The experience of rural medicine

Programs engage veterinary students to help provide services
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Attacks by feral dogs on sheep posed a problem last fall for a student extern and the veterinary staff with the Navajo Nation.

Illustration: Desert highway

Jennifer Ramsey, a fourth-year student at Kansas State University College of Veterinary Medicine, had never seen injuries so severe. The dogs inflicted deep wounds, but the sheep's owners were willing to try almost anything.

Ramsey said sheep are part of the lifestyle of Navajos, who depend on flocks for fleece as well as food, so she assisted with attempts to save animals that other owners would send straight to slaughter. In some cases, unfortunately, the sheep did not survive.

Yet, Ramsey learned many lessons and conquered many other challenges during her month with the Navajo Nation Veterinary & Livestock Program.

The Student AVMA Native American Project has arranged externships on the Navajo reservation for decades, mostly via the NNVLP. Rural Area Veterinary Services, through the Humane Society of the United States, is another program that brings students to rural areas with hardly any veterinary services—particularly to reservations, Appalachia, and other countries.

Rural medicine for production animals and companion animals poses a problem for the profession. Veterinarians must conquer socioeconomic challenges to provide services to remote regions.

The National Veterinary Medical Service Act, a loan repayment program for veterinarians who work in shortage situations, could help with one financial obstacle for practitioners willing to settle outside urban areas. The Department of Agriculture is about to implement the first phase of the act (see article). States and universities have started other programs to attract veterinary students to rural medicine.

In the meantime, both the Native American Project and the RAVS program will continue to introduce students to rural medicine while offering experience in the field.

Native American Project

Ramsey has participated in the Native American Project and the RAVS program.

"I'm interested in going into rural mixed animal practice, and these were great opportunities to go out and see what it's like," she said.

Ramsey grew up on a farm along the Kansas-Oklahoma border, so serving the Navajo Nation wasn't a complete culture shock. Still, veterinary medicine isn't the same on the reservation as at Kansas State University.

The two NNVLP veterinarians rotate among three clinics on a reservation extending into Arizona, New Mexico, and Utah. One clinic maintains student apartments, while the Native American Project provides small stipends.

During her stay, Ramsey assisted with deworming and dehorning livestock on the farms, learning to give Navajo commands to the cattle. She participated in vaccination and spay/neuter procedures at the clinics. She checked deer meat for food safety and interpreted necropsy results of other wild animals for disease surveillance.

Veterinary technicians and staff share the caseload at the clinics. The clients tend to arrive without appointments, though the veterinarians try to schedule surgeries.

"Whatever comes to the door in the morning is what you deal with, and you deal with as many as you can until the clinic closes," Ramsey said.

Ramsey said the Native American Project and RAVS place importance on both the health of animals and the education of veterinary students.

Dr. Scott Bender, one of the NNVLP veterinarians, shows students the diversity of veterinary medicine as a profession. His practice has grown to include large animals, small animals, wildlife medicine, and even zoo medicine at the tribe's zoo.

About 250,000 people live on Navajo Nation tribal lands or in bordering towns. The NNVLP is a program of the tribal government. It operates on a minimal budget, although a position for a third veterinarian has remained open for some time. Therefore, the externs are very helpful.

"They're learning as they're doing, and in doing so, they're actually helping us be able to provide service," Dr. Bender said.

That service ranges all the way from scrapie research to poaching investigations. The veterinarians handle more horses in the summer, when rodeos contribute to injuries, and more small animals in the winter—and during outbreaks of infections with parvovirus or distemper virus.

Dr. Bender has been with the NNVLP for a decade. Previously, he taught at the University of Prince Edward Island Atlantic Veterinary College. He's stayed with the NNVLP because he can teach and dabble in every aspect of veterinary medicine.

"There are the things that drive me nuts," he said. "There are the things that keep me around."

Many times, they're the same things. Dr. Bender feels as though he practices medicine between emergencies. The clinics and clients face constant limits on resources. The clinics share one ultrasound and one X-ray machine, and the staff struggles with the idea of passing on drug costs to mostly low-income clients. The tribal government has cut the program's budget about 10 percent annually for four years.

