Victor Luca, 4-Feb-20.
During the most recent local body election cycle in our district I was asked at a September 2019 BOPDHB public meeting the question of what I would do about improving Maori health outcomes? Although the media in our country has for many years been reporting poor health outcomes among Tangata Whenua, I have to admit that it was not a question I was prepared for.
Although I am a scientist, and was a Mayoral candidate, health is not an area in which I have specific expertise, and nor would health have been within my direct remit.
After a considerable amount of research into possible links between race, ethnicity and socioeconomic factors, including poverty, health care inequities and racism and health I cannot say that I have all, or indeed many of the answers. I do however have a theory that requires testing.
Thankfully, the hornet’s nest that is health policy is a national issue in which Mayors and District Councilors have little or no role to play.
Nevertheless, there are few issues in which we all have more of a stake than health, and therefore, in which we should all attempt to be informed.
Aotearoa’s largely publicly-funded health care system was initially established in the 1930s and was modeled on the UK’s national health system. However, it has evolved over time and it is pertinent to ask if it continues to serve us well and what modifications can be made to improve it?
Figure 1 shows Life Expectancy at Birth as a function of Total per Capita Expenditure on Health for different OECD countries. Life expectancy is a crude measure of health outcomes but has the virtue of being easily measured with reasonable accuracy. After all, one is either dead or alive.
It can be seen from the graph that we in New Zealand (nzl) plot in about the middle of the pack and far from the USA which I guess we would agree is an outlier. The Americans pay a lot for their healthcare and the outcomes (in terms of Life Expectancy) are poor, at least for the population as a whole. Interestingly, in the last few years Americans have seen a drop in life expectancy for the first time in decades.
Australia scores somewhat better than we do.
Figure 1. OECD 2010, “Health care systems: Getting more value for money”, OECD Economics Department Policy Notes, No. 2. https://www.oecd.org/eco/growth/46508904.pdf
Behind life expectancy as an indicator are socio-economic, geographic, life-style, nutritional, genetic and other factors etc. These are what we really want to know about.
However, to a first approximation it would appear that our healthcare system delivers reasonable overall outcomes, especially relative to the good old USA. I have had some personal experience of the health system in the US and wouldn’t want a bar of it here. It is absolutely based on inequity! The more you pay, the better health care you can access. You can have the best healthcare in the world or none at all especially if you are unfortunate enough not to have a job.
Whilst our public healthcare system may seem reasonable, and there are doubtless arguments suggesting we are not being served badly, it would also be fair to say that it is far from perfect and that there is also significant room for improvement, especially in so far as the under-privileged are concerned.
As I said before, the data in Figure 1 is complex. The life expectancy is for the population as a whole and many factors can contribute. I am sure that we all recognize that in a multicultural society like Aotearoa different races and ethnic groups may contribute differently to these statistics.
In terms of the health outcomes in Aotearoa, the difference in life expectancy between Tanga Whenua and Pakeha is marked (Figure 2). Maori males live about five years less than non-Maori males and Maori women about five years less than non-Maori women.
There is some suggestion that life expectancy differences have narrowed since 2011 probably due to the best efforts of central government and other entities to address the issue. Nevertheless, it is a sad fact that Maori continue to have a much lower life expectancy than non-Maori and in general worse health outcomes.
The NZ Ministry of Health is the government agency that compiles statistics for various ethnic groups and having access to reliable data is an important first step in addressing a problem.
Figure 2. Life expectancy at birth, by gender, Māori and non-Māori, 1951–2013 [1]
Breaking health down in terms of disease we can clearly see differences between Maori and non-Maori in these statistics (Table 1).
Table 1. Prevalence of certain conditions between Maori and Non-Maori expressed as an Adjusted Rate Ratio. Source: NZ Ministry of Health.
