Dr Lance O'Sullivan says he would not see most of Kaitaia's children with skin infections if he didn't go into schools to look for them.
"Vulnerable children are not getting into doctors' surgeries enough," he says in the general practice clinic that he opened last year at Kaitaia Hospital, from which he visits children in 14 local schools.
"We can sit here in a particular role, or we can take health services to where people live, work and play," he says.
"This is actually getting out of our rooms, getting off our butts and working through the schools and reaching the kids and getting them early."
Dr O'Sullivan, until recently one of only two Maori general practitioners in Northland, has taken Health Ministry funding for tackling rheumatic fever and topped it up with money from the food charity KidsCan to put five nurses and health workers into the district's schools.
His "Moko" programme (Manawa Ora, Korokoro Ora, or healthy hearts, healthy throats) reached 1000 children at six primary and intermediate schools last year and is extending to a further 1000 at another eight schools this year.
In South Auckland, the Counties Manukau District Health Board is embarking on a similar project on an even grander scale, with 150 fulltime equivalent nurses and health workers aiming to reach 23,000 children in 53 primary, intermediate and secondary schools from next term.
But it, too, depends on a charity - the Middlemore Foundation - to pay for bandages, hand sanitisers and nit combs, and possibly to extend to eight more at-risk schools.
And neither project has any guarantee of long-term survival because their base funding for rheumatic fever is only for three more years until 2016.
"The biggest problem with communities like this is actually getting people in the door," Dr O'Sullivan says.
"It's because they don't have the opportunity, they don't have the money, and they ring the doctor and they're told it's two days before you can be seen. One guy with severe abdominal pain was told he couldn't be seen for three days. I couldn't believe it. There is also how friendly is the service you are going to access, and I tell you it can be pretty awful and cold.
"I've heard of people turning up to an appointment and taking 10 minutes to limp in to the surgery and being turned away because they're 10 minutes late.
"Also, life is stressful, life is busy, for these people they live in stress, they don't know where the next dollar is coming from. It's a little bit about that too."
When a health system waits for people to come to it, many leave it too late.
On average, women in poor areas such as Kaitaia and South Auckland die six years earlier than women in the richest tenth of areas in the country.
For men, the gap is almost nine years. For Maori men it is even worse. Within each income group, Maori die earlier than non-Maori, and that is at least partly about not feeling welcome or comfortable in doctors' surgeries.
So Dr O'Sullivan believes that primary healthcare needs to go out to reach people - and for children, that means in schools.
"Kids work and play at school," he says. "What a great spot to place health services."
New Zealand has unusually high rates for a developed country of rheumatic fever, an inflammation of the heart caused by the immune system reacting against a throat infection by a bug called group A streptococcus ("strep-A"). It can cause scarring of the heart valves, and usually strikes children aged between 5 and 14.
Moko nurse Paul (Waka) Williams says the disease means "a 15-year-old could be walking around with the equivalent of a 70- to 80-year-old heart".
"They have no energy," he says. "People [with the disease] have been known to have cardiac surgery three times in their life. It certainly puts in danger any woman who wants to have children."
In the last few decades the disease has almost disappeared among Pakeha. But the rates for Maori and Pacific children are among the highest in the world and have actually kept on rising through the last 10 years.
Rates are 23 times higher in the most overcrowded fifth of homes than in the least crowded fifth.
The Maori Party persuaded the Government in 2011 to spend $12 million over four years on throat-swabbing children in high-risk areas and giving antibiotics to those with strep-A. Last year that was doubled to $24 million - $3 million in 2011-12, then $6 million a year until 2014-15 and $3 million in 2015-16.
In Northland, the district health board was already funding two local throat-swabbing programmes - in Whangaroa since 2002 and in Kaikohe since 2008.
The extra funding has paid for the Moko programme in Kaitaia from 2011 and more recently schemes in Hokianga, Whangarei and a large slice of mid-south Northland served by the Ngati Hine Health Trust.
Other programmes are operating in South Auckland, Waikato, Eastern Bay of Plenty, Rotorua, on the East Coast, in Hawkes Bay and in Porirua.
The Health Ministry says 10,635 children were swabbed and 1092 tested positive for strep-throat infection last year, and services will cover 44,300 children at 161 schools by June.
The Government has targeted cutting new cases of rheumatic fever by two-thirds, from 187 children in 2011 to 44 by 2017, as one of its "better public services" targets.
Kaitaia goes further
Lance O'Sullivan is an outspoken doctor who was not satisfied with throat-swabbing. Last year he quit his previous job with the local iwi health service, Te Hauora o Te Hiku o Te Ika, after it tried to stop him seeing patients with unpaid debts to the hauora.
He negotiated extending the Moko contract to cover skin infections as well - the only rheumatic fever programme in the country where the Health Ministry funds more than throat swabs.
"It seemed crazy that we were in there looking at throats when there was a kid covered in school sores," he says.
