Open Letter to the Hon Minister of Health, Tony Ryall, Dear Mr Ryall, We realise that health policy is determined by your advisors, but we believe that it's time for you to independently do some research on Pubmed, Google Scholar and apply some commonsense to the escalating industry entrenchment around the expensive testing for and treatment of rheumatic fever. What most concerns us is the apparent reading and research deficit suffered by the New Zealand medical profession regarding rheumatic fever, resulting in employment of chemical solutions rather than application of meaningful preventive strategies which if enacted would not only prevent rheumatic fever, but a whole raft of other medical conditions as well.
This letter is prompted by a January 4th Eurekalert, and an article on 15th November which describes a 2011 study which states that,"The latest study by public health researchers at Otago University shows that household crowding is one of the key risk factors for ARF, particularly in Maori and Pacific families.
In the past few years of the study, Maori rates of ARF were 20 times, and Pacific rates 40 times, that of New Zealand European and others." ...
"Dr Jaine said the latest research also indicated the importance of appropriate social housing at affordable rents for low income families, avoiding high-risk families `doubling-up' in overcrowded homes."
While the New Zealand Herald artice is specific, the actual study is not quite so specific and amazingly states that reducing crowded households, has the potential to reduce many diseases, including tuberculosis and meningitis. The study admits that "ecological studies are subject to the "ecological fallacy" In this study we cannot necessarily infer an association between ARF and crowding in the home at an individual level. However, this does not mean that observed association should be dismissed."
Which is pretty obvious when 99% of those living in overcrowded housing won't get rheumatic fever. But neither is any attempt made to understand what factor about overcrowding is the most important. Is it just headnumbers? Might it not be something else? Why is that important? It should be obvious.
It's hard to know how much "history" Drs Jaine, Baker and Venugopal actually know. To blame "overcrowded houses" is astonishing actually, because the key factor isn't actually the "over crowding", but the logistics of feeding 26 people living under one roof day in, and day out. Some simply default to four loaves of white bread, margarine and luncheon sausage. Or McDonalds.
Might not this Eurekalert be relevant?
"In this population of low-income Ecuadorians, we observed a pattern of high carbohydrate, high sodium diets lacking in healthy fats and good sources of protein. Our blood analyses indicates a significant number of participants weren't consuming enough of a range of micronutrients," says senior author Simin Nikbin Meydani, PhD, DVM, director of the USDA HNRCA and the Nutritional Immunology Laboratory at the USDA HNRCA. "After adjusting for age and sex, we observed significant relationships between the metabolic syndrome and two of the micronutrients, vitamins C and E."
"As a group, the participants did not exhibit low blood levels of vitamin E," Meydani continues. "The association suggests that having higher blood levels of vitamin E may protect against the metabolic syndrome." However, low blood levels of vitamin C were seen in 82% of the participants, which the authors suspect was due to limited intake of fresh fruits and vegetables. The bulk of the participants' calories came from white rice, potatoes, sugar and white bread. The authors noted 55% of the women and 33% of the men were overweight.
"With high-calorie foods lacking essential nutrients serving as pillars of the diet, it is possible to be both overweight and malnourished," Meydani says. "Our data suggests that limited consumption of nutrient dense foods such as chicken, vegetables and legumes makes this small population of Ecuadorian elders even more susceptible to the metabolic syndrome."
... Nutrition interventions, such as encouraging older adults to consume more nutrient dense foods, for example, locally grown produce, could reduce the strain on the health care system."
As I've been banging on about for years, .... Nutrition is the primary issue, not housing. This was proven decades ago by Alvin F Coburn, who studied rheumatic fever in poor tenements in Chicago. He contrasted families living in identical circumstances, but with different incomes, and found that the biggest predictor of rheumatic fever was exceptionally low incomes and inadequate diets. Coburn, James F Rinehart and many others, have repeatedly pointed out in the medical literature, that nutrition and rheumatic fever, are intimately intertwined. And so are meningitis and tuberculosis! In 2010, malnutrition being a driver of childhood meningitis was laid out quite clearly. Nutrition has a key factor with regard to susceptibility to Tuberculosis, has been known for so long, it shouldn't be necessary to give you links for that..
