Idea Transcript
26
CHAPTER 8
Rural deprivation Brian C Bonnar MRCGP
THE title of this chapter may appear to be a contradiction in terms. Agrarian poverty and deprivation were to be found in the last century but surely the days of callous landlords subjecting a submissive peasantry are forever gone? Not so; sociologists say that the social structure which caused this scenario still operates today and indeed it is argued by some that rural peasantry still exists, though in a modified form (Tovey, 1992). The concept of deprivation is most often understood in association with the problems of inner city ghettos, large housing estates and racial discrimination. To most people the countryside is a place of recreation or retirement where time stands still. The pleasant surroundings seem to confirm this idea of a rural idyll. Indeed the definition of countryside given by the European Communities Commission is "a buffer area and refuge for recreation ... vital to the general ecological equilibrium and ... assuming an increasingly important role as the most popular location for recreation and leisure" (Commission of the European Communities, 1988). Publicity about urban decay has led to a relative ignorance of its rural counterpart . Townsend (1979) in his extensive study in the UK provides valuable insight into the distribution and extent of poverty. Approximately 36% of the population will experience poverty at some time, although the prevalence, according to which measures are used, varies from 10% to 24%. Alarmingly, the majority of those impoverished are the elderly or single parents, in other words those most vulnerable in society. The link between poverty and social group and health status is well documented (Carstairs, 1981). That poverty is so widespread must be of concern to everyone in primary care. The growing body of evidence which reveals previously unrecognized deprivation in the countryside is of even greater concern as health resources generally concentrate in urban areas. As rural deprivation is recognized not only by providers of medical care but also and perhaps more importantly by those living within rural and isolated areas, important questions must be answered by those who allocate resources for health care.
Definition and history Defining poverty or relative deprivation is important, as without a definition, measurement is difficult. Poverty has been understood variously by social commentators but the definition of Townsend (1979) is helpful: "Poverty ... is the lack of resources necessary to permit participation in the activities, customs and diets commonly approved by society." By definition, therefore, poverty is a state of relative deprivation which depends on the expected norms of
society. The resources may refer to income, assets or benefits. Society itself determines what is normal in terms of housing, education, health care and recreation. Relative to the poorest 10% of Africans, the same centile of Britons would be considered wealthy. Historically the state has endeavoured to help the poor in society. The Poor Laws of the early nineteenth century reflected a belief that poverty was inevitable in society and that much of the poverty was self-induced. A more charitable view has since developed through reformers such as Booth, Rowntree and others. In 1942 the Beveridge Report stressed the need for a minimum subsistence as the basis for state benefits. This belief in a basic minimum seems to be a basic tenet of government policy, certainly with respect to health care. Introducing the Resource Allocation Working Party (RAWP) review of 1976/77, the Secretary of State explained: "The underlying principle of RAWP, that of securing equal opportunity of access to health care for people in equal need is not in question . . ." (DHSS, 1976). This basic assumption has major implications when considering the allocation of resources for health care. A fair means of measuring relative deprivation must be found which takes into consideration both rural and urban communities. In order to understand rural deprivation, consider the example of my own practice in the most impoverished part of the UK, Northern Ireland.
