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EXPERT REACTION: Māori diabetes inequality has persisted for a quarter of a century

Embargoed until: Publicly released:
Peer-reviewed: This work was reviewed and scrutinised by relevant independent experts.

Systematic review: This type of study is a structured approach to reviewing all the evidence to answer a specific question. It can include a meta-analysis which is a statistical method of combining the data from multiple studies to get an overall result.

People: This is a study based on research using people.

An international research team has analysed the health records of more than 45,000 people with diabetes in New Zealand over approximately 25 years – showing significant health disparities experienced by people of Māori and Pasifika heritage.

Journal/conference: Lancet Global Health

Organisation/s: Western Sydney University, Zhengzhou University, Keele University

Funder: This study was funded by Counties Manukau Health and Middlemore Foundation. The Diabetes Care Support Service was funded by the New Zealand Ministry of Health through Counties Manukau Health.

Media release

From: Western Sydney University

Professor David Simmons from the School of Medicine at Western Sydney University led the research, which also involved colleagues from First Affiliated Hospital of Zhengzhou University in China, and School of Medicine at Keele University in the United Kingdom.

Working with the Diabetes Foundation Aotearoa, the researchers tracked the health of the patients with Type 2 diabetes, aged 35-84 years, who were enrolled in the Diabetes Care Support Service (DCSS) program from 1994-2018.

Professor Simmons said Type 2 diabetes affects 250,000 people in New Zealand, and this study is the first to compare health outcomes in Māori, Pasifika and European populations over this period of time.

“Health disparities between Indigenous New Zealanders, and New Zealanders of Pasifika heritage, are well known – however, until now, we did not understand the full extent of the disparities in relation to Type 2 diabetes,” said Professor Simmons.

“This study confirms that there is an engrained ethnic disparity in Type 2 diabetes outcomes – which is a major public health challenge in New Zealand.

“Despite the advancements in treatment for Type 2 diabetes, the poor health outcomes for Māori and Pasifika have endured for over a quarter of a century.”

Through an analysis of linked data from the national death registration, hospitalisation, pharmaceutical claims, and primary care databases – Māori and Pasifika patients were compared with those of European heritage on the basis of:

  • Hospital admissions;
  • Clinical indications for hospitalisation; and
  • Age and cause of death.

The results, published today in Lancet Global Health, indicate that:

  • Patients of European background live the longest; have the lowest risk of co-morbidities such as heart disease, cancer and end-stage renal disease;
  • Rates of hospitalisation for cardiovascular disease and end-stage renal disease are highest amongst Māori and Pasifika patients;
  • Māori have the highest mortality rates, and the worst outcomes from cardiovascular disease, cancer and end-stage renal disease.

Professor Simmons said the study revealed a range of social, historical and biological factors, which could be contributing factors. However, the health disparities were still evident, even after adjusting for these factors.

“Patients of European background, had the lowest Body Mass Index (BMI), the lowest blood glucose levels, and were less likely to be smokers,” he said.

“Māori and Pasifika patients were similar in terms of BMI, however the highest proportion of current smokers were Māori, and Pasifika had the highest blood glucose levels.”

Professor Simmons said the issues facing Māori and Pasifika populations of New Zealand are exacerbated by inequities in access to modern medications.

“In New Zealand, there is a real issue in relation to modern medicine access equity,” he said.

“Māori and Pasifika have the greatest need for modern effective treatments without the complications of weight gain and low blood glucose and yet they experience significant barriers to accessing health treatments as if their risk was the same.

“Most of the modern medications for Type 2 diabetes that are commonly used in the developed world are just not accessible to Māori and Pasifika in New Zealand – which allows, at least in part, this serious health disparity to continue.”

Professor Simmons said giving access to these medications now would provide an immediate response – while more intensive approaches to prevention, early recognition and management of Type 2 diabetes are also put into place.

“There is an urgent need to develop and implement internationally validated strategies that allow diabetes specialist and primary care teams to work more closely together,” he said.

“Meanwhile, wider policies are needed to address the social determinants of health and empower communities to drive the development and direction of integrated and holistic models of health care that are culturally safe, effective, and acceptable to Māori and Pasifika.”

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Expert Reaction

These comments have been collated by the Science Media Centre to provide a variety of expert perspectives on this issue. Feel free to use these quotes in your stories. Views expressed are the personal opinions of the experts named. They do not represent the views of the SMC or any other organisation unless specifically stated.

Dr Rhys Jones (Ngāti Kahungunu) is a Senior Lecturer in Māori Health at the University of Auckland.

This article highlights longstanding inequities for people with Type 2 Diabetes, with Māori experiencing the poorest outcomes. However, as a descriptive study it is of limited value; there is already a wealth of evidence pointing to pervasive ethnic health inequities in Aotearoa and this study does little to advance our understanding in this area.

In fact, its framing and analysis of health disparities between population groups is highly confused and problematic. The study’s methods refer specifically to identifying patients according to Māori, Pacific and/or European ancestry, yet elsewhere in the paper the authors refer to ethnicityethnic groups and ethnic disparities. When identifying possible explanations for their findings they discuss differences between Māori and Pasifika populations in terms of heritage, reflecting an ancestral/genetic focus. Ethnicity, on the other hand, is a social construct.

