Too sick too learn

It’s been described as a disease that disproportionately affects the poorest of the poor. That New Zealand has one of the highest rates of rheumatic fever in the developed world…

Lance O'SullivancompressIt’s been described as a disease that
disproportionately affects the poorest of the poor. That New Zealand has one of the highest rates of rheumatic fever in the developed world is shameful. But what’s being done about it, and the other health problems associated with poverty that are impacting on our children and classrooms?

Elizabeth McLeod reports.

At the risk of sounding flippant, rheumatic fever seems to be the disease du jour: the Government’s throwing money at it, every week there’s a news story announcing a new initiative or decrying the lack of progress in bringing down rates. One recent article proclaimed that the fight against rheumatic fever was “being undermined by children not taking their medicine”, citing Ministry of Health documents suggesting fewer than one in three children prescribed antibiotics had taken them all.

“Yeah, blame the children,” muses Dr Clair Mills wryly when the article is mentioned.

In reality, says Mills, the Medical Officer of Health at Northland DHB, the causes of our high rheumatic fever rates – and our failure so far to make a dent in them – are a little more complicated.

Rheumatic fever occurs after Group A ‘strep throat’ is left untreated. It can damage the heart, leading to permanent disability and in severe cases, death.

It’s now widely accepted that overcrowding, poor housing, under-nutrition and inequitable access to primary health care all play a role in New Zealand’s high rates. We’re on a list of the five worst-affected areas in the world, in our indigenous population” up there with sub-Saharan Africa and south-central Asia.

Last year ESR reported 194 initial cases and 11 recurrent cases of rheumatic fever, an overall rate of 4.6 per 100 000. This was similar to the rate reported for 2012.

It’s highest among children over 5 (90%) and among Pasifika and Māori. In 2010, rheumatic fever rates were about 37 times higher for Pacific people than for people of other ethnicities, and 20 times higher for Maori. In Northland over 95% of cases are Maori. But there’s no ethnic component to the disease: this is simply about poverty.

“In low-income households that are challenged in every direction, an illness that seems to get better by itself is just going to be swept under the carpet,” says paediatrician and infectious diseases expert Professor Diana Lennon, “because, you know, you haven’t got the money for rent or the food. A small-time sore throat is not going to seem a big deal.”

The Government, as one of its 10 Better Public Service targets, is investing $65.3 million over six years on its Rheumatic Fever Prevention Programme (RFPP), with a target of cutting rheumatic fever rates by two-thirds by June 2017. DHBs, primary care and community organisations are also funding aspects of the prevention programme.

The RFPP has three strategies: improve access to strep throat treatment; reduce household crowding, and raise awareness among high-risk communities in the 10 DHB areas with the highest incidence of rheumatic fever hospitalisations: all in the North Island.

School-based swabbing

The Government and DHBs have been funding providers to go into schools and offer free throat swabbing, referrals and antibiotic treatment where necessary to children with sore throats in high-risk areas, and their family members.

Mills believes it’s an effective way to reach high-risk communities.

“The health providers are Maori, they know their community. They provide support for taking the antibiotics “they’ll text or phone every day or every five days or at the end of the course. They’ve come up with lots of ingenious ideas” one provider developed a sticker book, with a Maori story about the tui. They’ve done things where, if the kids bring back the sticker chart, they go in the draw for a voucher at The Warehouse or somewhere.

“The other advantage is that the school projects all use once-a-day doses of Amoxicillin. Many GPs still use three-times-a-day and that’s much harder for families to achieve: it’s difficult for anyone to stick for 10 days, especially when they feel well.”

Georgina Peterson is Program Team Leader with Manawa Ora, Korokoro Ora (MOKO), a throat swabbing programme established in a decommissioned dental clinic at Kaitaia Primary School by MÄaori doctor (and 2014 New Zealander of the Year) Lance O’Sullivan.

“We go door-knocking at each of our schools three days a week, and our workers ask all the children ‘does anyone have a sore throat today, does anyone have any sores that are red or pus-y?'” she explains.

“The kids don’t have to go out of school for treatment, the parents don’t have to take time off work, and it costs them nothing. So that’s more than a win-win.”

