Tuesday, July 20, 2021

Effi Lincoln: Gout and the Treaty-driven misrepresentation of health equity statistics.

“Research is political, and we must ask the question “who will benefit from the research?” [Irahapeti Ramsden.  Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu – 2002]

Yes. We must ask…

So what is gout?

Gout is a painful and debilitating condition.

It runs in my family.  Doctors frequently treated it poorly.

I recall an elderly relative turning his gnarled, tophaceous hands in bemused horror at what they had become; another, stricken with gout, wincing silently as she chopped the onions.


Their experience is a microcosm of the suffering many New Zealanders endure with gout.

It is an important condition that deserves wide recognition and continued efforts to manage using best practice.

How to explain gout:
Our bodies produce chemicals called urates.  Some people produce greater concentrations of urates in the blood than others. Some foods are known to increase urates in the blood.  Above a certain concentration these urates supersaturate and suddenly precipitate out in the joints; much like the point at which, when whipped, heated sugary cream suddenly crystallises into fudge.
It happens quickly and this crystalline fudge in the joints is phenomenally irritating.  The body goes into overdrive to get rid of it, switching on a process called inflammation.  It is severe.  The joint swells, becoming hot and red, and causes excruciating pain.

So gout is the clinical manifestation of an underlying problem with high levels of blood urates.

Inflammation of a joint is called arthritis. Inflammation of a joint caused by the precipitation of urates within it, is called gout.

Once this inflammatory pathway is triggered, the only way to stop the pain quickly is to use anti-inflammatory medicines; voltaren (an “NSAID” or Non-Steroidal Anti-Inflammatory Drug) and colchicine are known to work best at this stage, or steroids (prednisone), all of which suppress inflammation.

It is important to understand that once an attack of gout is happening, these are the best medicines to bring it under control. They are not perfect but there is no other choice if the doctor wants to relieve the patient’s suffering in that moment.  Doctors know that anti-inflammatories risk damaging kidneys, and steroids risk a raft of serious side effects.  Their duty is to weigh up the harms and benefits of these medicines and help the patient make an informed choice.

The reality is, when a patient is in that much pain, the potential future harms are given less weight than relief of the pain right now.  Doctors get no pleasure from their patients’ suffering. They want to help.  Patients take in little when they are in pain.  It is not necessarily because they don’t understand.  It is because pain does that, to everyone.

Eventually, the inflammation settles, the body reabsorbs most of the urates from the joint and life, seemingly, goes back to normal.  But quietly, the urates in the blood lurk, until such time as they suddenly precipitate out again, maybe in the same joint, maybe in another.  The excruciating pain returns and the drive to seek pain relief begins again, if not from the doctor then from the supermarket, or the chemist, or from whoever you can find who has the pills to bring you the relief you so urgently need.

These episodes may be triggered by eating food, such as shellfish, which is high in purines, a precursor to urates.   Until the advent of medications to prevent the build-up of urates in the blood the only hope of controlling gout outbreaks was to manage “lifestyle choices” such as weight, and food and alcohol intake.  This was particularly important for people who were more susceptible to gout.  It was recognized that Māori and Pacific people had such a susceptibility so, in good faith, the advice was to manage such “lifestyle choices” to the best of their ability.

Over time, the high blood urates, and repeated attacks of gout, cause long term damage; to the joints, and to the rest of the body.

The best way to avoid repeated attacks of gout, and long-term damage, is to use medicine to lower the blood’s urate level.  The medicine used is called allopurinol.  Like every other medicine it has side effects, but it is a generally safe and effective treatment although it must be taken daily for the long term for its benefits to be realised.  For many years doctors were taught that if a patient stops allopurinol then restarts without anti-inflammatory cover the patient could be precipitated into a further painful episode of gout.  This gave rise to caution in prescribing it if doctors thought their patient would have difficulty following the long-term plan.

So why do I believe there is a Treaty driven misrepresentation of health statistics, and why does it matter?

It matters, because health statistics in New Zealand are being used as a political tool to justify the introduction of radical exclusive biculturalism, a form of Ethno-Nationalism.