The food charity KidsCan has helped to fit out a disused dental clinic at Kaitaia Primary School as a base for manager Lisa McNab and two teams, each comprising a registered nurse and a kaiarahi [health worker]. A third nurse/kaiarahi team starts next month.
Dr O'Sullivan and his new Maori colleague Dr Kathryn Rollo each spend one morning a week at the clinic and Dr Rollo goes out with the teams on one afternoon.
The teams take throat swabs and hand out basic medication kits funded by KidsCan comprising plasters, sanitiser, tissues, nit combs and head lice treatments.
For more serious skin infections, they take photos with their cellphones and text them to Dr O'Sullivan, who prescribes medications by return text or brings children in to the clinic if necessary.
If a child has two strep-A bugs within three months, a team visits the child's home to swab and treat everyone else who lives there.
If the home is cold and damp, the team brings in services such as Healthy Homes Tai Tokerau, which is funded by the Northland District Health Board and charity ASB Community Trust to top up the Government's partial insulation subsidy, providing completely free insulation to families qualifying for the Community Services Card and with a relevant health condition.
Healthy Homes regional health co-ordinator Melanie Dalziel says the free insulation is available even where the families are tenants with a private landlord. About 60 per cent of the grants go to landlord-owned houses.
The Health Ministry funding pays for antibiotics or other treatment for everyone in the family with strep throats or skin infections.
For other medications, KidsCan has provided a $5000 prescription fund held by Kaitaia pharmacist Eric Shackleton. Mr Shackleton also holds other funds donated to Dr O'Sullivan for his general practice patients who can't afford their medicines.
"We've had people come up here from out of town and write a cheque for $250 saying, 'This is to help people who can't afford it'," Dr O'Sullivan says.
He and Dr Rollo use the funds with discretion. "I guess you get non-verbal cues," he says. "I can prescribe medication for a person who is gravely unwell and they will look at me as if to say, 'You know I'm not going to pick that up for two days."'
Almost a third, 378 out of 1193, cases of rheumatic fever in the decade to 2011 were in Counties-Manukau - almost twice Northland's rate per 100,000 people and a higher rate than in any other region except the East Coast.
The Government has given the district $10 million over three years out of its $24 million rheumatic fever budget, or $3.3 million a year.
District health board portfolio manager Sue Miller says the board is extending that to cover skin infections as well as throat swabs by raising extra money from its dedicated charity, the Middlemore Foundation, and by integrating its existing 35 public health nurses into a new combined team of 150 fulltime equivalents who will start working in 53 schools next term.
The public health nurses will now spend less time visiting schools in better-off areas and will be based in schools in the areas of highest rheumatic fever risk in Mangere, Otara and Manurewa.
As in Kaitaia, local general practitioners will work with each team, and the teams will visit homes of children with repeat strep throat infections to check other family members and housing conditions.
"They will be doing sore throats and skins, and the expectation in their scope of practice is that if they are in a home and identify another issue for a family, they won't do nothing," Mrs Miller says.
Middlemore Foundation chief executive Pam Tregonning says her foundation is raising money from Lions, other service clubs and corporates to fund $10 children's "hygiene packs" of plasters, sanitiser and sometimes flea bombs, a toothbrush, toothpaste and pyjamas.
"For a lot of our families, a toothbrush and toothpaste are too expensive," she says.
As in Northland, the foundation tops up the standard insulation subsidy to provide free insulation to home-owners or landlords where tenants have Community Services Cards and either children or elderly residents have respiratory or other conditions related to poor housing.
It also provides two prescription funds, one for children's glasses and one for general medicines where families can't afford the new $5 prescription charge.
"For a lot of families, even $5 is a lot of money. It's the difference between dinner on the table and no dinner," Mrs Tregonning says.
Mrs Miller says the health board is trying to find money to extend the children's programme from the initial 53 schools to another eight in high-risk parts of Papakura.
"The whole programme, if rolled out to all 61 schools, would cost $6 million a year," she says.
Outside Kaitaia, the rheumatic fever programme funds only sore throat swabs, leaving existing services to struggle with children's skin and ear infections and other problems. And the programme reaches only a few scattered pockets of need.
In Northland, Medical Officer of Health Dr Clair Mills estimates that even throat-swabbing reaches only half of Maori schoolchildren.
She says a study by Professor Diana Lennon found that similar programmes internationally reduced rheumatic fever by up to 60 per cent among the children covered.
"Given that we are not covering all the high-risk kids, it's going to be less than that. The ministry is thinking it will reduce it by 20 to 30 per cent," she says.
She says rheumatic fever is only a marker of underlying issues of poor housing, poverty and colonisation.
"One of the issues for me is where is our social housing policy, and what are we doing about rural unemployment and our youth?" she says.
"I would like to see a coalition between potentially social sector non-government organisations, iwi, health, maybe Housing NZ and maybe councils, to look at how we do actually improve our housing in New Zealand."By Simon Collins Email Simon