No sustainable funding

However, the Government’s focus seems to be shifting slightly away from this approach. It has allocated $11.25 million over four years for sore throat “rapid response” clinics at general practices and other community settings in high-risk parts of Auckland and Porirua. Meanwhile, funding of the school-based programme is due to stop at the end of next year.

Mills isn’t convinced the clinics will work in her region. High-risk kids, she says, “don’t go to general practice on the whole” and especially teenagers. The kids at highest risk of rheumatic fever are the least likely to see a GP.”

Kaitaia Primary principal Brendon Morrissey emphasises that diseases like rheumatic fever “are issues of poverty, and that has nothing to do with schools. That’s a wider issue happening outside the school. However, schools seem to be the place where we can solve a few of those things: because we’re always here, we’re always consistent, we can be easily found, we can help level the playing field to some degree.

“But the fact is, 80% of the things that impact on children’s learning happen outside of school. That says to me we’re focusing on the 20%, but 80 percent of the issues are not really being dealt with.”

Lennon, too, seems exasperated by the lack of progress.

“Honestly, this country needs to wake up and know that other countries don’t have these issues. And why don’t they? It’s because here, people crowd into houses because they can’t pay the rent.”

Strep throat spreads quickly, so tackling crowding is another focus of the RFPP. Housing New Zealand Corporation (HNZ) has introduced a programme to fast-track families with children at risk of rheumatic fever up the waiting list into larger homes. The Auckland-wide Healthy Homes Initiative (AWHI) also helps families of kids with rheumatic fever risk factors to find “housing solutions”.

Other poverty-related diseases

But what about all the Auckland kids who don’t fit the risk criteria, but are still living in crowded, damp or cold houses? What about all the kids throughout the country living in crowded, damp or cold houses? Health experts concur that reducing rheumatic fever rates is a high priority. But are we dropping the ball on other poverty-linked illnesses?

Children who are at risk of rheumatic fever are the same group at risk of ‘close contact infectious diseases’ like skin infections, respiratory infections, recurrent pneumonias and bronchiectasis (permanent lung damage caused by ongoing chest infection).

Again, says Associate Professor Nikki Turner, a GP and Child Poverty Action Group spokesperson, these conditions are related to the same range of factors: “the state of housing – overcrowded so bugs transfer more, poor heating so kids are cold and houses are damp, dampness and mould – and poor nutrition.”

While the Government has various, seemingly ad hoc initiatives aimed at improving insulation and ventilation in rental properties (including spending $76 million insulating all state houses that could be insulated), there’s little in the way of actual heating assistance, although HNZ offers to “assess the homes” of tenants concerned about heating.

AWHI offers some assistance to at-risk low-income families, but only if they have a child aged 0-14 who’s been admitted to hospital with extremely serious respiratory illnesses (ie not just asthma), or meningococcal disease or TB, and meet strict criteria. And, of course, live in Auckland.

Peterson says her team occasionally visits homes where “they might be living in a shed, or have draughty windows, no curtains: that’s a lot of cold air coming in. Some homes, the lawn’s always wet and even though the house has been insulated, there’s still dampness.”

A BRANZ survey in 2010 found only 22% of New Zealand’s rental properties were in good condition, while 44% were in poor condition. In a recent field trial of a Rental Housing˜Warrant of Fitness’, 94% of homes failed the WOF, with “not having a fixed efficient form of heating” one of the top five items.

Skin infections are one of the top three reasons for child admissions to Starship Hospital, says its Community Paediatrician Dr Alison Laversha. She regularly visits schools with a team of public health nurses and community health workers to discuss with principals what health issues they’re seeing. In low decile schools, she says, skin infections like school sores and infected excema are the biggest issue.

“When we talked with schools about the Rheumatic Fever programme, most people either didn’t know about it or didn’t see it as a high priority, because it’s low in numbers though high in cost and high impact. Whereas skin infection has high numbers and also has an impact on participation and learning.”

Lennon agrees that skin infections can impact severely on children and learning.

