Originally published on The Spinoff
The map of NZ showing the longest distances to high-level medical care looks a lot like a map of our most vulnerable communities. They're the same places hordes of city-dwellers like to escape on holiday. Toby Manhire asks the experts about the risks facing regional health systems.
The perfect storm looks like this: waves of people arriving from Auckland over summer, seeding Covid-19 outbreaks in the remotest communities of Aotearoa, among some of the most vulnerable and least vaccinated populations, in places where health provision is scarce and hospitals a long way away.
The risk of such a scenario playing out from December 15, when the final curtain is closed on the elimination strategy as the hard Auckland border lifts, is expressed in maps built by health geographer Jesse Whitehead. They show the distance of travel to the nearest local or metropolitan hospital. To a remarkable extent, however, those remotest shaded areas correlate with the areas that have the most serious social and economic deprivation; and they in turn correlate with the areas that tend to have lower vaccination levels.
There's one other correlation: many of these regions include destinations to which tens of thousands of city-dwellers travel for the quintessential New Zealand summer.
Does all that then risk a perfect storm? "Yeah, probably," said Dr Katharina Blattner, on her lunch break at Rawene Hospital, where she works in the Far North. "The other thing you could throw into that mix is the erosion of rural health services of the last two decades."
The influx could tip a delicate balance, she said. "In rural and remote health services we're used to dealing with distances and working across a really broad scope and with broad teams and very limited diagnostics … The worry is that when you throw a whole lot of people into those areas, that might push the boat over. There's no surge capacity, and that workforce crisis is probably the worst it's ever been."
Fresh Covid outbreaks in Te Tai Tokerau would weigh heavily on the system, she said, not just in the challenges of providing care for those who tested positive, but in the implications for others needing care. "Covid is really important but the worry is that it's taking our eye off the ball of the normal, everyday situation, which was already packed full of really acute, unwell people. Things like rheumatic fever. Heart failure. Infection sepsis. Pneumonia. Diabetic emergencies. I mean, that's all still going on." It is critical, she said, that "we don't take our eye off the main causes of morbidity and mortality in New Zealand while this is going on".
A high-risk population
Blattner was one of the authors on a paper published earlier this month that surveyed the experiences of 17 doctors in 17 rural hospitals across the pandemic to date. In the NZ Medical Journal article, Blattner and her co-authors set out the stark state of play.
"Even before factoring in access to advanced respiratory care, rural New Zealand is a high-risk population with respect to the Covid-19 pandemic. New Zealand's rural towns have on average the lowest socioeconomic status, highest proportion of Māori, oldest age structure and highest levels of dependency of any of New Zealand's geographic categories. There is evidence of poorer health outcomes for residents of rural towns, an effect that is accentuated for Māori. Māori retain a strong historical memory of the disproportionate burden their rurally based communities bore during previous pandemics, and in 2020 the projected Covid-19 infection fatality rate for Māori was 50% higher than for non-Māori."
They continued: "New Zealand's rural hospitals have neither the specialist anaesthetists and intensivists nor the facilities necessary to manage ventilated patients beyond brief periods in an emergency situation prior to transfer to a base hospital."
The pervasive mood among the 17 doctors surveyed was one of "anxiety", Blattner told The Spinoff. "The worry is around just being completely overwhelmed." The sentiment was not entirely bleak, however. "At the same time there is some optimism, in terms of the slow realisation across the country that there are specific things that rural and remote services face, that they are different to those in the city. There is a slow cottoning-on that they need to be heard, and their voices need to be at the table."
The meaning of the maps
The maps' message, said Whitehead, a research fellow at Te Rūnanga Tātari Tatauranga, the National Institute of Demographic and Economic Analysis at the University of Waikato, was clear: "There's a lot of rural communities out there that are a long way from any hospital treatment. And those facilities don't necessarily have the infrastructure to cope with Covid patients, especially over the summer period where a lot of health services are already really stretched every year."
Then there's the question of providing appropriate oversight and support for those isolating at home. "The risk is that if or when Covid gets into more remote areas in the country there will be a lot of people affected who don't have ready access to health services. We're already seeing, even in Auckland, people dying at home with Covid. So I'd hate to see what might happen if there are a lot of people in rural areas trying to manage a Covid-19 infection … We already know in health research that social and economic deprivation is highly correlated with broader health outcomes. So in those areas with high deprivation people aren't going to have the resources necessarily to manage Covid infections," he said.
