Te Tai Tonga: Cuts to targeted health initiatives hit Māori where it hurts

In Te Tai Tonga, an electorate where many of our future doctors are trained, voters want to see more action to improve Māori health following a spate of law changes this term that removed targeted policies that some parties say are unfair.

Te Tai Tonga covers the entire South Island and parts of Wellington, and it is home to one of two medical schools in the country.

The University of Otago has produced many GPs, surgeons, and doctors, but targeted entry pathways to medical school for Māori and Pasifika students have come under intense political scrutiny.

It is part of a wider debate around the need for what some parties call "race-based" policies designed to level the playing field for groups who face disadvantages.

Push-back from the coalition government has resulted in the dismantling of the Māori Health Authority, and the scrapping of policies like the Māori bowel screening programme and priority access to diabetes medication for Māori and Pasifika – moves that have ignited concerns from some voters in this electorate over the wellbeing of Māori health.

Dr Isaac Smiler, a GP based in Dunedin who trained at the University of Otago’s medical school, is a beneficiary of and an advocate for affirmative action pathways for Māori and Pasifika.

He said the purpose of targeted pathways was to address the needs of New Zealand’s health workforce.

“We've known for a long time a few things: one, that Māori have poor health outcomes, we know that already. We also know that there are very few Māori doctors or health clinicians in New Zealand.

“We also know that when people or patients are treated by clinicians that share the same cultural ethnic background, patients understand things better, clinicians understand their patients better, there's better trust, there's better rapport and ultimately there's better adherence to treatment plans,” Smiler said.

He said pioneers like the university’s Professor Peter Crampton and the University of Auckland’s Professor Colin Mantell, who died earlier this month, envisioned these pathways to increase the number of Māori clinicians, to address health inequities.

Smiler was the former president of the Māori medical student association, Te Oranga ki Ōtākou, during the time when the university was considering a proposed cap on the number of Māori and Pasifika admissions in 2020.

He and his fellow students fought against the proposal which was eventually abandoned.

This year has seen ACT Party leader David Seymour reaffirm his stance against targeted affirmative pathways at both medical schools, and his party is campaigning to have the programmes cut.

As part of the National-ACT coalition agreement, a review into the targeted Māori and Pacific admission programmes was undertaken by the Ministry of Health, but findings have yet to be made public.

Seymour told Stuff he had seen a copy of the report.

“We asked for the examination to demonstrate that racial discrimination is justified,” he said.

“If one student is going to miss out to one with lower grades, and if patients are going to be seen by doctors who would not have gained entry to medical school without special treatment, there needs to be a serious justification.

“As far as we're concerned, the examination hasn't delivered that justification, and the racial discrimination should end."

Smiler called it “regurgitated, unimaginative political footballing” in an election year, and on brand for a coalition government that has seen the abolishment of the Māori Health Authority, the introduction of the failed Treaty Principles Bill and Regulatory Standards Bill and removing te reo Māori from government services and children’s books.

“I can't help but feel if they had perhaps spent less time trying to de-Māori-fy New Zealand… then perhaps we could have spent more resources and effort and time on things that actually mattered, like the health system.”

Smiler believes the main issue opponents have of targeted pathways is around one question: do we want our medical schools to address the workforce in New Zealand or not?

“I think the tension depends on where you sit with that question. I'm one that believes that our medical schools should be catering for the deficiencies in the health workforce. Where others may think, no, it should be purely based on an individual person's desire to become a doctor.”

On a patient level, targeted health initiatives have also come under scrutiny.

Lisa Edwards’ father was 64 when he was diagnosed with bowel cancer.

“He went through a lot because in that first week of diagnosis he also suffered a stroke and had pneumonia, so that set him back with treatment, with all sorts of things, so we had to deal with the most obvious illness first, being the stroke.”

Despite the experience of seeing her father go through treatment, Edwards said she didn’t really know too much about bowel cancer, except how easily it can spread.

The cancer reached his liver, and she said it was a matter of a couple of years when her father died. He was 67.

Edwards was 51 when she herself was diagnosed with bowel cancer.

“I'd just finished work and I was on my way here to the gym, to do a workout, and I'd gone to the toilet, and I passed a really big blood clot. And I just knew that that wasn't normal, and I thought of my dad, straight away.”

She said she still went to the gym that day but felt as if she had a “mind-out-of-body” experience.

“I was in the gym and thinking, this isn't good. I need to make an appointment with my doctor soon as I can and just go from there.”

What followed was a series of appointments and scans to confirm she had stage 3 bowel cancer.

Edwards said she was fortunate to have been seen so quickly.

“I've heard stories about other people that have been waiting for months and months for a colonoscopy, yet I got mine within three weeks. I was seen at day surgery within three weeks and I couldn't believe that.”

