Imagine this: Oliver and Tamati both suffer from kidney disease. Oliver is Pākehā and Tamati is Māori. Being Pākehā means Oliver is more likely to live longer with the disease than Tamati, more likely to get a new kidney, get on a wait list, and receive the best treatment. This scenario is playing out across the health system every day in a range of conditions. Now, as Carmen Parahi reports, there is growing evidence systemic inequalities represent 'white privilege'.

In the public health system not everyone gets everything, but some people get more than others. Why?

​It's a question driving researchers such as Otago University senior lecturer Tania Huria from the Māori Indigenous Health Institute.

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Based on her new research, including her joint inequity study on dialysis practices in 2018, Huria says as bad as kidney disease is for everyone, the current diagnosis and treatment pathway is favouring non-Māori.

"Our findings add to the growing body of evidence that renal health services in New Zealand advantage non-Māori patients and sustain health inequities," the study found.

Huria refers to it as privilege. She is careful how she phrases the differences between non-Māori and Māori. She prefers to let the numbers tell the story of inequality.

Her research shows, generally, non-Māori are more likely to be put on the kidney wait list before they need dialysis than Māori, and mortality rates for Pākehā on the wait list is lower.

"Māori get the disease, then they go on dialysis, then the waitlist," says Huria.

Supplied University of Otago senior lecturer Tania Huria says as bad as kidney disease is for everyone, the current diagnosis and treatment pathway is favouring non-Māori.

Kidney disease is insidious, silent. One in 11 Kiwis have it and people generally don't know until it has progressed significantly and the kidneys are damaged.

The prognosis is grim for those who have dialysis: Half will be dead in five to eight years. Most from a cardiac event related to the disease. But even grimmer for Māori having dialysis: half will be dead in three to five years.

The best treatment, the gold standard according to Huria, is a kidney transplant. Although 45 per cent of kidney disease patients are Māori, together with Pacific people they receive only one in four transplants.

It's a similar story with dialysis. Best practice is to get a fistula, or a surgical passage for dialysis, in your arm. It has great access, not much risk of infection and it normally goes pretty well for the patient, says Huria.

The least preferred clinical option is to get a non-tunnelled catheter, a short-term intravenous line. It's a quick procedure that is low cost and can be performed in most hospitals, but globally it is viewed as the worst possible way to gain access to the blood vessels. It also increases the risk of infection, and death.

MURRAY WILSON/STUFF Research by Tania Huria indicates treatment is favouring non-Māori patients compared to Māori with kidney disease. Everyone should receive best practice, says Huria.

Huria's research team found NZ European were less likely to get that "quick, dirty, less preferred" treatment than Māori.

The Waitangi Tribunal red flagged the ongoing disparities in Māori health last year. It determined a likely cause of disparities was racism, both systemic and personal, and stereotyping in the health system.

If Māori were treated the same as non-Māori in health, the tribunal found, there should be no difference in health outcomes or interventions.

People often blame lifestyle choices and stigmatise type 2 diabetes for kidney failure, particularly for Māori.

There is a fallacy Māori do not want to donate or receive a kidney and other body parts for cultural reasons, Huria says. Clinicians should still offer the same options to Māori as non-Māori.

Huria says people don't want to believe a Māori patient is being treated differently to non-Māori. But there is privilege in kidney failure care and it favours non-Māori, whether it's conscious or otherwise.

"Generally, clinicians wake up in the morning (and) they want to do good. They don't go, 'I'm going to treat that Māori differently,'" says Huria.

"All we can say is there is implicit bias, it does have a presence in the health system and we need to understand as clinicians how our bias influences our decision-making."

Dr Curtis Walker, head of the Medical Council and a renal and general physician, says the council expects doctors to be culturally safe in their practice.

"What that means is, yes, recognising the system and personal biases which affect how healthcare is delivered."

He says institutional and systemic bias exists within society; everyone has personal biases. There is decades of overwhelming evidence it contributes to health inequities across the board for Māori, and one of the biggest areas of privilege was getting a kidney transplant.

MURRAY WILSON/STUFF Dr Curtis Walker is the head of the Medical Council and a renal and general physician. He says the Medical Council expects doctors to be culturally safe in their practice.

Take the scoring system that manages the allocation of the scarce number of donor kidneys. If people don't meet enough of the criteria - for example, an estimate that they will live for at least five years with their transplant - they won't get on the waitlist.

Walker says Māori, on average, find it more difficult to get on the donor waiting lists. When it was launched in 2012, it had "good intentions" but Walker believes there is now an issue of equity that may need to be considered.

He says it's uncomfortable to talk about racism because no one wants to think they have biases or are racist.

"Sometimes people don't necessarily mean to but need to be supported to practice in a better way. It doesn't mean people are deliberately racist. That's the most polite and non-confronting way you could possibly put it, it's unconscious.

