Many of the most remote parts of NZ are also the highest ranking on the deprivation index. Image: Tina Tiller
Many of the most remote parts of NZ are also the highest ranking on the deprivation index. Image: Tina Tiller

PoliticsNovember 23, 2021

‘The worry is being completely overwhelmed’: NZ regions brace for a Covid summer

Many of the most remote parts of NZ are also the highest ranking on the deprivation index. Image: Tina Tiller
Many of the most remote parts of NZ are also the highest ranking on the deprivation index. Image: Tina Tiller

The map of NZ showing the longest distances to high-level medical care looks a lot like a map of our most vulnerable communities. They’re the same places hordes of city-dwellers like to escape on holiday. Toby Manhire asks the experts about the risks facing regional health systems.

The perfect storm looks like this: waves of people arriving from Auckland over summer, seeding Covid-19 outbreaks in the remotest communities of Aotearoa, among some of the most vulnerable and least vaccinated populations, in places where health provision is scarce and hospitals a long way away. 

The risk of such a scenario playing out from December 15, when the final curtain is closed on the elimination strategy as the hard Auckland border lifts, is expressed in maps built by health geographer Jesse Whitehead (see below for interactive adaptation by Harkanwal Singh). They show the distance of travel to the nearest local or metropolitan hospital. To a remarkable extent, however, those remotest shaded areas correlate with the areas that have the most serious social and economic deprivation; and they in turn correlate with the areas that tend to have lower vaccination levels.

There’s one other correlation: many of these regions include destinations to which tens of thousands of city-dwellers travel for the quintessential New Zealand summer.

Maps by Jesse Whitehead. Scroll down for interactive version

Does all that then risk a perfect storm? “Yeah, probably,” said Dr Katharina Blattner, on her lunch break at Rawene Hospital, where she works in the far north. “The other thing you could throw into that mix is the erosion of rural health services of the last two decades,” she told The Spinoff.

The influx could tip a delicate balance, she said. “In rural and remote health services we’re used to dealing with distances and working across a really broad scope and with broad teams and very limited diagnostics … The worry is that when you throw a whole lot of people into those areas, that might push the boat over. There’s no surge capacity, and that workforce crisis is probably the worst it’s ever been.”

Fresh Covid outbreaks in Te Tai Tokerau would weigh heavily on the system, she said, not just in the challenges of providing care for those who tested positive, but in the implications for others needing care. “Covid is really important but the worry is that it’s taking our eye off the ball of the normal, everyday situation, which was already packed full of really acute, unwell people. Things like rheumatic fever. Heart failure. Infection sepsis. Pneumonia. Diabetic emergencies. I mean, that’s all still going on.” It is critical, she said, that “we don’t take our eye off the main causes of morbidity and mortality in New Zealand while this is going on”. 

A high-risk population

Blattner was one of the authors on a paper published earlier this month that surveyed the experiences of 17 doctors in 17 rural hospitals across the pandemic to date. In the NZ Medical Journal article, Blattner and her co-authors set out the stark state of play.

“Even before factoring in access to advanced respiratory care, rural New Zealand is a high-risk population with respect to the Covid-19 pandemic. New Zealand’s rural towns have on average the lowest socioeconomic status, highest proportion of Māori, oldest age structure and highest levels of dependency of any of New Zealand’s geographic categories. There is evidence of poorer health outcomes for residents of rural towns, an effect that is accentuated for Māori. Māori retain a strong historical memory of the disproportionate burden their rurally based communities bore during previous pandemics, and in 2020 the projected Covid-19 infection fatality rate for Māori was 50% higher than for non-Māori.”

They continued: “New Zealand’s rural hospitals have neither the specialist anaesthetists and intensivists nor the facilities necessary to manage ventilated patients beyond brief periods in an emergency situation prior to transfer to a base hospital.”

The pervasive mood among the 17 doctors surveyed was one of “anxiety”, Blattner told The Spinoff. “The worry is around just being completely overwhelmed.” The sentiment was not entirely bleak, however. “At the same time there is some optimism, in terms of the slow realisation across the country that there are specific things that rural and remote services face, that they are different to those in the city. There is a slow cottoning-on that they need to be heard, and their voices need to be at the table.”

