In Ontario, 90 per cent of the population resides within 160 kilometres of the American border. The remaining ten per cent of the province’s population, 1.46 million individuals, experience drastically different living environments. Differences between rural and urban health systems exacerbate inequalities and render it difficult to access care in Northern and rural Ontario.
Shirley Roebuck, a nurse from rural Ontario, works in a small hospital in Wallaceburg. In a collection of research, data, and stories about rural healthcare systems from the Ontario Health Coalition, Roebuck describes the “disregard exhibited by our political leaders as well as the healthcare leaders” as the reason for small community hospitals closing their doors.
Rural hospitals, with resources and services compromised, are struggling to serve their communities. Roebuck affirms that rural hospitals can become vibrant again with just a fraction of the services offered in urban centres. Enough budget cuts for rural centres, she demands. “As a nurse, I see every day how budget cuts have downloaded costs and stress onto patients and their families who struggle to travel further for care or go without, putting their health in jeopardy.” Rural communities are characterized by low population densities and large distances between town centres. Limited land and air travel due to road and weather conditions makes access to basic health care a challenge.
“The silence is heart-rending. Rooms that once offered sanctuary to the sick and halls that once resounded to the echo of busy feet are now filled with overflowing boxes and sundry equipment,” describes Kathleen Tod in the same report as Roebuck. Tod served as hospital administrator at Burk’s Falls and District Health Centre which recently closed after 61 years of serving the community. Her steps echo in the empty hospital halls. The local community of 7,000 in North Muskoka is advised that all lost services can now be “easily obtained” at three area hospitals—all 45 minutes to an hour away.
The Ontario landscape needs attention. “We are Ontarians, urban and rural. We are citizens, taxpayers and we are voters. We deserve the same respect and dignity, and access to care, whether we live in the countryside or in a city,” says Roebuck. Those in urban centres have the privilege of quick access to family doctors, ambulatory services, and special testing, while rural Ontarians struggle to book appointments, or get to the hospital in time.
Empty, dimly lit halls. Hospital beds with stale sheets. Mothers delivering their newborns hundreds of kilometres from their family. Physicians overworked and overburdened. A healthcare system in dire need of governmental and community support. Patients travelling across treacherous landscapes to reach services. A population stripped of years alive. An urgent need for change.
In 2009, the Institute for Clinical Evaluative Sciences reported that 185 Northern Ontario communities of 30,000 or fewer residents required more than 30 minutes of travel by car to reach an emergency department, and 55 communities, 27 of which are remote, had no access within 60 minutes. 68 communities required 30 minutes of travel to reach any source of primary care—the first point of access to health-care services for any health-related problems or needs such as a family doctor or walk-in clinics.
This staggering statistic means rural and remote Northern communities face avoidable premature deaths, compromised treatment courses, and poorer population health, as individuals struggle to access the most basic of health-care services.
What determines the disparities?
Numerous factors play a role in creating or exacerbating disparities that lead to isolation from proper health-care services. Such factors include the geographical distribution of communities; other social determinants of health; socioeconomic, cultural, and language differences; and available medical personnel, support, and technology—all of which result in poorer population health.
Health equity involves much more than just health care—it also encompasses the social determinants of health. The World Health Organization defines the social determinants of health as “non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life.”
In an interview, Dr. Kate Mulligan of the University of Toronto’s Dalla Lana School of Public Health tells me, “In the North, culturally safe health care is vital. If people won’t come for health care, they won’t be healthy—no matter how fancy your technology is, or how many physicians you have.”
Bias, exclusion, and racism in health care directed at marginalized Indigenous communities of the North have warranted mistrust. Colonial artifacts such as residential schools, “Indian Hospitals,” and the Indian Act have compromised Indigenous Peoples’ sense of safety when receiving care.
In an interview, University of Toronto St. George Human Biology and Health Studies professor Leanne De Souza-Kenney shares with me that “we know for certain that communication and building of trust between physicians or providers and their patients is critical and takes some time.” In Indigenous communities, building that trust involves being culturally sensitive, aware, and receptive to the fact that these communities often devise their own infrastructure of health based on cultural traditions of care.
Professor De Souza-Kenney says that practitioners must take on a holistic approach to assess individuals—instead of just considering the symptoms presented. “It’s about the whole person, where they work, live, grow, eat, play—all these things are important and factor into their ultimate care and their receptivity to the feedback of that physician,” she explains.
For many Indigenous and minority communities, the ability for healthcare groups to understand the health barriers that affect their symptoms, and subsequently offer a culturally sensitive diagnosis, is vital to their desire to apply and access care. Culturally sensitive care reflects the patient’s cultures, values, and beliefs, and influences the provider-to-patient relationship.
The needed reform
When applying the changes required to improve Indigenous health, it is paramount to support the health-related recommendations of the Truth and Reconciliation Commission of Canada, and the National Inquiry into Missing and Murdered Indigenous Women and Girls.