“They don’t necessarily lead to long term problems in adult life like sore throats and then rheumatic fever do. But they are very unsightly, very unpleasant and they spread easily among kids, so that if they graze their knee they get pus and cellulitis and end up in hospital, and sometimes get kidney infection.

“They’re common things that shouldn’t be in a civilised well-funded society. They are preventable.

“Rheumatic fever’s not an isolated problem. And that’s one of the concerns about the current government approach, that they’ve picked out one disease.”

Extend the schools-based model

Many school-based providers have extended their service to treat skin infections, as well as nits. Nearly all the health and educational professionals interviewed said they’d love to see the model extended even further. Things like asthma management and immunisations could be provided, says Mills. I’d like to see a more integrated model which also works with GPs locally, ideally.”

They want more social housing; “not just some of the token stuff that’s happening in Auckland at the moment” says Lennon – and WoFs not just for state houses but for private rentals. The Government refuses to commit to the latter.

Clair Mills would like sustainable funding for the school-based programme” and sufficient to cover all Northland Decile 1-3 schools and high schools.

MOKO’s Georgina Peterson has a bright idea: a food card that could be loaded up with, say, $200 a week, to be used only on food.

Brendon Morrissey has a dream: “There must be hundreds of school dental clinics in rural areas throughout New Zealand: imagine if one in 10 had a MOKO team to go out to the local schools. That could make a massive difference to all rural schools nationwide” and rural schools make up about 70% of schools. That would be impact.”

Not everyone is so keen on the school-based model. Nikki Turner believes the schools programmes are a distraction“The problem is, kids are only in school for about 20% of their time, and kids have sore throats not just in school time, but 24 hours a day 7 days a week. It’s a hugely expensive programme. Public health nurses in the schools need to focus on all the health issues of poor kids, like skin septicaemia, skin problems, other respiratory problems.

“I think schools programmes are really important for all our kids’ health needs, but equally if not more important is good access to general practice services.”

However, Georgina Peterson at MOKO isn’t convinced that policies like extending free GP visits to older children would make any difference in her region.

“Are kids going to be saying to their families˜I’ve got this sore, I think you should take me to the doctor’, or ‘we should go to that clinic’? I just don’t think that’ll happen.”

To Brendan Morrissey, the school-health partnership model “makes so much sense”.

“I’ve been tracking our attendance figures closely. Since 2008 to the end of last year we’ve noticed a gradual increase in attendance figures. Kids are coming to school more often because they’re more healthy. And if they’re here more often, we can teach them more.

“Our kids are really good about putting their hands up” and really good about putting their mates’ hands up and saying ‘you need to come too!’. Five-year-olds do that. They know how good this is for them. The most powerful thing is when a child becomes self-directed, in any way, but especially looking after themselves.”

Meanwhile, the RFPP’s success is still being evaluated. Mills says the national trend still seems to be upwards, but this may be due in part to better detection because of greater awareness amongst health professionals.

Lennon says the relatively small numbers involved mean it will take a while to see a difference. Ending the funding of the school-based programme next year is “patently stupid”.

“We think if we’re going to show a difference it’ll be another several years” we’re estimating in South Auckland by 2017.

“So let’s not panic” and also let’s not let the politicians pull the plug because they can’t see an immediate effect. Because it’s really just the beginning of trying to right some of these social injustices.”

Footnote: The Ministry of Health said it was unable to provide Education Aotearoa with information on its funding plans for the programme in time for publication. We understand DHBs wanting to continue the schools-based programmes beyond the end of 2015 will have to find the money from their own coffers” i.e. take it from somewhere else.

1. Main political parties’ policies around child poverty-related health issues

National – extend its free GP visit and prescription scheme to include 6 to 12-year-olds from July next year, at a forecast cost of $30m a year.

Greens – extend free GP visits and prescription scheme to the age of 18, at a forecast cost of $29m a year. Exploring extending the age eligibility for free after-hours care. School nurse for every low-decile school.

Labour – introduce a Healthy Homes Guarantee with all rentals having to meet minimum standards of heating and insulation along with their existing obligations. Lift minimum wage, “champion” a Living Wage.