Radical exclusive biculturalism demands a separate health system for Māori.

It goes like this:

1. Interpret that the Treaty promises 21st century equity, not equality, to Māori when compared to other New Zealanders.
2. Provide the abysmal health equity statistics on the latest condition.
3. Broadcast news of this terrible statistic far and wide.
4. Stress how this dreadful statistic proves that care to Māori is inequitable.
5. Declare this a breach of Māori Treaty rights.
6. Demand separate health system as partial reparation for Treaty breach.

Politics is all about the allocation of power.

“Power: The Most Fundamental Cause of Health Inequity” declared the heading in a recent international health affairs blog.

Māori argue that health equity is owed to them because of the Treaty.

The Treaty was between Māori, on the one side, and the government, representing all other New Zealanders, on the other.

Inequity is defined purely by the differential outcomes between groups.

It is simplistic, and it always blames the white oppressors.

It is not equality of opportunity, the classical liberal idea that encourages people to be the best they can be.  It is equality of outcome and its proponents “know” that it must also include a substantial weighting for perceived present, and past, injustices by the oppressor.

It encourages victimhood. It demands endless obeisance because oppressor offerings are never enough.  It is a boa constrictor of pressure that once applied, never lets up.

It is why Leanne Te Karu from the Auckland University Department of General Practice and Primary Healthcare feels justified in asserting in a 2020 qualitative research article on Maori and Gout that:
“The authors are unaware of previously published research on the consideration of advice to cease eating kaimoana as a breach of cultural rights. 
This consideration is underpinned by the traditional connection of wellbeing to resources over which rangatira exercised authority.  Article II of the Treaty of Waitangi specifically classifies fisheries as a taonga for continued access and authority. This raises the prospect of a breach of the Treaty if people are unnecessarily advised by healthcare workers to avoid kaimoana.”

[“The long shadow of inequity for Māori with gout.” Te Karu et al 2020.]

Activists are demanding more and more Treaty rights and reparations based on health inequity statistics.  It is important therefore that they are examining health inequity using a political, “Treaty-informed”, definition of inequity. To do this one must examine health statistics for Māori, as one party to that Treaty, and compare them with health statistics for all other New Zealanders, as the other party.

But this is not what has been happening!

In fact, if you consult the New Zealand Health Quality and Safety Commission’s Atlas of Healthcare Variation and search under “Ethnic Group” to see how much inequity exists between Māori and New Zealanders (non-Māori) you can’t do it!

They only allow you the categories:

  • All ethnic groups
  • Māori
  • Pacific Peoples
  • Non-Māori, Non-Pacific

But none of these comparisons allow the user to see for themselves if there is inequity in the one area that is politically important for all of us; Māori, compared with all other New Zealanders. 

This is the only “inequity” relevant to a Treaty claim.

In “Gout in Aotearoa New Zealand: the equity crisis continues in plain sight” in an editorial in the NZMJ in November 2018 Dalbeth et al proclaim:
“Data included in the 2016 just published [sic] show an escalating crisis in inequity: there is more gout nationwide, and worse and less treatment for Māori.”
It is noteworthy that it is Dalbeth, here complaining about “more gout nationwide” who informed New Zealanders that gout is primarily genetic.
She then declares that “As partners under the Treaty of Waitangi, there is a governmental obligation to ensure Māori have at least the same level of health as non-Māori.”

The irony of this is that if we use the Treaty-informed definition of inequity, Māori DO have equitable treatment with New Zealanders (non-Māori) when it comes to Gout!

Gout used to be seen mainly as an environmental disease but as Dalbeth informed New Zealanders, it is now widely accepted that genes are the major drivers to hyperuricaemia (high blood urate), the condition that underlies the clinical presentation of “gout” the inflammatory arthritis. [Evaluation of the diet wide contribution to serum urate levels- meta-analysis of population based cohorts Major et al BMJ 2018]

Further, the New Zealand Health Equity Explorer underwhelmingly alludes to the real-world difficulty in achieving the Utopian goal of equal outcomes in health, telling readers that “Health depends on many things, and ‘equal’ health is hard to achieve.”