Just how distant does it get? Consider Tokomaru Bay, up the coast north of Gisborne. Whitehead estimates that it would take six and a half hours to travel to the nearest metropolitan hospital in Hamilton. "And that assumes that as soon as a person's condition deteriorates they're able to get in a car and drive straight away. The reality is you've got to decide whether you're going to call an ambulance or a health professional. They're going to give you some advice, and if an ambulance does come, it's got to come from somewhere. If it's the summer period, an ambulance or even a helicopter could be dealing with any accident or emergency. So those drive times are a best case. Realistically it's going to be worse."
DHBs make their own plans
Major health reforms introduced by the Labour government will see the of District Health Board system scrapped, but before then each of the 20 organisations faces a big test: establishing and executing plans to deal with any localised Covid outbreaks. Across the country, regional hospitals have strategies ready to go. "As it moves through the country, there'll be outbreaks, numbers will spike in one area but not in another, and then it'll reduce but spike somewhere else, or it might spike in multiple places," the health minister, Andrew Little, told the Herald last week. "That's why it's important each DHB and each group of DHBs on a regional basis are equipped to be geared up."
If DHBs' performance across the years is a guide, those plans will vary both in scope and quality. One conclusion from the survey of 17 regional hospital doctors was this: "There was a universal sense among the participants of this study that the DHBs had a poor understanding of rural hospitals' facilities and capabilities."
Speaking on RNZ yesterday, Jacinda Ardern indicated that areas with low vaccination would remain in a "red light" setting when the traffic light framework kicks in from December 3, which would limit opportunities for widespread outbreaks. She was confident, she added, that plans were in place to cope with any cases that did emerge. "We've been considering all these issues, and we know the areas that have the most significant numbers of people coming into them," said the prime minister.
"With the District Health Boards and the Ministry of Health we've already identified the areas where we have the most significant growth in population. They've been stress-testing those DHBs' Covid plans because they are the areas that have larger areas of movement of people to ensure they are prepared for extra population in those areas … So, yes, I am confident that DHBs can cope, I am."
"I suspect it will vary quite a bit region by region," said Robin Gauld, professor of health policy at the University of Otago. "Down here at the Southern DHB, they're saying they're ready. They've put a lot of effort into the primary care response system … so you might be confident here. But in other regions you might be less confident, especially when vaccination rates are lower."
He added: "For most of us in the public outside Auckland, it's a pretty intense business, a city that has a couple of hundred cases a day, opening up on December 15. I guess we have to have confidence that the monitoring of people coming out of Auckland, either tested and clear of Covid or double vaccinated, is going to work … It's a really intense and difficult time for everyone from political leaders to local decision makers to try to get this right. It will be interesting to reflect back on this in the years to come."
As the health reforms evolved, one of the lessons to be drawn was the inadequate use of technology, he said. New South Wales had shown, for example, how valuable it was to have remote monitoring of Covid-infected people, lessening the load on physical resources. "We just don't do enough of it," he said. "In the future we need to think much more intelligently and in a more focused way on using technology."
The holiday question
Ministers have resisted any temptation to discourage people from travelling to parts of the country that may be more vulnerable over summer, but a number of community and iwi leaders have issued a simple message: stay away.
Tina Ngata, a Ngāti Porou scholar and advocate, laid out the questions for anyone contemplating a break on the East Coast. Were you to inadvertently bring Covid into the community, she wrote, "are you expecting all of the volunteer community hours going into supporting our own community to isolate at home, to then wrap around you? Who then looks after our whanāu here? Are you expecting us to volunteer to look after you when you walked away from a fully resourced health service wherever you normally live? Who is going to transport you to hospital and to which hospital? The one with only two ICU beds? Our whānau will be more likely to decline fast because of the diabetes, rheumatic fever, heart disease and poor housing. You've just spread it in our community, but you get the ICU bed?"
She added: "Every year, our population swells to three or more times its normal size, from tourists. That terrifies me when I consider how hard it is for us to plan to just look after our own whānau, and how hard we are working to stop them from getting infected too … I hope you care. I hope you care enough to wait just one more summer."
Blattner urged anyone planning a holiday to examine Whitehead's distance maps. "Think it through, and look at some of the other options around the country to go on holiday which may not be in the deep red index zone," she said. "Especially the remote Māori communities; think about not going to those places this year."
Whitehead put it this way: "Covid will end eventually. I think the best decision is to stay close to where you live, because you never know whether you could be infected and pass it on to vulnerable communities. There are going to be other Christmases."