Lawrie Knight is a doctor and former All-Black. The following is an abridged version of his submission to the select committee considering Pae Ora (Healthy Futures) Bill. The original version can be viewed here.
A decision has been made by government to create a separate Health Service for Māori based on Waitangi Report 2575 (Ref 15) and the Te Ora Report (Ref 1).
Māori doctors and health leaders have called the New Zealand health system "systemically racist" primarily contributing to poor Māori health and reduced Māori longevity.
The four most common claims made are:
1. Māori die seven years earlier than other New Zealanders
2. Decolonising the health system will improve Māori health and longevity
3. Primary contributing factors for Māori ill health are “systemic racism,” “white privilege,” and “unconscious bias” in the New Zealand health system
4. Non–Māori are not affected by inequitable health provision and services
1. Māori die seven years earlier than other New Zealanders
The data on the life expectancies of people living in New Zealand in 2018 are (Ref 2,3):
Genetics have been estimated to account for between 7% and 33% of the variance in longevity. The standard accepted figure for this genetic impact is 25% (Ref 4,5). Comparisons between different ethnicities regarding relative life expectancies must take this into account.
From the above Māori have the lowest life expectancy. However, it is not accurate to say that Māori die seven years earlier than other New Zealanders as each race in New Zealand has its own genetically influenced life expectancy.
Pakeha die nearly six years earlier than Chinese New Zealanders.
Do we also claim this is due to a “systemically racist” health system? The logic is missing. If genetics are not considered, then mistakes and faulty analysis occur.
2. Decolonising the health system will improve Māori health and longevity
The comment that “decolonising the Health Service is necessary to improve Māori health and longevity" is not supported by the Cook Island experience.
One way to estimate the impact of colonisation is to compare New Zealand Māori demographic data to a genetically similar population, namely Cook Island Māori still resident in the Cook Islands. The latter have also been subject to a degree of colonisation but have been decolonised for 56 years.
Females living in the Cook Islands have a life expectancy of 79.2 years (Ref 6), whereas Māori females living in New Zealand have a life expectancy of 78.2 years. For males, the relevant expectancies are 73.3 years and 74.2 years. These differences are not significant and do not support an argument that a 56-year period of decolonisation has had either a positive or negative effect on longevity for Cook Island Māori.
More helpful to the consideration of colonisation and its effect on longevity is that all Pacific Islanders, irrespective of their origin, have significantly increased their life expectancy by migrating to New Zealand – despite living in lower socioeconomic areas and despite having to use the allegedly “systemically racist” health system.
For example, using 2018 census data from Samoa (Ref 7), Tonga (Ref 8) and Fiji (Ref 9) the life expectancies for Pacific people living in the Pacific Islands compared to living in New Zealand are:
The average life expectancy for Pacific males living in Fiji and Tonga is 8.7 years less than Pacific males living in New Zealand, and for Pacific females it is 9.6 years less than Pacific females living in New Zealand.
These data show very significant increases in life expectancy for Samoans, Tongans and Fijians living in New Zealand. They also show that improving key social determinants of health – poverty, unemployment, low educational level, and poor housing - which presumably have been prevalent in the less economically developed Pacific nations, are the prime factors in determining better health and greater longevity, along with a health system that provides a more complete service than available in the Islands.
That 77.2% of Pacific people are choosing to use the NZ health system- higher than any other ethnicity (Ref 10) - suggests they do not perceive the system to be “systemically racist” or having an “unconscious bias” against Pacific peoples.
So, if shortened longevity for Māori is attributed to a "systemically racist" system, as claimed by the Waitangi Tribunal and Te Ora, how is the phenomenon of higher utilisation by Pacific peoples explained?
Also, what explains the significantly increased life expectancy of Maori living in the Marlborough region where Māori males have a life expectancy of 79.9 years (a 5.7-year increase) and Māori females have a life expectancy of 83.4 years (a 5.2-year increase)? (Ref 11)
Perhaps the health system is not “systemically racist“ in that region.
It does not make sense that 80,000 health workers are racist for Māori but not racist for Tongans, Fijians and Samoans, or the health workers in Marlborough are not racist but the workers in the rest of New Zealand are. The logic in the Waitangi Tribunal and the Te Ora report regarding systemic racism is not rational.
3. The primary contributing factor for Māori ill health is “systemic racism,” “white privilege,” and “unconscious bias” in the New Zealand health system
The third of the core statements - that “systemic racism”, “white privilege” and “unconscious bias” in the health system are key contributors to reduced Māori longevity, is listed as the primary cause in the Te Ora report.
What is “a systemically racist health system”? It is a system of health delivery in which services are separated, financed, and delivered on the basis of race. It existed in South Africa under apartheid.
