“Māori and Pacific people are not going to be pushing others further down the list. That’s just not how the tool is designed,” says surgeon Maxine Ronald. (Photo: John Stone) 

Māori health professionals have been bombarded this week by racist reactions to a new tool for prioritising patients on surgery waiting lists. The tool was developed by a group of doctors at Auckland Hospital which was tasked with reducing wait times. It includes ethnicity as one of five factors for making decisions.

In this conversation with Connie Buchanan, Māori surgeon Maxine Ronald talks about why the ethnicity factor is necessary and fair — but the discussion around it is not.

We know that ethnicity, by itself, is an independent risk factor for poor health outcomes.

My area of specialty is breast cancer. When we look at non-Māori women with breast cancer by decile, we see that wealthier women tend to do better. Women who are less well-off do worse.

But with Māori woman with breast cancer, all socio-economic groups do the same. Wealth is not protective for Māori. Ethnicity is the independent risk factor.

The things that contribute to that being true are access, treatment biases, racism, and those kinds of issues. There is a huge amount of research and data which explain that in detail. It’s why using ethnicity as one part of a prioritisation tool for surgery waiting lists is necessary and is justified.

The wealth gap we see among non-Māori groups is also why the same tool will account for a patient’s socio-economic status. And the gap we see in outcomes for rural people is also why the tool accounts for geographic location too.

The key thing about the tool is that it’s designed to ensure everyone gets seen within their correct timeframes. Māori and Pacific people are not going to be pushing others further down the list. That’s just not how the tool is designed. Rather, its purpose is to prevent slippage of Māori and Pacific within their allocated surgical timeframes.

It gives us the transparency that’s needed to actively address inequities when we see them happening in real time. It allows us to be explicit about why a patient might not be seen in their appropriate timeframe. So, while Māori or Pacific might score “higher” than non-Maori, the intention is for everyone to be offered treatment within the appropriate clinical timeframes, instead of Māori and Pacific being the ones that disproportionately fall out of their timeframe.

What people don’t understand is that we’ve always prioritised for ethnicity. The system is designed to privilege Pākehā, as it was designed for and by them. It works for Pākehā and it’s why they live longer, do better, have better outcomes in all categories.

So we need to be really deliberate about focusing on the groups that we know do badly. This tool is a small part of doing that.

If the research told us that our health system wasn’t very good at treating 50- to 60-year-olds then we would do something about that. This is just the same.

People are quite comfortable with the rhetoric of inequity, and with the handwringing about inequity, and everyone likes to agree that there’s a serious issue. But when it comes to actually doing something about it, people become very uncomfortable.

Which is what we’ve seen happen this week.

But this is what addressing inequity looks like. And the tool is not the blunt instrument it’s been made out to be. The clinical assessment of a patient remains the most important component of the prioritisation process. If you have a cancer, or something that’s life-threatening, your operation will be done within a certain urgent timeframe. If you’ve got something that is non-life threatening and benign, like a hernia or knee-joint replacement, those things will have a longer wait time. Non-Māori with cancer are not going to be pushed to the back of the list so that a Māori person can have something benign operated on.

So instead of fearmongering, let’s look at what we stand to gain.

One of the beautiful things that I’ve seen in my work is that when you implement equity structures into health systems then Māori do just as well as non-Māori. Pākehā don’t start doing badly — everyone starts doing well.

In the breast screening programme, there are really tight structures and requirements. All patients have to be seen in a certain time. Doctors have to get all investigations done in a certain time. Women have to be given their results within a certain time. This means that all groups receive the support and resources they require to have equitable outcomes.

When you compare life expectancy from breast cancer and you look at the woman who came through the breast screening programme, you see Māori and non-Māori doing just as well as each other. They have the same life expectancy and that’s because there’s equity in the breast screening programme.

Whereas if a woman has already developed a breast lump, then it’s different. The same structures don’t exist. She has to go to her GP, and the GP has to refer her to a hospital and she has to see a specialist. It’s not as tight a system. There are many more gaps for inequity to come through. The result is a massive difference in survival rates between Māori and non-Māori.

