience and launched (7). Whilst encouraging policies are in place, wider implementation is required to realise the benefits of cultural burns. Given the knowledge and skill required in conducting cultural burns, greater training is likely to be beneficial. Victor Steffensen, an Indigenous fire practitioner, co-founded the

Firesticks Alliance Indigenous Corporation, an organisation that runs workshops on Indigenous fire management techniques. He has become what some would call the face of the cultural burns movement after a series of ABC interviews earlier this year, in which he advocated for re-introduction of cultural burns to avoid catastrophic fires. Another prominent voice in the field, Aboriginal Elder Terrah Guymala, director of Warddeken Land Management, suggests a ‘two toolbox’ approach. This approach, which he described in a 2014 Sydney Morning Herald article, incorporates traditional knowledge and skills with Western tools such as helicopters and satellite imaging (8). Given the difference in the land since cultural burns were last practiced widely, as well as the advantage provided by new technologies, a blended approach such as this may offer us the best opportunity to improve our fire hazard reduction practices, and to better care for the land in the process. As we face increasingly long and ferocious fire seasons, greater implementation of Indigenous land management practices could help address a problem that overwhelmingly threatens the health, wellbeing and livelihoods of individuals living in our rural communities. Importantly, a shift towards cultural burning practices requires collaboration with and leadership from traditional owners. Cultural burns are not a panacaea and they may require modification to suit the current landscape, but they could be one tool in an arsenal we have at our disposal to face extreme bushfire events in the future.

DObO_2WlGNxIHx5VKlFwBpuPmE8 Korff J. Cool burns: Key to Aboriginal fire management [Internet]. Creative Spirits; c2020 [updated 2020 Jun 20; cited 2020 Jun 27]. Available from: https://www.creativespirits. info/aboriginalculture/land/aboriginal-fire-management Pascoe B. Dark emu. 2018 ed. Broome: Magabala Books Aboriginal Corporation; 2014.

current vegetation and land management policy, practice and legislation and their effect on the intensity and frequency of bushfires and subsequent risk to property, life and the environment [Internet]. Canberra: Parliament of Australia; [cited 2020 Jul 3]. Available from: https://www.aph.gov.au/vegetationandlandmanagement

References

6. Fisher A, Altman J. The world’s best fire management system is in northern Australia, and it’s led by Indigenous land managers. The Conversation [Internet]. 2020, Mar 10 [cited 2020 Jun 28]. Available from: https://theconversation.com/the-worlds-best-fire-management-system-is-in-northern-australia-and-itsled-by-indigenous-land-managers-133071

1. Werner J, Lyons S. The size of Australia’s bushfires captured in five big numbers. Australian Broadcasting Corporation [Internet]. 2020, Mar 5 [cited 2020 Jun 30]. Available from: https://www.abc.net.au/news/ science/2020-03-05/bushfire-crisis-five-bignumbers/12007716 2. Australian Institute of Health and Welfare. Rural & remote health [Internet]. Canberra: Australian Institute of Health and Welfare; 2019 [cited 2020 Jun 28]. 23 p. Cat. no. PHE 255. Available from: https://www.aihw.gov. au/reports/rural-remote-australians/rural-remote-health 3. Salas RN, Solomon CG. The climate crisis – health and care delivery. New England Journal of Medicine [Internet]. 2019 [cited 2020 Jun 27];381(8):e13. doi:10.1056/NEJMp1906035. 4. Inquiry into the efficacy of past and

5. Forest Fire Management Group. National bushfire management policy statement for forests and rangelands [Internet]. Melbourne: Forest Fire Management Group; 2014 [cited 2020 Jul 5]. 28 p. Available from: https://knowledge.aidr.org.au/media/4935/nationalbushfiremanagementpolicy_2014.pdf

7. Victorian Traditional Owner Cultural Fire Knowledge Group. The Victorian Traditional Owner fire strategy [Internet]. Melbourne: Victorian Traditional Owner Cultural Fire Knowledge Group; 2019 [cited 2020 Jun 28]. 32 p. Available from: https://knowledge.aidr.org.au/ media/6817/fireplusstrategyplusfinal.pdf 8. Smith B. New generation returns to care for country. The Sydney Morning Herald [Internet]. 2014, Sep 28 [cited 2020 Jun 28]. Available from: https://www.smh.com.au/environment/ new-generation-returns-to-care-for-country20140926-10me9n.html

For those interested in learning about the details of Indigenous land management practices, the following additional resources are quite valuable: Cheshire B. Australian story – fighting fire with fire [web streaming video]. Sydney: Australian Broadcasting Corporation; 2020 [viewed 2020 Jun 27]. Available from: https://iview.abc.net.au/show/ australian-story/series/2020/video/ NC2002Q009S00?fbclid=IwAR1pqsj2f1Y6UPSB_6XaAVrSI2w_E3fD-

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Rural Solutions / Personal Reflection

The Missing Piece

Jasmine Elliott | Monash University (III)

