GP and Child Poverty Action Group health spokesperson

11 April 2019


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.

 

Nikki herself grew up in ‘a fabulous home. My parents were poor but we were well supported. It was very nurturing emotionally, and a lot of stability.’ Neither of her parents was highly educated, although her father got a degree later in life. Her mother was dux of her high school but in those days there wasn’t considered to be any value in a girl getting a degree – instead, her brother went to university.

The fact they were poor didn’t particularly signify ‘because so was everyone else. There wasn’t a sense of being left out. It wasn’t like now, when we’re seeing wealth concentrated more and more into the 1 per cent.’

Inequality, in a word.

This is where the policy argument comes in: Nikki believes that we need policies in order for wealth to be distributed more fairly. ‘I’ve got the T-shirt that says I want to pay more taxes,’ Nikki says. ‘If we change policy, we’ll change cultural attitudes.’

One of the reasons she’s so certain about the need for policy directives is because she’s seen its effectiveness in her own area of work. Since the late 1990s, Nikki has directed the University of Auckland’s Immunisation Advisory Centre, and over that time New Zealand’s very low immunisation rate of barely above 50 per cent rose to over 90 per cent. ‘I’m really proud of that,’ she says. How was it done? ‘Policy and systems! First of all we got buy-in from the health community that it was important. Then we gave them the resources and the tools to make it happen. We developed the national register, and we put in national indicators, national goals. We developed the best frontline providers in the world with our practice nurses, who are educated, confident, keen, know what they’re doing, committed to their job, and supported.’ 

At the time the Immunisation Advisory Centre was set up, there was a vocal and influential anti-vaccination movement reflecting, Nikki believes, an absence of trust in science and a primary healthcare system that wasn’t very well organised. ‘When I started in this job I was the devil incarnate. I used to get a lot of hate mail. I had an unlisted phone number and my kids have a different surname. But over the 20 years, as the New Zealand community has got behind this, the angry anti-immunisation stuff is a lot less, because immunisation’s normalised now as a positive part of raising healthy children. Whereas back then you had to make an active decision to immunise, now you have to make an active decision not to.’

There has been a corresponding decline in harmful childhood illness. ‘New Zealand achieved measles elimination status last year from the World Health Organisation. Hib disease [Haemophilus influenza type B] used to be the most common cause of life-threatening bacterial meningitis in kids under five, but thanks to the Hib vaccine we pretty well never see that now. We’ve introduced the pneumococcal vaccine and seen a great reduction in pneumonia and meningitis disease. We introduced the rotavirus vaccine two years ago, and the reduction of hospitalisation due to vomiting and diarrhoea has been dramatic.

‘It’s a hard story to tell – it’s hard to get people to cry at the absence of disease. But it’s an incredible success story, and I’m particularly proud because, while in healthcare we usually see the traditional equity gaps where poorer people and those from certain ethnic backgrounds have poorer health outcomes, we’ve almost fully closed the equity gaps. Immunisation coverage now is the same for poor as for rich kids, and it’s pretty much the same across all ethnic groups, although there are still some gaps. Now New Zealand leads, and I think we’re one of the best in the world at systems that deliver primary healthcare effectively to our people.’

Nikki’s work in this area is recognised internationally. She’s a member of the World Health Organisation Strategic Advisory Group of Experts (SAGE) on Immunisation, and chairs the Measles and Rubella Elimination subcommittee.
She remains concerned that we have, as a nation, normalised child poverty. However, she believes there are good signs. ‘Our government now has a clear commitment to fighting child poverty in a way we haven’t seen before and I’m very thrilled about that. But the challenges are enormous because it’s so embedded in our bigger cultural and policy settings.’

It boils down to this: ‘We can’t live inside someone else’s skin. We can only listen to people’s stories and try to understand. General practice for me has been heart and soul. It has given me so much because it’s taught me about people.