Unfounded assumptions and ‘come from behind’ wins

Pasifika people have so far been the hardest hit in the latest Covid outbreak (making up around half of all cases). As well, nearly half of all active cases are in Counties Manukau. 

Last year, Pacific health providers (along with Māori providers) showed what they could achieve when they’re given the resources and trusted to make the calls for our communities. 

Dr Api Talemaitoga is a GP working in South Auckland and Christchurch, and chair of the Pasifika GP Network. Here, he writes about the lessons learned over the last two years, and how they should inform the response to the current Omicron outbreak.

 

Right at the start of the Covid-19 vaccine rollout last year, there seemed to be a strong narrative around vaccine hesitancy in Pasifika people. 

At the time, New Zealand was barely a month into the Group 1 rollout and there’d been little information on the vaccine for the general public, let alone targeted information for anyone who had English as a second language. 

Despite that, I was hearing comments from health officials in different parts of the sector, and certain GPs, along the lines of: “Oh, Pacific people are vaccine hesitant.”

I just thought: “What are these people talking about and where are the studies or facts that show this?”

You see, the Covid-19 vaccine was barely on the radar of our patients and families when their so-called reluctance was getting airtime in vaccination planning discussions. In fact, there hadn’t really been any attention, controversy or even excitement about vaccines — which for the majority of eligible people was about four months away at that point.   

It’s why generalisations around so-called Pacific vaccine hesitancy were so irritating. 

Even before we’d had a chance to talanoa or discuss what community education sessions could look like, Pasifika were being labelled as “likely to be difficult”. 

First, that was an unfounded assumption. 

Second, it was a fundamental misframing from mainstream health about anticipated obstacles to our vaccine rollout — and it was coming from officials at the Ministry of Health and DHBs and even some of my own GP colleagues.

And yet, by the end of the year, Pasifika were among the most vaccinated groups in the country. We hit 90 percent double doses for over-12s just after Christmas, after facing worryingly low coverage rates four months earlier.

Back in early September, when we were in the midst of the Delta outbreak, only 26 percent of eligible Pasifika had received two doses. The national rate was just under a third, while for Māori it was 19 percent. 

That turnaround in numbers wasn’t due to enlightenment around so-called vaccine hesitancy. Instead, it reflected a significant change in the actual vaccine rollout for over-12s. And that happened only when health officials realised their version of vaccine delivery simply wasn’t reaching Pasifika. 

I can’t stress enough how significant that is. Because, when it comes to health, especially among populations who sit outside of the mainstream, unfounded assumptions turn into misinformed policy. That then morphs into bad funding decisions and, ultimately, poor healthcare delivery. 

In the case of the Pacific vaccine rollout, this meant a raft of missed opportunities in the early stages and then serious catch-up while Delta was in full swing in the community. 

Remember the country’s first big vaccination event at the Vodafone Events Centre in Manukau last year?

That was at the end of July, just a few weeks before the Delta outbreak. A lot of fuss was made of the 15,000 vaccine spots they had available over three days, with Pasifika and Māori turnout being top priority. 

Those of us who worked in South Auckland had been so keen for an event — a big hit at the beginning of the general rollout to get lots of families in, dole out first doses, and, importantly, have discussions about Covid and the vaccine with members of our communities. 

The problem is that this event had been organised by Auckland’s DHBs and the ministry without our input. To get a vaccination, people would need an appointment. They’d also be sent texts and emails from the organisers inviting them to book directly.

Needless to say, it was pretty far off the Pasifika-themed, family-friendly weekend festival event we were thinking of. And, sadly, it also aggravated inequities in the vaccine rollout. Of the 15,600 people who received shots, only 1064 were Māori and 1819 were Pacific. 

Disappointingly, we’d also warned organisers of this outcome. The setup they’d put in place simply wasn’t suitable for their priority groups. Fundamentally, it was a badly thought-out health initiative. 

First, if the goal is to reach Pacific communities, you need to understand the competing priorities families have, especially at the weekend. For many households, there’s one car at home and a few different kids’ sports activities. Not to mention the interdependence between different households and the likelihood that one car, or adult, will need to get to a few different places in a day. 

It’s a variable you can’t shift, so as local health providers, we work with it. 

Appointment requirements for vaccinations do the exact opposite of that. Expecting a mum of three to turn up at 11.30am on Saturday is setting yourself (and them) up for failure. Also, the event had a shuttle system, so people with appointments had to get themselves to MIT, and then catch a bus to the Vodafone Events Centre. 

These are literal barriers to healthcare. It’s why walk-in events, where families turn up together and stay in once place, work.   

Second, have a look at what’s popular in the community when it comes to mass events. Auckland is home to Pasifika, the biggest Pacific festival in the world. We knew a themed festival with food, music and even ethnic specific villages for vaccinations would get a decent turnout and encourage positive conversations. 

This is the type of knowledge we have as local health providers. We understand that connecting with patients and families often means catering to life circumstances that don’t necessarily fall into “conventional healthcare”. 

When we talk about community healthcare, that’s exactly how we approach it. We work with church congregations, show up at community events, run group exercise classes, visit homes and families, and importantly, have staff who speak the languages of the community. 