The meaning of the maps

The maps’ message, said Whitehead, a research fellow at Te Rūnanga Tātari Tatauranga, the National Institute of Demographic and Economic Analysis at the University of Waikato, was clear: “There’s a lot of rural communities out there that are a long way from any hospital treatment. And those facilities don’t necessarily have the infrastructure to cope with Covid patients, especially over the summer period where a lot of health services are already really stretched every year.”

Then there’s the question of providing appropriate oversight and support for those isolating at home. “The risk is that if or when Covid gets into more remote areas in the country there will be a lot of people affected who don’t have ready access to health services. We’re already seeing, even in Auckland, people dying at home with Covid. So I’d hate to see what might happen if there are a lot of people in rural areas trying to manage a Covid-19 infection … We already know in health research that social and economic deprivation is highly correlated with broader health outcomes. So in those areas with high deprivation people aren’t going to have the resources necessarily to manage Covid infections,” he said. 

Just how distant does it get? Consider Tokomaru Bay, up the coast north of Gisborne. Whitehead estimates that it would take six and a half hours to travel to the nearest metropolitan hospital in Hamilton. “And that assumes that as soon as a person’s condition deteriorates they’re able to get in a car and drive straight away. The reality is you’ve got to decide whether you’re going to call an ambulance or a health professional. They’re going to give you some advice, and if an ambulance does come, it’s got to come from somewhere. If it’s the summer period, an ambulance or even a helicopter could be dealing with any accident or emergency. So those drive times are a best case. Realistically it’s going to be worse.”

DHBs make their own plans

Major health reforms introduced by the Labour government will see the District Health Board system scrapped, but before then each of the 20 organisations faces a big test: establishing and executing plans to deal with any localised Covid outbreaks. Across the country, regional hospitals have strategies ready to go. “As it moves through the country, there’ll be outbreaks, numbers will spike in one area but not in another, and then it’ll reduce but spike somewhere else, or it might spike in multiple places,” the health minister, Andrew Little, told the Herald last week. “That’s why it’s important each DHB and each group of DHBs on a regional basis are equipped to be geared up.”

If DHBs’ performance across the years is a guide, those plans will vary both in scope and quality. One conclusion from the survey of 17 regional hospital doctors was this: “There was a universal sense among the participants of this study that the DHBs had a poor understanding of rural hospitals’ facilities and capabilities.”

Speaking on RNZ yesterday, Jacinda Ardern indicated that areas with low vaccination would remain in a “red light” setting when the traffic light framework kicks in from December 3, which would limit opportunities for widespread outbreaks. She was confident, she added, that plans were in place to cope with any cases that did emerge. “We’ve been considering all these issues, and we know the areas that have the most significant numbers of people coming into them,” said the prime minister. 

“With the District Health Boards and the Ministry of Health we’ve already identified the areas where we have the most significant growth in population. They’ve been stress-testing those DHBs’ Covid plans because they are the areas that have larger areas of movement of people to ensure they are prepared for extra population in those areas … So, yes, I am confident that DHBs can cope, I am.” 

“I suspect it will vary quite a bit region by region,” said Robin Gauld, professor of health policy at the University of Otago. “Down here at the Southern DHB, they’re saying they’re ready. They’ve put a lot of effort into the primary care response system … so you might be confident here. But in other regions you might be less confident, especially when vaccination rates are lower.”

He added: “For most of us in the public outside Auckland, it’s a pretty intense business, a city that has a couple of hundred cases a day, opening up on December 15. I guess we have to have confidence that the monitoring of people coming out of Auckland, either tested and clear of Covid or double vaccinated, is going to work … It’s a really intense and difficult time for everyone from political leaders to local decision makers to try to get this right. It will be interesting to reflect back on this in the years to come.”

As the health reforms evolved, one of the lessons to be drawn was the inadequate use of technology, he said. New South Wales had shown, for example, how valuable it was to have remote monitoring of Covid-infected people, lessening the load on physical resources. “We just don’t do enough of it,” he said. “In the future we need to think much more intelligently and in a more focused way on using technology.”

The holiday question

Ministers have resisted any temptation to discourage people from travelling to parts of the country that may be more vulnerable over summer, but a number of community and iwi leaders have issued a simple message: stay away.