It may make more sense if we look at the statistics for Gout:

In 2019 the NZ Atlas of Healthcare Variation identified that:

  • 8.5% of Māori had gout.
  • 14.8% of New Zealand Pacific people had gout.
  • And 4.7% of New Zealand “Non Māori, Non Pacific” people had gout.

But I wanted to look at the Treaty-informed Identity groupings; that is, Māori and New Zealanders (non-Māori).

So I waded through the 2019 raw data and discovered the following:

  •      208713 New Zealanders had gout:

a.       41002 Māori.

b.      167711 New Zealanders (Non-Māori).

ie, of New Zealanders with Gout, 19% were Māori, and 81% were New Zealanders (non-Māori).

I then looked at the percentages regularly using urate lowering therapy (the long-term treatment to control gout). This measure of inequity relied on dubious assumptions, yet it carried particular weight for the angry authors of the 2018 NZMJ Editorial.

And what they did is interesting for they failed to include Pacific People in the group of New Zealanders (Non-Māori) with gout.

This is inexplicable.

Here are the figures needed to draw the correct conclusion about Treaty-informed equity with regard to the regular use of urate lowering therapy:

Numbers of those with gout regularly using urate lowering therapy in NZ in 2019:

  • Māori: 16168/41002 = 39.4% of Māori regularly used urate lowering therapy.
  • New Zealanders (non-Māori): 70988/167711 = 42.3% of New Zealanders (non-Māori) regularly used urate lowering therapy.

Given the complexities of estimating numbers using the information available, these figures illustrate the lack of magnitude of the inequity between Māori and New Zealanders (non-Māori) using regular gout therapy. 

A further example of the lack of inequity between Māori and New Zealanders (non-Māori) demonstrated by the gout treatment data is seen when we look at the numbers whose doctors ensured they had a serum urate blood test check within 6 months of starting long term therapy:

Numbers who had a blood test within the recommended time:

  • Māori: 12945/41002 = 31.6%
  • New Zealanders (non-Māori): 53630/167711 = 32%

That is, NO inequity between Māori and New Zealanders (non-Māori) with regard to blood testing.

Finally, let’s look at NSAID prescriptions for acute gout:

The only conclusion offered in the Atlas of Healthcare Variation. Gout: Key findings 2019 [] regarding the dispensation of NSAIDS in people with gout was that “Māori and Pacific peoples with gout were dispensed NSAIDS at significantly higher rates than non-Māori, non-Pacific”

Again, let’s now look at this through a New Zealand, Treaty-informed equity lens:

Numbers with gout given NSAIDs but no urate lowering therapy:

  • Māori: 6116/41002 = 14.9%
  • New Zealanders (non-Māori) 25571/167711 = 15.2%

ie, there is NO inequity between Māori and New Zealanders (non-Māori) in terms of prescriptions of NSAID anti-inflammatory medicines for gout. (The numbers for the 2017 year were 15.6% for each group)

Now let’s take prevalence of gout flares.  The Editorial authors believed this was an important marker because it showed how Māori were receiving less preventive care than other New Zealanders, and thus were receiving inequitable care.
They railed against the prevalence of gout being so high in Māori, and yet this is wrong, because Māori have a genetic predisposition to gout. And to argue that the presence of a gout flare represents poor treatment is not something that can be ascertained by the statistics used.  This is because gout presents much younger in Māori, and it raises the only flag that hyperuricaemia is present.  Also, New Zealand guidelines []  state that “long term urate lowering therapy is recommended for patients with recurrent gout flares (two or more per year)”  so the increased rates of clinical gout in the statistics may be not because Māori have been improperly treated but because young Māori are presenting with gout, but not meeting the guidelines for long term treatment.
This also may explain the numbers of Māori using acute anti-inflammatory treatment rather than long-term lowering therapy.

The concept of looking at hospital admissions related to gout is also interesting.  You could read it as being a failure on the part of the health professional, to control gout flares, but, from the stats given, you could also read it as a responsive health system providing excellent back up support to people smitten by acute gout for whatever reason, including the reason that maybe this was their first declaration of gout, or maybe they had chosen not to take long term treatment because this solution suited them better   we like to think that people make rational, evidence based decisions regarding health but we know this is not always the case and many, particularly the young, have trouble understanding future consequences of failing to take preventive medicines long term. 