The government scrapped the Māori bowel screening programme that lowered the eligibility age for free testing for Māori to 50 – despite over half of all bowel cancers among Māori being diagnosed before the age of 60, compared to just under a third for non-Māori.

Edwards said she was quite shocked at the move and described it as being “pretty wild” and “quite reckless” given the statistics.

She said it was disappointing knowing it goes against medical advice for targeted health initiatives.

She attended a protest at Parliament last year calling on the government to lower the age of eligibility for free screening tests.

“I met people who were in their 30s and 40s and what they've gone through, that affected their livers, their lungs,” she said.

When asked if she thought there were misconceptions around bowel cancer only affecting older people she agreed.

“I think that's silly. It's silly enough to be seen as a myth now because especially the young people that I met at Parliament that absolutely shocked me. But not only that, bowel cancer is the leading cancer death of all people that has cancer under 50 in this country.”

A report by the Bowel Cancer New Zealand found that around 3300 people are diagnosed every year with bowel cancer, and 1200 die from the disease. A confronting statistic considering when caught early, bowel cancer is more than 90% curable.

Cedric Rerehau was 33 when he was diagnosed with bowel cancer.

He said he suffered from severe symptoms which saw him admitted into hospital for a week before a doctor confirmed the disease.

“It was kind of out of the blue. The doctor came and approached me and my partner, took us from the ward and told me that I had cancer – stage four – and it had spread.

“It was pretty shocking, but I think the thing that was going through my mind at the time was I was really busy at work and it was kind of like 'I just don't have time for this'.”

Rerehau was not the only one in his family to suffer from the disease. His grandfather and two maternal uncles were also diagnosed in their forties or thirties, with one uncle passing a couple of years after his diagnosis.

On the removal of the targeted Māori screening programme, he said: “I think our community's a very vulnerable community. Not really [the] kind of people who talk about our health, and so not having access to that is going to put a lot of people at risk.”

“Wasn't the compromise 45?” asked Edwards.

“I mean, the pre-elective promise from Mr Luxon, prior to him becoming prime minister, he did actually say, and he's quoted as 'yes, we'd like to do that'.”

In September, the bowel screening age lowered from 58 to 56. Health Minister Simeon Brown said it was a step towards the government's commitment to lowering the screening age to match Australia which is 45.

The minister said a staged approach to lowering the age would allow for endoscopy capacity to safely support more people being screened.

"Every time the screening age is lowered, more people become eligible, more positive results need follow-up, and more colonoscopies are required. Building that capacity is what allows us to keep bringing the age down."

Edwards said while at Parliament she spoke to the minister about colonoscopies. She said he was concerned about having enough surgeons to cope with the demand, which she “completely” understands, but believes it is worth pushing.

She believes the health system could save money if they screened people earlier.

“Get it from the start first, let's keep it timely so that everyone has if they have a positive, whether they're Māori or not, they have a positive screen test, and then great, you can get your colonoscopy. See what's going on in there and then go from there.”

Dr Hoani Smith, a lecturer at Lincoln University in Ōtautahi whose research focuses on Māori and Pacific health and health equity, said that while some people may think it is unfair or unjust to have targeted health initiatives for Māori, they exist for a good reason.

He said when it comes to health disparities, Māori and Pasifika, in comparison to other nationalities in the country, carry the heaviest burden in terms of co-morbidities such as cardiovascular disease, diabetes and cancers.

A new study in the New Zealand Medical Journal found that ethnicity remains an independent predictor of preventable death even after adjusting for age, deprivation and income.

“What we're finding is that earlier on in life, Māori in particular are finding that by the time that they go to see someone and seek help, it is too late,” Smith said.

“They may have weeks or months to live, as opposed to having something that is accessible and they can afford it and they can get on top of it much earlier.

“If we don't spend time looking after our wellness we're going to have to be forced to spend time on our illness.”

When asked how much personal choice factor into disparity, he said it “absolutely” matters.

“For example... eating well, lowering your stress, lowering your workload, being present among whānau and friends. But in saying that, this is all good if everyone gets the same start in life.

“The reality is, is that we don't, and we have to factor in things such as the sociological income, age, illnesses that already pre-exist which can start others on the back foot.”

Smith said it was unfortunate targeted Māori health initiatives introduced in the previous government term, like the Māori Health Authority, were cut before the “fruits of their labour” could be felt.

He said structural change is needed: “It's as simple as early access, more often.”

He said people needed to make time for their health, but affordability and a targeted approach for whānau by whānau is also needed.

“We need to look at the research and the evidence to prove the validity and reliability of what we're actually measuring and how to target it as opposed to just a one-off or a two-off policy that may or may not stick, especially if it gets abolished within a two-year cycle.”