Dr. Bender is uncertain whether a private practice could ever be self-supporting in this region of the rural West. When he was in Canada, large animal veterinarians received operational funds from the government, but the model was giving way to private practice. He speculated that the United States might need to revert to government assistance someday to protect the food supply.

For his part, Dr. Bender tries to inspire the externs, showing the students his love of rural medicine and concern for public health.

Rural Area Veterinary Services

The RAVS program encompasses a reservation population, too, but it operates differently than the NNVLP.

April Chambers, a fourth-year student at the University of Georgia College of Veterinary Medicine, monitors a dog

Dr. Eric Davis, RAVS director, conceived the program while teaching at the University of Tennessee College of Veterinary Medicine. In 1995, with his wife and some students, he started volunteering veterinary services to reservations through trips with the Remote Area Medical group for human medicine.

The effort evolved into the RAVS program, which moved to the Humane Society of the United States a few years ago. Now the RAVS program has four veterinarians and two veterinary technicians, along with hundreds of volunteers every year. Donations and grants fund the program, though student volunteers pay travel expenses and submit a nonrefundable deposit.

Trip destinations range from reservations to high-unemployment Appalachian communities to international locations such as Easter Island, El Salvador, Guatemala, Mexico, Nicaragua, Palau, and Peru. Dr. Davis said the program's field clinics are like mobile veterinary teaching hospitals. The RAVS mission is education as well as service.

"I want veterinary students to develop an enthusiasm and a passion for providing veterinary care to animals in need," Dr. Davis said.

Dr. Davis perceives an unending need for veterinary services among people who can't afford care for animals. In the most remote regions, for economic reasons, veterinarians simply don't practice. In semirural areas, where some veterinarians practice, humane groups that serve low-income communities aren't always plentiful.

"Our basic principle is that we go to places where nobody else will work," Dr. Davis said.

On trips to reservations and Appalachia, the RAVS program handles mostly cats and dogs. Volunteers perform spay/neuter procedures, administer vaccines, treat illnesses and injuries, and educate owners.

The volunteers practice more equine medicine on trips abroad to areas where agriculture relies heavily on horses. In some spots, RAVS volunteers work with local veterinarians to improve standards for animal health. In other places, the program tries to establish long-term access to veterinary services. A foundation hired local veterinarians in a poor region of Guatemala, with government subsidies, after the RAVS program demonstrated the desirability of veterinary services to the residents.

In this country, Dr. Davis said, satellite clinics of private animal hospitals might be a sustainable solution for providing services to rural areas. For now, the RAVS program will continue to serve rural U.S. communities—and fulfill its teaching mission.

Caleb Frankel, a third-year student at the University of Pennsylvania School of Veterinary Medicine, said the RAVS program attracts second- and third-year students who want to work under veterinarians who understand the students are inexperienced.

Frankel has participated in two trips to reservations in Washington state and a trip to Tennessee.

On one of the reservations, the volunteers set up a field clinic in a building that opened onto the Pacific Ocean. The area was beautiful, Frankel said, but the communities lacked services. The volunteers relocated every other day because many animal owners didn't have vehicles. Frankel added that the trips were no vacation, even though students saw a part of the country they otherwise wouldn't.

Frankel faced some difficult cases, such as dogs that were not well enough for spay/neuter procedures. Yet, they had no other chance for the procedures. The volunteers kept the dogs for a couple of days to stabilize them enough to perform surgery. In many other cases, the volunteers treated illness in animals whose owners came to the clinic just for spay/neuter.

Frankel said the reservations he visited simply don't have access to veterinarians, and many cases were literally walk-ins. In Tennessee, veterinarians were at least nearby and residents had cars—but some animal owners couldn't afford services.

During the Tennessee trip, the clinic stayed in one location. The RAVS program had screened animal owners for financial need. While the focus of the clinic was spay/neuter and vaccinations, the veterinarians also performed surgeries to treat lacerations and a prolapsed gland of the third eyelid.

Frankel said the trips open the eyes of the students, who might never have seen severe flea infestations or other serious conditions of rough outdoor living.

"A lot of us walk in circles where animals are really well-cared-for," he said.

Frankel said the RAVS program performs a real service for rural residents who can't access or can't afford a veterinarian.

"They care about their animals just the same," he said.