It’s time for New Zealand to face up to the hard truths of how our health system is leaving people behind, writes paediatrician Jin Russell.
In an almost apocryphal account, my mother often tells the story of how once in the 1970s, after great rains, parts of Christchurch flooded. Their home, although mercifully elevated above the level of the waters, was completely surrounded by the floods. She was stranded at home, unable to get to Christchurch Hospital for the start of her work shift as a medical registrar on call that day. She phoned the hospital’s medical superintendent, who – confronted with the logistical nightmare of being a junior doctor short – quite incredibly dispatched an army truck to collect my mother from home. The army truck, so the story goes, could only reach the end of their street, leaving my mother stranded still. The neighbour’s teenage daughter, hearing of her plight, took out a canoe, and paddled my mother safely to the truck. She arrived for work completely dry. I’ve thought of this story many times over the last year, perhaps because of its parable-like quality. He waka eke noa.
Fast forward to 2010, and now it is me, rather than my mother, working as a registrar at Middlemore Hospital. One evening, in the paediatric emergency department, a young Tongan girl is brought to hospital, breathless. She had a sore throat a little while back, then some soreness in her body here and there. Today, she can’t get enough air in. I press my stethoscope to her chest, and instead of the crisp, reassuring “lub-dub” of the heart, I hear a whooshing sound – the sound of blood rushing backwards through a leaking heart valve. As she sits forwards, I can see the faint outline of the bed sheets pressed into the skin of her lower back. She is slowly swelling from excess fluid, one of the signs of rheumatic heart failure. I order an ECG, a chest x-ray and tell her I will return to place a drip. She will need to stay in hospital.
As I return to my desk to write my notes, it feels as if my heart, like hers, is heavy. In textbooks, rheumatic fever is described as a disease predominantly seen in the developing world. In fact, my mother once told me she could recognise it well because it was not uncommon to see patients in hospital with the illness half a century ago in Malaysia.
My parents left Malaysia in the 1970s as fresh-faced young doctors and migrated to Christchurch. There is an old photograph of my parents sitting in the Boeing that brought them to Aotearoa – a sepia-toned memory of their waka, as it were. Their faces are lit with excitement. They had heard angelic descriptions of this place, of its unimaginable beauty, and the promise of a better future for their children.
Sitting in the ED that night at Middlemore Hospital, I realised that the heavenly bits of this angelic country, for which my parents had uprooted themselves, were not equally distributed. Some communities had been left far, far behind. While the biological culprit that causes rheumatic fever is a bead necklace-like bacteria, the underlying social drivers of the disease are poverty and overcrowded housing.
“I can’t breathe,” the girl told me. “It feels like someone is sitting on my chest.”
The year 2020 will be engraved in my memory as the moment people said “I can’t breathe”. All around the world, ordinary people – in bed at home, in rest home recliners, on stretchers in bright emergency departments, and propped up in hospital beds watching nurses in masks fiddling with beeping machines – ordinary people said, “help me, I can’t breathe”. They came to hospital – for what else can a person do? In April, a major NHS hospital in the UK almost ran out of oxygen for patients on ventilators because so many people with Covid-19 needed help to breathe. Just ordinary people, unable to breathe.
Every now and then, I remember George Floyd, the Black man who was murdered under the knee of a white police officer. In protest, thousands of people took to the streets. They lay down on the asphalt repeating his last words, over and over, as a war-cry, or as a prayer. “I can’t breathe,” they cried.
Contrary to maxims designed to make us feel that we were all in this together, as the pandemic grew, it became increasingly clear that the virus did, in fact, discriminate. The largest outbreaks in the world were seen in prisons, homeless shelters and meat-packing plants. The virus spread further and faster through more deprived neighbourhoods. People who worked in low-income jobs were more likely to be classified as essential workers and were less able to shield.
The same sad social drivers of poorer health – overcrowded homes, lower-paid work, and structural racism – were driving the pandemic, intensifying the spread in disadvantaged neighbourhoods. Communities that had been left behind by health systems carried higher burdens of illnesses such as diabetes, heart disease and chronic lung disease. This left them more susceptible to the virus if they caught it. Hospital data analysed by the Covid Racial Data Tracker shows that Black people in the US are dying from Covid-19 at 1.7 times the rate of white people.
The tragedy was that it was all so predictable, given what is already known about inequities in health. Inequities in health are defined as systematic, preventable differences in the health of subgroups in a population according to differing levels of advantage or disadvantage. Inequities are, by very definition, unjust.
What the pandemic has shown is that where inequities in health already exist in human populations, pandemics will intensify these injustices. Instead of inequities in illness, disability and death playing out over decades, we are seeing them unfold over weeks and months.
In 2020, separated from the rest of the world by vast oceans, Aotearoa reinstated quarantine, the oldest infection control procedure in history. Quarantine is not only an effective response to infectious diseases; it is also psychologically convenient. There is a sort of “quarantine of the mind” that humans employ to protect themselves from feeling the full weight of the suffering of others. Out of sight, out of mind, as they say.
We can isolate thoughts of unimaginably large numbers of people overseas suffering from the pandemic and struggling to breathe, and seal them away. Examining these troubling realities in the full light of day threatens to overwhelm our delicate psychologies.
Where privilege exists, our minds are quick to employ similar strategies closer to home. We protect ourselves from the pain of fully sympathising with people who testify to racism in our healthcare systems. We avoid considering data showing that these inequities in experiences and health outcomes are manifold. But we should not quarantine these hard truths away. Widespread public support may give our government the courage to implement truly transformative health policies.
When reading the Simpson Report of the Health and Disability System this week, I was cut to the heart to read the Māori Expert Advisory Group’s aspiration for health equity. The desire was that “Whānau are living healthy and thriving lives, as Māori and as valued citizens of New Zealand. Māori enjoy equity of access, quality of care and outcomes. This is the norm for New Zealand.”
He waka eke noa. The vision is for everyone to be in the same boat. This is the heart song of equity.
I often think about my mother’s incredible passage to Christchurch Hospital that day the street flooded, how they pulled out all the stops, including a canoe, to get her to work. I ask myself, what would it look like for our health system to pull out all the stops so that our patients receive the care they need?
What an incredible health system it would be if we could crush inequities, the way that we have crushed this virus. I want to work in a health system like that, where everyone is truly in the same waka. I’m ready, 2021.
Dr Jin Russell (@DrJinRussell) is a developmental paediatrician in Auckland, and a PhD student in life-course epidemiology at the University of Auckland. She is a former member of the NZ Policy and Advocacy Committee and College Council of The Royal Australasian College of Physicians.
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