I grew up in rural QLD and the NT. When applying for medical school I selected the extended rural cohort as my first preference. As soon as the year began I immediately joined my rural health club. Now, I am the current Vice Chair of AMSA Rural Health as I complete my first clinical year in Bendigo. To most people, and myself – I live and breathe rural health. All those who have had the misfortune of reading my med applications, listening to my shaky voice during interviews will know; “I hope to channel my experience of health inequity into serving the rural communicates that face it.” I realised very quickly how naïve that dream was. As a single rural doctor, there was no way I could “fix” this inequity. Cynicism quickly replaced idealism and I was thrown into an identity crisis. Why was I doing this degree? Is it all truly futile – embarking on a journey stretching as endlessly as the road to Darwin from Nhulunbuy, separating the healthcare we had from what some of us needed? I felt more likely to dry up in the heat than to reach the destination, like a single puzzle piece in a sea of missing pieces, too disjointed to resemble anything meaningful. This poetic over-exaggeration coloured my relationship with my impending rural placement. Chasing a dream I no longer saw possible seemed a tragedy

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compared to the alternative – staying in Melbourne, close to the friends I had made and the life I had built. Alongside this dilemma, I saw my own health deteriorate and a global pandemic unfold. But more importantly, I was given the opportunity to channel my frustration into an intersection between two passions my highschool self saw at odds with one another. The intersection between medicine and politics; advocacy. Advocacy as a future health professional Workforce distribution, student support, the Rural Generalist Program… these concepts flew into my vocabulary of structural change. Change that didn’t impact my rural health journey or my patients but the medical students and the communities we will serve. Advocacy as a health consumer During my time emersed in advocacy as a health consumer I met the fellow Young Leaders of the Youth Health Forum, and discovered a common theme had emerged. Almost all of us had experienced illness in rural Australia. Why or how had this theme emerged? Our experience wasn’t what it had needed to be. We had fallen through the cracks, travelled for treatment and felt hopeless – not because of inadequate health

professionals, but an inadequacy of policy, literacy, navigation, inclusion… the list goes on. We have a shared passion not to improve our journey, but the journey of those whose feet sit in the shoes we once filled, navigating a broken pathway as rural Australians. It has become clearer than ever. Yes, rural communities need more doctors. But more importantly, rural Australia needs rural health advocates. Merely becoming a puzzle piece is not enough – rather than filling a gap in the context of more to fill is futile. Finding and moving the additional pieces is where change is built. We need to educate ourselves about diseases, conditions, and health… but match this with a knowledge of the broader health structure failing to address these fully. We need to match our passion for helping the patient and their illness, with a passion for helping the system they exist in to better meet the needs of Australia regardless of postcode. Studying medicine alone, completing rural placement alone, practicing rural medicine alone that was never going to fulfill my dream. Becoming a rural health advocate though? Now that’s a step on the journey to rural health equity I hope we can all embark on. A step from being just one lone piece, to being part of the puzzle. Jasmine Elliott is the 2020 AMSA Rural Health Vice-Chair External.

Rural Stories / Poetry

The Water Amy Thwaites University of Sydney (IV) The smell of rotting carcasses in the midday sun wafts through my old car’s air conditioning ducts and I see it, like fingers worming onto my skin and wrapping around my neck. Skinny lambs, nose at the dust, dreary and drawn, ribs sticking through like roadkill pecked at by crows, the same colour. Patient crows. Watching and waiting. Smelling. Paddocks more in name than function stretch brown and red and stony-bare across this vast state. Vines that should have burst green by now hang tired, dry and bare like old men held up by their supporting wires. Vines, wine – ancient luxury showered Dionysian By people in the city while in the country people just want a drink, need a drink, can’t get a drink. The city now far behind me such a different colour. Cars rushing, people rushing, water rushing, flushing

down the elevator, down the street, down the drain. Water. Big water stretching out to eternity with sand and blue and families. The illusion that there is enough water – families happy playing and they go on flushing and hosing and rinsing and spraying. Across the sea people huddle in boats on the water because this isn’t just a drought. This is Earth screaming. A woman cries ‘you’re hurting me!’ and no one believes her. We do nothing. Men sit in rooms with tall glasses of water and talk about whether Earth is lying and outside people wash their cars and others die in boats on the water. People stream across this planet because like water we can only stay in a space that holds us. Lambs lick dry dust and in the city people drink wine because water is for the lawn and the car and men sit in rooms and tell us we’re lying and somewhere, across the seas people die in boats. On the water.

Photograph by Kevin Mitchell Newman Western Australia

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Rural Stories / Personal Reflection

Photograph by Erica Musgrove Echuca Victoria

Rivers, Roads, and Returning to Rural Roots Erica Musgrove University of Melbourne (III) It was an ordinary day last year, in an ordinary lecture theatre in the metropolitan Melbourne hospital, when an email arrived in my inbox that caught my attention. The subject line read: ‘Expressions of Interest for Echuca 2020 ERC placement’. It was the kind of email that you see and think, ‘This might just change my life.’ I had previously visited Echuca, a small rural town situated on the Murray River dividing NSW and Victoria, and was comforted by its similarities to my own hometown, Mildura, a further 400km downstream. During my clinical placements in Melbourne, I’d noticed my passion for rural medicine growing, and found myself naturally drawn to rural patients who had been transferred into the city. I had always imagined that I would one day return to a rural setting for work, but how would I know if I actually enjoyed rural practice if I never tested that theory? The email presented an opportunity. Best case scenario: it would confirm my passion. Worst case scenario: I would spend a year on rural placement.

