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

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 ethnicity, ethnic 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.

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.

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. 

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.