"We haven't dealt with the practitioners that might be overtly racist. Let's leave it at the wider and more important problem which is the unconscious bias people have."

Supplied Dr Donna Cormack says the health system is designed around Pākēhā culture.

Dr Donna Cormack is an Otago University researcher and senior lecturer at Auckland University. She's spent years studying racism in health here and overseas.

She is a lot more critical and upfront about racism in the health system and amongst practitioners. Cormack says the term unconscious bias means the same as racism but is used by people so they don't offend others.

The health system is designed around Pākehā culture, she says. It's a heavily biomedical system still based on a western british model imposed after colonisation.

The privilege starts in the whole way health is conceptualised and whose ways of thinking about health gets embedded into the health sector. From what types of services, policies and interventions are funded, and who will benefit.

"For Pākehā people a lot of their interactions with the health system they can just be themselves," says Cormack. "The system is designed to deliver to them in English, to the sorts of values that come along with western ways of thinking about health."

She says not having to experience racism in the health system is a real privilege for Pākehā. She calls it being health protected.

MURRAY WILSON/STUFF Dr Walker says it's uncomfortable to talk about racism because no one wants to think they have biases or are racist.

Is it fair to call it white privilege?

"I can call it white privilege," she says.

"It's important to name where the privilege rests. I don't think of white as necessarily about the colour of the individual. It's about what our society values which is the systems, institutions and language that has come as part of colonisation from Europe. So it's whiteness as a conceptual category.

"People are literally dying. It's why I can't be bothered being polite about it. If it's life and death we should be angry and frustrated.

"I don't mind if a Pākehā person cries if I say that."

MURRAY WILSON/STUFF Dr Cormack is unapologetic about using the term white privilege to describe inequities in the health system.

When Cormack lectures about white privilege it's confronting for her students, she says. She has been criticised publicly and people have demanded her research funding be stopped. I'm not really interested in their comfort, Cormack says.

"Yes, it will make some people uncomfortable to talk about it.

"I don't think asking people nicely not to be a racist works either. This idea about being civil and polite to not call it white privilege or talk about unconscious bias or some synonym that might be less offensive to the people that are privileged, I'm not sure that changes things."

Non-Māori are more likely to have good experiences in the health system in their encounters with doctors, says Cormack.

Evidence also shows health providers have racist assumptions, stereotypes and beliefs about Māori patients across a range of conditions, she says. It has to affect the quality of the healthcare interaction as well as health outcomes for Māori.

For example, Māori get prescribed different medications. For antidepressants, Māori are more likely to get second generation medications which are older, tend not to be seen as effective and have more side effects than new medications.

MURRAY WILSON/STUFF Dr Cormack believes it's time for the government to respond to racism and declare it a public health crisis.

Poverty was another factor.

"Fundamentally you can't get away from the fact what a privilege it is for Pākehā people and their children to not live with poverty," says Cormack. "The reality is it's Māori and Pasifika kids living in poverty, overwhelmingly."

In a private v public health system people can move through the system faster, or differently, if they have money.

"They can buy medications or treatments not available through the public system. More likely to live in better conditions, less likely to have comorbidities."

But even if individual Māori have high incomes or aspects of privilege it doesn't make them immune to racist assumptions, says Cormack.

The whole system is designed to work for Pākehā and against Māori. As uncomfortable as it makes people feel, if we're not prepared to call out racism in the health system it will never change, she says.

Cormack believes it's time for the Government to respond to racism and declare it a public health crisis.

MURRAY WILSON/STUFF "What I see as a doctor is bloody hard. I see too many Māori patients," says Dr Walker, head of the Medical Council.

The Ministry of Health has been monitoring racism in New Zealand health surveys since 2002, acknowledging inequity and the presence of systemic racism. The thing that's still lacking is actually being prepared to act on it, says Cormack.

"We're not running anti-racism campaigns, making all healthcare providers and systems be anti-racist. It makes me really grumpy."

Walker isn't convinced racism is a public health crisis.

"But what I will say is that it's absolutely essential we eliminate its effects which are insidious and pervasive," he says. "We've got to deal with it."

As a Māori doctor he says the inequality is hard to deal with. He believes there are solutions and is pinning his hopes on the Government fixing the health system and his peers improving their response to Māori.

He hasn't had stand up confrontations but has corrected his colleagues if they're being culturally inappropriate around him or in a Māori setting.

Every Māori doctor in the system acutely feels an additional responsibility to do right by our people, says Walker. "We also know we can't do it alone and it's not just our responsibility. It's our country's responsibility to address Māori health inequality."

Although health inequities are complex, researchers believe there is a simple fix.

What the health system and practitioners give to Oliver the exact same needs to be given to Tamati.