Tina Ngata, a Ngāti Porou scholar and advocate, laid out the questions for anyone contemplating a break on the East Coast. Were you to inadvertently bring Covid into the community, she wrote, “are you expecting all of the volunteer community hours going into supporting our own community to isolate at home, to then wrap around you? Who then looks after our whanāu here? Are you expecting us to volunteer to look after you when you walked away from a fully resourced health service wherever you normally live? Who is going to transport you to hospital and to which hospital? The one with only two ICU beds? Our whānau will be more likely to decline fast because of the diabetes, rheumatic fever, heart disease and poor housing. You’ve just spread it in our community, but you get the ICU bed?”

She added: “Every year, our population swells to three or more times its normal size, from tourists. That terrifies me when I consider how hard it is for us to plan to just look after our own whānau, and how hard we are working to stop them from getting infected too … I hope you care. I hope you care enough to wait just one more summer.”

Blattner urged anyone planning a holiday to examine Whitehead’s distance maps. “Think it through, and look at some of the other options around the country to go on holiday which may not be in the deep red index zone,” she said. “Especially the remote Māori communities; think about not going to those places this year.”

Whitehead put it this way: “Covid will end eventually. I think the best decision is to stay close to where you live, because you never know whether you could be infected and pass it on to vulnerable communities. There are going to be other Christmases.”

Keep going!
John Edwards begins as UK information commissioner in the new year. Image: Tina Tiller
John Edwards begins as UK information commissioner in the new year. Image: Tina Tiller

PoliticsNovember 22, 2021

John Edwards is off on a ‘late-life OE’ as UK privacy watchdog, and he’s not done with Facebook yet

John Edwards begins as UK information commissioner in the new year. Image: Tina Tiller
John Edwards begins as UK information commissioner in the new year. Image: Tina Tiller

New Zealand’s privacy commissioner is swapping that job for a similar role in the UK, but on a bigger scale and a much bigger stage. He tells Toby Manhire about the new gig, what he achieved in New Zealand, and the attacks on Facebook that spread around the world.

John Edwards deleted the tweets but he didn’t disown them. On the evening of Sunday, April 7, 2019, the New Zealand privacy commissioner watched a US network television interview with Mark Zuckerburg, in which the Facebook CEO and chairman broke a long silence on the Christchurch mosque massacre of three weeks earlier. The terrorist had livestreamed the mass murder on Facebook, but Zuckerberg was disinclined to make changes to the service. Edwards opened Twitter. “Facebook cannot be trusted,” he typed. “They are morally bankrupt pathological liars who enable genocide (Myanmar), facilitate foreign undermining of democratic institutions.”

The social media giant had allowed, he wrote, “the live streaming of suicides, rapes, and murders, continue to host and publish the mosque attack video, allow advertisers to target ‘Jew haters’ and other hateful market segments, and refuse to accept any responsibility for any content or harm. They #DontGiveAZuck.”

He deleted the tweets the next day, “because of the volume of toxic and misinformed traffic they promoted”, but the comments had already made headlines the world over. They were still making headlines more than two years later, when it emerged that Edwards was set to be appointed by Boris Johnson’s government as UK information commissioner. The Sunday Times broke the news in July with the words: “Facebook-hating New Zealander John Edwards in line to be Britain’s privacy tsar”.

John Edwards’ tweets from April 7 and April 8 2019

Edwards did get the job. As part of the appointments process he was required to appear before the Digital, Culture, Media and Sport Committee for a good old British grilling. He joined the meeting via video link late into the night from his Lambton Quay office, and managed to make reference along the way, to the visible delight of the MPs present, to everything from Voltaire and Mark Twain to Fleetwood Mac. 

At one point he was asked: “What do you think in terms of Facebook and the fact that it is no longer morally bankrupt? What has it done?” After a short pause, Edwards replied: “I did not say that it was no longer morally bankrupt. I simply used a rhetorical device of hyperbole to express a very deep frustration about the silence in the face of a national tragedy the likes of which this country has never seen. I stand by that.”

He added: “The use of that hyperbole drew that matter to the attention of the world in a quite compelling way. It also helped bring that company and others to the table to set some modest boundaries around posting of extremist content through the Christchurch Call that was co-hosted between prime minister Jacinda Ardern and the French president, Emmanuel Macron. That now has, I think, made a real difference in the culture of some of those sites, at least pegging back the fetishised primacy of freedom of expression over all other values.”

