President's message. Reflections from Laos/Message du president. Reflexions au sujet du Laos.(Editorial)

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Laos has a population that is 70% rural, water that must be boiled before drinking, a population with a short life expectancy, and high rates of infant and maternal mortality. I have been working with the country's single medical school to increase its production of doctors to serve the needs of the rural population. This causes me to reflect on what makes a difference to the health of the people in any country. Which investments will create the biggest improvement in health? How can we improve on the 3 year-shorter life expectancy and poorer health status of rural Canadians?

Worldwide, higher family income and freedom from violence are strongly correlated with life expectancy. Initiatives aimed at community safety and employment will create improvements in health and longevity. Clean water and a secure food supply are prerequisites for good health. Many Aboriginal communities in Canada have coped for years with high levels of violence and unemployment. Unsafe drinking water has been a fact of life in many remote Aboriginal communities, and now, increasingly, in the rest of rural Canada. It's time to ensure safe living conditions, access to employment and clean drinking water for all Canadians. The money spent will reduce health care costs and provide an economic stimulus where it's been needed for years.

Public health and vaccines remain as important as ever, and most of Canada has access to vaccines. As governments look for ways to save money, we must remind them that cutbacks in these programs will eventually cost far more than the money saved.

What about health care? After income, safety, clean water, public health and vaccination, the contribution of medical services to the health of a country is modest. Studies looking at health indicators such as life expectancy have shown that access to primary care improves health; access to specialist care does not. (1-3) If we want our tax dollars to be used effectively, spending should be focused on improving access to primary care for all Canadians. For rural Canada, spending should focus on what is required to attract and retain family doctors, nurses and other medical staff. To do this, governments and health authorities need guidance: What are the necessary community supports to make rural practice attractive and viable? Does the presence of a hospital affect access to primary care? Does the range of services offered by a hospital make a difference in the recruitment of primary care doctors and nurses? What specialty services are required to enable a particular community to attract and retain primary care physicians and nurses? How can specialized urban hospitals better serve the needs of all people in their catchment area? Do all hospitals even have an identified catchment area? How accessible are these hospitals' services for rural people?

Research would help, but in the absence of studies, the best expert advice will come from those working at the front lines of rural primary health care: our Society of Rural Physicians of Canada.

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