Under apartheid, in historical tribal homelands various tribes administered their own health systems including hospitals. In the remainder of South Africa the public health system was divided into two – one system for “whites” and one system for “non-whites.”
There were separate hospitals, separate ambulances, separate services, and separate funding provided for “white” and “non-white” patients. There was vastly different government funding per head of population in the health budgets for the various races as per government policy. The standard of medical care on offer varied significantly between the “white” and “non-white” groups.
These are the characteristics of a "systemically racist" health system.
Until now, none of these basic criteria for a systemically racist system exists in the New Zealand health service.
Thus, for the Chairman of the New Zealand Medical Council, the two Associate Ministers of Health, and the CEO of the Ministry of Health, to state that we have “systemic racism” in the New Zealand health system, is just not factually correct. The New Zealand system does not compare to the internationally criticised South African health system, legislated to be completely systemically racist.
Under the Code of Disability and Consumer Rights, New Zealand has a health system legislated for equal services and access for all races, as required by the UN Declaration of Principles on Human Rights, the Declaration of Commonwealth Principles, and the New Zealand Bill of Rights. Had there been any discrimination on racial grounds, there would have been prosecutions. There have been none.
The accusation of racism in the New Zealand medical context has been levelled when cultural norms of the patient were not adhered to in primary practice or in the hospital environment. However, a lack of cultural knowledge is not racism, and given the New Zealand health workforce is so dependent on immigrant health workers (44% according to NZMC and Nursing Council data) accusations that 80,000 workers of diverse ethnicities are collectively racist are wrong and have caused significant resentment amongst medical and nursing staff.
The phrase “white privilege” implies that there are fewer obstacles in the way of non-Māori people to access healthcare. 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 as Māori in the same socioeconomic or geographical situation. In 2018 there were approximately 90,100 non-Māori unemployed compared to 40,300 Māori. That these people have “white privilege “is not correct. All these people battle and need assistance irrespective of their ethnicity.
The phrase “unconscious bias” refers to a strongly held belief that exists in memory and influences decision making. These beliefs arise from childhood conditioning and because they seem so normal, we are unaware they are affecting our decisions.
All people, from all races, including Māori, have unconscious bias – it is part of being a human being. Some people (in all races) will have an unconscious bias against members of a different race - this is the racial bias referred to in Te Ora. Some people believe that their culture is best or that their culture is not being treated fairly- this is the commonest unconscious bias that exists and is very much present in this discussion about health in New Zealand.
As an example of this, the current low vaccination rate amongst Māori, the lowest of any ethnicity, has been blamed on “systemic racism” and “government incompetence” by both Associate Ministers of Health (Ref 14)
Their unconscious belief in the complete responsibility of the government, and inherent racism in the health service, stops them from considering that the same factors causing poor vaccination rates in other communities and countries, may be contributing to vaccine hesitancy in Māori – e.g. anti vax sentiment, fear concerning genetic engineering, concern re the injection of foreign particles into the body, problems in getting off work, rumours of infertility, rumours of DNA issues, religious issues, needle phobia, tapu issues, concern re adverse long-term effects, and other misinformation/side effects etc. Why would these concerns not be affecting Māori in the same way as they are affecting a significant number of New Zealanders and millions worldwide? They are off course, and even Derek Fox has commented recently that a significant minority of Māori refuse to take the vaccination for their own reasons.
The Medical Council chair has stated that doctors have an unconscious racial bias against Māori. The bias presumably means that doctors believe Māori are somehow inferior and therefore are not treated as well as patients from non-Māori races. Where is the evidence for this? The fact that the highest utilisation by ethnicity of the health services is by Pacific peoples (Ref 10) suggests that they do not think that an unconscious bias exists for them.
We have had a Health and Disability support system for patients for over 20 years. If specific examples exist, where Māori have been treated with an inferior service due to their race, why have they not been prosecuted?
Throughout the reports, the poor Māori health outcomes documented in the Waitangi Report 2575 and the Te Ora report, are statements only of poorer health outcomes. There is no documented, factual evidence presented regarding the causes.
For example, the Te Ora Report states, without evidence, that the following are the causes of poor Māori health outcomes
- "Systemic racism," "white privilege" and "unconscious bias" in the health system
- the need for longer consultations
- the need for the doctor to get to know the patient better
- lack of Māori spiritual knowledge
- not having one doctor on an ongoing basis in Primary Health Clinics
- Māori knowledge not being incorporated into the consultation and diagnosis
- effects of colonisation
Aside from colonisation contributing to poverty, which has the greatest impact on health, the other nominated causes are not consistent with international medical opinion which states that disease prevalence and presentation is strongly related to the range of social deprivation factors which exist external to the health system, and for which the health system is not responsible.