Bushmills The town of Bushmills and its rural hinterland is situated along the beautiful north Antrim coast. Today Bushmills belies its name which originates from the time when there were no fewer than seven mills in operation, harnessing the power of the local river Bush to turn the wheels of industry. Now only one water wheel is working but sadly only as a salute to these former days when spades, nails, bicycles, flour and linen were produced and sold throughout the province. The economic history of the town helps one to understand the social deprivation which exists today and how this affects health. In the early part of the last century provision for the poor did exist although by the description proffered in Ordnance Survey Memoirs of Ireland there appears to have been no great need in the area: "There is no regular provision for the poor except the usual provision on Sunday. There are two loan funds in Bushmills ... There are but few poor in the parish, but in the summer many from the inland parishes infest it. The people in this, as well as in the parishes in this part of the county, possess sufficient charity to afford a
27 voluntary support to all, of any creed, who are unable to support themselves" (Day and McWilliams, 1992). This state of relative well-being was to be short lived. Ireland experienced the famine of 1855 which saw many flee for America. At the turn of the last century employment was to be found in the local mills, distillery, hotels and farming. With the progressive closure of the mills, local people were forced to look elsewhere for employment or turn to less attractive farm labouring. The market economy saw some farms enlarge while others reduced in size in the face of competition. These changes, not unique to Bushmills, led to a selective depopulation of younger adults and consequent relative increase in the elderly population. Rural townlands saw the loss of whole families, where once there were thriving communities. All of these social changes had the effect of reducing the general level of prosperity in the town. Inevitably this led to a reduction in local services. The population changes have had major implications in terms of health care and, in particular, care of the elderly. Medical care in Bushmills was first mentioned in 1879 when the local dispensary doctor was instrumental in obtaining a water supply from a nearby mountain spring. At that time the population of the town was 1103. As time passed, the need for a cottage hospital was realized, although it is now the site of a housing development. The number of general practitioners has remained at two for the past half century. Thankfully the days of charging 3/6d for a consultation with bottle and 5/- for a home visit are over. As one of the two local, non-dispensing general practitioners, I have been surprised since coming into the area at the level of social deprivation to be found. Our area boasts the largest throughput of tourists annually in Northern Ireland yet we are the only rural practice within our area Health Board to receive deprivation payments. Some of the most obvious problems exist in the small local housing estate, where a high proportion of mothers are single and teenage. Alcohol-related problems abound and many depend upon the state for welfare. Twenty-five per cent of mothers booking with us are single, and see motherhood as an escape route from an otherwise dull existence. In more rural areas 20% of our elderly patients live in simple cottages having retired from a life of farming. Many depend on infrequent local transport to access the town and medical centre. The local district general hospital is ten miles away, as are the main shopping areas. The general level of hardship experienced by many as a result of this relative deprivation is exacerbated by isolation and distance from many amenities. This hardship is often balanced by a stoicism which enables patients to walk in the rain to get to the surgery and then, after sitting for half an hour, greet you with a smile as you apologize for the delay. The sociogeographical change described is seen throughout many rural areas and especially those more remotely situated. Haynes (1987) describes well the inherent problems of rural depopulation. This effect is off-loaded to a certain extent by the influx of 'outsiders' to some rural areas, particularly more scenic parts, which increases the price of local housing, making it prohibitive for locals to remain in the area where their ancestors lived before them. Again this affects young people leaving home and setting up on their own. In the small seaside village of Portballintrae, just one mile from Bushmills, new houses are built to suit the tastes of more opulent 'outsiders', who are seen by the indigenous
population as depriving them of an opportunity to live near their families. This influx has further ramifications, as those who remain have a surplus of neighbours in the summer months but face a long lonely winter as those neighbours become absentee landlords. The social cohesion of the village is thereby affected. All of these factors lead to a dispirited, disempowered and underprivileged society. It is this sense of distance, powerlessness and seeming inability to influence change that leads to the barrier of opportunity as described by Devitt (1978) and is in essence what distinguishes rural poverty from other forms. The nature of deprivation Perhaps the problems outlined in the previous paragraphs sound familiar to those in urban practice. Differences do exist and these are not so much in the relative levels of deprivation, which are similar in both, but in the distribution of factors leading to deprivation, and more importantly, in how these are perceived by those experiencing them (Fearn, 1987; Watt et al., 1994) - that is to say, that rural deprivation has hitherto been largely unperceived and consequently ill understood. Fourteen indicators of rural deprivation