Public Health –
an essential part of rural practice?
Greville Wood
MBChB(UCT), FRNZCGP, DOM(Stell), MFGP(SA),
DipPEC(SA), DCH(SA)
Greymouth
West Coast, New Zealand

Public Health –
an essential part of rural practice?
I have no conflicts of interest

The tension!
 The main difference between public health and
medicine is that:
 PUBLIC HEALTH is mainly interested in the health
of populations, which has an impact on the
individuals in the population, while
 MEDICINE is mainly interested in the health of
individuals, which has an impact on the health of the
population.
 And this is how we teach and practice the discipline
in a separate silo.

Public Health –
an essential part of rural practice?
 Carole Reeve showed clearly in her presentation
that time spent working with Public Issues was a
formative experience for those junior doctors who
did a rotation in Public Health.
 But should public health principles and skills be an
integral part of the work we do in Medicine?

Case Discussions
 Giardia, endemic in the community, the story of its
control
 Strep. Erysipelas and its control in a closed community.
 A community’s response to a Pertussis outbreak

Giardia, endemic in the community,
the story of its control
 When John Snow removed the handle of the broad
street pump, he showed the way to prevent
waterborne disease and reduce outbreaks.
 In this community, drawing their water from the
river was the source, sharing baths and communal
ablution facilities the vector
 Discussion/education, patience and courage to act
on thinking the catalyst for change
 Filtering water, case identification and treatment of
infected pool.

Strep. Erysipelas and its control in a closed
community.
 Quarantine, which has been in use for hundreds of years,
was a major advance in the control of communicable
disease long before the idea of microbes was introduced.
 Agreement with the diagnosis – aided by pus swabs was
pivotal
 Identifying carriers – through nasal swabs
 Discussion/education, patience and courage to act on
thinking the catalyst for change
 Early identification, isolation, regular cleaning of
contaminated areas, judicial use of antibiotics

A community’s response to a Pertussis
outbreak
 Against vaccination
 Quarantined themselves letting only those who
had been vaccinated mix with the “outside” world
 Asking all those entering the community to wear
masks and
 Isolating their own for 3 weeks (what a long
incubation period) before mixing with community
again.

RMIP – Rural Medical
Immersion Programme
 2006 – the West Coast was selected as one
of the sites to distribute 5th year medical
students to
 We hosted 3 – and have continued to do
this for the last 8 years
 The students have a week intensive
Public Health input and a monthly
seminar with our Medical Officer of
Health.

a student’s reflection on his
experience
 At the time – “this was a waste
of a week.”
 3 years later- “you remember
that comment I made about
public health – I was wrong it
has proved to be very useful!
Thank you.”

a tutor’s experience
 Experience teaches us a few
things, especially what we wish
we had learned, and
 What we wish we had paid more
attention to when we were taught
it

learning objectives
 Is public health important in the rural health
curriculum?
 What skills are needed to manage the public health
issues in rural general practice?
 How is success measured?

Is public health important in the
rural health curriculum?
 WONCA Rural Medical Education Guidebook - See
handout
 Public health refers to ‘all organised methods ... to
prevent disease, promote health, and prolong life
among the population as a whole’ Integrating Public Health and
Medicine - Donovan
 “By absorbing the ‘hidden curriculum’ common in
large hospital centres, students can come to view
public health as an unimportant subject that reduces
the time available for learning exciting high-tech
medicine.” p.3

Is public health important in the
rural health curriculum?
 To maintain the health of the people in their area,
physicians assess the needs of their practice
population and community, orient their practice to
meet those needs and advocate for the health of the
local community
 Physicians are using epidemiology and applying the
principles of health promotion; community
development and empowerment.
 ‘community-oriented primary care’ (COPC) – p.6

What skills are needed to manage the public
health issues in rural general practice?
 We need to care for not only the individual, but also the
community we are part of.
 Jenner demonstrated how powerful the hypothetico-deductive
scientific method could be (Hopkins, 1983).
 This approach of carefully making observations, organising
these observations into a hypothesis,
 testing the hypothesis,
 modifying it to make predictions based on the modified
hypothesis and then testing those predictions,
 The encouragement, advice and coaching provided by a
good mentor.
 Perseverance

How do you measure
success?
 Napoleon Bonaparte had the highest regard for Jenner
and vaccination. When Jenner wrote to request the
release of an imprisoned British officer, Napoleon’s
response was, ‘Anything Jenner wants shall be granted.
He has been my most faithful servant in the European
campaigns.’ Napoleon had all his troops vaccinated in
1805 and all French civilians a year later.
 Sir Christopher Wren said of Jenner, in memoriam after
he died of a stroke on 26 January 1823, “His glory shines
in every fresh and healthy face...his monument is not in
one cathedral but in every home” (Anon, 1858b).
 Saunders V. & Durrheim D.N. (2003) Journal of Rural and Remote
Environmental Health 2(2): 41-45

Is public health important in the rural
health curriculum?
Discussion
 The physician in a rural general practice is likely to
be one of the few health professionals in the area.
 In small regions, they may have privileged contact
with influential people and organisations – and
 indeed, they may be seen as a resource for all types
of health issues, including public health and
community issues. p.7
 Donovan D. Integrating public health and medicine. In Chater AB, Rourke J, Couper
ID, Strasser RP, Reid S (eds.) WONCA Rural Medical Education Guidebook. World
Organization of Family Doctors (WONCA): WONCA Working Party on Rural
Practice, 2014. www.globalfamilyldoctor.com (accessed 22nd October, 2014).