In Rural WONCA (international FP) in Seattle in October, it was interesting
to discuss the great improvements in Australia in health care. Australia,
Ireland, South Africa, and Kenya keep popping up as areas far more upbeat
now that in times in the past. Australian contacts were by far the most
enthusiastic, and for good reason.

Rather than beating down all of the usual powerful medical and medical
education lobbies, there seemed to be a more direct approach that took into
account all of the different perspectives. The core 3 areas regarding
distribution of health resources were identified and addressed. Those in
charge already understood the key issues and as insiders, were able to get
the right situations implemented, even with the usual professional type
oppositions.

It also appears that distributions of education and higher education had
also been addressed, a great foundation for any change.

Australia is, as far as I know, the first and only nation that has reversed
the decline of rural born admissions to medical schools. The nation was
once over 25% (as was the US decades ago) and declined to 10% and then rose
again to 19%. The effort required changes in education, admissions,
distributions of medical training, new schools focused on GPs and rural
GPs, and support for physicians in rural practices. In the US, the declines
have resulted in less than 10% admitted despite over 20% of the population
rural.

There are 4 tiers of US admissions 1) 3 - 10 times probability  - children
of professionals/highest income/most urban/Asian  2) usual admissions at
slighly below average probability of admission - typical urban, higher
income rural, top income white and some middle income  3) 50% probability
of admission compared to population - rural, Black, lower middle quartile
income   4) 25% probability of admission - Hispanic, low income rural,
lowest income quartile, minority plus rural     Those most socially,
geographically different, fail to gain admission in the US.

In Australia, the gaps have been closed for geographic origins and the
distributions that follow with reasonably supportive health policy.

The government leaders in charge of the major decisions clearly sought out
solutions from the best sources of information.

The United States has a very different scenario, as is seen in the news
daily. We admit few different types of students to college and medical
school, fail to support medical education, fail to train students to meet
national needs, fail to influence them to meet national needs, and fail to
support those that make the "correct choices" such as careers and locations
outside of major medical centers.

There are many such areas that when suppressed, may end up in worsening
consequences, such as the dismissal of the Army Secretary to address the
real problems of goverment.  On NPR the top brass reaction to the appaling
conditions of the veterans returning from the Iraq war was, why did they
not report it? A top brass not aware of the very vulnerable population of
soldiers (like research on certain populations who are vulnerable) who have
been trained to respect authority and chain of command is a sad situation,
one that seemed to have been addressed post-Vietnam, (read Colin Powell
biography) but may be recurring.

When I sent preliminary reports about physician workforce in primary care
and rural and underserved areas to the Federal Office of Rural Health
Policy, they were appreciative, but did not pursue the implications. (I am
proud of the RuralMed folks in Canada, who do a superb job, much better
than we in the US, and have a bit more success although not all that is
needed)

I did not ask for funding from the Office of Rural Health Policy. I mainly
wanted the information to go out about what was happening in admissions and
in health policy, but the work was guaranteed to generate controversy. This
office, like so many others, decided not to rock the boat. It has become a
matter of survival for all such agencies, the ones who feel the pulse of
the nation and report vital signs, but the lines are down. All of the
agencies that are attached to lower and middle income populations are
running scared. We in family medicine focus on Title VII and each of the
groups has their own little pot of gold that is not so deep and does less
and also gets zeroed out every year, making all of us individually and
collectively, waste time on getting our own little piece and preventing
much needed reforms and restoring the flow of appropriate and essential
information that is needed to to run government effectively. We also fail
to rat on our own primary care  "brethren" who are all less than 50%
primary care except for general peds. It is no wonder that the government
gets a confusing message.

Robert C. Bowman, M.D.
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