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Sunday, 26 November 2017 12:30 am

Inequities in health linked to high stomach cancer rates for Maori

H Pylori feature image

A computer generated depiction of the bacterium Helicobacter Pylori CREDIT: http://www.bioquell.com/

Over 50% of people are believed to have it.

It spreads through human-to-human contact, has no visible symptoms and can stay with you your whole life.

Once it works it way into your system, it attacks the lining in your stomach and can create a condition inside which allows cancer to grow.

It’s known as Helicobacter Pylori and it’s a bacterium that is causing problems within indigenous populations around the world, including New Zealand.

So could it be one of the reasons why Maori have such high rates of stomach cancer?

And if so, is anything being done to increase survival chances for Maori?

Research H Pylori

Virginia Signal, an Otago University Student published a report last year, which looked at why Maori have higher rates of stomach cancer and lower survival than non-Maori.

Ms Signal had help from health professionals in carrying out the study, which was the first of its kind, and their findings were not pretty.

They compared notes from 800 cancer patients, both Maori and non-Maori, and 335 were from people with stomach cancer.

Of those with stomach cancer, 43% of Maori had distal cancer (cancer that occurs lower in the stomach), which was 17% more than non-Maori.

Now this is where the elusive bacterium, H Pylori comes into play.

Ms Signal says distal cancer is closely linked to H Pylori.

“It’s been shown in other studies throughout New Zealand as well.”

So why are Maori more likely to contract it?

Ms Signal says out of all the cancers, stomach cancer has one of the strongest socio economic gradients.

“The poorer you are, the more likely you are to get stomach cancer.

“H pylorus is often passed around in families, particularly those living in overcrowded conditions.

“Of course Maori in New Zealand are much more likely to live in overcrowded homes and thus they have much higher prevalence of H pylori than non-Maori.”

H pylorus is difficult to spot and Ms Signal says this is one of the reasons why awareness needs to be raised.

“There aren’t any visible symptoms however it can be screened for and removed through antibiotic treatment.”

“Stomach cancer is potentially preventable in a lot of cases,” she says.

“There might be a role for primary health care to play in terms of screening for and helping to get rid of H pylori, as well as raising awareness that Maori are much more likely to contract it.”

Research survival rate

Stomach cancer is the fourth most diagnosed cancer amongst Maori males and seventh for females.

Ms Signal says the numbers aren’t as high compared to other cancers however the disparity between Maori and non-Maori is very large.

Rates for Maori are up to five times those of non-Maori and according to the report, Maori are 27% less likely to survive their stomach cancer.

So why is this case?

Ms Signal says one of the common theories is that Maori get diagnosed later so are more likely to die.

However they found no difference in stage of disease for most of the patient notes they examined.

One of their conclusions was that there is a systematic failure within the health care system.

It’s a failure that is resulting in poor access to services and poor quality of treatment for Maori and consequently decreasing survival chances, but there are people fighting for change within the system.

Nina Scott

Finding Maori cancer patients who have had a smooth journey along the treatment pathway is a rarity for public health specialist, Dr Nina Scott.

“It’s not the ones who have had the bad journey who stick out because that’s most of them.

“There are a lot of tragic stories out there,” she says.

When I interviewed Dr Scott, she had just come out of a meeting with Hei Āhuru Mōwai, a Maori cancer leadership group.

The name of the group means a warm embracing cloak for everybody and its metaphorical meaning was to ensure that everybody in the cancer pathway received optimal care.

Dr Scott, whose iwi is Ngāti Whātua and Waikato, is a Maori representative on five other cancer groups nationwide.

She says some people still refuse to accept there is a systematic failure.

“There are still people out there who think it’s a Maori cultural problem, a cultural reluctance to present for care.

“There is no evidence to support this,” she says.

“It’s total victim blaming and we need to move away from it.

“Victim blaming gets us nowhere, it distances accountability from health provider obligations, and so changes are not made or even attempted.”

Dr Scott says one of the most concerning issues is the racism evident within the system.

“It’s very clearly documented.

“Maori are more likely to be at the receiving end of person to person racial discrimination and racism is bad for your health,” she says.

“I’ve had an oncologist say to me that Maori patients are fatalistic, i.e. they don’t mind dying.”

However Dr Scott says it’s more productive to look at the bigger picture.

“I prefer not to focus on the individual doctor-patient relationships and focus on improving our health system.”

And she is optimistic that fair and equitable cancer care for all New Zealanders, can be achieved.

“Otherwise I wouldn’t be here, I’d just give up and go hide in a cave,” she says.

Her focus has been on Maori health ever since medical school.

“I wanted to make a difference within the health care system and I could see it was all about systems.”

“Patterns of disparity between Maori and non-Maori were evident and to change them I knew I needed to work collaboratively within the system rather than throwing spears from the outside.”