Condition Adjusted Rate Ratio
Heart failure 1.85
Ischaemic heart disease 1.64
Diabetes 1.95
Type 2 diabetes (proxy) 1.98
Stroke 2.28
Arthritis 1.22
Asthma (medicated) 1.57
Gout 1.55
Osteoarthritis 1
All teeth removed due to decay 1.69
The adjusted rates ratios give an idea of the prevalence of a particular condition for Maori versus Non-Maori. Thus, in the case of heart failure it can be seen that Maori are about two times more likely to be afflicted by the condition than Pakeha. Such data has given clear acknowledgement in health, political and societal circles that there are disparities in health outcomes between Tangtawhenua and Pakeha and this has been much debated.
The central question to be address here is why it is that Maori have poor health outcomes and what can be done about it?
Let me start by first defining what is meant by the terms race and ethnicity.
Race is defined as “a category of humankind that shares certain distinctive physical traits.” The term ethnicity is more broadly defined as “large groups of people classed according to common racial, national, tribal, religious, linguistic, or cultural origin or background.”
The mapping of the human genome has shown that humans share over 99 percent of their genetic material with one another [1], and variation occurs more between individuals than ethnic groups.
There is strong scientific evidence nowadays that health disparities have relatively little, or at best, only a very blurry connection with genetics (baring exceptions such as Sickle Cell, TaySachs and Crohn disease).
Rather, disparities are more likely to derive from differences in culture, diet, socioeconomic status, access to health care, education, environmental exposures, social marginalization, discrimination, stress and other factors [2-4].
So where do we look for the answers? Let’s start by looking at ourselves and our habits, circumstances and life-style choices. Call me naïve, but genes aside, I consider my health, in the first instance, to be determined by me and my choices. That is, I have the initial primary responsibility for my own health by virtue of the choices I make. Why do I say this?
In lectures I used to give to senior university students on the risks of nuclear technologies I presented Table 2 which I compiled from primary data. The numbers in red are the total number of deaths attributable to each of the causes on the left. One can see that the top spot is taken by air pollution which is responsible for a whopping 7 million human deaths per year globally. We are all doubtless aware that this air pollution is due to industry, power generation and motor vehicles. There is little an individual can do about these. The next most important causes of human death are smoking, alcohol consumption and obesity in that order. These are activities that are entirely in the hands of the individual and are risk factors for non-communicable diseases including ischaemic heart disease, cancer and diabetes.
My point in compiling this table was to emphasize that despite our fears about nuclear energy, the number of deaths from this form of energy generation is well down the list and comparable with shark attacks. The 4,319 deaths listed in the table include presumed deaths from the Chernobyl accident, which have for the most part, not eventuated. My point is that perception of risk is one thing and the reality is another. We need to be objective and not let our emotions and prejudices get in the way.
Table 2. Global annual causes of death.
When it comes to our health also, the most easily avoided of all of these causes of death are smoking, drinking and over-eating or eating wrongly. When it comes to health outcomes in Aotearoa it would seem to me that the same activities also, in large measure, determine our health outcomes. In the first instance.
Our very own health statistics bear out the fact that Tangata Whenua are between 1.5 and 2 times more likely to smoke, drink heavily and be obese. Smoking, drinking and obesity are risk factors for diseases such as heart disease, stroke and cancers which are three of the leading causes of mortality in our country. Such activities have a direct negative consequence on our health and yet are totally within our own control. This is why I say that to first order WE exert the most influence on our health outcomes. Whilst each of us has the genes we are born with, and might have predisposition to a certain disease that we can do little about, environmental factors play a major role. As I said before, on average there is little difference in genes between different races. There is little evidence suggesting that Maori as a whole have any particular genetic predisposition to one disease or other, although there is some tentative evidence suggestion of prevalence of stomach cancer in Maori [5]. However, I am sure we have all heard the expression “you are what you eat”. I would modify that to “you are what you eat, drink and smoke”.
The next question to ask is why it is that Tangata Whenua are more disposed to smoking drinking and eating badly. Right off the bat I would dismiss suggestions that racism in our health system is somehow responsible for health disparities. We can look for answers on this issue from data reported in the literature which suggests that of all the ethnic groups in Aotearoa, it is Asians that most perceive that they are discriminated against in our health care system.
