Same diagnosis, so why the different treatment?
Carmen Parahi reports on how Maori and Pakeha patients with the same medical problem can receive contrasting treatments from the same doctor.
AMaori man sits in a GP’s office, asking for help. He’s having heart trouble, which the doctor recognises as possible cardiovascular disease. The doctor gives him lifestyle advice: exercise more, improve your diet and quit smoking. When that’s sorted, we can help you with some medication, the man is told.
A Pakeha man turns up the next day with the same symptoms. The doctor gives the same advice: stop eating so much rubbish and kick the nicotine habit. But the patient gets the medication up front.
This scenario describes some of the findings from a decade of research into heart disease carried out by the Maori/ Indigenous Health Institute at Otago University.
Associate Professor Suzanne Pitama is a founding director of the institute. She’s been at the forefront of Maori health research development for the past 20 years.
‘‘The medication and treatments exist now to really reduce cardiovascular disease. But Maori are being underdiagnosed and under-treated,’’ Pitama says.
‘‘The problem was Maori weren’t getting screened. If they were being screened, they were less likely to get medication and more likely to get lifestyle advice. They got what we wouldn’t consider best practice first.
‘‘So Maori had to be really well-behaved, stop smoking and lose weight before they were allowed the medication. Whereas Pakeha were more likely to get the medication and then get the lifestyle advice.’’
The institute found that if a
Ma¯ ori patient and non-Ma¯ ori patient presented with the same symptoms, were both screened and treated according to the guidelines, they had the same outcomes.
The diagnosis
Pitama’s work has come into focus since the publication of two major reports.
In July, the Waitangi Tribunal published stage one of its Maori health services and outcomes inquiry, detailing Crown failings and Treaty breaches allowing Maori health inequity to continue.
Then this month, the first report of a system-wide review, led by Heather Simpson, was made public. It too concludes health outcomes for Maori are not fair or appropriate and says the current model of care must change.
Pitama describes the Waitangi Tribunal’s report as a map for creating a system more responsive to Maori. In particular, it lays out ways to reorganise and redistribute resources.
‘‘There will be some kickback when we reorganise the resources,’’ she says. ‘‘But it has to happen if we’re serious about equity.
‘‘Maori want equity but non-Maori have different aspirations to live longer and live with a better quality of life. We don’t have the resources to do both all of the time.
‘‘It sounds simple but it will be complicated to navigate with all those who benefit from the current arrangement.’’
In the past two decades researchers have been able to monitor the health system better because of integrated databases between the Ministry of Health, district health boards and primary healthcare services and practitioners.
‘‘The databases can help us hold the Crown and Crown-funded agencies to account for this inequity. With the greater data sources that’s how I know
about where the gaps are in the health pathways and where Ma¯ ori have to jump the hurdles.
‘‘Non-Ma¯ ori are jumping five hurdles, Ma¯ ori are jumping 10 hurdles. Everyone is trying to get to the end at the same time. Those hurdles are created by clinical bias and structural bias.
‘‘It’s terrible. I wish it was more complex than that. I’ve been doing this research for 20 years. The more research we do, the more we go ‘my gosh, it’s the same fricking story created in a different way’.’’
The treatment
The tribunal’s report recommends a rewrite of the Public Health and Disability Act to include Treaty of Waitangi principles. It also calls for a new Ma¯ ori health authority or model.
But Pitama says a whole new system is not needed in order to understand health inequities.
‘‘When you look at the data and think, ‘Well, how do we solve this problem,’ you look at the Pa¯ke¯ha¯ community and say, ‘Oh look, they’re not dying of this 20 years earlier. So what are they getting? Oh, that’s the solution, so how do we get it?’
‘‘This data is allowing us to see when they get it, how they get it, are offered it. So we’re able to look at the intricacies of how privilege works and how we can get access to the same privilege. Ma¯ ori want the same privileges.’’
For years, Ma¯ ori patients have been paying for and accessing healthcare as much or more than non-Ma¯ ori. But Pitama says it’s of little benefit if Ma¯ ori aren’t then receiving the same standard of care.
‘‘The issue isn’t a lack of Ma¯ ori engaging in the health system, it’s the health system not engaging with Ma¯ ori. It’s because the health system is not set up to respond to Ma¯ ori. It has set resource and is designed to privilege non-Ma¯ ori.’’
Ma¯ ori clinicians and researchers know how good modern medical science is, she says. ‘‘We just want access to it in a way that equitably meets our community’s needs.’’
The Ministry of Health is yet to announce how it will respond to the Waitangi Tribunal’s recommendations. Its Ma¯ ori health director-general, John Whaanga, has met claimants to discuss how to address some of the issues raised during submissions.
‘‘Now that the tribunal has reported on stage one, it will be important to review its findings and recommendations to inform how best to progress matters further,’’ he said in July.
There’s a will, now for the way
Pitama says she is frustrated by practitioners who continue to use anecdotal experiences to frame their view of Ma¯ ori health instead of using clear evidence.
‘‘There is nowhere else in medicine where you’d get away with that,’’ she says. ‘‘ . . . when it comes to Ma¯ ori health, practitioners are positioning themselves in places where they’re not producing evidencebased practice.’’
She acknowledges it can be hard to see inequity in the system – even many clinicians don’t know where it occurs. But she is heartened by the changes she’s seen among her peers, who are eager to understand.
‘‘We’re being approached by so many clinicians who don’t want inequity and [who are] asking, how do we know we are being inequitable.
‘‘They want to be responsive but a lot of training has to happen in how they can measure their own inequity.
‘‘We’re getting there, those services are only just being designed.
‘‘Most of my colleagues are excited to understand where the gaps are and do something about it. I think there are some amazing people out there trying to support health equities. It’s very new.’’
‘Non-Ma¯ori are jumping five hurdles, Ma¯ori are jumping 10 hurdles . . . Those hurdles are created by clinical bias and structural bias.’’