Photo by John Cameron on Unsplash

Racism in healthcare and COVID-19 – Expert Reaction

Two studies have documented the effects of inequity and racism in our healthcare system.

A Te Pūnaha Matatini study shows the estimated COVID-19 infection fatality rate for Māori is 50 per cent higher than for non-Māori – and could even be higher depending on the impact of other underlying illnesses.

Meanwhile, a systematic research review from the University of Otago finds self-reported racism is associated with reduced access to and quality of healthcare, as well as poorer mental and physical health.

The SMC asked experts to comment on these studies.

Professor Michael Plank, COVID-19 study author, School of Mathematics and Statistics, University of Canterbury; and Principal Investigator, Te Pūnaha Matatini, comments:

“Māori and Pacific populations are historically at greater risk of hospitalisation and fatality from pandemics. This study shows that COVID-19, if it were to become widespread in New Zealand, would be no different.

“We estimated that the risk of fatality for someone infected with COVID-19 is at least 50% higher for Māori than for New Zealand European ethnicities. Pacific people are also likely to be at higher risk of fatality. These outcomes are associated with higher rates of underlying health conditions and lower life expectancy, and stem from widespread inequities in the healthcare system, and the ongoing impacts of systemic racism and colonization. These results show the need for equitable data collection systems and measures that work with affected communities to protect at-risk groups, communities and regions from the impact of COVID-19.”

Michael is an author of the COVID-19 study.

Natalie Talamaivao, systematic review author, University of Otago, comments:

“He tino āhuatanga tautuhi hauora tēnei mea te kaikiri, koia hoki tētahi pūtake o ngā korenga e ōrite i Aotearoa, i tāwāhi anō hoki. Kei Aotearoa nei ka āta kitea te pānga kaha, pūmau anō hoki i waenga i te kite wheako i te kaikiri me ngā putanga hauora kino ake puta noa i te whānuitanga o ngā tohu hauora (hei tauira ngā tohu mō te hauora ā-hinengaro, ā-tinana, ā-whakatauranga whaiaro, mō te oranga, mō ngā whakaraerae hauora whaiaro, me ngā tohu tiaki hauora), ā, ka hāngai tēnei ki ngā taunakitanga ā-ao. Oti anō, ka hiahiatia ināianei he rangahau hei whakatau i ngā mahi me mahi, arā te huri i te rangahau hei wawaotanga, hei kōkiri kaupapahere tērā ka whakatutuki me te whakaheke i te kaikiri me ōna pānga ki te hauora.”

“Racism is an important determinant of health and a cause of inequities in Aotearoa New Zealand and internationally. In New Zealand there is a strong and consistent relationship between experience of racism and poorer health outcomes across a range of health indicators (eg, mental health, physical health, self-rated health, wellbeing, individual level health exposures and healthcare indicators) and this is in line with international evidence. What is needed now is research into, and action on, the next steps – translating research into interventions and policy initiatives that address and reduce racism and its impacts on health.”

Natalie is an author of the systematic review.

Professor Denise Wilson, Taupua Waiora Māori Research Centre, Auckland University of Technology, comments:

On the COVID-19 study:

“COVID-19 heightens the risk of a perfect storm occurring within our Māori communities. This research confirms existing Māori concerns about COVID-19 getting into our communities – Māori are 50% more likely than other ethnic groups to die of COVID-19 infection. Existing inequities in health conditions (like diabetes, heart disease, asthma, cancer, and smoking) contributes to Māori dying prematurely. Coupled with this, they face ongoing inequities in unmet healthcare needs and the racism when accessing health services. These factors together with COVID-19 increases the likelihood of widespread death among Māori.

