The health gapThe Press | Saturday, 16 December 2006
Is the appalling state of Maori health the result of lifestyle choices, or are deeper forces at work - including discrimination by the health system? KAMALA HAYMAN reports.
"They talk to me as if I'm dumb. I've got four degrees but I tend to find medical practitioners assume I'm a bit thick."
Dr Rawiri Taonui, head of Canterbury University's School of Maori and Indigenous Studies, says he now avoids the doctor.
Even a trip to the pharmacy has left a bad taste. On asking for a flu remedy, he was told it had run out although he was sure he could see it on the shelves. It dawned on him they thought he had criminal intent – some flu remedies are used in the manufacture of pure methamphetamine, or P.
"They are looking at me not as Dr Taonui but some big brown guy that might be cooking up stuff at home," he says with disgust.
When it comes to health care, Taonui has no doubt: Maori are treated differently. And the evidence is more than anecdotal.
"There is racism and discrimination," says Wellington School of Medicine researcher Bridget Robson bluntly. "I don't think it is conscious but I think there are different attitudes towards Maori patients, possibly towards poorer patients."
Doctors speak about their Maori patients in a different way, Robson says. They are "non compliant"; less likely to turn up for appointments, to understand their health issues, to take their medicine.
A doctor may be less likely to suggest private health care to a Maori patient, assuming they cannot afford it.
"What if Maori can afford it, or can raise the money through whanau?" challenges Robson. "People get p...ed off when they're not given all the options.
"When health professionals are busy and under stress they are more likely to resort to stereotypes and that's risky in individual health care."
New Zealand Medical Association chairman Ross Boswell is sceptical of such a view. The health disparities between Maori and non-Maori are undisputed, but the bald statistics do not explain why.
"All we know are the reported rates. The reason for those remain unknown or obscure.
"Does it go along with being Maori, or being poor, or unemployed, or smoking more, or all the other things?"
Maybe Maori are less likely to turn up for hospital appointments because they are made to feel less welcome, Boswell says.
But maybe there are other reasons. He knows a Far North GP who has difficulty referring patients to Whangarei Hospital. "Patients won't go because if they've got unregistered cars they will be put off the road."
Boswell says the health service "could and should do better" for those with greater health needs, many of whom are Maori.
But he points out many people with the highest health needs are also smokers, are overweight or obese, and are high users of alcohol and/or recreational drugs.
Certainly, Maori are disproportionately represented in such statistics.
Half of all Maori are smokers compared with one in five non- Maori. Nearly 30% of Maori report "potentially hazardous" drinking patterns compared with 20% of non-Maori. One in five Maori are regular marijuana users compared with 7% of non-Maori. Maori children are twice as likely (16%) to be obese as non-Maori (8%).
Arguments rage over the reasons for such self-destructive behaviours – poor self-control versus ruinous environmental factors which overwhelm those with few resources.
Such arguments aside, statisticians say lifestyle factors and poverty cannot account for the alarming eight-year gap between Maori and non-Maori life expectancy.
It seems other, more disturbing forces, may be at play. Research has found that:
* Maori are 18% more likely to get cancer but nearly twice as likely to die from it.
* Heart disease kills nearly twice as many Maori (200 per 100,000 people compared with 118 per 100,000 non-Maori and non-Pacific) but Maori are only one-third as likely to have an angioplasty (a common procedure for clearing blocked blood vessels – 14 per 100,000 compared with 48).
* Maori are 212 times as likely to suffer diabetes but 312 times as likely to suffer kidney failure, and five times as likely to suffer a lower-limb amputation.
* Maori are a third more likely to be admitted to hospital for gallstones but far less likely (one-seventh the rate) to have a cholecystectomy (surgery to remove the gallbladder).
* 7% of Maori hospital patients suffer a preventable adverse event compared with 5% of non-Maori.
Are Maori refusing the care offered non-Maori? Are they too sick by the time they see a doctor to be successfully treated? Are Maori being offered a different, lesser standard of care?
Rawiri Taonui recalls how his sister was prescribed depo-provera, a long-lasting injectable alternative to the daily contraceptive pill. She suffered serious and chronic side-effects, not least of which was continuous bleeding for almost three years. "She was never given the option (of the pill)," says Taonui.
Now, he knows that Maori women in the 1980s were four times more likely than non-Maori to be prescribed depo-provera. Taonui says doctors assumed young Maori could not be relied on to take the pill regularly.
Might GPs be treating patients differently?
Peter Jansen, of Maori health consultancy Mauri Ora Associates, says they do.
A paper published in October shows Maori patients have fewer investigations, fewer blood tests, are less likely to be recommended follow-up appointments, and are less likely to be referred to hospital specialists for further care.