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A few texts to a friend who was also going to Echuca and a few emails to the admin team and then it was set. I would be returning to my rural roots, and to the mighty Murray River that I like to call my ‘spiritual home’. Fast forward to February this year and I was settling into Echuca. Upon arriving in the town, I was definitely struck by that familiar sense of ‘small town’ hospitality that I feel when I go home. Everyone I met, from our rural school coordinators and the admin, to the cleaners and the hospital staff, were warm, friendly and seemed genuinely excited to have medical students there. The GPs at my practice were quick to give me some autonomy and freedom in taking histories from their patients. They included me in every consult, I was not just a “piece of furniture” observing from the corner. Within a few days I was given my own room and the chance to parallel consult, seeing my own patients with varying levels of input from my supervising GP depending on the complexity of the case. I felt my confidence and clinical skills growing, and I felt at home. By the end of the third

week I was more or less set on the fact that a career in rural general practice would suit me just fine. I loved the diversity of the cases seen in one day, the ability to do extra training in speciality areas and work in the hospital as well, and above all, the feeling of being a part of a community. I got the impression that in rural towns that you’re not just a doctor, you are one of the doctors. Obviously COVID had other plans for this year, and so I was devastated when we were pulled from placement and have (to date) spent the better part of 16 weeks doing online classes. The silver lining is knowing that this leap of faith into the rural cohort has confirmed that my passion for rural medicine is not just theoretical, it holds up in practice too. Who knows what the future holds for me, or any of us, but it does seem that the fateful email may just have changed the course of my life toward a bright and rewarding rural future. Erica Musgrove is the Incoming Vice Chair Internal for AMSA Central 2021

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Rural Stories / Interview

Georgina Price

A Passion for Public Health in a Pandemic Tianna Graham James Cook University Communications Officer For sixth-year medicine student Georgina Price, the opportunity to work in the Public Health Unit at the Townsville University Hospital was the chance to test her passion for the field. But with the COVID-19 pandemic on the rise, she had no idea just how important her role would become. Hailing from the Central Queensland town of Emerald, Georgina’s love of public health stems back to her boarding school days. The self-proclaimed ‘public health nerd’ gained an understanding of how different her experience was in accessing healthcare.

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“I was boarding with girls from towns and from properties, and it really made me think about how different the access to healthcare is in a small town versus a city. Instead of doing a six hour round trip to go to Rocky, people in the city could access specialists just up the road. I chose to study at James Cook University because I knew they shared my passion and would foster it.” “I stayed interested in public health because I like the big picture. Disease has a big impact on individuals and being able to make a difference for people one-on-one is a real privilege. But, through public health you can make a positive contribution that affects a big chunk of the population, and helps a lot of people.” During her recent six-week placement in the Townsville Hospital and Health Service Public

Health Unit, Georgina quickly found her feet amongst staff dealing with an unfolding pandemic. Working under Dr Steven Donohue, Dr Julie Mudd and the Communicable Disease (CDC) Nurses, she was able to relieve some of the pressure on the team. “Every day I would sit in with teleconference meetings and learn about the planning process. I was putting together findings from the literature being published (on COVID-19). I put together a list of local GP practices and began calling them to see how they were going – if they were actually able to see people and if they needed support from us,” she said. “Each day, a new issue would come up that the doctors wanted to deal with, but were too busy. They just needed someone, not already

overloaded with work, to sit and think about it for a while – so that’s what I would do.” Georgina found herself right in the middle of a health communication storm, where GPs and hospital staff were combating everchanging messaging on what they could and couldn’t do during the pandemic. “If GPs aren’t seeing people then everybody has to go to the hospital. Then we can’t have a functioning health system. But the messaging was so confusing and it was changing all the time. I think at some point the GPs were told if you don’t want to test anyone, you don’t have to. But that could be taken as – maybe we shouldn’t be testing everyone because we are taking on risk. It was tricky. I conducted a survey just so we could gauge where everyone was at.” She was instrumental in helping set up and man a Clinician Hotline. The number was established for GPs, clinical nurses and their practices to call through with any queries around COVID-19. “The Hotline took some of the workload off the four CDC nurses in the unit. They needed someone who could filter some of the calls. “Fifth-year students on their GP rotation and a sixth-year student on his clinical elective were bought in to help. My role was to orientate the students in what information they needed to know and where they could direct enquiries if a question had to go to a doctor.” Georgina relished the task of health communication with the unit. She said one of her proudest projects was distilling government information to create factsheets for clinicians and patients. “One thing that was really stressed by Dr Donohue was the difference