With Covid, there’s an extra layer of resources needed for the job. It’s why the shift in vaccine coverage can be pinpointed to a $26 million fund for Pasifika providers in early September. 

The fund was championed by Aupito William Sio, the Minister for Pacific Peoples. It enabled providers to run ethnic-specific vaccine events and mobile vaccination clinics away from the DHB and ministry’s setup, as well as online sessions about Covid and the vaccine in Pacific languages. 

The high vaccine rates we achieved for Pasifika (97 percent with one dose, 95 percent double vaccinated) are what I’d call a come-from-behind win. They proved we were best placed to handle the Covid response in our communities. 

Interestingly, it’s not the first in the past two years. 

There was the AOG cluster in Māngere where communication between public health authorities and the congregation almost broke down entirely. From the outset, Pasifika providers struggled to get information about what was going on. Public health officials were reluctant to share specifics around positive cases, ethnicity, and who was involved. In the first few days, that meant unhelpful drips of information like “a church in South Auckland is a location of interest”. 

This is another critical point. The reason why Pacific health providers push for ethnic-specific information is so we can mobilise quickly in the right language. The feedback from the church congregation — and what significantly contributed to communication difficulties between them and public health — was the heavy-handedness of the official approach. 

A big part of this was around language. I can’t stress enough how ineffective it is to have public health staff cold-calling households where English isn’t a first language, and informing whoever answers that they’re a “close contact” or a “positive case”. 

We knew that after the August 2020 cluster, when public health staff made repeated calls to a household in Auckland that needed to be tested as close contacts. The calls were always disconnected before any real conversation.

Eventually, the Fono, a West Auckland health provider, was asked to help out. They knew the family, and they sent a nurse who spoke the same language to their home. From outside, she let them know what was going on and asked about the calls from public health staff. 

Their response was: Oh, I didn’t know what they were going on about so I just put the phone down. Why couldn’t they have just got you, my nurse, to do the job? You speak my language.

There was a similar problem with the AOG cluster a year later. After about a week of little progress — and mounting tension and distrust — between public health staff and congregation members, South Auckland provider South Seas was asked to take over management of the cluster.

Bear in mind, on both occasions, the country was in lockdown — and containing community cases was essential to shifting out of that. Let alone the impacts of Covid in Pacific communities. 

These aren’t good scenarios. We never want to be called to rescue failing mainstream efforts. As we’ve seen, the problem has almost always escalated, especially with a disease as fast-moving as Covid. 

It’s why the progress we’ve made through the pandemic has been equal parts frustrating and encouraging. 

Certainly, on the other side of Delta, things seem to be a lot more straightforward for Pacific health providers. Unlike the earlier beats of the response, direct funding for initiatives around booster shots and the paediatric vaccine has come a lot quicker. 

But even then, we’ve still had a few speed bumps.

Late last year, when we were discussing plans about caring for cases in the community, we were initially told by public health officials it would take three days to hand over information about a positive Omicron case. 

Again, we had to point out the potential harm in delaying contact from a trusted health provider for 72 hours. With the highly transmissible Omicron, it doesn’t take much to imagine the impact of an uninformed positive case continuing to go about their daily life for three days. 

I’m pleased to say positive cases are currently being referred to the appropriate Pacific health provider within 24 hours of a test result. 

After two years, it’s good to look at the how things have changed and why. It hasn’t been easy and when you look at case and contact numbers, it’s clear Pasifika, alongside Māori, have borne the brunt of the pandemic. 

Currently, the focus is on managing Omicron and getting our booster and child vaccine rates up. Our community vaccine campaigns for both those rollouts only began three weeks ago and the next month will be critical in increasing coverage. 

This time around, there’s also been a noticeable shift in interactions with health officials.

Funding for the vaccine rollout and community management of cases has been a lot smoother. I’m confident that if more resources are needed, we’re well-placed to argue our case. I’d like to think there’d be an acknowledgement of those come-from-behind wins. 

In saying that, there are other challenges looming. 

Undoubtedly, Covid has highlighted the value of our Pacific health workforce — those Sāmoan, Tongan, Niuean and Fijian nurses who work on the frontlines. 

Without them, and other Pacific health professionals, there is no ethnic-specific response. But after two years and a relentless vaccine rollout, alongside regular clinical work, sustainability is a concern. Looking beyond Covid, we need to think about how to develop this workforce, which has never had any dedicated funding. 

Implicit in that is an ongoing understanding from mainstream health of the role of Pacific health providers in the wider health system. 

After all, progress can’t be limited to one-off crisis initiatives. It requires long-term change — and, as we’ve seen, a strong dose of sustained enlightenment.  

 

Dr Api Talemaitoga grew up in Suva, Fiji, and is a GP in Christchurch and South Auckland. He is a graduate of the University of Otago medical school and was the Chief Advisor, Pacific Health, at the Ministry of Health from 2008 to 2013. He is also chair of the Pasifika GP Network. Api lives in Tāmaki Makaurau with his partner Al.

This is Public Interest Journalism funded through NZ On Air.

© E-Tangata, 2022