The Truth and Reconciliation Commission of Canada aims to educate and foster dialogue between Canadians on the profound injustices faced by First Nations, Inuit, and the Métis Peoples. The Commission prioritizes education as one of their recommendations. Addressing inequities requires a new generation of Canadians with an unbiased and informed understanding of Indigenous Peoples, their communities, and their practices.
Self-organized community programs—such as the Ontario Telemedicine Network, the Sioux Lookout First Nations Health Authority, and other rural health hubs—have developed to address the disparities in social and economic determinants of health, the cultural nuances of the North, and the acute health care needs. Yet, despite many efforts, poor access to health-care services persists.
In her essay “Issues Affecting Access to Health Services in Northern, Rural and Remote Regions of Canada,” Professor Annette Brown from the University of British Columbia writes:
Reform involves three broad initiatives: developing more cost appropriate ways of delivering health care, a shift to community-based versus hospital-based care, and an increased focus on the social determinants of health including the health effects of poverty and powerlessness.
Primary care as a pillar for health has been eroded by decades of cost-cutting and a health system focused on acute care—a type of care that is not designed to address chronic, complex illness, mental health issues or addictions, but only deals with health issues once they can no longer be ignored.
Beyond the role that physicians play in addressing inequalities, Canadians must be sensitive to the lived experiences of others. When completing their education, signing up for a course, or listening to a podcast episode, it is important to reflect on capacity building—the investment in the effectiveness and future sustainability of Canada. Professor De Souza-Kenney explains that we must ask “how can we be equitable, not equal—because some people need more than others.”
Additionally, without the knowledge, training, and capacity to address the social determinants of health, “we are putting out fires instead of getting in front of them,” tells me Professor De Souza-Kenney.
When conducting her research, Dr. Amanda Sheppard of the University of Toronto’s Dalla Lana School of Public Health, concluded that “women in remote communities couldn’t access mammography [services] to the same extent as other women in the province who were also age-eligible.” In response to Dr. Sheppard and her colleague’s work, new initiatives and programs were created to account for the lack of access.
The government must provide health-care services in all communities, but “they’re not in the business of knowing how to do that well,” Dr. Sheppard explains to me. Governmental entities have fallen short, and continue to do so, by not building relationships with communities and asking those on the frontlines what health care should look like. According to Dr. Sheppard, we can assume that communities would prefer to “have control of the healthcare dollars that are meant for their peoples.”
The politics of healthcare
Very little has changed at the hands of the provincial government regarding access to health-care services in Northern and rural Ontario. Local communities have empowered themselves to take better control of their own health and well-being. Although regrettable to have been forced into such a position, out of necessity came invention, solidarity, new ideas, and community governance.
“NGOs, non-profits, and other groups are making it work with very little funding […] and they will continue to do so, but if our government can step up, then they can do more,” says Professor De Souza-Kenney. Health policy is important when it comes to public and global health. However, a constraint on the relationship is that “science has a different timeline than policy.”
The Covid-19 pandemic has made it evident that “policy makers need their answer now, and science takes some time to double check and confirm,” adds Professor De Souza-Kenney. Implementing health policy training for students in various fields could aid in creating a clear line of communication between science and governance, while welcoming the perspective of others.
In January 2021, the Northern Ontario School of Medicine Physician Workforce Strategy publicized that a minimum of 313 full-time physicians across Northern Ontario were needed to fulfill the health care needs of the Northern community.
However, Dr. Sarah Newbery, Inaugural Assistant Dean of Physician Workforce Strategy, and rural generalist family physician for 25 years in Marathon, Ontario, tells me that it’s “not as simple as making it mandatory that physicians go and work in in rural northern settings.” She explains that the safety and success of the physician may be compromised if they haven’t prepared and trained to work in a rural or remote environment.
This is the case because of the breadth of care required from physicians practising in rural and Northern communities. Dr. Newbery shares that family physicians in rural regions “work part of their time in the office, part of their time in the emergency department, and part of their time providing procedural and inpatient care in the hospital.” For a physician that has not been trained in handling and managing a wide range of care, this situation can be challenging, and to take it on without training is not fair to the clinician or the community.
Unfortunately, maintaining the skillset needed to provide a wide breadth of care is not the only stressor for physicians of the North. Delivery of care in low-resource settings—settings lacking specialist and technological support—compared to high-resource settings is a challenge, limiting the care available to individuals in those communities.
The Northern Ontario School of Medicine
The Northern Ontario School of Medicine (NOSM), with campuses in both Sudbury and Thunder Bay, is one of the few medical schools in the world with an explicit social accountability mandate aimed at improving the health and well-being of people in its service region. The NOSM has become the primary source of doctors for Northern Ontario. The institution’s curriculum and mission produce a skilled and diverse medical workforce with appropriate and crucial cultural and linguistic competencies that allow for understanding of rural and Northern Ontarians and their medical needs.
