Republished with permission from Penguin Books New Zealand
When you’re a GP, you see the whole life spectrum of your patients – it’s a unique opportunity to see inside people’s lives. And for someone like Associate Professor Dr Nikki Turner, who from childhood burned with the desire to help, being a family doctor was a tailor-made career. Up to a point.
Here’s an example of why sometimes being a doctor is not enough: A young mother brings her new baby into the practice. He is absolutely gorgeous, of course, beloved, an emblem of hope and possibility. But by the time that same baby has become a toddler, things aren’t so good – he’s getting sick too often, maybe skin infections, rheumatic fever, pertussis, bronchitis, poor dental health, behavioural problems appearing. By the time he’s seven years old, he’s failing at school, not keeping up with expected standards, struggling to read and write. By 13, he may well have slipped right off the school radar and already have problems with drugs and alcohol.
‘What happened?’ Nikki demands. ‘What happened to that life, to that potential? You look at the end product – an adult with a lot of challenges, social struggles, mental illness or physical problems – and so much of it is from what happened in the early years of life. It’s so unfair. We see it, and we can’t fix it in general practice. I can just listen and offer support and compassion, but I’m not able to change anything.’
The problem, she quickly saw, went beyond just health. Her instinct, borne out by oceans of international evidence, is that there’s a correlation between low income and poor health. ‘Income is the single most important determinant of health,’ she says.
Nikki is a very bubbly, vivacious personality, and she laughs a lot. But on this subject she is deadly serious. Angry, in fact. Yes, she acknowledges, there is a narrative afoot in our society that maintains this cycle of bad health and ‘bad behaviour’ is due to bad parenting.
‘But the data shows that’s completely incorrect. Obviously parenting has a significant input into how we all turn out. But the parenting is also from the situation we live within and experiences carried from previous parenting. All the evidence shows very strongly that the parent, the child, the family all exist in the context of the physical, social and emotional environment. So money matters. It matters a lot. I’ve worked in very low-income general practice all my life and you look at someone in these chaotic environments where there’s limited resources, little money, no emotional support, no potential for jobs, no sense of power, and you expect them to make the same decision I make? Of course they won’t. The whole argument, that this is a parenting issue, is so simplistic. It makes me angry. I feel angry about how judgemental we all are.’
Which is why she became health spokesperson for the Child Poverty Action Group, the independent charity working to eliminate child poverty in New Zealand, using careful research and strong advocacy to try to change government policy. ‘Policy shapes society a lot,’ she says.
Nikki worked as a GP at the Waipareira Trust in West Auckland, then helped establish a general practice at the Auckland City Mission. She is now working part-time at the Pacific Health Centre in Wellington’s Strathmore, where many of the patients are immigrants and refugees with complex needs. These experiences led Nikki to believe that ‘equality’ is not the most useful guiding concept when it comes to developing policies for helping struggling people. Rather, ‘equity’ is a far more meaningful construct. The difference between the two terms is significant: equality infers that everyone should be treated the same; equity is about giving everybody enough proportionately so that they have the same opportunities in life.
‘From those early days I’ve supported an argument for what we call proportionate universalism. I’m a strong believer that if you don’t have a universal base, people miss out. So “universalism” in health means everything is available, and then “proportionate” means some people need more.’
Nikki showed a strong sense of fairness from a very young age. As a young child she took on board the stories of the starving victims of the Biafran famine and was stunned at the contrast between her own life, and others’. Her worldview was undoubtedly shaped by a Catholic upbringing and the context of liberation theology – although a bit later, as a young woman, she visited the Vatican and saw ‘rows and rows of cardinals in their beautiful outfits and not a single woman, and I thought, This is not my world.’ She worked in Africa and India and saw enormous inequalities, and her childhood feeling of wanting to be useful was strengthened. But there’s no point feeling smug, she realised, that New Zealand is better than elsewhere, when she was confronted every day by evidence of increasing inequality here, too.