The World Health Organisation makes the following statement about social determinants of health:
“World Health Organisation - Social Determinants of Health (SDH)
The SDH have an important influence on health inequities - the unfair and avoidable differences in health status seen within and between countries. In countries at all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health. The following list provides examples of the social determinants of health, which can influence health equity in positive and negative ways:
- Income and social protection
- Unemployment and job insecurity
- Working life conditions
- Food insecurity
- Housing, basic amenities and the environment
- Early childhood development
- Social inclusion and non-discrimination
- Structural conflict
- Access to affordable health services of decent quality.
Research shows that the social determinants can be more important than health care or lifestyle choices in influencing health. For example, numerous studies suggest that SDH account for between 30-55% of health outcomes. In addition, estimates show that the contribution of sectors outside health to population health outcomes exceeds the contribution from the health sector.
Addressing SDH appropriately is fundamental for improving health and reducing longstanding inequities in health, which requires action by all sectors and civil society.”
World Health Organisation (Ref 12)
Since 2000, most Māori health services for Māori enrolled on the Māori electoral roll in both rural and urban regions have been provided by seventy-seven Māori Health providers (Ref 13). They have been funded by the state but completely managed by iwi throughout New Zealand during this time. They were created over twenty 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. Overall, the 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. The reasons for this are debated with Māori claiming inadequate funding as the cause, and the funding agency stating failure to reach agreed health targets, poor management, and incorrect spending priorities are to blame. The Waitangi Tribunal, when starting their investigation into Māori health, refused to publish their findings into why this health service delivery system failed, stating it was “sensitive” (Waitangi Report 2575). This is irrational as the information is crucial to assisting with the success of this new Act.
4. Non–Māori are not affected by inequitable health services
The Te Ora report states that three measurements confirm Māori are
receiving an inferior health service to other New Zealanders:
1. Māori have a higher ASH figure than non- Māori
2. Māori have poorer surgical recovery than non-Māori
3. Māori have a higher death rate from a range of medical causes than non-Māori
The number of hospital admissions that could have been prevented by access to timely and competent general practice care (Ambulatory Sensitive Hospitalisation - ASH) were 2,171/100,000 for the non–Māori population, and 3,686/100,000 for the Māori population between the years of 2007 and 2018.
The Te Ora report neglects to mention the 2016 ASH rate for Pacific adults was 8,787/100,000 – a figure over twice as high as Māori, and the rate for Pacific children aged 0-4 was 12,079/100,000 (Ref 10). These figures are not seen when subsumed by the 83.5% of the population comprising Pakeha, Asian and other non-Māori ethnicity groups. There are also no ASH figures collected for the disadvantaged section of the Pakeha population.
That Māori have a longer post operative stay in hospital is indicative of a poorer surgical
outcome for the same procedure. However, this outcome is consistent with greater comorbidities in the patient at the time of surgery and, in acute medical situations, a later
presentation at hospital due to not seeing a GP early in the illness process (plus significant distance to travel to the hospital compared to the non-Māori population.) To automatically state that the longer stay is due to inferior surgical service is wrong.
That Māori have a higher death rate from a range of causes is again consistent with the
presence of co-morbidities coupled with genetics and poor primary health care as outlined in Section 1 and 3.
As the vast majority of these Māori have had their general practice health provided by one of the seventy-seven “by Māori, for Māori” primary health providers since 2000, and, as the ASH figure is a measure of a poor level of accessing and utilising general practice during this time, then the reasons that Māori do not access primary health services must be clearly identified. Without clarity around the reasons, there will be a repeat of the failure of the system of the last 20 years, where services have been provided by "Māori, for Māori", but have not significantly improved Māori health as hoped.
The absolute number of non–Māori with avoidable hospital admissions in the Te Ora report - 90,000 - is three times higher than the absolute Māori number. This is an enormous number of non-Māori patients who have not had access to timely or competent primary health care.
The proposed restructuring of the health system does not recognise these disadvantaged multi-ethnic non-Māori New Zealanders who are patients on the fringes of the non–Māori society. The figures below from Stats NZ indicate the size of this non-Māori medical underclass living in poverty in 2019.
Child Poverty figures for children living in New Zealand, Stats NZ 2020 (Ref 16)
From the above, there are twice as many children living in poverty in the non-Māori (Pakeha + Pacific group) – 145,000 children - compared to the Māori group - 61,000.
An alternative view of the same figures is a significantly greater number of Pakeha children are living in poverty than the total number of Māori and Pacific children.
