“David Seymour is scrambling to find evidence to support his position, rather than having evidence determine policy,” says Dr Anthony Jordan, who resigned from the Pharmac board over ministerial comments about Te Tiriti. (Photo: Cornell Tukiri ©)

Dr Anthony Jordan (Ngāti Wai) resigned from Pharmac’s board of directors last week, in response to a letter of expectation from the associate health minister David Seymour. In the letter, Seymour dismissed an existing expectation for Pharmac to embed Te Tiriti o Waitangi in its work.

Here, Anthony tells Siena Yates about his decision to quit, and why “needs-based” healthcare isn’t possible without Te Tiriti.

I resigned from Pharmac because the things that the associate health minister David Seymour said in his letter of expectations were uninformed and frankly just wrong.

Putting Seymour’s playground style of politics aside, for him to say that focusing on ethnicity is somehow racist to everyone else ignores the reality that simply being Māori means you face barriers to healthcare. The fact is, being Māori leads to discrimination and worse health outcomes.

David Seymour’s letter started off okay. He talked about Pharmac’s organisational values, maintaining legitimacy, credibility and trust, and striving to perform better than the minimum required by the statutory obligations — all things I agreed with. We’d had an increase in funding for medicines during relatively dark fiscal times, and I felt that we were in a good place to build positive relationships with the stakeholders he mentioned.

Then I hit the paragraph entitled “Treaty of Waitangi”, and I thought: “Why did you have to ruin it?” It just flowed so casually into a diatribe that dismissed our nation’s founding document. It effectively said that the obligations of the Treaty partners to each other were a mere distraction. At that point, I knew we had a problem.

Still, I waited for David Seymour’s media stand-up in case he said something that might change my mind. I hoped that I would be reassured. Stupid me, I know. My jaw dropped when he said that the work Pharmac had been doing to embed the Treaty in its work was “performative”. I knew then that I had to step down.

The difficult thing about my decision is that I feel sad and also quite guilty about leaving my Māori and non-Maori colleagues at Pharmac unsupported, especially after having their efforts dismissed as performative.

To recognise their work, and the progress being made, I want to give an example of how Pharmac’s effort to meet our obligations under Te Tiriti isn’t merely performative.

In 2021, Pharmac prioritised Māori and Pacific patients in its funding of two new type 2 diabetes drugs, Jardiance and Jardiamet. The decision wasn’t without controversy within Pharmac, so I thank those stakeholders and colleagues whose guidance helped us to get there.

One thing that was very clear throughout that process is that we knew the need. Māori are three times more likely to be affected by diabetes than Pākehā and mortality rates for Māori with type 2 diabetes are also seven times higher than for non-Māori.

Initially, Pharmac opted to fund the new diabetes drugs based on clinical criteria alone, under special authority. However, this approach didn’t address those health inequalities for Māori and Pacific patients. A re-evaluation based on outcomes, using a lens of ethnicity, made it clear that Māori and Pacific patients, who had the greatest need, would benefit significantly, independent of further clinical criteria.

Well, did it work? Yes, it did. In a 2021-2022 review of over 50,000 patients with type 2 diabetes from Auckland and Waikato (of whom 20 percent were Māori and 20 percent Pacific), the proportion of Māori and Pacific patients with cardiovascular and renal disease who were prescribed these drugs was significantly higher than other groups (42 percent versus 30 percent). In those without cardiovascular and renal complications, the rates were even higher (55 percent versus 30 percent).

These figures are a big step towards ensuring equitable health outcomes for Māori.

Because these medicines reduce complications in diabetes, where we see stark inequities by ethnicity, both in the incidence and severity of complications, their increased use by Māori (and Pacific) patients is good news for everyone.

Fewer complications, and fewer hospitalisations from diabetes, allows us to preserve precious health resources for everyone, not just Māori.

The thing about the Treaty is that, in any arena, it provides us with really clear principles on how we approach Crown-Māori relationships (and some pretty good values all round). It talks about equality. In the case of medicines, rather than just focusing on equality of provision, why not focus on equality in outcomes?

Imagine if all doctors just gave people the same dose of the same medicine regardless of whether it achieved the desired outcome. To do that in the name of equality would be crazy, right?

Instead, every day at Pharmac, we looked at the robust evidence and strived to improve health outcomes for Māori and non-Māori, considering many factors, including ethnicity, to ensure we were closing the gap in outcomes.