In Aotearoa, ethnic inequalities in health have been strongly linked to the inequitable distribution of the social determinants of health, which in turn is due to processes of colonisation and racism. The study’s emphasis on genetic explanations for ethnic differences is out of step with current thinking and evidence, and raises concerns about overseas-based researchers studying Māori and Pacific health without a solid grounding in these academic disciplines and without a critical understanding of the social context in Aotearoa.

Last updated: 16 Oct 2020 10:27am
Declared conflicts of interest:
None declared.
Dr Geoff Kira, Senior Lecturer, School of Health Sciences, Massey University

The authors raise the spectre of poor access to healthcare for Māori and Pasifika Peoples in New Zealand with T2DM (Type Two Diabetes Mellitus). While the T2DM data for this publication has been collected over 20 years, it should be acknowledged that Māori have experienced disparity and inequity in health, and other aspects of society, for much longer - more than a century. While there has been some absolute gain for Māori in that time, for example an increase in longevity, a substantial gap in inequities remain.

It is at this point that this reader would like it noted that the article is more than a publication about the disparities, but an example of the exercise of colonisation. The authors had good intentions in bringing notice to disparities in T2DM. However, given the lack of action from the plethora of published work highlighting the disparities over many decades, the value of this work is diminished. Surely the emphasis in the literature must now be placed on what addresses these disparities. We need more work about how to overcome the structural and societal discrimination that exacerbates the health disparities.

Furthermore, there is a question of the inclusion of a Māori or Pasifika author on the author panel for this publication. This common oversight sends a subliminal message to readers that Māori cannot manage the health of their own people. In deference to Te Tiriti o Waitangi, this work should involve Māori as equal partners. As Māori, we welcome data collection and research work, however we should be directly involved in the analysis and interpretation of results (at the very least). It imperative that non-Māori scientists, who work with data drawn from Māori, understand the implications of their outputs and that this data is not just information ‘about’ Māori, it is us.

Last updated: 16 Oct 2020 10:08am
Declared conflicts of interest:
No conflict of interest. Note: I have no professional or personal bias against the authors, I do not know them. My statement is about the excessive number of academic publications which focus solely on tracking data.
Peter Crampton, Professor of Public Health, Kōhatu - Centre for Hauora Māori, University of Otago

This is a high impact paper with some important policy implications for New Zealand’s health system. The paper reports on a 24 year longitudinal study (1994-2018) of about 45,000 patients with type 2 diabetes who were enrolled in general practices in South, East and West Auckland. The researchers measured various outcomes for these patients including deaths, hospitalisations and kidney failure. They compared Māori and Pacific patients with New Zealand European patients.

Māori patients had worse outcomes than New Zealand European patients for all the clinical indicators for the entire duration of the 24 year period. At a national level these differences equate to literally thousands of extra preventable deaths and other adverse outcomes for Māori. The results for Pacific patients were more mixed; overall Pacific patients had roughly similar death rates as New Zealand European patients but poorer outcomes in other areas.

All patients in this study were seeking care for their diabetes and were engaged in the health system, and yet Māori patients experienced consistently poorer health outcomes than New Zealand European patients. The findings of this study graphically underscore what we already know: despite having full knowledge of the health needs of Māori patients the system has persistently failed to mount adequate responses at all levels—policy, community and hospital. In many areas of health service policy and delivery it is hard to avoid the conclusion that the health needs of Māori are frequently ignored or marginalised. 

On a positive note, many organisations and groups are responding vigorously to this challenge. For example, the Medical Council of New Zealand and others are emphasising the need for cultural safety training for health professionals, the Mirror on Society policy seeks to populate the health system with Māori and Pacific health professionals, and there are ongoing discussions about the creation of Māori health commissioning agency. These and other pro-equity initiatives will hopefully help to change the trajectory of our health system. 

Last updated: 16 Oct 2020 9:39am
Declared conflicts of interest:
None declared.
Dr Ofa Dewes, Pacific Health Research Fellow, School of Nursing and Department of Molecular Medicine & Pathology, University of Auckland, and Associate Investigator, Maurice Wilkins Centre

The direct inclusion and active engagement and participation of Māori and Pacific peoples in and from their respective communities, at all levels of research, consultation, funding and policy development, is critical to addressing the health equity issues they continue to face.

We need concerted efforts (this is not a competition), people working together across bio-medical research, health promotion and education, treatment and management in primary and secondary care - the whole social, health and economic systems - to be strategically funded and positioned in the communities affected the most to provide and inform comprehensive knowledge, information-sharing, and practice with and for them.

The response to the voices and needs of Māori and Pacific peoples, in addition to scientific evidence, needs to be prioritised and actioned immediately if we are to make any impact on providing better health outcomes for them. COVID-19 has shown that NZ can do it – and we can do it again in the fight against Type 2 diabetes.

Last updated: 16 Oct 2020 7:56am
Declared conflicts of interest:
None declared.

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