“To ensure COVID-19 stays out of our communities, we need a targeted equity strategy developed with our iwi, community providers, Māori health experts and government. We have seen the effectiveness of whānau, hapū, iwi and communities taking the lead in the COVID-19 pandemic. Māori iwi, hapū, whānau and communities mobilised across Aotearoa to respond to whānau needs, deliver care packages, and have worked with Police to monitor movement in and out of their rohe. They know what to do to keep our whānau healthy and well. Māori communities are highly motivated to avoid the high death rates seen during Spanish Flu and the 2009 influenza pandemics.”

On the systematic review:

“It is well established that racism is a modifiable determinant of health outcomes. This research provides strong evidence that racism makes you sick and is an underlying cause of health inequities. Exposure to racism causes people to become unwell. It affects physical and mental wellbeing.

“Māori frequently report being treated differently or having difficulty receiving equitable and quality healthcare services. The sad reality is that when in the system, Māori are also more likely to experience an adverse event. This year, the Waitangi Tribunal’s WAI 2575 Report and the Health and Disability Sector Review Report highlighted the need to address racism in the health system. While knowing about racism within the healthcare system for some time, nothing has changed. The nature of people’s attitudes and decision-making that perpetuate racism for Māori and other groups of people can be changed. It would help in improving health outcomes, access to health services, and quality of care. The research highlights that exposure to the racism that people experience in Aotearoa is harmful.”

Conflict of interest statement: I have served on committees with Dr Donna Cormack and Dr Paula King (co-authors of the systematic review).

Dr Clive Aspin, Senior Lecturer, School of Health, Te Herenga Waka – Victoria University of Wellington, comments:

On the COVID-19 study:

“COVID-19 is the latest pandemic to arrive in New Zealand. Many people alive today have first hand experience of living through the AIDS epidemic as well as strong memories from our forbears of the impacts of previous epidemics, such as those caused by the Spanish Flu and polio.

“Since the onset of colonisation, Māori have suffered disproportionately from introduced illness and disease. The earliest example of this occurred when Cook moored off the coast of Te Tai Rawhiti and allowed his ship to be turned into a floating bordello, with this leading to the inevitable spread of sexually transmitted infections and other diseases throughout the region.

“Today with the impact of social determinants of health such as marginalisation, poor housing, and poor access to health care, it is no surprise that Māori and other groups such as Pasifika communities are likely to be adversely affected by COVID-19.

“This article provides a cautionary lesson that must be heeded by decision makers in particular if we are not to see the history of pandemics repeating itself.”

On the systematic review:

“The most important message of this article is contained in the final sentence: ‘Now is the time for action in identifying and implementing policy initiatives/interventions to address the irrefutable negative impact racism has on health.’

“For decades, this team of researchers and their associates have been conducting research into racism. With support from New Zealand’s health research funding agencies, they have conducted research that has documented glaring evidence of systemic, structural, and institutional racism and its harmful impact on Māori.

“This article describes the analysis of 24 quantitative studies into racism produced in the last 15 years. The fact that half of them were produced in the last three years is of great concern because it is proof that racism continues to be a major blot on our health and social landscapes, with little sign of abating. All 24 articles document people’s experiences of racism within the health sector.

“This research is vitally important in identifying one of the most insidious barriers to good health of Māori. But now is the time to act. We all need to take responsibility for identifying and implementing programmes and policies that will make a difference and eliminate racism from our health system. If we don’t do this as a matter of urgency, the disparities between Māori and non-Māori health outcomes will continue to increase.

“Government funded research teams have a major responsibility to ensure that these findings are implemented in their own research. In particular, they must identify actions from their research that will contribute to a reduction in racism and the achievement of equitable health outcomes for Māori.
These actions must be implemented at all levels of the health sector as a matter of urgency.”

No conflict of interest.

Dr Lisa Te Morenga, Senior Lecturer Māori Health & Nutrition, Te Kura Tātai Hauora—School of Health, Te Herenga Waka—Victoria University of Wellington, comments:

“This week Māori academics have been dismayed to learn that the University of Otago is considering making changes to their policy relating to targeted admissions to the medicine programme. These changes would effectively limit the number of Māori admissions proportionate to the Maori population and see fewer Māori students admitted than current numbers. This move is not proposed because we have now achieve equality in terms of the proportion of Māori and Pākehā but because some Pākehā families believe that targeted admissions are unfair.