between quarantine and isolation. One of my earliest jobs was to put together a fact sheet that you could give to a person so they would know what they needed to do if they were in quarantine and what to do if they were in isolation. It actually got published on the health service website and also got handed out to a lot of people. So that was pretty cool.” This was just one of a number of factsheets Georgina would go on to create. “It’s the sort of thing Dr Donohue and Dr Mudd could easily generate from their knowledge and their background in health communication. But it was one less thing for them to do and clinically I could do it. So it was nice to find my spot. “It was really good health communication experience. It was something that I had never thought that I would be interested in but I became really passionate about it.” On finishing her public health placement, Georgina travelled back to her hometown of Emerald to begin her rural term at the local hospital. It was here she had to put her COVID-19 knowledge into practice, when ironically, the budding doctor became the patient. “On my second day I woke up with a sore throat. I had to isolate in my home and I got tested. I think it was probably a bit of fatigue or hay fever – but I couldn’t go in if I had a sore throat,” she said.

transmission is happening - you know when it reveals itself.” “It was hard being isolated, being stuck in one room, especially when you don’t feel sick. I mean, I wrote the fact sheet on what it means to be in isolation and all the things that you can’t do. You can’t have people in your room, you can’t leave your room and you need to try and use a different bathroom if you can.” Luckily for Georgina her test came back negative and she had been feeling well for several days, and was able to return to the hospital. Looking to the future Georgina said she will follow her passion into public health, but wants to work in the community with patients in her early career. “Dr Julie Mudd gave me some great advice during my placement. She said wherever I go, I can be a help to people and it should not be about career. You can be a good clinician for someone, a good GP for someone, be a good junior doctor for someone. The ability to be of help to people is where the value is. That really struck me. I think that’s important in my early years as a doctor, to focus on being of help to people on an individual basis.” “I want to do hands on things and see patients, gather experience and then later on be able to contribute to policy that lifts up the health of disadvantaged communities.”

“I knew that I hadn’t come into contact with any respiratory cases, I knew that I hadn’t been seeing patients in Townsville. The only thing I was concerned about, which the Public Health Unit was starting to worry about, was community transmission in Townsville. You don’t really know when community

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Rural Stories / Placement Report

My time in Cunnamulla Nicole Milanko University of Melbourne (III) On 11th November 2019, I ventured to the rural town of Cunnamulla, Queensland for my second placement of the John Flynn Placement Program. Located far south-west in the Sunshine State, Cunnamulla is a mix of outback and desert, with quintessential dusty red plains, afternoon torrential rain and roasting hot days with cool nights. On placement, my colleagues and I were given the opportunity to participate in morning ward rounds at the local hospital and then spend the day in clinic, shadowing one of the two doctors who worked there or help with community activities. Whilst shadowing the practice nurse, we participated in a range of practical skills including venesections, cannula insertion, wound dressing, suturing, vaccination and observing minor procedures. Many of our patients experienced socioeconomic disadvantage and this highlighted the importance of fostering a respectful relationship, facilitating improved health literacy and patient outcomes through a partnership. I present here some of the transcript of the diary entries I recorded during my time there. I hope you enjoy.

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Day 1 I have had some wonderful opportunities to branch out from GP medicine and experience the roles of allied health and community services. These include mums and bubs programs where we interact with toddlers in a classroom and an aquatic environment. It is very rewarding to see parents trusting us with their children, expressing their gratitude towards our involvement as we watch the kids grow in confidence in the pool. Days 2 to 14 During this time on placement, I have definitely seen the ups and downs of being a rural GP. The doctor found it difficult to admit a patient recently diagnosed with cancer to a larger regional hospital due to the inability to receive the results for blood tests taken earlier that day. These services close at 11 AM on Fridays, which is when the consult took place, and are not due to reopen until Monday the following week. This tedious process, already made hard by having to break the news of cancer, made me appreciate the same-day results that we are able to obtain at tertiary hospitals. I have also gained an appreciation of how a simple referral can mean travelling for hours, sometimes days, requiring accommodation, and incurring heavy expenses for those living in relative geographical isolation. A missed fracture now means that a drover must find someone to mind their animals just to see an expensive private orthopaedic surgeon who

would re-break and realign a malunion that had already started to heal. Healthcare is much more complex out here, not just from the patientsâ&#x20AC;&#x2122; number of comorbidities but also their circumstances. Doctor continuity is a luxury here. It makes it easy for abnormal results to slip through the cracks and for communication to go astray. Notes by all healthcare workers: doctors, allied health professionals, and nurses alike are fundamental in providing the best healthcare possible. Unfortunately, notes are not always as informative as they should be. I also suspect the lack of a familiar face partially contributes to poor patient appointment attendance, with a few patients having a habit of missing their consults, and patient adherence. However, both these themes have a huge variety of contributing factors (i.e. social determinants of health) which may play a greater role than doctor familiarity. Day 15 Today opened up my eyes to the possibility of locuming rurally. After some discussion with one of the doctors, he explained the process of becoming a locum as well as the pros and cons to participating in this kind of practice. The more I am here the more appealing it becomes. Day 16 to 22 I was provided with some fantastic resources for next year.

