'TIDAL WAVE'
Experts are accusing the Government of ignoring a disease that’s set to bankrupt the health system. They say New Zealand’s growing rates of type 2 diabetes are shameful, racist, and at crisis proportions. Virginia Fallon reports.
Why type-2 diabetes will overwhelm our health system
Joseph’s legs were amputated years ago, yet sometimes he still feels them. Taken off below the knees because of continual ulcers and wounds that wouldn’t heal, the missing legs sometimes itch, and he finds himself waking in the night to scratch at something that isn’t there.
The 55-year-old used to be a truck driver, but these days he spends his time zipping about Lower Hutt in his electric wheelchair, chatting to people; enjoying the sun, and trying not to feel embarrassed. That’s why he doesn’t want his last name used.
‘‘Everyone looking at me knows it’s diabetes... thinks it’s my fault for doing it to myself. It’s hard not to feel ashamed.’’
There are two stories to tell about type-2 diabetes, and they’re both about cost.
In terms of money, New Zealand’s health system spends more on the disease than it does cancer, and that sum is predicted to rise from the current $2.1b to $3.5b in social cost within two decades. A person diagnosed at 25 will cost the country $565,000 over their lifetime.
In terms of suffering, the cost is incalculable. If left untreated the disease can result in renal failure, heart disease and shorten lifespan by up to a decade. It’s responsible for at least 609 amputations a year.
More than 250,000 Kiwis have it, and Pacific people are the worst affected; a new report says in the next 20 years a quarter of New Zealand’s Pasifika community will be afflicted.
Ma¯ ori and Pacific Island children are 18 times more likely to develop type-2 diabetes than European children.
Dr Bryan Betty says type-2 diabetes (T2) is a tidal wave set to devastate our health system, and both the Government and Ministry of Health are ignoring it.
‘‘The problem is reaching crisis proportions in terms of what’s going on.’’
The GP sees plenty of people with T2 in his Porirua clinic and says two people who died earlier this year highlights its inequities: One was a Pacific male in his early 40s; the other a Ma¯ ori male in his early 50s.
‘‘If we start to talk equality, disparity and outcome, you don’t have to look much further from a medical point of view than diabetes and what’s actually going on here.’’
Betty’s haunted by a phrase from an international conference a few years ago summing up both the severity of the disease and the inequality of those it predominately affects.
‘‘One of the experts said diabetes is the measles of the 21st century, as far as indigenous populations are concerned. That was a profoundly disturbing statement because what we’re seeing in terms of Ma¯ ori and Pacific in New Zealand is reflected in indigenous populations around the world.
‘‘What really gets me about the situation is the politicians and the ministry just ignore it, it’s the only way I can describe what’s going on here.’’
There’s plenty to worry about the disease – NZ’s lack of a national strategy is baffling – but Betty says most concerning is the growing number of young people affected. Where once it was a disease for those aged over 60, it’s now common to diagnose people in their 20s.
‘‘Time to complication is 20 years. If you’re diagnosed in your 20s, you’re in your 40s when you have your heart attack or kidney failure.’’
Betty’s comments are reflected in a recently released report packed full of bleak predictions and damning expert comment.
Commissioned by several health groups, including Diabetes NZ, words like ‘‘staggering’’ and ‘‘urgent’’ are scattered through the 145 pages as it tallies the costs of a disease described as likely to be the biggest global epidemic in human history.
‘‘New Zealand is on a trajectory to reach epidemic proportions of the disease in the next 20 years,’’ it warns, and calls for immediate action to curb the disease, including ‘‘lifestyle interventions and funding more medications – a move Pharmac made this year’’.
T2 has traditionally been a disease of middleaged and older people related to excess weight, diet and lack of physical activity but, for genetic reasons, people of Ma¯ ori, Pacific and South-Asian ethnicities are particularly at risk. It happens when a person’s body can’t control its blood glucose levels properly, something it does by insulin produced in the pancreas.
When cells become insulin-resistant or there’s insufficient insulin produced, the body relies on other energy sources in its tissues, muscles, and organs. If untreated, the condition can ravage the body.
Associate Minister of Health Peeni Henare ‘‘most definitely’’ accepts the predictions laid out both in the report and from experts interviewed for this story.
‘‘My father ran a Ma¯ ori health service, and we’ve been seeing this among our people for a long time. Now what we have is quite a strong research and evidence base that tells us and confirms what we already know, in particular places like South Auckland.’’
While Henare says he wasn’t surprised by the report, he is concerned about T2’s growing impact on New Zealand’s Asian and Indian communities. ‘‘With respect to Ma¯ ori and Pacific, we always knew it was bad, now we definitely know.’’
Speaking before the Government’s announcement that it would scrap
District Health Boards (DHBs) and centralise NZ’s healthcare system,
Henare says he’d initially asked about the national T2 strategy, or lack thereof. ‘‘I was told at the time the research wasn’t quite definitive and that different DHBs were on a specific programme to tackle (T2) in their communities and others weren’t. It was enough for them to blame the fragmentation of the health system that was operating.’’
Henare says plans to tackle T2 include revamping ‘‘The Living Well with Diabetes Plan’’, and recruiting and training more podiatrists.
‘‘It’s all very well to be calling for better assessment of feet for the wellbeing of diabetes patients, but we simply do not have the workforce to actually do that. In order to grow that workforce we’re working on a workforce plan that will see an increase in those less well-known health careers.’’
More work around labelling, nutrition and exercise is being done to stem T2, which will have a huge follow-on effect on associated health issues.
‘‘We know if you have diabetes it’s highly likely you’ll have a heart condition; it needs a plan that will tackle prevention in the first instance, and then we’ll have to look at how we make living with T2 better and manageable.