In the opening submission to the Tribunal Hauoras Enquiry, the Crown counsel accepted that “there is no need for this Tribunal panel to enquire into the question of whether Māori health status is significantly worse than for non-Māori at a population level; this is well established and not disputed."
This statement is incorrect.
As shown above, as poverty is the prime determinant of health outcome, this was a mistake on behalf of Crown counsel, who also appears to have had a limited knowledge of health statistics. At a population level, we don't have the data to state that Māori health is significantly worse than that of a large portion of the New Zealand population who live in poverty, as the level of health and longevity of this cohort of disadvantaged Pakeha has not been measured. Why not? In absolute numbers, as shown above, it is bigger than both the Māori and Pacifica combined.
The new Health Act states its role is to
(a) protect, promote, and improve the health of all New Zealanders; and
(b) achieve equity by reducing health disparities among New Zealand’s population groups, for Māori; and
(c) build towards Pae Ora (healthy futures) for all New Zealanders.
To not address the needs of this exceptionally large non–Māori medical underclass, twice the size of the Māori medical underclass, and selectively increase the per capita funding for Māori, is an infringement of the UN Declaration of Human Rights, the Commonwealth Declaration of Principles, and the New Zealand Bill of Rights. Each of these pieces of legislation require equality of access to health care for equally disadvantaged groups, irrespective of race, gender, sexuality, religion, age etc., as a basic human right.
While it is right for Māori Doctors and Māori leaders to advocate for better health
for the Māori people, it is not right that they attribute all Māori ill health to a “systemically racist” system with "unconsciously biased" doctors and health service staff. These accusations have caused huge resentment amongst health workers.
If this belief continues, the problems will never be solved.
It is wrong that health statements made by various Māori leaders and the Waitangi Tribunal are taken at face value and not challenged. Māori doctors know the four statements discussed are factually incorrect but persist in stating them. They are also aware of the WHO social determinants of health (Ref 12) which they ignore in this discussion. The Waitangi Tribunal is aware of the reasons for the lack of success of the current “by Māori, for Māori system,” but refuses to release their findings as they are “sensitive” (Ref 15).
The points I make are not an argument against addressing equity issues which exist for the lower socioeconomic groups of all ethnicities in New Zealand. I fully support the argument that a significantly increased number of Māori doctors must be produced on an annual basis to help solve the Māori health problem. It is exceedingly difficult for a non-Māori doctor to assist with mental health, spiritual or psychiatric issues in traditional Māori patients who live in the traditional Māori world These patients require a doctor with an understanding of that world view. The significantly increased number of Māori medical graduates, now approaching 120 a year – 30% of the total graduates - will be the solution to this problem.
It is also undeniable that many Māori in remote rural, lower socioeconomic groups have poorer health than others living in urban New Zealand. The need for improvement for these people is unquestionable, as it is for the non-Māori who are in the same situation,
However, the argument that "systemic institutional racism" is responsible for Māori living relatively shorter lives than other New Zealanders is incorrect.
The causes for all groups within Māori and non-Māori ethnicities not accessing primary health providers in a timely manner, and therefore scoring higher on ASH figures, are multiple. I believe that the Medical Council, the Māori Medical Practitioners group, the Waitangi Tribunal, and the Ministry of Health, are afraid to properly call out the real causes of not only Māori poor health, but the poor health of a large percentage of all racial groups, Pakeha included. Pakeha and all other ethnicities present with obesity, hypertension, addictions, smoking, coronary artery disease, depression, anxiety disorders, gout, cancers, diabetes, respiratory problems, genetic disorders etc., on an ongoing basis. The fact that Pakeha males, the creators of the health system, and the sector of society accused of privilege, are in the lower half of life expectancy when compared to the other ethnicities in New Zealand (see table 1) does not fit at all with any “white privilege” or "systemic racism " theory. It does fit well with the internationally accepted medical opinion that disease prevalence and presentation is strongly related to multiple social deprivation factors outlined above, to which Pakeha and Pacifica are not immune, and that these factors ‘sit’ outside the health system and require their own research and solutions. The New Zealand experience of very significantly improved life expectancies for all Pacific peoples who now live in New Zealand confirms this.
1. Systemic racism is not the cause of Māori health issues, but without clarity around the actual causes of the problems there can be no targeted solution
2. Funding the Health System without dealing with the Social Determinants of Health will not solve the problem
3. The government can allocate any amount of funding it wishes to Māori health but must also fund other equally medically underprivileged groups with the same per capita amount. Not to do so is in breach of New Zealand and international law and the stated aim of the Pae Ora (Health Futures) Act.
Dr L. Knight
MSc (Hons) MBChB