The differences are not large but they are real and they are all in the wrong direction.
Jansen says it may be that GPs – who also report less rapport with their Maori patients – are unwittingly providing less care to those with the greatest health needs because "the lack of a shared background or understanding inhibits the therapeutic relationship".
There is "powerful evidence of sub-optimum care" says Auckland sociology professor Peter Davis. His research, published in international medical journal The Lancet in June, showed Maori were more likely to suffer preventable "adverse events" in hospital than non-Maori.
"Something is going on" and it is widespread, said Wellington School of Medicine associate professor Tony Blakely at the time.
"It's not deliberate, but it's insidious and it accumulates."
And more research is under way. His Wellington colleague, Bridget Robson, expects to publish a study next year on the care of 92,000 heart patients admitted to hospital from 1996 to 2004.
It will lay bare any differences in treatment offered Maori and non-Maori – the size of the study allowing her to correct for complicating factors such as other illnesses.
Christchurch Hospital is also the subject of a new four-year study into readmission rates, which will look for ethnic disparities.
Robson hopes revealing areas of unequal treatment will help bring change. "Most health professionals don't want to be discriminatory."
"OUR LINES ARE WELL," says single mother-of-three Melani Burchett, 41, her fingers stroking a freshly shaped clay pot in her Dallington home.
"My people worked hard to build marae out of nothing, to turn big tracts of land covered in gorse into gardens. Maori have a huge capacity to create visions that last for all time, and that capacity is still there."
Burchett has had a series of short-term jobs, but one too many rejection letters saw her change tack and discover a new talent for pottery.
The walls and windowsills of her riverside home are filled with paintings, pottery and weaving, much of it her own.
But unemployment means she cannot always afford to go to the GP when she needs to, although she will always take her daughters if they are ill.
She says her GP is "empathetic" but she still bristles at the memory of a visit to another doctor who "gave a huge lecture" to her and her 18-year-old daughter.
"That particular doctor needs to get a grip on the psyche of our people . . .
"The message that came across was you're a bad mother and you're an irresponsible teenager.
"I'm not a bad mother. I'm a good mother and my daughter is not irresponsible."
Burchett says Maori do not complain enough. "We internalise it, go home and moan to our whanau."
Jonathan Koea hates "moaning Maori" studies implying his race are all victims.
Koea, a hugely respected oncology surgeon in Auckland, says people have to take some responsibility for their own health.
"You can't force people to stop smoking unless they want to. You can't force people to change their diet unless they want to.
"People do need to change the way they see themselves and the way they behave."
His own research shows Maori men account for four out of 10 cases of gallbladder cancer – an unusual but deadly condition associated with chronic gallstones.
He says the health system has "some responsibility" to bear. After all, Maori are not getting surgery for gallstones at the same rate as non-Maori and their consequent rates of cancer are high.
In a system where the squeaky wheel often gets the oil, Maori are missing out, says Koea, by failing to insist on better care.
They are also less likely to have health insurance, allowing a fast-track diagnosis and referral into the public system.
It is "quite scary" to consider that Maori may be getting unequal treatment, says the Canterbury District Health Board executive director of Maori health, Hector Matthews.
"New Zealanders pride themselves on being one of those societies that's not racist or sexist. But for many in the system it doesn't quite work out that way."
He had a mole cut out last week "because I insisted on it".
"If you're poorer and less educated you won't do that, so you get different levels of service."
One Christchurch-based health service is showing it can get the same results with Maori and non-Maori.
Education for Change helps pregnant women quit smoking. Four out of 10 participants are still non-smokers six months later, an impressive success rate in an area where a 20% quit rate is considered acceptable.
But it is the Maori quit rate that makes the programme stand out – as many Maori quit and stay off the cigarettes as non-Maori.
Director Stephanie Cowan says 18,000 babies are born every year to mothers who smoke during pregnancy. Many are Maori.
The softly-spoken Cowan says her programme is "an exploration of ambivalence", asking women to think about why they smoke, what they like, what they don't like and how their life would change if they stopped.
Smokechange educator Gina Blair, who joined the organisation less than three months ago, says it is the first place she has worked where participants were empowered.
"I think that's why the organisation has such a success rate."
Cowan says many women on Education for Change's books are reluctant quitters referred to the service by their midwives. Keeping in touch can be an enormous effort but an effort that must be made.
Equity means believing that "every single person matters" and treating them "so they have the same outcome" rather than treating everyone in the same way.
"You can't give everyone a leaflet. You have to do what it takes for them to be healthy.
"If you really want to change the health status of those who are disadvantaged, you have to stand in their shoes and think they can't catch the bus if they have four kids and can't afford all their bus fares.
"But if you don't give up, you can make a big difference. Inside all of those families are people trying to lead good lives."
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