One such resources was a template created by Venturafamilymed.org (Cener), ScriptApp and QuickBooks. I also spoke about the pre-screening requirements for women wishing to become pregnant. Day 23 What an adventure we had today! We tried to head to Charleville with a car which (little known to us) was completely unreliable. 30 minutes in, the car failed and we flagged down a lovely gentleman on his way to Canberra whilst help was on the way. He offered us a

bottle of coolant and water for the reservoir. When help arrived, they topped up the coolant and reserve, and sent us on our way. About a minute down the road, we heard a bang and pulled over immediately. We popped the hood to find the radiator had completely split down the middle. The car was towed the rest of the way into town and left for repairs. The whole ordeal took about four hours, with us waiting in the sun for two. We had planned earlier in the week for a car breakdown and bought substantial water which goes to show the

importance of communication and water in the outback: two key components for survival. Day 24 to 26 This afternoon we had a wonderful Christmas lunch complete with Secret Santa, more presents and speeches. It was a lovely way to bid farewell (for the time being). On our last day we waved adieu to a week of 40+ degree heat and lightning storms, heading back to a frosty 19 in Melbourne. What an experience!

Rural GP Registrar Registrar couple Zoe and Ryan’s training journey has taken them to Warwick in South East Queensland. Community

“People are genuine and friendly. They are grateful for new doctors coming to town and increasing local medical services. They’ve welcomed us with open arms.” Ryan

Support

Ry a n & Zo

“The senior doctors at our practice and at the hospital are passionate about passing on their knowledge and they really want to help us succeed in this setting.” Zoe

Flexibility

“Being part of the program has opened our eyes to all of the possibilities a rural generalist career can offer. Seeing what other Registrars have done has shown us there are just so many options.” Ryan

Skills

“I love anaesthetics and providing inpatient treatment at the hospital. The General Practice side of things is completely different and so rewarding.” Zoe

Visit https://bit.ly/2Xl0UM0 to read Zoe and Ryan’s story.

Educating, inspiring and preparing GPs to deliver quality primary care.

Rural Medicine, More than an RMO

FRONTIER! I Vol 5 I Issue 2

Kelly Bell The University of Notre Dame Fremantle (IV) If you told Victoria Everton when she first started medicine, that in 2020, she would be living in outback Australia, on her way to becoming a rural generalist and registered as a foster carer, she would have chuckled at your expense. But fast forward 6 years, and you’ll find this reformed ‘country girl’ doing just that. It was a placement in the Kimberley region, in the far North of Western Australia, that first piqued Dr Everton’s interest in rural health. The University of Notre Dame Fremantle sends all their second-year medical students for a week-long community placement in the region. There is no medicine, no formal hospital or clinic time – instead students live and work alongside station workers, school teachers, Aboriginal artists and other locals to learn about what it means to live in the bush. The program aims to empower students by equipping them with the knowledge to identify and understand the barriers rural patients may encounter, while asking them to identify areas of need, and challenging stereotypes of country life. This was Dr Everton’s first exposure to the bush. She then spent her penultimate year as a medical student, living and studying at the Rural Clinical School in Derby. It was in those wide brown spaces, that Dr Everton realised the bush was where she belonged.

“RCS in Derby made me realise I love rural life and rural medicine, and that I’ve been a country girl at heart,” she told me. In ol’ Derby town, she embraced country life by getting involved in community, including taking on a role in the local volunteer fire service, and realised that medicine in a remote location, is about much more than just being the local doctor. After graduating in 2018, she took an internship in Mount Isa, Queensland – part of the State’s rural training pathway. Fast forward to 2020, her first as a resident medical officer, and a desire she’d had for years snuck back in and grew. You see, when you live and work in a remote community, you witness firsthand the areas of need, and being a Doctor doesn’t make you immune from wanting to help. “During my time in medical school, especially whilst living in the Kimberley, and then working in Mount Isa, I realised the desperate need for carers, mentors and support workers for young, Indigenous kids,” Dr Everton explained. Despite the pressures that come with being a junior doctor – it was a moment, on the couch, watching a Netflix series about foster care, that pushed Dr Everton to take the next step. “Eventually, I found myself working fulltime with a spare room and decided it was time to take the plunge – I’ve always had some involvement in volunteer work, and at that time, I wasn’t doing anything else, and I missed being part of the community,” she said. Out-of-home care, including foster care, is the care of children from birth to 17, who are unable to live with their primary