“What is unfair however is that only 3.4% of the medical workforce are Māori. Targeted admissions are required to build the workforce so that it is better able to address the considerable and inequitable health needs of Māori. Evidence tells us that minority groups are better served by doctors that share cultural understanding, background and language.

“Two articles published today highlight why greater representation is important. A systematic review of New Zealand studies by Talamaivao and colleagues found that self-reported experience of racial discrimination was consistently associated with poorer outcomes for a wide range of health indicators relating to mental health, maternal health, physical health, health behaviours, wellbeing and healthcare. Further, the majority of studies showed that Maori were disproportionately exposed to racial discrimination and its health consequences.

“The other study by Plank and colleagues attempted to model the differential effects of ethnicity on risk of death from COVID-19. They estimate that infection fatality rates are likely to be at least 50% higher amongst Māori compared with Pākehā as a consequence of factors such increased risk of infectious, respiratory and non-communicable diseases. These risk factors are exacerbated by the experience of racism in the healthcare system. Having more Māori doctors working is one way to improve the experiences of Māori in the New Zealand healthcare system.”

No conflict of interest declared.

Dr Lynne Russell, Senior Research Fellow Māori Health, Health Services Research Centre, Victoria University of Wellington / Kairangahau Matua Hauora Māori, Te Hikuwai Rangahau Hauora, Te Herenga Waka, comments:

On the COVID-19 study:

“This paper is based on research by a team of experts whose aim was to estimate inequities in the rates of death from COVID-19 infection in Aotearoa, by ethnicity. Analysing both national and international data in the early months of the pandemic, they concluded there were likely to be significant ethnic differences in the health burden from COVID-19 in Aotearoa. Alarmingly, they estimated a 50% higher death rate for Māori than for non-Māori, and with the greater likelihood of Māori experiencing multiple underlying health conditions, this rate was expected to be even worse.

“Planning for this risk by preparing health care services and establishing measures to protect at-risk groups, such as rural Māori communities where more older Māori with higher unmet health care needs live, is important. Although numbers of infection amongst Māori were lower in the first wave of COVID-19 in Aotearoa, the second wave has seen this spike. Against a history that saw the Māori death rates during the 1918 influenza pandemic seven times higher than for Pākehā, the need for this current research was obvious.

“The authors also warned that the anticipated inequities in health burden from COVID-19 would be exacerbated by racism within the health care system. Interestingly, in the last month, Te Rōpū Whakakaupapa Urutā, the National Māori Pandemic Group, has called out racism in the government’s COVID-19 response, challenging the stereotypical and paternalist quarantine rules that have come into play now Māori and Pacific infections rates have markedly increased.

“The authors do caution that their results need to be treated as a preliminary estimate of relative inequity by ethnicity, rather than predictions of absolute infection fatality rates.”

On the systematic review:

“This paper reports on a systematic review of 24 quantitative studies of association between self-reported racial discrimination and health care indicators in Aotearoa. It confirmed that experience of racial discrimination is an important determinant of health and there is urgent need to address this in Aotearoa.

“A number of these researchers have been investigating racism as an underlying cause of ethnic health inequities for decades. Their credibility is unquestioned. That yet another paper should confirm the link between racial/ethnic discrimination in Aotearoa, and poorer health outcomes, is to some degree disturbing.

“Although there is a continued need to understand and explore this relationship, particularly for Indigenous and minoritised ethnic groups – those most affected, the time for action to address what they refer to as ‘the irrefutable negative impact racism has on health’, is now. The identification and implementation of policy initiatives and interventions to address this underlying cause of ethnic health inequities is well overdue.”

No conflict of interest.