So we know we can make a difference by introducing deliberate equity initiatives — part of which addresses the differential outcomes of different ethnic groups.

Inequity is not something which is in our whakapapa as Māori — it’s what happens to us when we interact with a system which is not designed for us. For example, genetics related to ethnicity have a really, really small impact on cancer outcomes. Māori do tend to get more aggressive breast cancers, and we tend to get more stomach cancers because of a particular gene, but, overall, genetics do not contribute significantly to our poor health outcomes.

We need equity structures in all of our health systems so that everybody is getting the same level and the same quality of treatment.

Then there’s also the economic burden of Māori health inequities which costs us around $863 million a year. So, there’s a financial as well as a moral imperative to address equity.

To be honest, it feels like we’re wasting our time having to explain all these things over and over to people who aren’t willing to listen or learn. Because when media stories come out that are framed in the way this one has been, with no context, and with none of the research whakapapa that sits behind the action, then people react viscerally, exposing their implicit and, sometimes, explicit biases. That includes the politicians.

Christopher Luxon, for example, is wrong. The things he’s saying are factually wrong. Why can’t he have a look at the data, talk to us, read the research, and get his head around it? But, like a lot of people, instead of thinking deeply about it, he just chooses to go with a gut response that the tool doesn’t “feel” right. That’s being quite careless with important things. Reactions like that are dangerous and harmful.

If people learned about the importance of personal biases, which we all have, took the time to recognise and critique them as well as educate themselves about the issues, we could have much more constructive conversations.

It’s amazing how quickly the damage gets done. My worry is that people will now push back against the tool, that the many layers of people who are involved in organising waiting lists will misunderstand it because they’ve been encouraged to misunderstand it, and so they may undermine its use and how it is implemented, and then it will fail. And our other equity initiatives may fail because of the same kind of thing. That’s a real risk.

We could easily have had a different discussion based on the facts if this had been reported in a different way at the outset. And perhaps Te Whatu Ora could have anticipated this reaction and front-footed the conversation in a much more proactive way, so that, as Māori doctors, we’re not left scrambling to justify and explain it.

It’s so frustrating and it’s tiring. There’s an actual physical tiredness of having to deal with it, especially when it’s been landed on us as a surprise, as a headline out of the blue, which creates the conditions for racist reactions and interpretations.

Any tool like this is not going to be perfect. It’s being rolled out slowly and it’s going to be continuously evaluated as it’s put into use. Here in Whangārei, it’s being used in just two specialties now. It’s also only ever going to be one part of the solution. It doesn’t address the issues Māori and Pacific have in getting to see a specialist in the first place, and even getting on to the waiting list. There’s a whole other area of mahi that needs to happen for our people to receive their surgery in the appropriate timeframe.

There’s so much to do, and as Māori and Pacific doctors and surgeons, we shouldn’t have to keep stopping to explain why it needs doing.

Inequity isn’t a Māori problem. We didn’t create it. It’s not our house that needs to be rebuilt. We just want to get on with ensuring our people get the care they need and deserve.

Dr Maxine Ronald is Te Kapotai ki Ngā Puhi, Ngāti Wai, Ngāti Hine and Ngāti Rangi, and a general surgeon working in Northland. Her sub-speciality interest is breast cancer. Dr Ronald is the first Indigenous councillor at the Royal Australasian College of Surgeons (RACS), a member of the Aotearoa New Zealand National Committee Surgery and past chair of RACS Indigenous Health Committee. She is a clinical advisor to the Māori Health Authority, member of the Planned Care Task Force, member of the Steering Committee for Medical Workforce, the National Māori Pandemic Group, and Hei Āhuru Mowai (Māori Cancer Leadership Group.) She was recently appointed to Te Pae Whakatere — Breast Screen Aotearoa Review Committee. She is an advocate for Māori health equity and increasing the Indigenous surgical workforce in Aotearoa New Zealand and Australia.

As told to Connie Buchanan and made possible through NZ On Air and the Public Interest Journalism Fund.

© E-Tangata, 2023