have been proposed by the Rural Voice Health Group, an organization composed of those bodies with a particular interest in the countryside (Fennel, 1992). These are summarized below: 1. Lack of local services 2. High cost of living 3. Public transport problems 4. Housing cost and quality 5. Information deprivation 6. Income levels low, often with seasonal component 7. Job opportunities limited (especially for women) 8. Limited adult education 9. Inadequate social facilities 10. Lack of services for particular groups 11. Lack of political influence 12. Lack of control over local resources 13. Stigma associated with certain groups (e.g. single parents) 14. Lack of anonymity when using local services. The factors mentioned in this report are felt all the more acutely, as rural deprivation exists alongside considerable affluence. This feature is well highlighted by McLaughlin (1986), who describes an economic polarization within rural communities studied in England. This polarization distinguishes the rural poor not only from the majority of urban poor but also from the poor who historically shared their poverty in common with most of their neighbours. Agricultural employment in the UK has fallen by 12% between 1978 and 1988 and a further 10%-15% fall is predicted for the 1990s (Watt et al., 1994). Those who leave such areas are sadly the indigenous young and those with aspirations of obtaining non-manual jobs. The inevitable effect of this population movement is a relative increase in the numbers of elderly. This geographical change has been well described by Haynes (1987), who states that the size of some rural populations is increasing as people move out of cities into rural commuter areas and elderly migrants retire to their country homes, especially in scenic or coastal areas. The influx is balanced by the previously described loss of
28 the younger indigenous population in search of greater opportunity elsewhere. In more remote and also less desirable areas, the total number of residents is decreasing. These changes in population have important knock-on effects in terms of service provision, not only with respect of health care but also wider public services. The local village shop in Portballintrae, the small seaside village one mile from Bushmills, has closed within the last year reflecting the trend towards concentration of facilities in more populous areas, where costs can be kept low owing to high turnover of stock. Schools similarly face closure for reasons of economy of scale. These changes make public transport all the more crucial yet market forces determine a downgrading of services. A vicious circle of lower use and higher fares leads to a slow erosion of public expectation and demand. The higher percentage of rural residents owning private transport may be viewed as increased wealth but actually reflects increased necessity. Housing in rural areas tends to be of lower quality and the rate of homelessness greater than that in urban districts (Watt et al., 1994). Choice in housing is restricted as one moves away from towns and cities; this lack of choice is also seen when considering shopping and social activities. Travel to access such facilities can therefore become a very limiting factor. It is facile to think that people choosing to live in the country can expect to live next door to Marks and Spencer or have the variety of social outlets which are available in more populated areas, but basic requirements for life should be accessible to all.
The effect of deprivation The health needs of rural residents have been considered by Watt in Chapter 2. Deprivation is strongly associated with increased health needs, morbidity and mortality (Carstairs, 1981). The effect of centralization and rationalization of health care represents a serious threat to rural residents, especially those most vulnerable - the elderly and single parents. It can certainly be argued that the pattern of health service provision in the UK has deprived many rural residents of equity in health care, a basic tenet of the National Health Service. Branch surgeries are generally by their very nature less sophisticated than the main surgery, offering fewer facilities and more limited opening hours (Fearn, 1984). They tend to offer local care to those most in need and the majority of patients attending do so out of need, not preference. Their tendency to closure in more rural areas with reducing demand does not necessarily reflect reducing need (Fearn, 1987). As larger partnerships are formed, patients have correspondingly less choice of practice. These changes, coupled with distance and access problems to local hospitals and specialist services, have led some to propose the theory of distance decay, whereby the physical difficulties of access result in under-use and possible health risk (Haynes and Bentham, 1979). In the introduction to Sharing Resources for Health in England, it is argued that where there is reduced demand, supply of service will decrease and conversely where demand is greatest so will be the provision (DHSS, 1976). Within rural areas there exists an unperceived and therefore understated need which has not been fully considered by those either measuring need or allocating resources accordingly (Watt and Sheldon, 1993). Herein lies the need to
recognize, measure and evaluate rural deprivation in all its protean forms. The measurement of deprivation, poverty and need has been undertaken by many including Jarman (1983), whose underprivileged area score has been criticized on a number of levels (Watt et al., 1993). The score was devised using urban examples and is not a sensitive indicator of underprivileged rural areas. Devitt (1978) suggests that poverty for some becomes a way of life resulting in psychological barriers of opportunity and a psychology of defeat. This attitude perpetuates a vicious circle of low provision leading to low expectations and low demand (Fearn, 1987).
