How to provide health care in a rugged, vast and low populated country?

Question

Background

In a far flung land, there exists the country of Coldesia. It is large, around the size of the US state of Alaska. Most of the country is covered with either barren mountain ranges or large forests. The weather is frequently cold (as the name might imply) and as a result, the country is often covered in snow, sleet and rain; The temperature rarely reaches above 10 degrees Celsius, with the country seeing temperatures of 5 to -20 from September to May. It has a population of 600,000 - 700,000, with a majority of its citizens living in communes or villages of roughly 100 - 300 people. A majority of these villages are sparsely spaced apart, with human activity not evident for hundreds of miles in areas. Most Coldesians either live off the land, as farmers/ranchers (not an easy task) or work in the extensive mining industry.

Coldesia has been ravaged by war, due to various parties conflicting for control of the state's large supply of minerals and metals. As a result there have been several purges which have left the country short of highly skilled workers (teachers, lawyers, doctors, etc.) The current government has a firm grip on the political situation of the country and are well-liked by the populus. They are modernizing and investing in the country's critically underfunded public services, especially in public transport, education and health care, but this massive task will take years, if not decades, to complete due to the expanse of country and due to how sparsely populated it is.

Gravel and unpaved roads account for 80% of the road infrastructure. Most people have access to widespread transport through the mainly complete railway system that covers most large Towns and cities.

Question

How would a country, such as Coldesia (described above), provide a good level of health care throughout the country when there are so few doctors to go round, along with the sparsely populated territory?

NOTE - I did some reading into the Barefoot doctors that China had during the 1930s-80s. Would a scheme like this be possible?

Additional Context

This world is set in the early 1990s, with the same technology level as the real world at that time. To answer @DJClayworth comment about Flying doctors being a good option, additional sub-question - would this be possible in due to the fact that there is high wind speeds and icy conditions frequently?

Answer 1

There are a number of variables that need to be taken into account.

• Immediacy: People are breaking bones and catching colds kinda all the time.

• Education curve: Combat medics can be trained comparatively quickly, but they require support. Full surgeons require a minimum of 4-10 years depending on whether or not you want to risk throwing out the benefits of residency.

• Transport costs: It's cold, it's north, and blizzards are not conducive to transportation.

• Equipment: And your average village of 300 can't support the cost of an MRI anyway.

So...

Step #1: Demographics rule the first day

You have a limited resource. Your country can't survive with lots of happy 300-person villages. Its your industrialized centers with government and education (which are usually the largest populations during the 90s) that are first. You don't tell us exactly, but let's assume one doctor per 1,000 people.

That's 700 doctors for the nation. You must protect your national assets, so 2.5 doctors per 1,000 people in the higher density populations, spread the rest around. At a guess, one doctor for every 6-8 villages.

This is most sensitive to transport, especially where inclement weather is concerned, but we're talking bush doctors here (planes, cars, trucks). Note that by the 90s the majority of your nation will have a reasonable transport infrastructure — it's really an issue of how much of it was destroyed by war and how much of your repair and maintenance infrastructure went with it. So your real problem is helping people who can't wait 2-4 weeks to see the doctor, or (worse) can't be helped without equipment located at a central location.

This is a 60% solution. You'll have people die due to lack of sufficient medical care, but that's what will happen.

Step #2: Triage Education

Each village is expected to send 1-2 people for immediate basic-care training. These folks don't learn about medicine per-se other than first-aid (bone setting, wound cleaning and stitching, very basic illness care). Their predominent purpose is to oversee welfare: clean drinking water, good sanitation habits, etc. Stuff of a preventative nature. This is 6-12 months of training to relieve the stress on the bush doctors.

Step #3: Medics/Physician Assistants/Certified Nurses Assistants ASAP

Thankfully, the proverbial 80%¹ of doctoring is made up of cuts, bruises, broken bones, and "basic" illnesses. Panicked 1st-time parents are frequent customers. The vast majority of this kind of doctoring can be dealt with using what in emergencies would be much-simpler-to-train combat medics, PAs, and CNAs. This would minimize the need for doctors to visit the remote areas all the time, leaving them free to focus on the more critical issues that demand their education and experience. These folks would most likely be drawn from your population centers and farmed out to the remote villages on a "we'll pay you a bonus for your sacrifice" plan.

Expect (mandate) that each village supplies 4 people for immediate and intensive training. One general practitioner, one PA, one RN, one CNA. What would normally be 4 years of medical school, 3 years of residency, and 2 years of specialization is now 2-3 years of school and 0.5-1 year of residency. Yes, that kind of cramming comes with a price, but it bumps you from 80% of the solution to 90% of the solution.² So, within 3-4 years of the "epoch" you have most of your doctoring back in place.

Step 4: Equipment & logistics...

Now that you have the people in place, you need pharmaceutical distribution, hospitals, places that need equipment, warehousing, and other logistics. You can draw the people you need from the locations of the (probably) regional healthcare centers. This will include pilots, administrators, everything down to janitors and security. This is the bulk of your redevelopment. Even assuming some of this infrastructure was still in place, it will have needed repair and renovation. At best, 8-15 years.

IMPORTANT

I've made some outrageous assumptions, not the least of which is that a war that knocked off so many skilled surgeons didn't also destroy the truck drivers, warehouse workers, office labor, pharmaceutical manufacturing, and everything else that a very complex 1990s medical industry needs to operate. It's not just the handful of people at the tip of the iceberg (doctors) that you'll need, it's the 50-100 people (minimum) each needed to support them. I'm basically ignoring this other than Step 4. If you must rebuild the entire medical industry from a minimum condition, you're "national healthcare" will be set back to the 1880s. What few doctors exist may know a lot about what to do, but they won't have access to equipment, supplies, and medicine.