I am not saying this is what has happened here.  What I am saying is that this data cannot answer that question.

So where does this leave us?

It is clear that activists for Māori separatism have destroyed the boundaries between medicine and political activism.  They have used the plight of New Zealand’s Pacific peoples in particular to advance the cause that New Zealand is a racist society, highlighting statistics that show poor Pacific peoples’ health (often poorer than Māori health) but then they covertly switch tack, removing all trace of New Zealand Pacific peoples’ health stats to falsely show a level of inequity between Māori and other New Zealanders that in fact does not exist.

In order to do this they have bamboozled New Zealanders with words and concepts they fail to define.

Who knew, all this time, that the activists had unceremoniously dumped our Pacific peoples into the equity rubbish bin and failed to even count them in our national “Treaty-informed” equity statistics?

We should have known.  It was there right in front of us in the fact that we were referred to not as “New Zealanders (non-Māori)” but as the “Non” people: “Non-Māori, Non-Pacific”  but then again, in the final wash up, New Zealand’s Pacific peoples were not referred to at all.

Why does this matter?

Apart from the ethical nightmare? ­­– Because health costs money!

Every dollar that is now put into a Māori health system is one dollar less available for all other New Zealanders, including our Pacific peoples, and including Māori who wish to stay within our current system.  There is much poor health in New Zealand, and much that needs to improve.  I am not arguing against that.

What I am arguing is that that level of poor health is not inequitably spread from a Treaty-informed perspective and therefore there is no reason, from within an Inequity framework, to move to a massively expensive, risky, untried, separatist Māori health system which is predicated on the idea that Māori suffer more health inequities than other New Zealanders.

My opinion is but one in the team of five million but I fear what is coming enough to spend this time writing when I would rather be doing other things.   I believe a separate health system for Māori is a bad, bad idea for team New Zealand.

We are a small country.  We need to continue to work towards excellence in the system we have.  We can be excellent.  We need to continue to improve access to best-practice care for all New Zealanders, not destroy the system we have and rebuild from the ground up with only a bunch of kiwi-build incompetents and a dystopian visionary to guide us.

New Zealanders want to support our government to help Māori thrive and get good access to the care they need.  It does not require a card-carrying commitment to Critical Race Theory to feel this way.  It is why the Treaty settlements were supported and have been able to happen; Most New Zealanders support inclusive biculturalism in a democratic-nationalist state as the best way to build for our future as a fair and free country, celebrating our differences and celebrating our unity.

But this is bigger than just health inequity statistics.

The fin is emerging, but the shark is huge.

The changes we are seeing now have been brewing for a long time.  They have been well planned and are now being rapidly executed. 

Nothing is as it seems:

“And if you talk to, say, a little marae based group that are trying to set up a health clinic or something they will not use the jargon of “Cultural Safety” or they won’t even use the jargon of “sovereignty” probably, but that is actually what they are trying to do”. [Moana Jackson, interviewee in Ramsden, 2002]

Some New Zealanders are positioning us all for a dystopian future of Exclusive Biculturalism in an ethno-nationalist state, by using the political instrument of the Treaty of Waitangi to demand ever increasing rights and privileges for Māori.  One of these “rights” is the “right” to a health system of their own; a health system for Māori but funded by all New Zealanders.

New Zealand can’t afford this, and it won’t work.

Attracting and retaining the skilled and dedicated staff required to run one health system is difficult.  The cost of running two will be crippling.

Some Māori want to be funded by everyone to practice more of their own form of “medicine”.  The reality is that Māori life expectancy has increased dramatically over the last century because of western medicine.  It increased in Māori women from 40 years in 1926 to 77 years in 2013.   And it can keep doing so if we continue to learn from the past and build towards the future. 

