Building political will for rheumatic fever prevention
All About Equity: Building political will for rheumatic fever prevention in New Zealand
World Congress of Cardiology, Melbourne Convention and Exhibition Centre
E ngā mana, e ngā reo, e ngā karangaranga maha, tēnā koutou.
Thank you for inviting me to the World Heart Federation World Congress of Cardiology session to share some of our experiences from Aotearoa New Zealand.
I believe that very essence of global health equity comes from realising that something as precious as health is a citizenship right that all should be entitled to.
I know that I am already speaking to the converted – and that any one of the representatives of the over two hundred member societies gathered at this conference, would sing that same song.
Of course, it’s quite one thing for people to know the lyrics – the real challenge is about getting everyone singing in tune, let alone in harmony.
My particular focus, then, this morning is to reflect on how we are making the difference in rheumatic fever prevention in New Zealand.
I was interested to note in my invitation from the World Heart Federation, that with regard to political will to end rheumatic heart disease, New Zealand is described as a “shining star in a wasteland of neglect.”
I want to say, first and foremost, that the wasteland metaphor is as apt a description of our setting as any other jurisdiction. I have frequently said to audiences at home that no-one can be proud of the inequities that we have witnessed. We should be ashamed that we are still seeing the impact of a preventable third world disease upon different groups across New Zealand.
When I talk of health equity, I am taking a definition cited by Dr Paparangi Reid and Bridget Robson in Hauora: Standards of Health – namely, “Differences which are unnecessary and avoidable but in addition are considered unfair and unjust.”
Health inequities do not just occur naturally or randomly without any explanation. There is always a close association with social and economic policy and practices leading to what you have described as the wasteland of neglect.
The reasons that compelled us to make reducing rheumatic fever a priority in New Zealand come from an increasing rate of hospital admissions for acute rheumatic fever since 1995 with three in four hospital admissions for acute rheumatic fever being children aged 5-14 years. Rheumatic fever is now the leading cause of acquired heart disease in childhood in New Zealand.
In total, there are about 550 hospitalisations and 140 deaths for rheumatic heart disease in New Zealand a year.
I was – and continue to be – particularly concerned about the large disparity between tangata whenua and tagata Pasifika groups, and Pākehā/Palagi, which had worsened in the last two decades. Is this fair? Is this just? Was it avoidable? Let’s examine the facts.
New Zealand has a population of about 4.5 million
people, with 15% identified as Māori and 7% identified as
Pasifika. And yet, at least 90% of rheumatic fever cases
are in Māori and Pasifika children.
This profile is totally unacceptable to me. No ethnic groups or geographical communities should be disadvantaged by higher rates of rheumatic fever.
Rheumatic fever first episode hospitalisation numbers show we appear to be making some progress with Māori rates – they have remained stable in the past few years.
However, there has been a continued increase in first episode rheumatic fever numbers and rates for Pasifika peoples across all age groups. I am told that this increase is not unexpected. The heightened awareness of rheumatic fever among the public and health professionals may have resulted in more people being diagnosed with rheumatic fever who were previously missed.
So I want to focus again on the issues of fairness and social justice. There is no evidence to date which would suggest that Māori and Pasifika people have increased genetic susceptibility to rheumatic fever. We are not born to be vulnerable.
What we do know, however, is that it is highly likely that a combination of crowded housing conditions, socio-economic deprivation and the subsequent higher burden of throat infections with Group A Streptococcal bacteria and their inadequate access to primary healthcare are important factors leading to their higher rates of rheumatic fever and rheumatic heart disease.
So what to do about it?
The priority for tackling rheumatic fever emerged out of the Relationship Accord between the Māori Party and the National Party.
I pushed to get it placed high on the Government’s health agenda so we could start a campaign to stamp out this preventable, avoidable, unnecessary third world disease.
With the political will that can come from negotiations across parties, in Budget 2011, I was able to announce a $12 million programme to reduce the rates of rheumatic fever in the most vulnerable communities. And then in 2012, we established a series of Better Public Services targets which made reducing rheumatic fever a national, cross government priority.
These target areas were chosen because they are
important issues requiring action across government to
address. Indeed, when Prime Minister John Key announced the
targets, he said that achieving results would be difficult
and demanding – in some cases, “extremely difficult.”