NOSM’s social accountability mandate focuses on 3 populations: rural populations, Indigenous populations, and Francophone populations.
At the undergraduate level, NOSM offers a case-based learning approach to its curriculum, with cases set within Northern contexts and populations. So, from the start, the focus is on the context in which patient encounters and cases occur. Dr. Newbery emphasizes that “rural exposure during medical training increases the chances that a learner will subsequently choose rural practice.”
The institution also offers learners a ‘Rural Generalist Pathway’ meant to “enrich the support that we provide to learners and create a cohesive pathway from high school to practice for those learners who want to become rural generalists.” The social determinants of health, particularly geography and poverty, “mean that rural clinicians in Northern Ontario often have to manage locally, a much higher complexity of patients,” explains Dr. Newbery, “and the training and education learners receive must support them to manage that complexity.”
The NOSM 2025 Challenge strategic plan focuses on the transformation of health human resources, health education delivery, and research. For example, in addition to the Rural Generalist Pathway, NOSM will offer Francophone and Indigenous Health and Wellness Pathways. This supportive education for those interested in learning how to better serve their populations will allow for the delivery of primary care across the urban-rural continuum.
Physicians of the North
Besides the stress imposed by the breadth of care required from rural and Northern physicians, urban practise is also more attractive because of the perceived greater viability of a family, personal life, employment, and development in a large city centre, as well as greater professional supports. Dr. Newbery emphasizes that “it’s not so much that [physicians] are avoiding the North, but the same attractors don’t exist.”
However, some efforts have been made to help with the perceptions of working in the North. Prior to Covid-19, physicians were seldom able to access educational conferences due to the difficulty to schedule time off. The pandemic has introduced opportunities for health care providers to continue their education and interact with other professionals in their field with ease through virtual settings. Additionally, Dr. Newbery predicts that this may “create new opportunities for physicians to live and work in rural northern Ontario if their spouses can work from home and be connected to an urban workplace but not have to live in an urban environment.”
When attracting physicians to Northern and rural communities, Dr. Newbery says that “money is an easy incentive, but I think it’s increasingly not the most important incentive.” Physicians are looking for virtual supports and mentorship opportunities. She urges the ministry to invest in creating an environment where “physicians can take the time off that they need, can access the continuing professional development that they need, can collaborate with colleagues easily, can easily access mentorship, and can acquire the leadership skills that they need to lead well through a crisis like Covid-19.” All these factors would work towards making Northern practise an attractive career.
“We’re not going to successfully draw physicians into rural communities if those communities don’t have some degree of economic vibrancy,” adds Dr. Newbery. Investing in infrastructure such as development of school systems, working trades, and leisure activities that supports rural communities and their industries may be the key to the future of healthcare in Northern Ontario.
The Northern population experiences chronic, complex, and serious health issues. On average, people in Northern Ontario live two years less than the rest of the province’s population and are challenged with complex chronic illness such as diabetes and kidney disease. Specifically, the amputation rate for diabetes is higher in Northern Ontario than in any other of the province’s regions. Additionally, impoverished communities that are rural, remote, or isolated are most affected by acute health outcomes.
With these factors in mind, Dr. Newbery urges “communities to think differently about the number of physicians it takes to care for a population.” The margin of capacity has been consistently compromised, partly due to the assumption that the doctor-to-population ratio in rural Ontario should be the same as to that in urban regions. We need to investigate how many physicians it would take to meaningfully care for a population that has a higher burden of complex chronic illnesses and faces limited access to additional resources, such as mental health counselors, physiotherapists, occupational therapists, and addictions counselors.
The future of Northern and rural healthcare
We don’t often think about our neighbours, whether next door, on the next street, or a thousand kilometres away. Yet, what we deem to be simple, effective, and easily attainable in urban centres, such as access to family or emergency care, can be difficult, take hours, or unavailable in rural Ontario.
Northern, rural, and Indigenous communities in Ontario urgently need practise models and networks that are innovative, grassroot, equitable, rural-specific, team-based, and culturally appropriate. This means that governments need to prioritize meaningful conversations between policy makers and community leaders, and provide greater financial and technological supports to health care providers.
Instead of cutting first and measuring later, governmental support programs must work with communities to determine what supports must be established to help Northern and rural communities flourish. Ontario nurse Shirley Roebuck describes the Ontario health system as a “car headed for a cliff, if the voters—the taxpayers—don’t make the policy makers turn on their lights. […] [We] must restore Ontario’s small and rural hospitals and the vital care they provide.”
There are many nuances to the changes necessary in addressing these disparities. But the first step is always understanding the presence of such disparities and listening to those living through them. Isolation from health-care services in Ontario is a life-threatening issue that must be addressed. Now.