caregivers. As of 30 June 2017, 47,915 Australian children were living in out-of-home care (1). Of these, 93.2% were in homebased care, with 37.8% in foster care – other forms of homebased care, include relative/ kinship care and third-party parental care (1). Compared with other states and territories, according to 2017 statistics, Queensland had the highest proportion of children living in foster care at 47.6% (2). In all regions, the proportion of Aboriginal and Torres Strait Islander children on out-of-home care placement orders is higher than that for other children (2). One of the major factors in the delivery of out-of-home care, especially in rural and remote locations, is the recruitment of enough carers. Research has consistently shown that recruiting and retaining enough carers to cope with the increased demand for foster care is a concern for most states and territories (3-5). Dr Everton saw the need, she had the ability and shift work gave her flexibility, so she sent off a formal expression of interest to Queensland agencies. She then spent six months negotiating interviews, home assessments, paperwork and training days, before was received her registration and took on her first emergency placement. Now, she juggles shift work in the emergency department, with respite and emergency care placements for one or more children, for up to a week at a time. “All the kids I’ve had so far have been an absolute joy and it’s been a nice way to get to know other carers and families in town,” she said. Things are busy, and sometimes

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Rural Stories / Interview she isn’t sure who has worn out who more, but Dr Everton wouldn’t change it for the world – these moments are opportunities for empowerment, growth and finding nail polish on your dining room table. “I love picking out toys and books that create conversations about body safety and empowering kids to feel confident in treating themselves and others with respect,” she said. After sharing news of her registration as a foster carer on social media, Dr Everton was surprised by the number of people who contacted her and shared their desire to do something similar. She’s realistic about her advice to fellow doctors or doctors-to-be – know how much time you can commit and how often, and accept help from family and friends when they offer. But most importantly, if you find yourself in a rural or remote location – offer a solution for rural problems by becoming involved in the community. “If foster care isn’t something you feel is right for you, there are lots of ways to advocate for people in your community – such as volunteering with the local youth groups, sports coaching, being a committee member of a club you’re interested in, joining the local fire authority or at community events – there is a perfect position for everyone.” References 1. Australian Institute of Health and Welfare. (2018a). Child protection Australia 2016–2017 (Child Welfare Series No. 68). Canberra: AIHW. 2. Australian Institute of Health and Welfare. (2018b). Child protection Australia 2016–17. Supplementary data tables. Canberra: AIHW. 3. Delfabbro, P., King, D., & Barber, J. (2010). Children in foster care: Five years on. Children Australia, 35(1), 22–30. 4. McHugh, M., & Pell, A. (2013). Reforming the foster care system in Australia. Melbourne: Berry Street. 5. Osborn, A., Panozzo, S., Richardson, N., & Bromfield, L. (2007). Foster families (NCPC Research Brief No. 4). Retrieved from aifs.gov.au/cfca/publications/ foster-families

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Photograph by Thomas Mann

Wilson’s Promontory Victoria

COVID Problems: Online Solutions Running RHS in 2020 Elli Izrailov Monash University (IV) Laura Mallett and Emma Deacon were planning on running the fifth Rural Health Summit (RHS) in the highest medical school across Australia, at the University of New England Campus in Armidale. However, as we all well know by now, COVID had different plans for us. We at AMSA Rural Health ‘sat down’ with Laura and Emma, the coordinators for RHS 2020 to discuss the challenges they faced with organising a convention of this size with Covid lurking in the forefront, and how they were able to find innovative solutions to get RHS running in 2020. Tell the readers a little about yourselves. Who are you and why did you decide to take on the role of coconvener for RHS20? Laura: For sure! After growing up in Sydney for most of my life, I moved to Armidale (NSW) to study medicine at the University of New England in 2017. I did my first 3 years of medicine there, before moving to Tamworth this year to undertake my year-long placement at Tamworth Base Hospital. In my free time, I love spending time with friends, baking, playing netball, going to church, and travelling. Emma: I also grew up in Sydney and moved to Armidale to study medicine. I’m currently in my 3rd year and have really enjoyed the opportunity to study medicine rurally and with such a tight-knit cohort in Armidale. I enjoy music, movies, travelling, and podcasts. I met Laura whilst volunteering for our MedSoc and was excited about the opportunity for us to work together on a new project.

Photograph by Laura Mallett Armidale New South Wales

Back in January and February, we didn’t fully realise to what extent coronavirus would become a pandemic and shut down countries all over the world. I think it really started getting real for us when coronavirus had spread to Australia and restrictions were beginning to be established. When you learnt that venues and events of over 100 people were to be cancelled in the foreseeable future, what was going through your heads? At that stage, RHS was still 6 months away, so we were hopeful that restrictions would be lifted before September. However, as more and more restrictions were put in place with social distancing and as borders were closed, we were concerned whether RHS would be able to go ahead this year. We also started to worry about the safety of a physical RHS in regards to the health of our delegates and the health of our rural community. In the best of times, there are always challenges to organising an event of this scale. What did you find were the challenges you faced from organising an event in the coronavirus landscape? We have both remarked at how ridiculous it would have been if when we were interviewing for the position last year if the panel had asked “If there was a global pandemic, how would that impact RHS and how would you overcome it?” I think it shows how crazy and unexpected this year has been - no one could have expected it.