According to Dr Scott, the situation is getting better for Maori and we should expect to start seeing some improvements.

“Although it never used to be the case, equity is now at the top of the agenda for most cancer leadership groups nationwide and the Ministry of Health is becoming more focused on it as a key issue.”

Dr Scott says guidelines, treatment standards and monitoring them by ethnicity will make a big difference in the quality of cancer care for Maori.

“People don’t go out to cause inequities, they don’t even realise they are happening.”

“Once you start monitoring something and start reporting back and people see that there are inequities within their district health board, within their practice then they can address them.”

She doesn’t think it will be too hard to achieve equity.

“It’s not like we need to spend millions of dollars developing new treatments to save all these lives.”

“All we need to do is do what we know works but make sure it happens for Maori as well.

“We need to make that our top priority.”

Research differential treatment

A key finding of Ms Signal’s report is that Maori are less likely to receive specialist treatment.

Only 44% of Maori were treated in a main centre, whereas 88% of non-Maori were.

Maori were also less likely to have a specialist perform their surgery, 38% compared to 79% for non-Maori.

Ms Signal says this is a concern as surgery is the main stage of treatment for stomach cancer.

So not only are Maori more likely to get stomach cancer but also less likely to receive specialist care.

These findings point towards a very large disparity in health status between Maori and non-Maori.

George Laking

Oncologist, Dr George Laking has worked within the New Zealand health system since 1993 and more directly in Maori health since 2008.

His iwi is Te Whakatōhea and he says there are a range of issues that lead into a worse health status for Maori, racism being one of them.

“It gets a bit depressing,” he says.

“There’s quite a bit of work which shows it is an issue.”

Pausing to consider his next comment, he says: “Even if you take into account where people live, how much money they have for petrol etcetera.

“There’s still less interaction, engagement, access and uptake of services for Maori.”

Dr Laking has seen first-hand the lengths that some Maori have to go through to get to their appointments.

“I always think of the people who have to borrow money to buy petrol to go to the cash machine to get money out to come and see me at the clinic.

“That’s the struggle some people have to go through,” he says.

“So what’s the remedy for that?”

Dr Laking believes people’s health status is an expression of all the elements of their social situation, not just how much money they have.

“So much of the illness we see is explained by the way our society is organised in terms of inequalities and disparities,” he says.

“It’s very relevant with Maori.”

However, like Dr Scott he says the situation is improving.

“I guess one good development is that the Ministry of Health has recognised there is a problem with access to services for many Maori people.

“It has recently established some new jobs called cancer navigators, people who form a bridge to make sure no one is lost in the system.”

He says they can play an important role in improving communication between patient and doctor.

“Otherwise what tends to happen is we make an appointment, the person doesn’t show up and we give up.”

Communication is also something that Dr Scott highlighted as extremely important for cancer patients and she refers to a study done by two Hamilton nurses as an example.

“Taking anti-hormone therapy after you have been diagnosed with breast cancer can be really important for a lot of women, but some stop taking it,” she says.

“All these nurses did was ring the women on the therapy twice and it increased their adherence by 20%.

“Two phone calls. Amazing.

“They couldn’t keep doing it though, they were taking the lists home and phoning them after hours.

“Funding needs to be made available so these types of activities can grow.”

Dr Laking also points out that trust is an issue for Maori.

“For example if people have had bad experiences in the past they might not trust the health care system so much,” he says.

Dr Laking believes Whānau Ora, a cross-government work programme jointly implemented by the Ministry of Health, Te Puni Kōkiri and the Ministry of Social Development, can also make a difference in improving the situation.

“The system is quite powerful so to get good communication and good relationships you have to build trust and that’s where navigators and Whānau Ora can make a difference,” he says.

“Somewhere within each person’s whanau there will be a point of engagement so they are not alone and challenged by their access to services.

“Engage with the whanau and hopefully someone will help them get to their appointments.”

Dr Laking says improvement in these areas could go along way however there are other issues that need remedying to ensure survival rates are higher for Maori.

“It’s not worse survival because they are bigger lumps, not worse survival because they are older people and its not worse survival because they are sicker.”

“All the explanations have been adjusted for, what does that leave,” he says.

“It definitely raises the question are Maori missing out on surgical expertise.”

He agrees with the report’s conclusion on what needs to happen next.

It states, “These findings support the development and implementation of national stomach cancer treatment standards for New Zealand. They also highlight the imperative that these standards have an equity focus and prioritise the needs of Maori.”

“I like their conclusion that the findings support the development of some national standards for cancer care,” Dr Laking says.

“Create the standards and then see what happens to the survival rate.”

“It’s reasonable to expect that it will improve.”

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is is a Whitireia journalism student
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