In 2020, my report, Pharmac: The right prescription? for the New Zealand Initiative found much to compliment in Pharmac’s pursuit of its statutory duty to obtain the best reasonably achievable health outcomes for eligible people from pharmaceuticals within the subsidy budget.
No race-based preferences are implicit in that concept. So, I was surprised last year to see the Pharmac Review Panel recommend that Pharmac bias its subsidy and employment decisions in favour of “priority populations”, notably Māori.
Investigating further, I found that a race-based focus has invaded health policy more generally.
For example, in a submission in 2018 on behalf of the Crown, the then Director-General of Health asserted to a Treaty of Waitangi Tribunal hearing that “the impact of personal and institutional racism is significant on both the determinants of health and access to and outcomes from health care itself”.
In her Waitangi Day Speech this year the Prime Minister told Māori that they die younger than everyone else because they are Māori.
What evidence did the prime minister and the Director-General have for making such unequivocal causative assertions?
Separate Official Information Act requests for the most authoritative empirical analyses supporting the respective statements were answered earlier this year by the Ministry of Health.
I examined this material looking for two things: evidence of causation (as distinct from correlation) and evidence that the adverse causative effect was of material significance.
My findings were published this week in my report Every Life is Worth the Same: The Case for Equal Treatment, for the New Zealand Initiative. University of Auckland, professor of Medicine, Des Gorman, wrote the foreword.
Shockingly, the best empirical analyses the Ministry could supply proved to be silent as to both causation and materiality. They did not establish that racism is a material cause of the relatively poor health outcomes for Māori.
Two articles in the same issue of The New Zealand Medical Journal in 2020 sum up the inconclusive state of empirical research.
The first article was a “systematic review” of quantitative studies in racism and health in New Zealand. The review’s opening sentence roundly declares that “Racism has been firmly established as an important determinant of health and an underlying cause of ethnic health inequities in Aotearoa New Zealand and internationally”.
In contrast, the body of the review article makes it clear that the studies it reviews establish correlations. It did not identify any empirical research that establishes causation, let alone materiality.
The correlation arises because those who self-report a higher experience of racism also tend to self-report a poorer state of health status. Perhaps the former causes the latter, perhaps those feeling poorly about their health take more notice of prejudice or discrimination, or perhaps causation works in both directions. Or something else could be behind the dual experiences.
And even if we assume one-way causation, how material is its effect, and through what channels does it mostly work? The Ministry of Health routinely presents health outcomes as being 40% determined by socioeconomic factors (e.g. education and income), 10% by the physical environment (e.g. housing quality), 30% by personal lifestyle choices, and 20% by the quality of the health care sector. Pharmac’s contribution to the 20% could be quite small. There are too many unanswered questions.
The second article was an editorial. To its credit it did not assert that the review article established causation. To fill that gap, it baldly asserted that large and enduring group average differences “is evidence of the fact that institutional racism occurs in New Zealand”. What sort of fact is that? If it is a fact, how material is it? Are Māori helpless in its face?
The editorial thus essentially accuses the hospital boards and practising medical professionals en masse of institutional racism. In 2018 the then Director-General of Health had done much the same.
In medicine, careful diagnosis should precede prescription. The same is true for public policy.
To return to the role of Pharmac, requiring it to bias its decisions in favour of a “population priority” must reduce the health outcomes for eligible people overall. It could even make those in the priority population worse off.
Suppose, for example, that the budget can fund treatment for at most 10 people, and of those only two belong to a priority population. Next suppose instead that Pharmac biases its subsidies to benefit conditions that most affect the priority group. Now its money will not go as far. Perhaps it can now fund only seven people, including three of the priority group.
That proposed approach values the single gain to the priority group as being worth more than the lost benefit to four of the non-priority group. This ratio represents an enormous affront to human dignity. The civil presumption for government is that every life is of equal value.
Next notice that the more expensive the medicine favouring the priority population, the bigger the cut in the numbers who can be treated. Suppose that instead of seven, the budget can afford to treat only three sufferers, of which one is a member of the priority population. Now even the priority population is worse off than under a neutral funding approach.
Officials defend race-based preferences on the grounds of equity and The Treaty. Yet to favour a well-off person in a ‘priority group’ over a less well-off person in another group violates vertical equity. To favour someone in a ‘priority’ group over someone in the same state in another group violates horizonal equity. Yet, the documents I reviewed largely ignore the ‘fair process’ concept of equity.
On top of all this, much international evidence on the results of race-based affirmative action aimed at “‘closing the gaps” is discouraging. Official documents seem to be uninformed by this evidence.
Those who do not care to accurately diagnose a problem cannot care much about whether the remedy will work. Surely some in the Ministry of Health care?
Finding remedies that work for all is critical. The previous government’s social investment approach had that focus. The current racially polarizing approach does not.