Laura: Emma and I applied to convene RHS20 because we wanted to show off beautiful Armidale to Australian medical students! For me personally, having grown up in Sydney, I had never really considered moving to the country until I received my UNE offer - and I am so glad I did! I absolutely loved living in Armidale, mainly the rural lifestyle and the strong community, and because of it, am definitely considering pursuing a career in rural medicine. I wanted to help convene RHS20 so other medical students could have the same experience and be just as excited and empowered by rural health as I have been.

The main challenge we have faced in the last few months is the uncertainty. Even at this stage, we still don’t know whether large gatherings will be able to take place or when borders will be opened, and even if they are, whether there will there be another resurgence of the virus. Trying to plan an event when you don’t know what format it will take was really tricky.

Through January to March, as the world was learning about COVID and seeing it spread, did you have any concerns as to how that would impact RHS20?

We have been having discussions with our team, the National Executive, and the Board about the format of RHS20 in this climate since March. This included brain-

Can you tell us about the decision-making processes that went on behind the scenes about how and where you were going to take on RHS20?

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Rural Opportunities / Interview

Photograph by Sami Hossain Armidale New South Wales

storming a large variety of ideas regarding the format of RHS and looking at the pros and cons for each option. For us, it was very important that whatever decision was made, our entire team was on board and still passionate about organising the event. We also wanted to ensure that the event could stay true to its original aim of promoting rural health to medical students from across Australia. Our other main consideration was determining what would be best to ensure the safety of our delegates and the Armidale community. In the end, the team decided the best way forward was to switch to an online format. In this way, we could still stay true to the original vision of the conference, show off Armidale, and support local businesses, while ensuring that all delegates and the Armidale community would be safe. Whilst we are sad everyone won’t be able to come to Armidale physically (you should really come visit some other time if you get the chance, it’s great!), we are so so so excited to bring Armidale to everyone. We hope everyone viewing the online event will be able to meet up at our ‘satellite sites’ to maintain some of the social aspect of the event in a COVID-safe way. This option also guarantees RHS will be accessible to ALL medical students, rather than potentially just those located in NSW. Were there any additional challenges you faced organising an event rurally? How do you think these compare to organising an event of this calibre in a capital city? There definitely were, which made the decision process even more difficult. For those who don’t know, Armidale is a town in NSW of about 25,000 people, roughly halfway between Sydney and Brisbane. The hospital in Armidale doesn’t have an ICU and is over 4 hours away from its closest tertiary hospital in Newcastle. For us, the risk of getting people to travel to Armidale with the potential risk of a coronavirus outbreak in a town not adequately equipped to manage an outbreak, was too risky. We did

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RHS 2020 Co-Convenors Emma Deacon (left) and Laura Mallett (right)

not want to endanger the rural town we have come to love, which was a big reason behind the online switch. In line with the theme ‘Rural Problems – Rural Solutions’ what do you think were your most innovative ‘rural’ solutions you came up with when organising RHS20? Being located rurally often requires you to be creative, to think outside of the box and take full advantage of technology due to your distance from big cities and services, which I think we have definitely done! We are coming up with exciting and innovative ways to deliver RHS in an engaging online format, allowing us to reach medical students across Australia, particularly those based at rural locations. An online RHS in 2020 is very much in keeping with the innovative nature of rural medicine. Finally, what are you most looking forward to for RHS20? Why should readers come to RHS20 and Rural Health Summit in general? Laura: Can I say all of it?! I think what will make RHS20 stand out compared to any other online conference is its interactive nature. We are planning interactive workshops, social events and our very own realistic virtual Rural Rescue Challenge (which I am pumped for!!). Emma: I’m excited because this year’s RHS is super special and different. This year has been an opportunity to create something totally new and really cool! I’m also excited to see all our team’s hard work come to life and watch people enjoy getting involved. I’m also really excited for our online Saturday night social event! Laura: Come to RHS to be equipped, inspired and empowered about how you can make a difference in rural communities. If you’ve ever thought about coming to RHS, when it is most accessible and cheap, then it’s really a no brainer! I look forward to seeing you there :) Emma: All the rego details and conference reveals will be announced over the coming weeks on our Facebook page and on our website: www.rhs20.com

Making the Most of Your Rural Placement Belle Culhane Deakin University (IV) You have just been told that you’re going rural, (yay!) maybe you expected this or maybe it is a big surprise. Either way going rural for a medical school placement, even for a short period, is going to be extremely rewarding. And although it may seem like an impossible task, it is certainly going to be a memorable experience. It is understandable to be fearful of being isolated or put in the deep end, but it is important to make the most out of your rural placement. Seizing the opportunity will ensure that you have a great time but will also allow you to overcome challenges and develop both personally and professionally. Before you go – plan and prepare Research the area before you go, including asking your clinical schools about things like mobile phone reception, facilities and services in the area. For example, if you’re going to a remote region, there might be a specific mobile provider for that area - if you know beforehand, you can prepare by getting a temporary SIM. You can also prepare by organising what you need to bring which might be hard to get whilst you’re there. Get to know the community you’re going to. What sports are popular in the region and what

