The Tyranny of Distance
Breast cancer in rural New Zealand
By Sue Claridge
pink magazine, October 2009.
Living in the country has many advantages over living in the city, but, as participants in the Breast Cancer Network’s First National Conference in October 2007 attested, this is not the case when one is faced with a serious illness.
The “tyranny of distance” – a phrase coined by author Geoffrey Blainey – is an apt summation of the impacts on rural and provincial New Zealanders when dealing with a serious illness. In fact, distance from providers of the
required treatment and care, and the hardships imposed
by that distance, were the main issues of concern among women attending the Rural Women workshop at the 2007 conference and remain the main concerns among women spoken to during research for this article.
Cancer in Rural and Provincial New Zealand
There is no clear cut classification of rural and urban and various definitions are used. Thus it is hard to accurately characterise who we mean when we talk about rural and provincial New Zealanders with breast cancer. Originally based on population numbers, the modern classification is determined not only by where a person lives but the proportion of the usually resident population whose workplace addresses are within a larger urban area, giving rise to three urban and four rural categories (main urban, satellite urban, independent urban, rural with high moderate and low urban influence, and highly rural or remote).
According to Hayley Bennett and her colleagues, who investigated the effect of urban versus rural residence on stage at diagnosis and survival for women with breast cancer in New Zealand (New Zealand Medical Journal, 2007), of all the women who were diagnosed with breast cancer between 1998 and 2002, 73.3% resided in the main urban areas, 3.3% in satellite urban communities, 13.3% in independent urban communities and 10.2% collectively in rural and remote areas.
There are six cancer centres in New Zealand: Auckland, Hamilton, Palmerston North, Wellington, Christchurch and Dunedin. According to the research by Bennett et al. just under a third of the cohort of women they studied lived within ten kilometres of a cancer centre, one third lived between 11 and 50 kilometres away, 15% lived between 51 and 100 kilometres away, while 22.3% lived over 100 kilometres away from a cancer centre.
In another study by Dr Robin Haynes and colleagues (Social Science and Medicine, 2008) New Zealanders diagnosed with five common cancers between 1994 and 2004 were investigated for the combined effects of ethnicity, deprivation and geographical access to health services on the likelihood of survival. The researchers found that for breast cancer patients half lived within 2.1 minutes travel time of a primary health provider (e.g. GP), and half lived within an hour’s drive of one of the six main cancer centres, but that there was a small number of patients with a very high travel time.
Distance and Survival
One of the policy concerns when it comes to health service delivery is disparities between different groups is a community; that is disparities between ethnic or racial groups, socio-economic groups and those living in different parts of the country. Such disparities are measured at the most serious level on the basis or outcomes or rates of survival from serious illness.
International research has identified that there are urban-rural health disparities and research in Australia, the US and Canada has found that people living in regional and remote areas have higher mortality rates than people living in urban and suburban areas; one of the major contributors to high death rates is cancer. Bennett et al. refer to research that has found both later stage at diagnosis and poorer survival in rural residents. For example, a study of over 60,000 patients in Scotland diagnosed with one of six common cancers, found that increasing distance from a cancer centre was found to be associated with poorer survival.
However, the studies by Hayley Bennett et al. (2007) and Robin Haynes et al. (2008) in New Zealand both concluded that there is no disparity in outcomes between rural and urban breast cancer patients. Bennett et al. found that there was no statistically significant difference in stage at diagnosis or survival. Haynes et al. found that while there were disparities based on ethnicity (poorer outcomes among Maori versus non-Maori) and residing in an economically deprived area, “there was no evidence that people living furthest from a GP or from a cancer centre were diagnosed at a later stage in the disease than those living closer.”
The only survival disadvantage was the already well known poorer survival associated with later stage at diagnosis, which in itself was not associated with distance from primary health care or a cancer centre.
The Issues for Rural and Provincial Women
While it must be comforting for women in rural and provincial New Zealand to know that they are at no greater risk than city dwellers of being diagnosed with more advanced disease, or dying from breast cancer by virtue of where they live, the distances that they must travel to obtain treatment, are nevertheless, disruptive and difficult, and impose hardship on many families.
With only six cancer care facilities in New Zealand a large number of New Zealanders must travel long distances to obtain the treatment recommended to them. One of the biggest issues for women who were spoken to for this article is radiotherapy. While regional hospitals perform mastectomies and can deliver chemotherapy treatment, radiotherapy is only done at one of the six cancer centres. Therefore, women in some of our largest towns and cities – in fact, everywhere but Auckland, Hamilton, Palmerston North, Wellington, Christchurch and Dunedin – must travel often significant distances for radiotherapy. The difficulties, financial hardship and separation from family endured by women in cities such as Gisborne, Rotorua and Nelson hint at the even greater difficulties that must be endured by women who live in our remotest regions such as parts of the Far North and the West Coast.
The National Transport Assistance Programme
The Ministry of Health administer a National Transport Assistance Programme for people who live at distance from required health care. Travel assistance is available when a publicly funded specialist (not a GP) has referred a patient onto another publicly funded specialist if the patient meets specific criteria. That criteria includes the distance travelled, the number of times a patient must visit a specialist in a given period of time and whether or note the patient is a Community Services Card holder. Under certain circumstances, accommodation assistance and assistance to cover a support person is available.
Various forms must be filled in with the assistance of the patient’s hospital travel coordinator, health or disability specialist or social worker. The travel allowance is 28 cents per kilometre which seems inadequate given considerable petrol price rises in recent years and in light of Inland Revenue mileage rates and rates recommended by the AA to cover vehicle running costs. The accommodation allowance is up to $100 per night.
People wishing to claim for reimbursement under the scheme must have their claim form signed and stamped by the attending facility or hospital, or must attach signed and stamped proof of attendance, for example, an appointment or discharge letter on hospital letterhead. Claimants must also attach original, itemised receipts for public transport and/or accommodation. Application forms must be received by the Ministry of Health within 90 days of the last date of treatment to qualify for reimbursement.
A 2008 New Zealand Institute for Rural Health discussion paper described the National Transport Assistance Programme as being of particular concern to them. The discussion paper said of the scheme:
“It does not adequately compensate, it is available to limited numbers, it assumes transport is available to all New Zealanders (public or private transport), it further assumes that rural New Zealanders can afford to pay for the transport and then seek reimbursement and finally the claiming process is daunting to even the most expert form filler.”
The conclusions of the New Zealand Institute for Rural Health discussion paper support two of the recommendations of the BCN 2007 First National Conference for those affected by breast cancer. The first is that patients need better information on the travel subsidies available. The second is that, although rural women understand the restrictions imposed by cost, rural patients’ needs must be considered at local and central government and policy making level. In light of the current economic climate, and the significant hardships imposed on those rural and provincial residents diagnosed with cancer, there is justification for a review of the availability and accessibility of the National Transport Assistance Programme.
More Information on the National Transport Assistance Programme can be found at http://www.moh.govt.nz/travelassistance or by phoning 0800 281 222