In an interview with The Spinoff last week, again from his office but this time in daylight and absent a necktie, Edwards said of the Facebook tweets he had no intention to “become a cause célèbre”. But: “I don’t regret it in the least. What that achieved was a kind of cut-through that a more reserved, system-respecting, considered response [could not]. It was a time of very raw emotion, and we saw these people completely missing in action.” It had hit a nerve, summing up a wider sense “that these corporations and platforms are completely divorced from the impact of the harms that they can cause in the world”. Such companies had routinely seemed to shrug off official censure and financial penalty, but “the chorus of criticism of which those series of tweets were a part – I think it does have an impact. Whether it’s appropriate for someone in an office like mine to be making them is another question.”

John Edwards appearing before the Digital, Culture, Media and Sport Select Committee and, bottom right, in conversation with The Spinoff

If British media reports are to be believed, however, it is precisely Edwards’ willingness to go hard at the digital giants that appealed to a British government that is one of many currently moving towards a harder line with transnational tech companies. And it wasn’t the first time Edwards had stood up publicly to Zuckerberg. When his investigators were stonewalled in seeking information on data held by a complainant in 2018, he issued a statutory demand to Facebook. That was rejected by the company, which essentially refused to accept it was subject to New Zealand privacy laws. 

Another person in the role might have upbraided Facebook, issued a thundering press release, even. Edwards did both of those and went one step further. As he explained in a Spinoff article in 2018, he logged on to Facebook and deleted his account. “Yeah,” he said last week, with a bashful shrug. “It’s a little bit performative, perhaps. There is an element of that that is required in some of these roles. But behind that was just a very quotidian exercise of our little southern hemisphere jurisdiction.”

Quotidian, maybe, but it encapsulated something bigger. “I thought it was important for people in New Zealand to know that if they were dealing with a company that collects and holds personal information of about 1.2 million New Zealanders, that sells advertising to businesses up and down the country, that eats the media’s lunch, that gives you a recommendation of a cafe in Whanganui because one of your friends has been – for them to say, ‘we are not subject to New Zealand laws,’ would be contrary to the expectations of most Kiwis.” 

That exercise ended in a victory for Edwards when the government agreed to make it clear that such companies were included in the requirements of the Privacy Act when it was overhauled last year.

Edwards leaves New Zealand halfway through his second five-year term as privacy commissioner. After a couple of decades working as a public lawyer and with organisations including the Office of the Ombudsman and the Ministry of Health, he was appointed to the role in 2014 by then justice minister Judith Collins. (“An outstanding example of her judgement at its best,” is all I can draw Edwards to say about that.) 

His work has been in the defence of privacy, but he takes issue with that being “framed as a false dichotomy”, as if there were two forces locking horns: “Do you want efficient government or do you want privacy? Do you want security or do you want privacy? Do you want a good pandemic response or do you want privacy?” In Edwards’ view, such opposites are bogus. “We should be saying, ‘I reject that, I want both,’” he said. “I want to be secure and also to have my personal information respected. I want to be safe when I walk down the street but I want expectations of privacy met. I want to contribute to the management of the pandemic and I will give up freedoms to do so on the condition that my privacy is respected as we do so. Those pressures to frame the need to give up rights in ways that simplify, I think, need to be resisted constantly.”

The achievements of which Edwards is most proud across those seven-and-a-half years are “probably not the ones that race around the world after an idle tweet”, he said. “They’re very often the ones that aren’t noticed at all.” The daily work of interacting with ministers, commenting on cabinet papers and submitting on legislation are where the important work happens. “We see a dumb idea, and if we’re able to get in and say, ‘look, this is uncalled for and it’s a solution that doesn’t fit the problem, it’s disproportionate, it’s going to hurt people’ – If we can do that without any fanfare and without the tweets and without claiming any credit, then that’s something we’ve achieved. We’ve done a lot of that. The stuff that we do crow about is the tip of the iceberg of our influence.”

The push to make intelligence and security agencies subject to more of the Privacy Act as part of the Intelligence and Security Act 2017 was a big win, in the face of years of pushback. “I just kept hammering and said there is no reason why those agencies should not be subject to the information and privacy principles in the same way as everybody else is.” The timing made this matter especially: he took up the role as the Snowden revelations emerged, with disquiet growing around New Zealand’s participation in Five Eyes. He points also to the successful campaign against “excessive and disproportionate” Ministry of Social Development requirements for NGOs to provide client information as a condition of funding. “I went to see the minister and said, you know, we want a woman who has endured years of abuse to summon the courage to take her children to go to Rape Crisis or Women’s Refuge and seek help, and when she has mustered the strength to do that, we don’t think that the first thing is that she should see, when she walks across that threshold, a form saying ‘I need your name, your date of birth, your children’s names and dates of birth, and this information will be given to the Ministry of Social Development.’”