community events are held? Find something you can engage with to help make friends and be a part of the town. For example, in a lot of rural communities joining a local sporting club is a great way to meet people and socialise. Learn about the region. What is the environment and weather like? Can you swim there? Are there any prominent hikes or camping spots? Once you’re there go and explore the region! Become knowledgeable about the natural history and key events that have taken place in the region. For example, what Aboriginal and or Torres Strait populations are located in the region and what is culturally significant in the region, including language and sacred sites. Before you go consider if there are any prominent health issues that might be relevant. Rural and remote medicine is unique, in many remote areas specialised knowledge might be required to make the most out of your placement. Learning about specific health issues is a great way to understand the underpinnings of health in the region. Have a positive mindset and be enthusiastic. A country town might be different to what you’re used to, but people are friendly, and they’ll want to involve you, so don’t be afraid to ask.

Whilst you’re there – get involved! Now that you’re fully prepared for your rural placement, it’s time to make the most of it! Your rural placement might seem unstructured or unorganised however the hands-on experience and learning by actively participating is one of the best methods to develop your practice. If you’re a person that likes to be organised, then plan your days. It is also important to set learning goals and make plans to achieve these. If you are struggling, don’t be afraid to reach out to your clinical school and university and ask for support. Seek out opportunities! With less students on rural placements almost any opportunity you can think of is available, plus you’re more likely to get hands-on experience as there are fewer competing students. Be proactive and ask to join the doctors and nurses on their ward rounds, patient reviews and when they’re performing procedural skills. You may be able to form great relationships with supervisors because of all the one-on-one time you get to spend together, an opportunity almost non-existent in metropolitan hospitals. Memorable and rewarding experiences will come from actively engaging with patients. Take histories and perform examinations to develop proficient clinical skills. Also ask patients about their lived experience in the town and their healthcare journey so far. Ask them about the challenges they face accessing healthcare and what they think could be

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Rural Opportunities / Opinion improved. Learning about rural health care might surprise you. People from rural areas are extremely resilient and are able to overcome challenges and barriers which seem impossible. Reflect on the similarities and differences between metropolitan and rural health. You will better understand rural health by seeing as many patients as possible and learning from their unique experiences. Be a part of the community! Join the sporting club, gym or running club. Go exploring and see the region on weekends, whether that be through hiking, camping or traveling to other local towns. Dine in at the local cafés, restaurants and pubs. Visit the local art galleries and community centres. It is important have fun on rural placement and not become socially isolated. Therefore, designate time for social activities. Also remember that your friends and family are only a phone or Skype call away and would love to hear all about the fun you’re having. Ask your clinical supervisors about their journey to practicing in that location. What challenges and barriers do they perceive in the health system? What do they love about rural medicine and why did they choose to stay there? How is practicing medicine in the country changing? After you’re gone – recognise and reflect Reflecting on your rural placement will be very beneficial to your development and future practice. What did you learn? What challenges did you overcome? How can you move forward from your placement?

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Afterwards is a good time to recognise and reflect on the health and people in the region you were placed. Learning about rural disparities whilst on placement will help you to understand the health and well-being of rural Australians. Moving forward you will be in a better position to advocate for rural patients. Even if you are still reluctant about going rural, I encourage you to take up the challenge. Even if you are set on working in a metropolitan hospital you will still see patients from rural backgrounds. Hands-on experience and first-hand knowledge will better position you to care for patients from rural backgrounds. Plus, it is likely you will come to love rural medicine and the amazing opportunities it has to offer. Belle is the AMSA Rural Health General Officer for 2020

CONTRIBUTORS

Photograph by Claire Demeo Nhulunbuy Nature Northern Territory

EDITOR-IN-CHIEF Elli Izrailov

FRONTIER! EDITORIAL TEAM Brianna Watts Kisal Fonseka Peony Tan Thedini Pinidiyapathirage

AUTHORS AND PHOTOGRAPHERS Amy Thwaites Belle Culhane Claire Demeo Erica Musgrove Gabrielle Hayman Isaac Wade Jasmine Davis Jasmine Elliott Jess Yu Judah Grubb Kelly Bell Kevin Mitchell Laura Mallett Lorane Gaborit Milla Izrailov Nicole Milanko Nicole Moon Paul Michael Sami Hossain Sarah Clark Thiyasha Wanniarachchi Thomas Mann Tianna Graham

SPECIAL THANKS TO

Cody Derbyshire, Elijah Katranski, Melinda Sobol, Milla Izrailov and Sarah Clark for providing valuable suggestions and advice in shaping this issue of Frontier! Our printers at the Printing Hub for bringing Frontier! into the real world and our sponsors, RDAA and GPTQ for making all this possible. The content of this magazine is from individual members and does not necessarily reflect the views of the entire AMSA organisation.

FRONTIER!

AMSA Rural Health Volume V Issue II 2020

From the Frontier! Editorial Team and the AMSA Rural Health Committee thank you for reading!