As the pandemic races towards an unenviable two-year milestone, the Otago Global Health Institute’s Covid-19 Masterclass Series is bringing together a network of experts to discuss key Covid-19 topics. We’ll be running a piece daily until December 5.

The impact of the current and likely future waves of Covid-19 will depend on our ability to achieve and maintain high Māori vaccination coverage, and to provide safe and effective care to whānau experiencing Covid-19, argues Professor Sue Crengle

With increasing alarm, my Hauora Māori colleagues and I watched the development of the respiratory illness that would come to be known as Covid-19.

Māori had experienced adverse outcomes in previous outbreaks of infectious diseases. The smallpox outbreak in 1913 largely affected Māori communities whose living conditions reflected the consequences of the colonial process that had swept the country in the preceding 70 years, leaving them at much greater risk of the disease than their non-Māori counterparts.  

Despite this, and in contravention of Health Department orders, smallpox vaccination was preferentially delivered to non-Māori communities. Bans on travel and movement were applied to Māori communities, even those who were hundreds of miles from the outbreak, causing further economic and social harm.

Five years later, an influenza pandemic swept the country. Māori mortality rates were about seven times higher than European rates. Te Puea Herangi responded to the outbreak by establishing shelters where those affected by illness could isolate and be cared for, and taking in children whose families had succumbed to the illness.

Current epidemiology highlights the ongoing excess burden of infectious disease experienced by Māori communities with higher rates of, for example, endemic influenza and respiratory infections. Inequities in the social determinants of health underlie much of this excess burden.

Early in this pandemic, Hauora Māori experts drew attention to the inequitable impact that Covid-19 was likely to have on Māori communities due to increased transmission and increased risk of more severe disease outcomes within Māori communities.

Employment in essential services and other occupations where opportunities to work from home are limited increases the risk of exposure to Covid-19. Within-household transmission is common; the factors driving this include poverty and social deprivation, and poor quality and overcrowded housing. 

Māori experience higher rates, at younger ages, of long-term conditions associated with more severe Covid-19 outcomes. Furthermore, the existing inequities in access to, and outcomes from, health services were likely to be exacerbated during a pandemic event.

The Government’s response to Covid-19 in early 2020 has rightly drawn praise – Aotearoa has, to date, had relatively low rates of infections and mortality while the impact of pandemic control measures on the economy was much less than many other countries. Nevertheless, the economic impacts were inequitable, with Māori women bearing the initial brunt of these measures.

The sequencing of the implementation of Covid-19 vaccination focused on risk (border and health care workers first) and age with people aged 12 to 30 years being able to access vaccinations from the beginning of September. This approach has been criticised by Hauora Māori experts and advocates as it failed to adequately account for the factors that contributed to the increased risk of transmission and severe disease in the Māori community.

The use of diagnosed long-term conditions as an eligibility criteria didn’t take into account the relative under-diagnosis of conditions such as chronic lung disease and diabetes. The recurring inequities in the delivery of the annual subsidised influenza vaccination programme (which also uses long-term conditions as access criteria) had already illustrated the limitations of this approach.

As the Māori population has a significantly younger age structure, a larger proportion of the Māori population was unable to access vaccines until late in the programme, leaving this group more vulnerable to the vaccine mis- and disinformation that has flooded social media in recent months. Public discourse criticising Māori for ‘slow uptake’ of vaccination has usually failed to take this in to account.

Further criticism of the implementation programme has focused on the relatively slow inclusion of Hauora Māori providers in the vaccination delivery programme and the timing and extent of funding for these providers. Their expertise in delivering accessible and effective Kaupapa Māori programmes has been a major driver of the increasing Māori vaccination coverage. 

Effective Māori community and provider responses have not been limited to vaccination delivery. During lockdowns and, more recently, as people self-isolate while waiting for a Covid-19 test result or after a positive test, Māori communities, NGOs, marae, hapū and Iwi have provided social support, kai/food, hygiene packs, and information and communication campaigns. Māori commentators, Hauora Māori experts and groups such as Te Rōpū Whakakaupapa Urutā have been vocal advocates for equity in the pandemic response.   

So, where do we find ourselves today? About two-thirds of the Covid-19 infections during the initial wave that led to the first lockdown in March 2020 were related to people returning from overseas. European people accounted for the majority of the cases.

In the current outbreak, to date, Māori account for about half of cases, one third of hospitalisations and about 40 percent of the deaths.

While the number of new cases reported daily appears to be reducing in the Auckland, Northland and Waikato regions, the move to the ‘traffic light’ framework will almost certainly see the spread of infections across other regions, especially those whose vaccination coverage is lower than those in Auckland. Ongoing efforts to increase Māori vaccination coverage in these regions is essential.

During the current outbreak, community-based management of Covid-19 cases has been introduced. Planning for the management of Covid-19 in the community is underway in regions and nationally. Ensuring that community-based care is safe and effective requires these management frameworks to both take account of the health and social factors that increase the likelihood that Māori will experience more severe illness and outcomes and deliver this service in ways that engage and support Māori whānau.

The recently completed review of the extremely sad, and possibly preventable, deaths of two men in community care in Auckland identified important improvements that should be incorporated in all community care frameworks.

The impact of the current and likely future waves will depend on our ability to achieve and maintain high Māori vaccination coverage, and to provide safe and effective care to whānau experiencing Covid-19.

Whether Covid-19 evolves to become endemic, burns itself out, or continues in a pandemic state remains to be seen. Regardless, we must learn from our past and current experiences to ensure that Māori inequities in Covid-19-related outcomes are eliminated. Ka mua, ka muri.   

*Professor Sue Crengle is appointed to the Māori Health Authority and a registered GP whose research has a focus on health inequities, health services research and quality of care, and youth health. She was a co-leader of Te Rōpū Whakakaupapa Urutā from March 2020 to May 2021, re-joining the Rōpū at the beginning of the current Covid-19 wave.

Professor Sue Crengle is a Māori public health expert, from the Department of Preventive and Social Medicine, at the University of Otago.

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