Addressing deprivation Having shown that significant deprivation exists in the supposed haven of the countryside, what should be the response? The structure of society is such that differences will always exist and the nihilist might argue that this fact must simply be accepted. Egalitarians would counter this by saying that if inequity exists, then intervention is required. It is the issue of equity as discussed by Watt et al. (1993) that is at issue. If a hitherto unperceived need is present, then surely it must be considered when allocating resources and planning delivery of health care. As one commentator has suggested, this may open a Pandora's box of demand and problems which cannot possibly be met under existing financial restrictions. Jarman (1983) pointed out that by identifying deprived areas and increasing health care expenditure, the retums in terms of improved health are not guaranteed. Addressing deprivation implies first that it is possible to recognize it and measure it objectively. However, it is still not possible to do this reliably in rural areas. The general practitioner is well placed, along with other health personnel, to identify health care need, although often the problems are more deep seated. Social deprivation is inextricably linked to health deprivation. When funding was withdrawn from a small rural hospital in New South Wales, Australia, the local community formed a co-operative and funded its own health care (Newman, 1993). Renewed interest in rural health care has been heralded by some in America as a 'rural renaissance', as congressional attention has focused on increasing rural unemployment, lowered central funding and issues of access (Patton, 1989). Information dissemination, as proposed in ACRE's report (Fennel, 1992), increased research, and awareness of the issues of rural deprivation and health care are needed if deprivation is to be addressed at government level. Although some might argue that changes such as fundholding improve equity, increased centralization of services poses a threat to already deprived rural areas. At the moment, the oft quoted inverse care law of Tudor Hart (1971) applies to the health of the rural poor and it remains to be seen what changes will transpire in the next decade. References Beveridge Report (1942) Social Insurance and Allied Services. London, HMSO. Carstairs V (1981) Multiple deprivation and health state. Community Medicine 3, 4-13.
Commission of the European Communities (1988) The Future of Rural Society. Brussels, EC Commission.
29 Department of Health and Social Security (1976) Sharing Resources for Health in England. London, HMSO. Day A and McWilliams P (1992) Ordnance Survey Memoirs of Ireland 16, 47-48. Devitt P (1978) On the nature of rural poverty. International Development Review 20, 16. Feam R (1984) Accessibility to primary health care in rural Norfolk: the role of the branch surgery. Family Practitioner Services 11, 179-81. Feam R (1987) Rural health care: a British success or a tale of unmet need? Social Sciences and Medicine 24, 263-74. Fennel J (1992) Health Care in Rural England. Cirencester, ACRE. Hart JT (1971) The inverse care law. Lancet 1, 405-12. Haynes R (1987) The Geography of Health Services in Britain. London, Croom Helm. Haynes RM and Bentham CG (1979) Accessibility and the use of hospitals in rural areas. Area 2, 186-91. Jarman B (1983) Identification of underprivileged areas. British Medical Journal 286, 1705-9.
McLaughlin BP (1986) Rural rides. Poverty, London 63, 15-17. Newman B (1993) The state opts out, the people opt in. World Health Forum Geneva 14, 13-15. Patton L (1989) Setting the rural health services research agenda: The congressional perspective. Health Services Research 23, 1005-51. Tovey H (1992) Development of the field. Irish Journal of Sociology 2, 96-121. Townsend P (1979) Poverty in the United Kingdom. Harmondsworth, Penguin. Watt IS, Franks AJ and Sheldon TA (1993) Rural health and health care. British Medical Journal 306, 1358-9. Watt IS, Franks AJ and Sheldon TA (1994) The health and health care of rural populations in the UK: better or worse? Journal of Epidemiology and Community Health 48, 16-21. Watt IS and Sheldon TA (1993) Rurality and resource allocation in the UK. Health Policy 26, 19-27.