But if they were easy targets, they wouldn’t be worth
When it came to setting to goal for eradication – or least dramatic reduction in incidence I argued rather forcefully some might say, to reduce the incidence of rheumatic fever by two-thirds to 1.4 cases per 100,000 people per year by June 2017.
There was some contrary advice that we should set goals in incremental steps. I have to admit I operate far more from the premise that there are no limits on what you can achieve except the constraints you set upon your own imagination. What you believe to be possible will always come to pass.
But I am also very aware, that the two-thirds target is a big challenge. It will take the Government, health services and communities working together in new and different ways to improve outcomes for young Māori and Pasifika people. And there’s nothing wrong with that!
While the evidence isn’t clear about exactly what should be done to reduce acute rheumatic fever rates, what is clear is that we need strong partnerships to achieve such a challenging target. The new target meant that for the first time, government agencies were required to work collectively and collaboratively with communities and relevant non-governmental organisations to reduce rheumatic fever rates.
Political will to stamp out rheumatic fever has provided a platform to develop and launch an expanded Rheumatic Fever Prevention Programme. It has also provided funding to trial a range of new initiatives, to see which are the most effective for New Zealand.
To date, the Government has invested $45 million – and just before I hopped on the plane to come here, I announced a further $20 million of central funding to address rheumatic fever, in addition to other actions through DHBs, primary care and community organisations.
Stamping out rheumatic fever demands action on many levels, including improved housing, reduced crowding, improved access to primary care, better detection and treatment and improving community awareness.
Of course, as I started off by saying, it’s one thing to have a goal – to know the lyrics off by heart – but how do we get everyone singing in tune?
The Rheumatic Fever Prevention Programme has three key
· Improving access to Group A Streptococcal throat treatment
· Reducing household crowding
· Raising rheumatic fever awareness among high-risk communities.
The project was initially delivered through a school-based throat swabbing programme in schools and communities in high-risk areas throughout the North Island.
One of our greatest assets in the campaign has been the role of dedicated Māori and Pasifika health providers in helping improve access to sore throat treatment in schools and community settings. These providers know their communities and the daily barriers faced by families. They are therefore best placed when it comes to understanding how rheumatic fever prevention initiatives affect the lived experiences of at-risk families.
There is of course, a strong link
between housing conditions, particularly crowding, and
rheumatic fever. Recent research indicates an 88%
increased likelihood of rheumatic fever in a crowded home
versus a non-crowded home. To this end, Housing New Zealand
Corporation, which manages state housing and tenancies, now
has a programme to fast-track families with children at risk
of rheumatic fever into appropriately sized state
To address the inequities amongst reach, a Pacific Engagement Strategy was launched at the end of last year to raise awareness about rheumatic fever with Pasifika people, promote healthy communal living and to increase levels of rheumatic fever health literacy. It relies on existing Pacific health providers already making health visits to homes in our large urban areas where most of the cases arise.
Rheumatic fever awareness campaigns – youth-focused and a national campaign – have been planned for autumn/winter this year, with the national campaign launched on 1 May. Both campaigns will also have a strong Māori and Pasifika focus.
So have we got it right? Are we truly addressing the inequities as they arise? Time will tell –but we must be vigilant with our scrutiny of the programme – everyone must know that sore throats matter; that the health and wellbeing of our children matter.
Finally, I want to strongly endorse the World Heart Federation’s global goal of reducing mortality from rheumatic heart disease for those aged under 25 years by 25 percent by 2025.
The strategy to make 25 by 25 by 25 a priority; to develop a roadmap that works; to learn from best practice models and strengthen and expand the global network seems to be an excellent formula for making the change we need.
Yes it’s a big vision – but let’s not be afraid of ambition. It we want to limit our strategies to those with little goals then all we can expect are little achievements.
We need to think boldly – to aim for success – and to operate in a way which will inspire confidence and engender the political will to create the transformation we need.
Finally, I want to leave the last word in my presentation to the Katoa family - a Tongan family who have experienced rheumatic fever first hand. Their experience reminds us of the importance of being vigilant, being bold and taking action in the interests of a better future for us all.