Lynne
Chepulis, University
of Waikato and Sara
Mustafa, University
of Waikato
For the tens of thousands
of New Zealanders who live with type
2 diabetes, managing the chronic condition can start to
feel like keeping score.
A patient is given a list
of numbers by their doctor. Blood sugar, blood pressure
and cholesterol levels are tracked closely, with targets
designed to reduce the risk of complications
such as heart attacks, kidney failure, blindness and early
death.
In theory, those targets apply equally to
everyone. In practice, they are far harder to reach for some
New Zealanders than others.
Using health records
from more than 57,000 adults with type 2 diabetes, our newly
published study found Māori and Pacific people are much
less likely than New Zealand Europeans to meet key clinical
targets, even when they are seeing a doctor regularly.
The same pattern holds for people living in more
deprived neighbourhoods and for many rural
patients.
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Consider HbA1c
(glycated haemoglobin) tests. These measure average
blood sugar levels over the past three months. A
lower result is better. But fewer than half of all
people in the study hit the
recommended targets for HbA1c.
Among Māori,
just 43% met the targets. Among Pacific people, the rate was
lower still, at 36%. By contrast, around one in two Asian
and New Zealand European patients were at target. We also
found the proportion of people not meeting targets also
rises dramatically relative to social
deprivation.
These disparities can come with dire
consequences. Over time, high
blood sugar damages blood vessels and nerves, driving up
the risk of amputations.
Māori and Pacific people
face
these complications earlier and more often than other
New Zealanders, often due to being diagnosed
much earlier in life. The same pattern shows up for
blood pressure and cholesterol, key predictors of strokes
and heart attacks.
Clear targets, unequal
outcomes
At first glance, they can look like the
result of individual choices. A common refrain is that
people are simply not trying hard enough. But that
explanation doesn’t hold up. It assumes a level playing
field, which
does not exist.
Most health targets are set as
if everyone has easy access to care: a regular doctor,
reliable transport and enough income to support healthier
choices. But managing diabetes demands more than
willpower. It involves regular appointments, blood
tests, adjusting medications and building long-term
relationships with clinicians.
That may be easy to
write into a guideline, but it is much harder if a patient
lives far away, can’t get time off work or is juggling
transport, childcare and tight budgets.
For patients
in rural areas, a routine appointment can mean taking
half a day off work and spending hours on the road, along
with the cost of fuel. Specialist services are often even
further away. With ongoing workforce shortages, continuity
of care can be difficult to maintain.
Many patients
end up seeing a different doctor or nurse each visit, which
makes it hard to build any kind of relationship with the
person managing their care. For Māori and Pacific patients,
this lack of continuity can compound care that already feels
rushed or culturally unsafe.
When people do not
feel heard, it becomes harder to stay engaged. Missed
appointments are often labelled as “disengagement”, when
they are more accurately a reasonable response to a system
that does not fit people’s lives.
Newer diabetes
medicines that protect the heart and kidneys are now
available, but access is not always straightforward.
Although these drugs are funded in New Zealand, tight
eligibility rules and follow-up requirements mean many
people who qualify never
receive them.
Others stop taking them because
of side effects, cost, or uncertainty about how the
medicines are meant to help.
Cost matters, too.
Even in a publicly funded system, people still face
co-payments for GP visits, prescriptions
and transport. For families already stretched by housing and
food costs, diabetes care must compete with everything else.
Accordingly, people living in more deprived areas
face
greater challenges keeping glucose at optimal levels,
regardless of motivation.
What the targets are
really telling us
Over time, these small frictions
accumulate. Blood sugar creeps up, blood pressure stays
high, and targets are missed. The system records a
“failure”, but that failure is not evenly
distributed.
Clinical targets developed under ideal
conditions are not neutral when applied universally. They
remain useful, but only if there is honesty about what they
capture. In practice, they often reflect how well the health
system is working.
More equitable diabetes care
would look different: seeing patients closer
to home, longer
appointments and support that includes whānau as well
as individuals. It would mean removing cost barriers,
ensuring continuity and investing in rural
and kaupapa
Māori services alongside urban hospitals.
Read
this way, diabetes targets become indicators of system
performance. Right now, they show where care is accessible
and effective – and where inequity persists. Ignoring
these signals risks embedding inequity for another
generation.
Lynne
Chepulis, Associate Professor, Health Sciences, University
of Waikato and Sara
Mustafa, Research Fellow in Health Science, University
of Waikato
This article is
republished from The
Conversation under a Creative Commons license. Read the
original
article.
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