Thursday, April 14, 2022

Graham Adams: Can the Māori Health Authority really boost Māori life expectancy?

The purpose of the new race-based agency is mostly to fulfil the radical co-governance aims outlined in He Puapua.

Patrick Gower asserted recently on Newshub Nation that the burning question David Seymour has to answer in opposing co-governance is:

Why if a Māori child is born, like in the house next door to me, do they live for seven years less than the child born in this [Pakeha] house?

Newshub’s high-profile national correspondent was undoubtedly referring to the claim that the Māori Health Authority will improve poor Māori health statistics, including life expectancy.

It is due to swing into action on July 1, but both Seymour and Christopher Luxon have promised to abolish it if a National-Act government is elected next year.

Pointing at the house to his left, Gower announced his challenge to Seymour with an air of triumph — as if he had gone straight to the heart of the matter with a unique and devastating personal insight.

In fact, setting up a new bureaucracy with the ultimate aim of closing a gap in life expectancy is quixotic, to say the least. A Māori Health Authority makes no more sense than seizing on the fact men die on average 3.5 years earlier than women and setting up a standalone Male Health Authority — with independent commissioning powers, its own budget and an effective right of veto over health plans for females — to improve the situation.

Who would imagine an autonomous “by men, for men” health agency would be the best answer to that particular difference in life expectancy?

The obvious response would be to first investigate genetic influences, lifestyle (including exercise, diet, obesity, prevalence of drinking, smoking and drug use, stress and risk-taking) and why men are generally more reluctant than women to seek timely medical help for health problems. And to investigate the barriers some men — particularly those living in poverty — face in accessing health care.

None of that would require a new and expensive bureaucracy.

As it happens, the average disparity in life expectancy between Māori and Pakeha is paralleled by the gap between Pakeha and Chinese, who — as the longest-lived of all the ethnicities in New Zealand — last nearly six years longer than those of European stock.

And, other Asians in New Zealand live roughly three years longer on average than Pakeha. For that matter, the average life expectancy for Samoans in New Zealand is more than three years longer than for Māori.

Clearly the question of differing life expectancies between ethnic groups is complex — and it certainly can’t be explained by “systemic racism”, “unconscious bias” or “white privilege”. Anyone who wants to argue that racism is responsible for lower life expectancy for Māori has to explain why health workers might be much more racist towards them than towards Samoans and Asians.

One reason Gower looked so pleased with his insight about the possibly reduced life expectancy of the child next door was no doubt because he had, in fine journalistic fashion, turned an impersonal statistic into a personal comparison. However, that tactic immediately ran into problems.

First, the statistic is an average. Shorter life expectancy is closely correlated with the ill-health and less accessible health care associated with poverty. Consequently, a poor Pakeha child will not necessarily have a better chance of a long life than a poor Māori child.

It is also worth noting there are a lot more deprived Pakeha children than Māori children, with similar problems in accessing health care. In fact, it was calculated in 2020 that there are more than twice as many Pakeha children living in poverty (114,300) compared to Māori (61,000).

From the look of the immaculate and well-appointed living room in which Gower was speaking to Newshub Nation, he didn’t appear to be living in straitened circumstances; nor, it seemed likely, in a poor neighbourhood.

It was entirely possible, of course, that the Māori child next door was doing it far tougher than a well-paid media star but the question lingered of whether the youngster was also enjoying the benefits, and life expectancy, of a comfortable middle-class upbringing.

Social media commentary about Gower’s neighbourly comparison also raised the question of just how “Māori” the neighbour’s child was. If the child had one Pakeha parent, and most of his or her grandparents were Pakeha, did that queer Gower’s argument about life expectancy? And what if one of the parents, and a couple of the grandparents, were Chinese? Given that Chinese males in New Zealand live to a whopping 87.2 years, on average, and females 90.1, how would that influence the child’s life span?

Doctor and former All Black Lawrie Knight tackled these problems in his submission to the select committee considering the Pae Ora (Healthy Futures) Bill. The legislation will replace the existing 20 District Health Boards with Health New Zealand and the independent Māori Health Authority, both working in partnership.

As Dr Knight pointed out:

Genetics have been estimated to account for between 7 per cent and 33 per cent of the variance in longevity. The standard accepted figure for this genetic impact is 25 per cent… If genetics are not considered, then mistakes and faulty analysis occur.

Knight also addressed the question of “white privilege”, which implies there are fewer obstacles in the way of non-Māori people accessing healthcare. The notion has been widely used as a justification for a Māori Health Authority.

He asked:

Where is the evidence? Pakeha and other non-Māori races affected by unemployment, poverty, poor education, poor housing or living in rural areas have as much difficulty in accessing health [care] as Māori in the same socioeconomic or geographical situation.

Yet, he says, the figures for hospital admissions that could have been prevented by access to timely and competent general practice care are not collected for the disadvantaged section of the Pakeha population.

Perhaps Knight’s most salient point is the evidence from experience. He says the proposed system will expand the network of Māori health providers Helen Clark’s Labour Government set up 20 years ago to “close the gaps”. But, as he says, if results have not improved significantly in 20 years, why would they make a difference now?

Since 2000, most Māori health services for Māori have been provided by 77 Māori health providers. They have been funded by the state but completely managed by iwi throughout New Zealand during this time. They were created 20 years ago to provide a ‘by Māori, for Māori’ health service as a solution for the Māori health problems — the identical reason as for this current bill.

