Māori make up a third of patients starting treatment for kidney failure, yet are 14 times less likely to receive a pre-emptive transplant.
Chronic kidney disease affects hundreds of thousands among New Zealand’s population. But the impacts of the disease are felt disproportionately by Māori.
Unsurprisingly, the statistics make for grim reading. In Aotearoa, Māori experience chronic kidney disease at three times the rate of non-Māori, non-Pacific New Zealanders. In 2019, 208 patients who identified as Māori began treatment for kidney failure, representing 32% of all patients starting kidney replacement therapy – despite Māori representing just 16.5% of the total population. And yet, in the last five years, just seven Māori patients have been provided with a pre-emptive kidney transplant compared with 125 non-Māori, non-Pasifika patients.
Studies have shown that patients who have a successful kidney transplant live longer and with less restrictions on work, travel and quality of life than those who are treated with dialysis. Median survival rates on dialysis are five to six years compared to 12 to 20 years post-transplant. However, pre-emptive kidney transplants as first treatment for kidney failure occur 14 times less frequently among Māori. Research has found that Māori are less likely to be put on the transplant waitlist, and that the difference in waitlisting cannot be completely attributed to differences in underlying health conditions. Meanwhile, the rate of dialysis among Māori was five times higher than for non-Māori, non-Pasifika patients.
But far from being an inevitability, these inequitable outcomes are the result of policy choices, says non-profit organisation Kidney Health New Zealand (KHNZ). They’re calling for immediate government action in response to “woeful” Māori rates of kidney transplantation.
“We’ve long been aware that while patients identifying as Māori make up one-third of all patients starting treatment each year for kidney failure in Aotearoa New Zealand, their actual rates of receiving a transplant, especially a pre-emptive planned transplant from a living donor, are woefully low compared to non-Māori,” said acting KHNZ general manager Traci Stanbury in a statement. “The government needs to be doing more.”
Stanbury described this situation as “a breach of Te Tiriti ō Waitangi”, which is acknowledged by Aotearoa health authorities as the basis of Māori rights to equitable health outcomes.
The organisation pointed to research published last year that found that racism and prejudice is a significant barrier to equitable access for Māori patients.
“Despite not being asked specifically about racism in this study, participants reported feeling disempowered and disadvantaged in a health system not designed for indigenous people, nor with easy access to culturally specific assessments, weight management criteria and support, and resources for awareness campaigns and marae-based education,” said Stanbury.
Published in the Journal of Racial and Ethnic Health Disparities last year, the study, carried out by a collective of experienced renal physicians and nurses, interviewed 40 Māori patients and whānau at various stages in the kidney transplantation process in 2020. Researchers found that participants experienced prejudice and racism within the system in a variety of ways.
Study co-researcher and Christchurch kidney specialist professor Suetonia Palmer explained that many participants reported feeling excluded and devalued by a healthcare system that did not incorporate tikanga Māori values and practices. Participants reported feeling unworthy, unconfident and whakamā throughout the process. According to the study, these experiences resulted in increased alienation and disengagement.
“Personally mediated racism was experienced by many of our study participants as racial profiling, with explicit forms of racism reportedly directed towards patients and their family,” said Palmer in the statement. “This unfortunately led to their mistrust of the healthcare system and perceived failures in shared decision-making.”
Disparities around kidney transplants don’t exist independently. Rather they’re just one consequence of the broader tangle of systemic racism that makes up New Zealand’s health system. A report commissioned by the Ministry of Health for Renal Services called “Māori Pacific Attitudes Towards Transplantation: Professional Perspectives” suggested a range of potential barriers to Māori undergoing kidney transplant. These included a potential deficiency of cultural competency and communication by clinicians, as well as bias around “deserving patients”. There’s the impact of being excluded from transplants because of BMI (body mass index) or diabetes – of which Māori have a higher prevalence, a lack of access to GPs, leading to higher rates of presenting in later stages of illness, and a lack of donors and awareness of kidney treatment within communities.
In order to achieve equity of care in Aotearoa, KHNZ said both Health New Zealand Te Whatu Ora and the Māori Health Authority Te Aka Whai Ora must encourage more transparency and stronger tikanga Māori policies and practices, including consideration of a proposed Māori kidney transplant taskforce.
In 2021, the organisation urged the government to establish an equity taskforce to “examine the underlying systems and structures driving inequity” and to “put an end to decades of disparity for Māori and Pasifika patients needing kidney transplants”. At the time, it highlighted Australia’s National Indigenous Kidney Transplant Task Force which was established in 2019 to improve access to, and outcomes of, kidney transplantation for Aboriginal and Torres Strait Islander peoples. The call for a similar programme was backed by Midcentral DHB nephrologist Dr Curtis Walker (Whakatōhea, Ngāti Porou), who commented at the time, “I look around Aotearoa’s dialysis units and see far too many Māori and Pasifika patients who are clearly disadvantaged, who can’t access the ‘gold standard’ treatment of a transplant.
“Kidney transplants allow people to have a near-normal quality of life, free from the daily commitments of dialysis. This is an investment in quality as well as quantity of life.”
The Māori Health Authority Te Aka Whai Ora was born out of a commitment to embed Te Tiriti o Waitangi and health equity in all parts of the reformed health system, in an acknowledgment that the existing system reproduces inequity. “Te Aka Whai Ora’s mandate is to direct and guide the health system to understand and respond to the needs of whānau Māori,” said Stanbury. “There is much work to do and we hope real progress is seen soon, before more Māori patients desperate for kidney transplants miss out on life-saving care.”