‘We’re tired of being resilient’

This week, an Auckland high school shut its doors after students tested positive for measles.

It’s a difficult disease to contain when vaccination rates are below 95 percent in the population, and right now, our rates are at a historical low — with Pacific and Māori least protected.

As Pacific health expert Dr Suitafa Debbie Ryan explains to Teuila Fuatai, managing measles really means doing right by Pacific and Māori.

 

Measles is one of the most infectious diseases that affects people — it “seeks” out the unvaccinated.

In health circles, measles is called an indicator disease because when we see outbreaks, it’s a sign that there are holes in different parts of your system. And, as we see in research and health system reports again and again, these gaps and shortfalls are intertwined with inequities for Pacific and Māori communities.

Because measles is so infectious, public health experts set the vaccination coverage bar at 95 percent to achieve herd immunity. This means that when 95 percent of the population is vaccinated, outbreaks are unlikely to occur after a measles case is introduced.

In New Zealand, two doses of the MMR vaccine are recommended for children — the first at 12 months, and the second at 15 months. You’re also considered immune if you’ve had the disease before.

But our childhood vaccination rates have been falling since about 2016, and this was further exacerbated by Covid-19 — the focus on the pandemic meant other aspects of health like childhood immunisations were not prioritised. Right now, our childhood immunisation rates are at their lowest since we started tracking them 18 years ago.

At the end of last year, 82 percent of Pacific two-year-olds were up to date with immunisations. For Māori, it was 68 percent. The rate for Pākehā was 87 percent, and for Asian, it was 94 percent.

Part of the problem in New Zealand is that we have immunity gaps in young adults who were not immunised as children. These are the people who missed the big vaccination pushes through the early 2000s, when the health system prioritised immunising children.

The gap for Pacific (and Māori) in this group is also more significant because we know our vaccination rates were less than 50 percent when the system started to focus on vaccinating.

Furthermore, we don’t know the immunisation status of more recent Pacific migrants because we simply haven’t collected the data. We didn’t have a national vaccination register before 2005, so targeting these more recent migrant groups for vaccination is difficult.

We know there’s a measles epidemic just waiting to happen. But as we can see, despite the very low and, for some groups, declining vaccination rates, effective action is not being taken to protect our children and families.

For Pacific families, it’s particularly worrying because history shows we’re more likely than other ethnic groups to be affected by outbreaks of infectious diseases.

In the 2019 measles outbreak, of the 2185 recorded cases, most were in Auckland and from the Counties Manukau and Waitematā district health board areas. Forty-one percent were Pacific, while 26 percent were Pākehā and 24 percent were Māori.

One of the key lines from the public health leadership during Covid was they were building the plane while flying it. It gave the impression that we weren’t well prepared to respond to a viral pandemic.

And sure, in many ways, the Covid-19 pandemic was a once-in-a-lifetime event, and no country was fully prepared. But for me, actually, the pattern of the pandemic is very much what we’ve seen over and over for Pacific in New Zealand with other infectious diseases.

We saw it with meningococcal B before the vaccine was developed in the early 2000s, and in 2010 with the swine flu outbreak. We see it with rheumatic fever and the flu. And we see it with Covid and measles.

Over the years, we’ve documented how and why Pacific people are more susceptible to these diseases. We’ve evaluated outbreaks and learned how the health system can be strengthened so that Pacific people receive the same quality of care and public health services as other New Zealanders — so that we’re not constantly relying on big, crisis-orientated patch-up jobs during emergencies.

Those sorts of reactions are what I call “workarounds” where Pacific workers, community groups and providers are called in to bolster an emergency response because our communities are disproportionately affected and the system simply isn’t equipped to deal with them.

Before the Covid pandemic, our system was poorly prepared for contact tracing, for isolation, and for good communication with Pacific.

Yet we saw during the pandemic response that, despite a slow start, getting the right messages out — through Pacific media, churches, Pacific providers and community organisations — meant our communities were empowered to find their own solutions to public health challenges.

More Pacific people were recruited to work at all levels of the system. Resources flowed to our community providers who advocated strongly for testing facilities and led effective and innovative immunisation outreach and welfare support.

The Pacific response to the pandemic kept our communities safe, and it was fantastic to see.

Unfortunately, it also reinforced bad patterns in the system.

We saw the government allocate significant short-term resources in response to an unfolding crisis so those on our frontlines could meet the emergency of the day. It was the workaround in action.

It’s a pattern that doesn’t need to keep happening, because we know what we need to do before we’re in a crisis or emergency.

I worry about whether there’s any real system-learning in what I like to call “peacetime” — when we’re not responding to an emergency like Covid or under a direct attack from measles.