Having dismissed racism as a major factor, I would have to look at socio-economic and cultural factors in greater depth.
In Aotearoa today, the degree of wealth disparity is at an all-time high. More than 900,000 people live below the poverty line and in excess of 150,000 of those are children. We have become a low wage society with a median income of about $52,000. In our district the median income is about half of this. Housing affordability is at an all-time low, and for those that do not escape the rent trap, getting stuck in poverty is a real possibility. We have the highest rate of youth suicide in the world, high rates of domestic violence, high rates of drug use and abuse and other social maladies.
I contend that for those caught on the bottom rungs of an increasingly stretched socio-economic ladder there is only despair and resignation. It is a sorry fact Tangata Whenua and Pacific Islanders are disproportionately those that inhabit the lower rungs of this ladder. Is it any wonder therefore that when these folk look up the ladder and see how difficult or impossible the climb up has become, they lose hope and turn to anything that can make their daily existence feel a little more tolerable. Most often that brief boost comes from the use of alcohol, tobacco and other drugs. I would include as drugs, sugar and fat, since they are both addictive and adversely affect our health. With poverty comes psychological trauma and stress. The consequence is all too often relationship and family disruption. Poverty also makes accessing the medical system more difficult once illness sets in, especially if that system is increasingly private and for-profit.
The longest study of human wellbeing is the Harvard study which commenced in 1937. It has shown that the quality and depth of relationships is as important in determining our health as eating well and not smoking or drinking.
This study in many ways supports Te Whare Tapa Whā which is a traditional Māori view of health (hauora) as it is presently articulated. This view of health ostensibly takes a wellness and holistic approach with physical (tinana), mental (hinengaro), spiritual (wairua), and family (whānau) dimensions. So Maori seem to have been ahead of the curve on this one.
Access to a modern scientifically advanced health system is also an obvious and critical element. In a health system that is fully public I could argue that access is relatively equal. However, as the system becomes more privatized, as has slowly been happening in Aotearoa, the playing field slopes more and more in favor of those with money. Privatization of our health system is an unfortunate trend that should not be allowed to continue since it is the under-privileged that are going to be most disadvantaged, and in Aotearoa, that is Maori.
There is no excuse for not doing everything possible to improve the equity of health care in our country by taking greater account of culture and life-style specific needs of Tangata Whenua. However, in the end what needs to happen is that as a society we focus on improving the well being of all our people and that involves leveling the playing field so that everyone gets a chance no matter where they are on the ladder or where they live. Fundamental in achieving improvements in health is the aspect of prevention and this requires education and individual responsibility. Clearly, our families and schools have a significant role to play here.
In the meantime, anything that drives us toward a healthcare system such as in the DisUnited States is something to be avoided at all cost. In the good old USA, the Medical-Industrial Complex has ensured that those without financial resources are essentially screwed.
References
[1] Redon, R. et al., Global variation in copy number in the human genome. Nature 2006, 444, 444-454. [2] Pearce, N.; Foliaki, S.; Sporle, A.; Cunningham, C. Genetics, race, ethnicity, and health 2004, 328, 1070-1072. [3] Sankar, P.; Cho, M. K.; Condit, C. M.; Hunt, L. M.; Koenig, B.; Marshall, P.; Lee, S. S.-J.; Spicer, P. Genetic research and health disparities 2004, 291, 2985-2989. [4] Collins, F. S. What we do and don't know about 'race', 'ethnicity', genetics and health at the dawn of the genome era. Nature Genetics 2004, 36, S13-S15. [5] Ellison-Loschmann, L.; Sporle, A.; Corbin, M.; Cheng, S.; Harawira, P.; Gray, M.; Whaanga, T.; Guilford, P.; Koea, J.; Pearce, N. Risk of stomach cancer in Aotearoa/New Zealand: A M-üori population based case-control study2017, 12, e0181581.
[6] Ellison-Loschmann et al., Risk of stomach cancer in Aotearoa/New Zealand: A Māori population based case control study. PLOS ONE 2017, 12(7), e0181581. doi: 10.1371/journal.pone.0181581