It was over 30 years ago that “Cultural Competence” was brought into New Zealand nursing to great fanfare.  It was eagerly embraced by the nursing profession and Māori-centred care has been part of our DNA ever since.  The fact that there are imperfections, the fact that we don’t have a health utopia, is because people are fallible; we get tired, we get grumpy, we get distracted ­­– no matter how much we love our jobs and want the best for those we care for.  There is no reason to believe a Māori health system will magically find nursing staff who are any more dedicated to “culturally competent” care than those in our current system.
In fact, I believe that health workers overtly trained within the framework of Critical Race Theory will be more rigid in their beliefs and less empathetic to “Others”, than current health workers.

When it comes to empathy for “Others”, the poor, woke soaked Māori immersion medical students don’t stand a chance. 

This path of educating new generations of Critical Theorists (this enforced “Critical” education is known as “praxis”) holds risk that has been given too little scrutiny by New Zealanders who have a great deal to lose.

It is already happening that New Zealand doctors and nurses are being lectured by their Theory indoctrinated peers that they are racist even when they believe they are not. 

More dangerously, all health practitioners need to be aware that “Cultural Safety” is here, and it is defined as being whatever the oppressed patient says it is, which means that being a New Zealand (non-Māori) health practitioner in the Māori Health System will become increasingly medico-legally dangerous. Every interaction you have as a health professional in such an environment will, by definition, expose you to Māori patients whom you may inadvertently upset through saying or doing the wrong thing.

The imposition of Cultural Safety has been planned for a long, long time:

“Cultural Safety gives the power to the patient or families to define the quality of service on subjective as well as clinical levels.” [Ramsden 2002]

Be aware too, that “Cultural Safety” is not a social term. It is a political term, a spawn of Critical Theory, the radical leftist political belief system. [For more on Critical Theory, see my Breaking Views Blog of 26 June 21; Why I stopped learning te reo]. To be “Culturally Safe”, as per the New Zealand Medical Council definition, you must not only abide by their political beliefs in your external practice, they are demanding even your thoughts be brought into line.

In case you think “this can’t be!” I urge you to read the NZMC’s “Statement on Cultural Safety” [October 2019].

It is a Critical Theorist’s Mind-Control Manifesto. 

You must read it!

They even spell it out for you:
“Cultural Safety encompasses a critical consciousness”

Or, in more depth:
“…cultural safety represents a more radical, politicized understanding of cultural consideration, effectively rejecting the more limited culturally competent approach for one based not on knowledge but rather on power”  [Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition.  Curtis et al 2019]

Dr Elizabeth Rata warns in her Breaking Views Blog on July 5 that “When we politicise ethnicity – by classifying, categorising and institutionalising people on the basis of ethnicity – we establish the platform for ethno-nationalism.  Contemporary and historical examples should make us very wary of a path that replaces the individual citizen with the ethnic person as the political subject”.

The reality is, we all share far more than some of us realise.  When you read articles about what Māori find unfair about the present health system, they are the same things all New Zealanders find unfair: long wait times to get into GPs; high costs of visits; a different doctor every time; doctors not understanding you; visits way too short to properly connect;  difficulty accessing care due to onerous work commitments, or lack of transport; prescription costs.  This burden is particularly acute for New Zealanders living in poverty, but it affects everyone. 

It is also these things – the utopian ideals we would all like to see implemented in our health system – that Māori maintain are indicators of why they need a separate system. 

 [The long shadow of inequity for Māori with gout. Te Karu et al.  2020]

In their own system, they expect these things to be provided to them.

And to be paid for by everyone.

And if you’re in any doubt about the true nature of the Equity push, a quote from James Lindsay’s New Discourses Dictionary “Translations from the Wokish” gives this illuminating glimpse into our future if we choose equity over equality.  He says:

“In early 2020, and rather shockingly, in the Washington state legislature, an “Equity Task Force” was assembled that offered the following definition for equity:

“Equity = Disrupt and Dismantle.” 

Which is to say an explicit call for a systemic revolution (NB: The Task Force was assembled even after the state voted against Affirmative Action.)  The Task Force took pains to explain that they (the Social Justice supporters present) know that equity means disrupt and dismantle, and debated whether or not the language was too naked to be able to be approved by the legislature. 