David Seymour himself says Pharmac’s role is to improve health outcomes for all New Zealanders, “underpinned by robust data and evidence” and “based on actual need, without assigning their background as a proxy of need”.

Are Māori not New Zealanders too? And if we look at need, it couldn’t be more clear. If Māori are dying seven years earlier than non-Māori, last time I checked, shouldn’t we try to do something about that? By making the right targeted funding decisions, we can start to address that.

Demographics are bloody useful in determining need, after all. Being female is a risk factor for breast cancer. Age is a risk factor for cardiovascular disease. These things, like ethnicity, may not be modifiable, but it doesn’t mean you get to ignore them. It’s all part of the “robust evidence” that informs our assessment of need. If you know, for example, that outcomes are poor in a particular group, like older people with Covid-19, you can make your access criteria align with the need to try to achieve better health outcomes.

So here’s my question: If something is an independent risk factor, why would you ignore it? Why would you need to look for another, less robust, surrogate? Unless, of course, you simply hate the premise, based on your ideology.

It seems like David Seymour is scrambling to find evidence to support his position, rather than having evidence determine policy. That’s a really bizarre way of approaching things.

The other major issue with his directive is that it will push Māori even further away from the health sector. Because when someone says: “We don’t care about your Treaty, and we don’t care about you being Māori,” you start to believe that’s how the health sector sees you. Is that going to encourage you to engage with those services? That’s a bloody hard message to overcome.

Once you’ve seen the reality of considering ethnicity and the impact that can be made when we consider it, that’s not something easily unlearned. You can try to ignore the evidence, but you can’t deny its existence.

At Pharmac now, there’s a good awareness that ethnicity can be an independent indicator of need. I have faith that this will still guide their decisions, as they develop views on medicines. And a letter of expectation is just that — it’s someone saying: “Here’s what I expect of you.”

I don’t expect David Seymour to read this and change his mind. I don’t think it matters what evidence I present to him of the harm caused by such a callous “footnote”, as he called it.

What interests me more is what the agency will write in response, in its Statement of Intent, where it will outline what it plans to do in the next year. I think that’s where we’ll see how Seymour’s expectations influence the work to be done. It will be especially important to see which things are no longer mentioned.

I was lucky to be in a position to be able to follow my principles and leave Pharmac, because this wasn’t my sole source of income, nor my only job option. But this isn’t the case for many people out there at the moment, in the health sector or other parts of the public service. Many people will be subject to these directives as part of their full-time job, and they still need to pay their bills. For them, it’s not so easy to walk away. The harsh truth is that having integrity and standing up for what is right can be a costly endeavour, personally and professionally.

Because I had the ability to leave, I felt that not doing so would’ve been an endorsement of David Seymour’s letter. It would have suggested that I thought it was okay, or not a big deal, when I definitely do think it’s a big deal. I think what Seymour proposes is a huge step backwards for Pharmac and for our country.

When I resigned, I genuinely thought that it was a private thing. I would exit, and that would be the end of the story. I never thought there’d be this much interest. But now that there is, I do hope some good can come from bringing these issues to everyone else’s attention. I think that’s why I’ll keep talking to people about the issues this raises.

It was the right thing to do, for me, but it still feels really stink. I didn’t want to leave that job. I didn’t want to leave the colleagues I was working with. I didn’t want to stop doing something that I was genuinely passionate about, and which I hoped would be for the benefit of all New Zealanders.

I will miss providing support for Māori — both for those working at Pharmac and those who are affected by the healthcare decisions we made. I didn’t want to give up any of that. I’m passionate about those things.

But the thing that gives me hope is that I know there are so many Māori and non-Māori in the health system who will, no matter what, do whatever they can to deliver for our people. So many of you in the last two weeks have reached out via text, email or in person to make sure that I’m okay, and to show your support. Thank you.

I couldn’t stay in that role given what was written and said. It felt so wrong for me. So if my resignation has given anyone pause to think, the courage to say no, or to continue doing the right thing no matter what someone else says, then I think that’s my most important contribution yet.

Dr Anthony Jordan (Ngāti Wai) is a senior clinical immunologist, allergist and physician. He took a lead role in the northern Covid-19 response, is a member of Te Rōpū Whakakaupapa Urutā (the National Māori Pandemic group). Before tendering his resignation, he had served as a Pharmac board director since December 2021.

As told to Siena Yates, and made possible by the Public Interest Journalism Fund.

E-Tangata, 2024