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_{¹ You know, 80% of the work takes 20% of the time.... I'm using the same kind of generalization.}

_{² You know, 20% of the work takes 80% of the time.... I'm using the same kind of generalization.}

Answer 2

I'm going to go with the earlier suggestion and suggest you take a very good look at flying doctors. You might want to look at how this is dealt with in remote locations in our world, such as Alaska, the Australian outback, and similar locations.

You do ask about "high winds and icy conditions".

Ice is definitely managable by aircraft, if known and planned for. Onboard deicing and anti-icing systems, properly dimensioned, can deal with a lot. External deicing, such as that provides on airports by deicing trucks, can also help. (Do note the difference, here; deicing removes ice which has formed, while anti-icing prevents ice from forming. You'll want both in an aircraft intended for flying in icy or icing conditions.)

Ice on the ground isn't that much of a problem; heck, airplanes regularly go to Antarctica and back. Skis on the plane is one way to deal with it; using helicopters and simply taking off and landing nearly vertically (with negligible horizontal velocity) is another. You could also keep a snow plow handy near each field and simply call in with a request for the runway being cleared of snow before you land. Each way of dealing with it has its own advantages and drawbacks, but it's not an insurmountable problem by a long shot.

Plain wind isn't a huge problem, at least as long as it isn't causing major turbulence near the ground. What's a problem for an airplane is crosswind. The crosswind component is the equivalent wind were the wind to blow at the aircraft straight from the side. This can be mitigated by simply clearing out more than one runway at each location, thus allowing the pilot to choose the one offering the most favorable wind conditions at the time. Runways don't need to be hard-surfaced; soft field operations is a very real thing, especially in general aviation. So is, also, what's known as "short field" operations, where the focus is on getting off the ground and getting some obstacle clearance in as little ground distance as possible (and correspondingly, getting down and stopping in as little ground distance as possible). Demonstrating proficiency with short field and soft field techniques is a requirement to get a pilot's license in our world. A small aircraft, especially if equipped with a powerful engine, doesn't need much ground distance to get airborne. To get an idea of the speeds involved, the rotation speed (when the pilot starts lifting the aircraft off the ground) of something like a Cessna 172 is around 55 knots or 100 km/h.

The only major societal concern I'd have with this is probably the fact that "there have been several purges which have left the country short of highly skilled workers (teachers, lawyers, doctors, etc.)". For this to work, you are going to need both doctors and pilots; ideally doctors who are also pilots, but pairing them up for the trip can work, too. Your government is going to want to somehow encourage people to learn such trades. As JBH mentioned, early triage is going to be critical to manage the scarce resource, and first aid is going to be critical because even if they're literally sitting at the airport ready to go, it's going to take a while for your doctors to arrive. (Estimate 150-250 km/h airspeed for small aircraft. Subtract whatever the headwind component they're fighting against is, or add the tailwind component, and you can easily look at a ground speed of anywhere in the 100-300 km/h range.)

Answer 3

I live in Nunavut, which has an area larger than Alaska, a population of 40,000 people, and a climate significantly worse than what you propose; -20 C during the period of September to May? That's balmy where I live. A temperature of -20 C for winter months can be the record high for some communities.

So, some actual data.

First, your population is going to be mroe urbanized than you think, with not many people living in small villages of 100-300 people. Both Alaska and Nunavut demonstrate this. Of the 40,000 people in Nunavut, nearly 1/5th live in Iqaluit, capital and largest (and only) city. There tends to be a flow from the smallest communities to the larger ones, so the small ones keep getting smaller and the larger ones bigger.

Alaska has 740,000 people, and Anchorage and the intermediate surrounding communities have over half of them (402,000), then Fairbanks and Juneau with about 31,000 each.

Larger communities will be the ones offering greater services, which will attract more people, which will increase demand for services, which will draw more business and spending, which will attract more people, and so on. The government will set up regional centers from which their services are provided to surrounding, smaller, communities, and people and private services will likewise gravitate toward those centers (or communities in close proximity).

In terms of medical service, what you're likely to see, based on the system I work with here:

• Hospitals and major treatment centers will be located in the largest cities and regional centres. Your specialists will be in the major cities.

• Smaller communities will have clinics. They will be staffed (not counting support staff) primarily by nurses and nurse practitioners. Doctors and some specialists will probably do rounds among several clinics within their operating area.

• Patients who need long term care or more intense treatment will likely be flown to the major centers. The government may put up special facilities (those for psychiatric treatment, elders' care, and such) in communities outside the main ones, but they will serve people from multiple communities.

• Major emergency situation will be handled by aircraft medevac, with dedicated aircraft and medical flight teams to transport patients. What counts as an emergency requiring aircraft will vary: assuming no additional significant injuries, something like a broken arm, as long as properly set and in a cast, can be handled locally. On the other hand, a possible cardiac event will likely require medevac. The aircraft will be based in centralized locations, so there isn't a plane waiting in every community all the time. This means it's possible for hours to elapse, or worse due to weather conditions, before someone may get treatment they require.

• When possible, patients will be flown under medical contracts on regular airline flights (we call them "schedevacs").

Answer 4

Given that level of technology Flying Doctors are definitely an option, since they were flying planes in Antarctica earlier than that, and the alpine rescue choppers in the Himalayas date from as early as the 1970s.