Rheumatic fever persists in Maori and Pasifika children – is that why we are dragging our tails?
Photo Kenny Rodger/HZH
Two of the most acutely embarrassing features of contemporary New Zealand healthcare would have to be the measles epidemic and our high rates of rheumatic fever. The measles epidemic could have been so easily avoided – there’s a vaccine, and if enough parents got their children immunised, we wouldn’t have an epidemic.
Rheumatic fever should not, in theory, exist in a 21st-century developed country, either. It’s one of those diseases that disappeared from most developed countries in the middle of last century, yet it persists in New Zealand, almost exclusively among Maori and Pasifika children between the ages of five and 15. Healthcare always is a socio-economic issue, but in New Zealand – and Australia – rheumatic fever is a starkly ethnic issue.
“It casts a long shadow,” says Dr Norman Sharpe, medical director of the NZ Heart Foundation. “It is indicator of child health or the lack of, and also an indicator of equity or the lack of it.” Unlike with measles, you can’t vaccinate against rheumatic fever; it is not caused by a virus, but is a hyperactive immune response to a streptococcus infection in the throat. In other words, it’s not the bacteria that causes the damage, but the hyperactive inflammatory response, which damages the valves, muscles and outer lining of the heart.
Children who develop acute rheumatic fever may need immediate heart-valve replacement surgery, followed by a lengthy stay in hospital. Afterwards, they’ll need monthly penicillin injections to prevent a recurrence of the disease, and they will need to get them for years, usually into adulthood. “There are a thousand children on the Auckland register having monthly penicillin injections,” says Sharpe. “And these injections are not pleasant.”
The children may need further heart-valve replacement surgery later in life, possibly more than once. In other words, rheumatic fever predisposes a child to a lifetime of frail health and to premature death. Scientists still don’t know why some immune systems respond in such a way to a streptococcus infection while others don’t, but what they do know is that rheumatic fever occurs in overcrowded houses, where streptococcus can move easily among the inhabitants.
Rheumatic fever was common among European populations until the 1960s, but disappeared as living conditions improved. “We could see a similar decline in rheumatic fever in Maori and Pacific populations if we were to reduce overcrowding,” says Michael Baker, associate professor at the University of Otago’s Department of Public Health, who says Maori children under 15 are six times more likely to be living in an overcrowded household, and Pasifika children 12 times more likely.
Healthcare specialists are calling the rate of rheumatic fever a national disgrace, but they have been saying this for decades. Still, the issue gained some traction this year, with the Ministry of Health approving a $12 million programme aimed at reducing the rates of the disease, including schools campaigns, throat swabbing in schools, and promotional material. It will specifically focus on eight “hot spots” and will mean more children are treated for their strep throats before the infection prompts an immune response that can wreck their hearts.
Sharp is “guardedly optimistic” about the programme, but acknowledges similar ones have been run before and this one is guaranteed for only four years. He notes both main political parties recently started talking about open and easy access to primary care for children, which is even more promising. “But come on, guys, we should have had open access to primary care for children decades ago. It’s a crime, socially speaking.” He also points to rheumatic fever being symptomatic of a greater problem – the inadequate conditions in which such diseases thrive and in which people in New Zealand are living.
Lance O’Sullivan, a Northland-based GP who regularly treats children “who are walking around with the heart of an 80-year old”, is also grateful for the funding – well, sort of. “It’s just not enough. The reality is that this is a disease of poverty, and brown kids … this is a race-based problem.” And where there’s a governmental will, there is a way. Solving the housing problem might take a few years, but is possible. Ensuring every child has free access to a local doctor would reduce the rates of the disease almost immediately.
O’Sullivan says the response to the meningococcal outbreak this year was well resourced and swift, as it should have been – so why not with rheumatic fever? “Because meningococcal is indiscriminate. It kills brown kids, white kids, old people, young people, students, mums and dads. No one is safe, so you get funding. But when you’re dealing with little brown faces, we drag our tails.”
Health Foundation booklet illustrated by Ant Sang
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