Historical perspective

Historically, medical care has followed the movement of society as it has shifted from agrarian to more urban environments. The history of the evolution of medical care in remote areas is unique to each country, dependent on the specific political and economic forces in play. In the United States, there have been five eras, as described by Rosenblatt and Moscovice, that characterize the evolution of rural and/or remote health services in the United States. The period of colonization to industrialization (1620-1850) was characterized by health care delivery by nonphysicians: midwives, clergy, and men who “moonlighted” during their off-hours. The pre-Flexner era was marked by general practitioners providing care without necessarily undergoing standardized medical education or training. The Flexner era (1910-1940), named after the Flexner Report, revolutionized the practice of medicine by formalizing the education required to practice medicine in the United States. As a result, the number of poorly trained general practitioners significantly declined, as many were no longer considered qualified. Around this time, however, a new stigma also emerged associated with general practitioners who were not pursuing a career in a medical “specialty” in an urban setting. This created a significant health care access disparity leading to the era during the War on Poverty (1940-1970), which was characterized by the federal government’s effort to increase hospital and medical care access, especially in more remote, rural areas of the United States. The last period that they describe is our current era, the “Technological Era” (1970-present).

In addition to hospital and clinic-based programs focused on preventive and routine medical care, the establishment of the emergency medical technician (EMT) in 1966 by the National Highway Safety Act significantly improved and increased access to emergency medical care outside of the hospital and clinic throughout the United States. With the advent of the EMT trained to a specifically defined curriculum, people in remote regions in the United States began to have access to trained medical professionals who were able to provide initial medical stabilization without a physician physically present. Over the last 50 years, subsequent changes in prehospital care have led to an expanded system in the United States known as the emergency medical service(s) (EMS) system.

Similar changes have also occurred elsewhere in the world. In the 1970s, select European countries chose to employ an emergency medical care model known as the Franco-German model, which did not use EMTs but rather projected emergency medical care outside of the hospital setting, with physicians in the field. The focus was to provide definitive treatment in the field and avoid hospital transfer, in contrast to the U.S. system’s practice of stabilizing and transporting to the nearest facility.

Current practice

Health care access in remote settings is dependent on not only the existence of appropriate medical facilities and infrastructure but also the distribution of physicians and other trained medical specialists in the area. In the United States, only about 10% of physicians practice in rural environments, despite that almost a quarter of the population lives in rural areas. This lack of access to trained medical professionals, sometimes for even preventive medical care, in these environments has led to a higher prevalence of chronic medical problems, such as cerebrovascular disease and hypertension, in remote areas in the United States. In developing regions of the world, rural areas demonstrate higher rates of malnutrition in children compared with urban areas. This lack of access to preventive care in remote regions is even highlighted during humanitarian emergencies, when in addition to the acute medical issues, many chronic medical conditions come to the forefront.

In an attempt to close this health care gap and address the medical issues afflicting remote populations, there has been a movement to recruit nonphysician medical professionals to provide basic care in these regions. More specifically, this movement has included the incorporation of physician assistants (PAs) and nurse practitioners (NPs). ^, This movement has resulted in the evolution of health care teams that can be a mixture of physicians, PAs, NPs, nurses, rescue workers, and/or EMS providers. Thus the roles of each team providing care are often dynamic, with adaptability being a key characteristic for the optimization of care in remote environments.

Beyond the chronic medical issues seen in this population, there is an increased rate of morbidity and mortality associated with accidents and trauma in remote regions. Accidents leading to serious injury or death account for 60% of total rural accidents versus only 48% of urban accidents in the United States. It has been proposed that this discrepancy is likely secondary to delays between the time of the accident and the first receipt of medical care (18 minutes in rural areas versus 8 minutes in urban areas). Sometimes, this increased length of time to care is due to not only the physical distance but also the environmental challenges in accessing these remote locations (i.e., terrain, weather, road conditions, etc.).

Related to issues of access, the EMS system in the United States has developed subspecialty capabilities including the development of wilderness EMS training. Other similar emergency systems have been adopted around the world. However, many developing countries do not have an established EMS system or, if a system exists, it is often only in its infancy.

Preplanned large-scale events in remote areas, such as the Burning Man festival, which occurs every year in the Nevada desert and in 2013 hosted 65,000 visitors, produce special challenges for the provision of medical care to large crowds in remote areas. The medical response to the 1969 Woodstock Festival highlighted the severe difficulty in accessing populations remotely, especially during mass gatherings. The unexpected volume rendered the prearranged and existing medical system impractical. In response, more providers were emergently mobilized; schools were converted into triage centers; and an employee tent was transformed into a field hospital. Unfortunately, the mass of people obstructing the roads also limited the use of ambulances to transport injured and sick patients to area hospitals, and there were significant problems with the delivery of medical supplies to the site, requiring that helicopters be employed. Thankfully, because of on-site improvisations, the morbidity and mortality rates were relatively low, although the event still serves as a monument to the importance of evidence-based preplanning.