While some of the hauora have provided an excellent range of public health measures and personal health services, others have not been so successful. This network of hauora has not had the breakthrough in improving Māori health statistics that had been hoped would occur with a ‘by Māori, for Māori’ service provider.

It is true that some Māori patients entering hospital have inferior outcomes from treatment but, Knight says, that is “consistent with the presence of co-morbidities, coupled with genetics and poor primary health care”.

It is worth repeating Knight’s point here:

The vast majority of these Māori have had their general practice health provided by one of the 77 ‘by Māori, for Māori’ primary health providers since 2000.

Knight quotes the WHO in arguing that the Social Determinants of Health (SDH) — including education, employment, work stability, housing, early childhood development and food security — are highly significant factors in health outcomes and often vastly outweigh the role of health providers.

The same conclusion was reached by 2019’s Health and Disability System Review, Interim Report, commissioned by the government:

Although many people continue to consider health care in the context of clinical and medical care only, it is widely acknowledged that this accounts for only about 20 per cent of a person’s health and wellbeing status. The other 80 per cent arises from the conditions in which a person is born, grows, lives, works, and ages, including physical, cultural and natural environments, housing, education, the distribution of power and income, and health behaviours.

A Māori Health Authority, as outlined in the Pae Ora bill, is clearly not going to be able to address these factors. A far more successful strategy would have been to have reduced inequality in housing, education and poverty during Ardern’s four and a half years in office — as she promised.

Despite Gower’s apparent self-satisfaction at posing what he saw as a crucial question for Seymour to answer, his insight was hardly original. He was simply echoing the Prime Minister, who repeats the statistic about differing life expectancies at every opportunity to justify overturning our entire health system and establishing a separate Māori Health Authority — at an overall cost of $486 million to begin the transition and in the middle of a pandemic, no less.

The Prime Minister rarely attempts to explain how a Māori Health Authority might improve the dismal statistics. Mostly, her argument is barely more sophisticated than: “What we’ve been doing isn’t working so we have to try something new. A Māori Health Authority is something new. So let’s do this.”

Most pertinently, the Prime Minister and her Health Minister, Andrew Little, have asserted that the Treaty “partnership” demands it.

However, when David Seymour tried in Parliament on March 29 to examine the links between the Government’s co-governance agenda and the Treaty and how a Māori Health Authority fitted in, Ardern once again avoided answering the actual question put to her and returned to life expectancy and health outcomes.


Does she see any distinction between co-governance arrangements for specific taonga returned through Treaty settlements, such as the arrangements for Auckland’s maunga, on the one hand, and co-governance of entities that did not exist in 1840, such as public healthcare systems and three waters infrastructure, on the other, or is co-governance now a wholesale policy, regardless of that distinction?

Ardern lacks both the political will and the intellectual heft to directly address the intricacies of a question like that so she slipped around the side.

She replied:

Perhaps we should come at it from a different angle from the member. We have not, since the signing of the Treaty of Waitangi, had the Māori Health Authority. Yet what we have had is a national health system that has generated an outcome where Māori die younger than other New Zealanders and where Māori have worse health outcomes, for instance, in cancer care and treatment for every cancer there is other than melanoma.

It is not right in this country that because you’re Māori, you are often sicker and you have poorer treatment in our health system. So we are responding to that, yes, with an entity that didn’t exist before, because this is a problem that has existed because we have not confronted it as we should.

Yes, that is truly coming at the question “from a different angle” — which is to say a sudden and illogical swerve to avoid answering a question about whether the Treaty implied a requirement for co-governance in managing health and water services that didn’t exist at the time it was signed.

And, yes, her Government is “responding” to the dismal health statistics for Māori but not necessarily in a logical, productive or cost-effective manner.

In fact, the real driver for setting up a separate Māori Health Authority is political and improving health outcomes is secondary — much like giving iwi a 50:50 co-governance role in Three Waters is not primarily about improving water quality and delivery.

Both are aspects of the co-governance agenda set out in He Puapua that rests on a radical interpretation of the Treaty as a 50:50 partnership between iwi and the Crown.

However, in its promotion of both the Māori Health Authority and Three Waters, the Government mostly avoids offering the true reasons for its separatist policies and instead offers flimsy and often emotive pretexts.

Unfortunately, some of our most prominent journalists and media organisations automatically repeat the Government’s pretexts and talking points in such a mindless fashion it’s impossible not to think of Lenin’s description of the credulous supporters of his ruthless politics as “useful idiots”.

Last week, RNZ began an article on the Māori Health Authority with: “The new Māori Health Authority to be in place from July could radically improve life expectancy for Māori — but two political leaders [Luxon and Seymour] want it scrapped.”

As is common when the mainstream media discusses co-governance initiatives, RNZ didn’t offer a shred of evidence that the new authority would be likely to arrive anywhere near such a happy outcome.

Graham Adams is a freelance editor, journalist and columnist. He lives on Auckland’s North Shore. This article was originally published by and is published here with kind permission.



Anonymous said...

i think this is the outcome of decreasing numeracy levels across the population over time. one of the profound concepts in statistics is to understand 'with-group' variation vs 'between-groups' variation. for generic measures like health, wealth and education, most of the time, the former trumps the latter. which means using averages for comparison gets media attention but provides no meaningful insights.

Jill said...

Education is basic to everything.

Doug Longmire said...

Taking a quote from Paddy, and adjusting the nouns... "Why if a European Male child is born, like in the house next door to me, do they live for seven years less than the female child born in a Chinese house?"

Sauce for goose.....