With applications for the New Zealand role closing at the end of the week, what advice might he have for his successor? Edwards stared for a few seconds away from his screen. “Choose your battles,” he said. “An office like mine has a limited amount of influence. You build that up by helping people achieve their objectives in ways that do respect privacy. You build that up by calling out really good practice, and saying, ‘Hey, I really like the way you did that, making positive submissions to select committees or cabinet committees.’ So being seen not as that guy who always gets in the way. When you then see something that you think, ‘actually this is going to really seriously affect human individuals, and I want you to sit up and notice,’ when you take that step, you can make sure they do step up and take notice.”

For Edwards, the new job means “a kind of late-life OE, one that doesn’t involve sleeping on friends’ couches and pulling pints in Shepherd’s Bush”, he told me. In the more rarefied company of the select committee at Westminster, he put it like this: “I am very much looking forward to living and working in the UK. I have not had that pleasure before. Actually, that is a lie; I had one day on a building site and a Scotsman dropped a brick on my head, and that was it.”

The information commissioner role in the UK is no facsimile of the New Zealand job. It is, of course, a lot bigger, with a staff of more than 800, most of whom are based at the HQ in Wilmslow, a town just south of Manchester that these days is home to the opulent mansions of some of Europe’s wealthiest footballers. As well as a focus on privacy, the Information Commissioner’s Office deals with freedom of information complaints, a task in New Zealand that resides with the Ombudsman (“I’m looking forward to that – it’s a really important part of a functioning democracy”) and considerably toothier powers of sanction.

He will arrive to a stacked in-tray, including engagement with British plans post-Brexit to forge its own data protection and privacy regulations as distinct from Europe, a potential revamp of the Information Commissioner’s Office itself, and an online safety bill currently working its way through the legislative process. There is also the prospect of a much more active and vociferous cohort of think-tanks and lobby groups, including the Open Rights Group, which recently took out advertisements declaring “the next ICO commissioner is dead on arrival” – an intervention prompted by a job advertisement that called for a skillset including “commercial and business acumen” and an appreciation of the “wider benefits of data sharing”. It was here that Edwards reached for Mark Twain. “Rumours of my death have been greatly exaggerated,” he said. “I respect the passion represented by that. What it said to me was that there is a significant group of people who hold these values dearly, and I was heartened by that … But I also reject the premise that bringing a commercial or commercially savvy lens to this crucial role diminishes the importance of the human rights and consumer safety side of the role.”

Swerving back to Facebook and the rest of the tech giants, are they getting the message? Have we reached a tipping point? “They can see the temperature rising like anybody else,” he said. And yet, “we’ve been saying that for a few years and it hasn’t got to a point where things have snapped … But without seeing changes in behaviour that societies are demanding of those platforms – and it’s not just Facebook – there will be increased pressure to regulate and to regulate in different ways in different jurisdictions. And that makes their business model very complicated. So they are motivated to try to reach a regulatory system which is going to suit the greatest number of jurisdictions.”

In Britain, the example of that action is the online safety bill, designed to substantially curb social media companies’ attempts to wash their hands of responsibility for what takes place on their platforms. Along with the proliferation of misinformation, one of the challenges regulators face is “the insidious algorithmic nudging”, said Edwards, which sees users of platforms such as TikTok radicalised towards extreme content.

It’s here that two of Edwards’ preoccupations – inflated concepts of free speech and false dichotomies – dovetail. It all comes back to “what I call the ‘fetishisation of the first amendment’”, said Edwards. “That exported US cultural value is an obfuscation which dumbs down the debate of ‘people should be able to say what they want’ and ‘good ideas beat out bad ideas’. It drives us into this binary, when we need more sophisticated solutions. It’s open to those platforms to de-emphasise or de-amplify, which is not the same as shutting down speech.”

Edwards begins his new job early in the new year. The complications of Covid mean he’ll travel alone at first, with family likely to join him later. His appointment does still have one last hurdle to clear, however: the Queen needs to sign it off. Could it be that she’s just doing a last check, scrolling his Twitter feed in search of any archived insubordination? “No, I think she’s on light duties,” said Edwards. “ She’s been driving around in her Range Rover. Maybe she’s put the letters patent in the glovebox.”