Mobile or deployable clinics have also been used both in the United States and globally, to address the difficulties in delivering care to remote regions. The forms of various mobile clinics can be quite diverse, and they can be configured to tackle a number of different medical issues, from routine medical care to vaccination campaigns to the provision of surgical services. Mobile clinics are often employed in disaster settings for both frontline care and as tertiary care. For example, in the November 2013 Philippines’ Typhoon Haiyan disaster response, in addition to the mobile clinics and operating theaters installed on the ground, China’s “Peace Ark” ship, a fully staffed and equipped 300-bed hospital, with 20 ICUs and eight operating theaters, was available offshore for tertiary care. The United States Navy’s hospital ships, the USNS Comfort and USNS Mercy , have often served in a similar role in events such as the Indonesian Tsunami and Hurricane Katrina.

Similar in concept to these mobile clinics is the military’s MASH, the 60-bed Mobile Army Surgical Hospital deployed during the Korean War to provide more advanced care to injured soldiers as close as possible to the battlefield. (Because of the popularity of the movie and TV series M*A*S*H , colloquial use often refers to any small mobile military field hospital, and multiple similar military variants now exist.) During the Burning Man festival, previously mentioned, three small portable medical care facilities, termed MASH units, are deployed and staffed by volunteers.

Medical care can also be delivered to remote areas not only through mobile clinics but also by using telecommunication technologies, often known as telehealth or telemedicine. Telemedicine has recently been employed as a tool to reach patients in remote areas, for a wide variety of reasons, including provision of primary care, as well as for immediate access to emergency specialty care, such as with acute stroke and trauma surgery consultation. ^, In an attempt to close the geographic gap and better address the health needs of remote communities, telemedicine has improved not only health care access but also the quality of care delivered for both chronic and more recently, more acute conditions. Widespread adoption of radiological services through telecommunication is evident in rural communities throughout the United States, and this success could be translated internationally. These services have continued to expand to include more specialized care, such as neurology for stroke evaluation. More recently, beyond the clinical consultation aspect of telemedicine, the tool has also been employed for training sessions and continuing medical education for personnel in remote regions.

It is important to note that telemedicine requires the presence of certain infrastructure (i.e., electricity, Internet, satellite connectivity, etc.) to be a feasible method of providing medical care. Therefore, in areas of extreme austerity and remoteness, or even in complex environments such as disaster settings, telemedicine has been more challenging to implement.

Expedition and wilderness medicine specialists have unique challenges when providing medical care in remote settings. These specialists need not only a wide knowledge base to be able to care for those in distress but also the ability to be able to depend solely on the resources they carry with them. Similarly, disaster medical teams working in remote areas or in areas with widespread infrastructure destruction may be limited in the care they can provide to the materials and supplies that they bring with them to the event. In such settings, the objectives may often be only to triage and stabilize the patients for transportation to the nearest facility for definitive medical care, even the nearest facility may be days away. Therefore teams require a skill set to be able to address ongoing medical concerns during the period of evacuation as well.

It is important to note that rural and/or remote populations may also be demographically different from their urban, metropolitan counterparts in terms of age, gender, and educational and occupational backgrounds, among other factors. Remote areas often have different proportions of children, pregnant women, people with disabilities, and the elderly than those found in urban centers, and all of these groups might require differing levels and types of resource availability. Moreover, the demographics and health risks of a region can actually evolve rapidly, particularly with a period of significant worker migration or immigration. This was recently evident in North Dakota, where there was a massive influx of oil workers into a relatively remote region of the state because of economic change. The existing health care infrastructure was overwhelmed by not only the rapid increase in population size but also the unique health needs of the incoming population. For example, with this change in regional population demographics, there was a sudden and significant increase in sexually transmitted diseases, requiring local and state health departments to implement vaccination campaigns, increase clinic availability, and start educational programming. The advanced determination of the most suitable medical equipment, essential medications, and knowledge of appropriate specialty health care facilities if transfer is needed is critical to providing care in remote regions.

Cultural norms also must be considered when planning to respond to an area’s medical concerns. Specifically, understanding how medical problems are typically approached in a community is important. In some remote areas, people exhibit an increased dependence on family and social support ^, and might be hesitant to seek formal medical care, delaying definitive treatment. Additionally, some communities might have certain preconceived notions and perceptions of “Western Medicine,” and this should be considered when trying to provide effective care. ^, For example, the reasons for the 2013 reemergence of polio in Syria’s complex humanitarian emergency was multifactorial in nature, but it appears to have been exacerbated in part by a false rumor spread by certain Muslim groups that the medication was a Western attempt to create “a poison meant to sterilize Muslim women.” In an effort to mitigate this belief, the World Health Organization worked with notable Islamic scholars to campaign the message that those who opposed the vaccination process were “un-Islamic.” Therefore, in addition to the challenge of vaccinating in remote regions of Syria from a logistical standpoint, cultural challenges also must be addressed to be an effective response.