In the end, the centrality of disruption and dismantling was considered so crucial to the proper understanding of equity, lest anyone in the future mistakenly leave it out as a result of their euphemisms, that the language was included in the proffered definition.”

By their words you shall know them…

…And by your words you shall resist them.

Effi Lincoln is a sixth generation New Zealander. Her roots are sunk deep in the South Island’s soil. Her heart beats in its beaches and its bush. Her eye is firmly on its now seriously threatened future as a fair and free place for her children, and her children’s children, to thrive.


Jigsaw said...

Extremely interesting - if rather long which may put people off reading it. I am very interested in the difference between equality of opportunity and the equality of outcome-which is what socialists seem to be demanding and yet a most cursory glance around our society shows the utter impossibility of ever achieving that. We are all limited in some some way by the abilities that are dictated to us by a whole host of factors and then of course by our own habits and ways in which we develop or not the abilities that we have.
In my job one of the requirements was to be organized and being able to plan ahead. This was not a strength of mine and yet when I eventually realized that was a weakness of mine I worked as hard as I could and with some determination turned it into a strength. I could have more easily just turned away from the challenge. I am sure that in other areas I did turn away- my point is we all have such challenges. We are capable -or not- in turning opportunity in outcome- whether we do or not is our own decision.

Alexandra Corbett Dekanova said...

Thank you for this excellent article. It all is so frustrating. It took nearly 100 years for mankind to recognize that classical Marxism with its exploited versus exploiters class struggle leads to economic and moral abyss of hell. How long will it take to recognize that a tentacle of Marxism Hydra monster, which is Critical Theory with its struggle to liberate various kinds of oppressed (predominantly minorities)from oppressors (mostly white Westerners) leads to the same place? Do we here in New Zealand really need to undergo the dangerous social experiment of ethno-national society to recognize it does not work? What will happen when there will be no desired improvement in health for Maori population under new order based on race? Do we need to waste resources to learn what is obvious to all doctors and nurses? For their sake we all should feel offended and insulted by accusations of racism. Critical Race Theory focusing on one element of statistics is the biggest obstacle to address the real causes of complains and problems, the insufficient number of GPs, nurses, midwives etc.
Alexandra Corbett Dekanova.

Ross said...

There is an unstated mystery here though: why is this happening now? Dumb ideas have been around for ever. But they are usually nodded at and ignored. Now, suddenly, they are not only being championed from within government, but actually enacted (Maori language, Cultural competence requirements, Maori purchasing quotas, Maori research grants, Maori wards, Maori health etc). Also, there seems to be complete buy in by the media who are either incapable or unwilling to question, and who actively discourage dissent by labelling opponents racist. You mention:

"The changes we are seeing now have been brewing for a long time. They have been well planned and are now being rapidly executed."

This is a coup. I can't think of any other word to describe it. It is a sudden decisive exercise of force in politics (Merriam Webster). But the mystery remains. Why is this lunacy given any oxygen at all. Most incredibly, why is a western democracy so willing to abandon everything that voted it into existence.

Alexandra Corbett Dekanova said...

This nonsense has been around quite a long time, invaded Western Universities, Academies, schools, institutions and enchanted youth with its seemingly fight for social and other justice. Do you remember students in 1968 in tees with Che Guevara? Now several generations have caught this socialist infection.
Alexandra Corbett Dekanova.

Don said...

Admirable and very impressive research worthy of wide publication and discussion. Most of us want to know the time rather than how the clock works.
A concise summary of this would be more likely to be read by interested persons like myself who have only three degrees and lost the thread here and there requiring me to re-read and concentrate more than I am accustomed to at my advanced age. When can we drop this stupid bicultural thing and paddle together in the same waka?

Anonymous said...

Interesting that Leanne Te Karu, one of the authors of “Gout in Aotearoa... NZMJ", is one of six on the INDEPENDENT 2022 review panel of PHARMAC - three of the six are active inequality researchers.

Is it hardly surprising that equity will become a focus of PHARMACs restructure.

Where will Labour's disingenuity end ?