How do we stop rebuilding the plane while we’re flying it, and instead build equity into preparedness plans and the delivery of vaccination programmes?

When my colleague Gerard Sonder and I reviewed the health response to the 2019 measles outbreak, we saw how different parts of the system operated well for the majority. But when it came to Pacific, there were gaps and weaknesses which meant we were far more vulnerable.

From the outset, we had a low immunisation rate which meant there was no herd immunity, and transmission was difficult to interrupt. Although cases were recorded in 17 of New Zealand’s 20 district health board regions, the mobilisation of an effective national response was delayed and clear communication about the developing crisis was lacking.

We found people weren’t able to isolate, and information translated into Pacific languages, or staff able to speak those languages, wasn’t always made available to them.

And even though the epicentre of the outbreak was in South Auckland and disproportionately affected Pacific as well as Māori people, Pacific involvement at the decision-making level was limited.

We also found that contact-tracing resources had run out by the time measles had reached Pacific and Māori communities in South Auckland — and reactive, large-scale vaccination programmes likely mostly reached the worried well. Poor recording systems for ad hoc vaccination delivery added to the ongoing problem of understanding the gaps in immunity.

But what we saw, too, is how well the system pivoted to deal with Covid. The last measles case before this was about a month before Covid. And it seemed to me that when the threat was to all of us, the system was able to mobilise. With measles, the people at risk are almost all Pacific and Māori and the response was less comprehensive.

Don’t get me wrong. I believe a strong response to Covid was needed. No one had been immunised and we had no idea how severe the illness was going to be. Shutting down to stop the spread was an appropriate action. It also gave us time to build other planks of our public health defence system, like contact tracing, isolation support, and eventually high vaccine coverage.

Those in charge managed to land the plane and protect the country. And, in many ways, the Covid response was very successful for Pacific.

On the other hand, this recurring pattern of infectious diseases that affects our Pacific and Māori communities over and over again means we should never have to be building the plane while we’re flying it.

We understand that change has to occur at all levels of the system and we know what to do. We saw it in action during Covid and it worked, eventually, once communities were involved.

In order to address long-standing equity gaps we have to pay attention to the underlying aspects of the system that need longer term attention to change.

During Covid, we found an extra 45,000 Pacific people in the country who weren’t registered as part of the census. They were identified only after coming into contact with the health system. They weren’t on any population data sets before the pandemic and they weren’t enrolled in primary care.

The extra numbers make it hard to understand how well protected we are from infectious diseases. They compound the lack of certainty we already have around the groups of unimmunised adults in our communities.

It just puts more holes in our defence system against infectious diseases.

The other implication of the Pacific population undercount is that the government doesn’t have accurate information for planning and resource allocation. Of all the districts in New Zealand, the problem is most pronounced in Counties Manukau where the majority of the Pacific population live. The former Counties Manukau DHB has reported on the under-resourcing of hospital services — they estimate they’ve missed out on about $300 million in the last 10 years.

A recent primary care report also highlights the underfunding of primary care practices who serve our communities in areas like South Auckland. Furthermore my primary care colleagues say that they’re struggling to deal with the level of unmet need following three years of constant pressures responding to measles and Covid.

There’s no capacity in primary care to follow up their enrolled patients who may not be immunised and it’s not clear whose responsibility it is to find and immunise people who are not enrolled in primary care.

There is also limited appreciation of the importance of real-time monitoring of health system performance so that we can make the right changes.

For example, while more resources were put into the contact tracing system during Covid, another review I did with Gerard and other public health colleagues of the Delta outbreak in August 2020 showed contact tracing worked least well for Pacific people compared to all other ethnic groups. We also found the system didn’t record important information for Pacific such as preferred language and household size.

This is significant as Pacific people had the highest numbers of cases, contacts and hospitalisations. And these problems with data collection persist. There’s also a lack of clarity about who is responsible for leading health system change for Pacific.

One of the other things we reported on in our measles review was the link between the lack of proper isolation in Pacific families and financial costs.

People with measles are required to remain in isolation for four days after their rash develops. The infectious period for measles is about 10 days and is determined by when the rash develops.

For case contacts, quarantine requirements depend on immunity status. If you’ve had measles before, or have had both shots of the MMR vaccine, then you’re not required to stay home. If you’ve had one dose of the vaccine, you’re also not required to isolate, but you should watch for symptoms for 14 days after being exposed. You should also get a second MMR shot as soon as possible and stay away from high-risk settings like childcare centres, churches and health clinics — where you’re likely to come into contact with people who are more susceptible to measles.