‘‘When we look to the acute end of the services, like dialysis and amputation, I hope we can curb that, although we know we have a mountain to climb.’’
He recently spent a day in Middlemore Hospital’s renal unit talking with patients who had lost limbs and undertook daily dialysis, and says it was both heartbreaking and eye-opening.
‘‘It forced me to say after that day that my hope is I never open another renal dialysis unit, and that means the challenges are on us to tackle care as well as prevention.’’
Dr Jim Mann understands another renal dialysis unit is being built in Auckland right now. Having spent 40 years working with the disease – and one of the report’s expert advisers – the professor says he’s disappointed about the lack of action.
‘‘There is stuff we can do. There is stuff that will cost money, but there is actually stuff that will cost little or no money. To redress it will require some investment now, but if we don’t make the investment now – I’ve said it so many times it’s become corny – it will cripple the health system in New Zealand.’’
Mann says he’s been fighting for decades for appropriate foot care; a relatively inexpensive fix that would virtually eliminate amputations and have an instant impact both for patients’ lives and government coffers.
He wants more dieticians and would welcome a sugar tax, but says the most effective move would be the immediate reintroduction of a healthy eating programme taught in schools, much like the HEHA programme cut by John Key’s National government.
‘‘Diabetes is responsible for so many other diseases... heart disease... kidney disease, diabetes is responsible for having your feet or your leg chopped off. It’s a bit corny to say it’s a hidden killer, but it is.’’
Dr Matire Harwood agrees with the sentiment, though says the disease is anything but hidden in South Auckland where her practice is inundated with T2 patients.
‘‘DHBs and funders are not responding to what is an overwhelming tidal wave of diabetes. It’s the same with rheumatic fever, you can’t help but wonder if it’s because it’s such a brown problem.
‘‘They’ll throw little bits of money at Ma¯ ori and Pacific providers to try and address it, but it needs a whole nation behind it if we’re going to do anything to fix it.’’
The extent of the local issue hit home after an audit of Harwood’s clinic showed she prescribes diabetes medication at a rate five times higher than the national average.
‘‘It is an epidemic. It’s shameful that we’ve allowed this to get away from us. It’s shameful that we’ve had leaders talk about it as it being an individual problem and that (patients) have individual choice and an agenda to tackle this.’’ The lifestyle aspect of T2 has been oversimplified, she says, because the disease doesn’t happen in a vacuum. Poverty, a lack of access to healthy food, and a health system long alienating non- Pa¯ keha¯ are massive contributors.
‘‘All these things we know impact on their ability to manage diabetes, and we’re not helping here. We’re not building the walls to protect them from those, we’re not allowing them to thrive. People should just be being gorgeous in this country, and it’s awful… it’s tiring.’’
Harwood says the focus needs to be on access to healthier food, and education, advocacy and support needs to be provided by people – ‘‘not necessarily with degrees’’ – from within the communities most affected’’.
People need to be empowered to make changes in their lives.
‘‘There’s a stigma and there’s diabetes-shaming, ‘you’re overweight, you’re brown, it’s your problem’. Everybody has a role to play, and we need to step up.’’
Richard Tait says there is no shame in having T2; he certainly doesn’t feel any. Diagnosed 20 years ago, the Wellington man says if T2 is managed well there’s no reason it will ruin a person’s life. ‘‘You can live with it, you’ve got to be considerate of your diet, but you can have a normal life.’’
Tait receives excellent care at Wellington Hospital’s Diabetes Clinic where he’s undertaking T2 drug trials, and apart from a lack of sensation in his
feet – ‘‘It feels like I’m walking on cotton balls’’ – he just gets on with things.
‘‘My father is type-1 and my mother is type-2 , so I’m very deeply genetically disposed to have it.’’
Tait says his message to people newly diagnosed or managing the disease is to educate themselves, take care of their health, and ignore any stigma or embarrassment they may feel. ‘‘It is a disease that hits people like any disease, should people be ashamed of getting cancer?’’
Dr Lisa Te Morenga is a senior lecturer in Ma¯ ori health and nutrition at Massey University and says it’s taken for granted all families have a car, fridge, and pots and pans.
‘‘When you don’t have all those things the environment we live in doesn’t support people to live in a way that minimises their risk of diabetes and weight gain. People will say ‘why is poverty associated with obesity? Surely if you’re poor you don’t have enough food to eat?’
Like Mann, Te Morenga wants healthy food and drink policies in schools, as well as some form of sugar tax.
‘‘Something like 70 per cent of adults would like to see some sort of levy or tax on sugary drinks and food, so the government needs to be brave and go ahead and do that.’’
Limits on the marketing of unhealthy food to children is another must.
‘‘That could be hard because they are exposed to 26, on average, junk food adverts a day. Just walking to school they’re bombarded.
‘‘It’s a multifactorial fix and our governments, our leaders, are not doing everything they need to do.’’
In an emailed statement the Ministry of Health said diabetes was an ‘‘urgent priority’’, but no one agency could address the disease alone.
A spokesperson said the Living Well with Diabetes document was still largely relevant, but was being reviewed.That would include looking at more effort being put into prevention.
‘‘Healthy Active Learning is another initiative to promote and improve healthy eating and physical activity in schools, kura and early learning services across Aotearoa.
‘‘Improving equities in health and access to health care for all continues to be a priority.’’
Back in Lower Hutt, Joseph is off to buy a cup of coffee before heading to the shopping mall where he’ll catch up with one of his kids.
His three children and two grandchildren are the light of his life. His children have all got type-2 diabetes too.
‘‘To redress it will require some investment now, but if we don’t make the investment now – I’ve said it so many times it’s become corny – it will cripple the health system in New Zealand.’’ Jim Mann, above