If you aren’t immune to measles or don’t know what your immunity status is, your quarantine period starts seven days after you’ve been exposed to a case, and lasts for at least seven days. If you develop measles during this period, then your four-day isolation countdown begins once your rash develops.

During the 2019 outbreak, working members of families often couldn’t afford to follow these requirements. At the time, MSD had a two-week stand-down period before you were eligible for welfare support. These financial barriers to isolating just fed the spread of the disease.

With Covid, the government made sure welfare support was available from the start because everybody was at risk. Alternative isolation and quarantine through the hotels was also a big part of our system response.

It’s disappointing and unfortunate that the same priority hasn’t continued through to responding to other infectious disease outbreaks, such as measles, that require isolation or quarantine.

There’s no specific financial support for affected families, though MSD says those who need assistance, can apply for it. There’s also no isolation options even though we know that made a difference to our families in Covid.

I think one of the things Minister Aupito William Sio said very effectively during Covid was “E fofo e le alamea le alamea.” The solutions to the challenges of communities lie with communities.

And we saw how things really started to work once our communities were empowered to find our solutions.

On the other hand, I think we shouldn’t underestimate that changing the system requires expertise. That means understanding how policy is made, and making sure that we’ve got really robust data and evidence to present to decision-makers about what the health system priorities and solutions should be.

In summary, I’ll say it again even though we all know it. There’s a higher likelihood of infectious diseases spreading among Pacific people because many of our people live in South Auckland and our ability to isolate families is limited, not only because of our housing situations but also because we’re much more social and engaged with family and church activities.

Typically isolation and quarantine guidelines are designed for the majority population average nuclear family, who live in a three-bedroom house. This approach doesn’t work for people who live in large, often intergenerational families, with connected households, for whom social gatherings are the norm. Having alternative accommodation is important to stopping the spread of infectious diseases.

It seems that for every new infectious disease outbreak we have to relearn these lessons and we have to develop workarounds for systems that are designed for majority populations.

During Covid, Pacific health workers, especially nurses, were recruited at short notice to work in different parts of the system, from contact tracing to leadership roles in the Ministry of Health to staffing quarantine facilities.

Most of these health workers have now returned to their previous roles.

Our recent analysis of the Pacific health workforce shows that while there have been some improvements in the number of Pacific people gaining health qualifications, we’re still short about 5,500 people. At the rate we’re going, it will be 120 years before the Pacific health workforce reflects our communities.

And there doesn’t seem to be any urgency to address that gap now Covid has settled.

But the knowledge we have from our data, and our knowledge of our communities, should inform how we’re funding and rolling out vaccination programmes — particularly when we’ve known for some time that another measles outbreak  in the community was almost certain.

A Pacific workforce could be mobilised to increase vaccination coverage and respond to falls in vaccination more quickly. If we can reach a sustainable coverage of over 95 percent, the need for outbreak response, isolation and quarantine for measles would become redundant.

For Pacific, it really means we should be targeting the whole family to come in for their MMR vaccinations, rather than focusing on just young children, which tends to be the message going out. That way we can immunise those who need it and collect missing data on immunisation status.

It’s how you build equity into the immunisation system, which inevitably prevents a flurried emergency response at the other end when there’s widespread infection because we’ve failed to vaccinate widely enough. It’s how we avoid the workarounds and how we’ll stop building the plane while we’re flying it.

No doubt we’ll manage this threat of measles as we have the many previous outbreaks of infectious diseases. But I reflect on the response from a community health worker faced with dealing with yet another crisis, who said: “We’re tired of being resilient.”

Imagine what our families, communities and even health providers could be doing to disrupt the inevitable cycles of well-meaning action that doesn’t reduce inequities, if they had the commitment, energy and resources that have gone into these short-term programmes.

With measles, we already have enough evidence to act. I just hope we’re in time for what’s around the corner.

 

Dr Suitafa Debbie Ryan is the principal of Pacific Perspectives, an independent provider of policy, research and workforce development programmes. Debbie has extensive experience in the health sector as a general practitioner, manager, senior public servant and researcher. She was a member of the Ministerial Covid-19 Continuous Improvement Committee and also part of the Ministry of Health’s Covid-19 Pacific Response team. The team at Pacific Perspectives have led the development of key health system reports including the Tofa Saili report on Pacific health for the Health and Disability System Review and Bula Sautu: A Window on Quality 2021: Pacific health in the year of COVID-19. Her research interests have focused on equity and health system and health services responses to minority groups. The views expressed in this article are her own.

As told to Teuila Fuatai. Made possible by the Public Interest Journalism Fund.

© E-Tangata, 2023