We read the odd story about older people in some of these areas growing veges, and trying to teach those who live around them to garden, but there is one big problem with this idea. L A Z I N E S S. Take a walk around, and have a look at all the people sitting on porches, doing nothing, while their vast expanse of lawn around older houses grows long grass.
Why is nothing serious being done about the real nutritional problems facing Maori and Polynesian people in New Zealand - which we know exists by the ton ? How do we know this problem exists? As far back as 2005, we have been told that while many kids might not look like skeletons, ten percent of those same kids may have serious nutritional issues. Yet here we have the same paediatrician who said that in 2005, saying this:
"Relative to other developed countries, NZ has a large ALRI disease burden in pre-school-aged children. Pneumonia and bronchiolitis hospitalisation rates are two to four times greater than other developed countries. The ALRI disease burden varies with ethnicity, being highest in Pacific, intermediate in Maori and lowest in European children. Three of the four key nutritional risk factors for global ALRI disease burden - low birthweight, zinc deficiency and suboptimal breastfeeding - are potential contributors to ALRI disease burden in NZ. In addition to these factors, vitamin D deficiency during early childhood and maternal vitamin D deficiency are also potentially important particularly with respect to the larger disease burden in Pacific and Maori children. Conclusion: The contribution of malnutrition to ALRI disease burden in NZ requires greater clarification. Such clarification is necessary to inform the development of nutritional policy, which seeks to improve early child health.
This same group of "experts" has been studying children's nutritional deficiencies since 1997!
We are what we eat.
It's not rocket science.
You know that, I know that.
So why is it that Dr Grant has been talking about it for over 10 years now, yet NOTHING meaningful gets done, other than lots of medical papers published by him?
The first job of a Starship physician seeing a Maori of Polynesian child with acute rheumatic fever, should be to send someone to the house to search the kitchen fridge, pantry, cupboards and bread bin on at least three separate occasions over the next 6 weeks. And the kitchens of that family's wider whanau. The answers will stare at them in the face.
These same nutritional risk factors which apply to other respiratory illnesses, apply to rheumatic fever. Dr Cameron Grant's talk about "the need to clarify the problem" is either time wasting rhetoric, when he knows what the problem is, or an attempt to grab more research money for study for another ten years. He already knows what he will find, when he looks, providing parents don't wise up to why he is looking and rush in a few supplies to skew the results. Because the strange thing is that a lot of these people know they are eating crap, but they eat it because it's easily accessible; they want to eat it, and they are too lazy to cook proper food for their families. And we know this, because even the newspapers admit it. But in the meantime, millions are spent in antibiotics at the bottom of the rheumatic fever cliff, instead of implementing what is already known about nutrition at the top of the cliff.
It's not the numbers of people in a house that counts, but what goes into the mouths of the people in the house that counts.
Yet. this article in the New Zealand Herald says: "...the biggest potential gains against rheumatic fever were in reducing household overcrowding and in detecting and treating strep throat." Just what big pharma ordered. Mustn't kill the goose that lays the golden eggs....
Wrong. The biggest potential gains will be when the politicians and medical profession band together to seriously change people's mindsets about nutrition, and to get real with some of the big commercial companies to make, market and make a financial killing out of selling "empty" food. But that will never happen with a corporate government, and a medical profession orchestrated by the pharmaceutical industry.
Nigel Wilson, Starship's cardiologist, whose recently published article is behind the Herald article, has an interesting take on this issue. He things that the rates of acute rheumatic fever and rheumatic heart disease are significant breaches of Maori rights under the UN Declaration of human right, and breaches of the Waitangi Tribunal. He says that, "effective prevention of ARF requires a range of strategies (which_ include addressing the socio-economic and living conditions that increase the risk of GAS infection and subsequent ARF." He goes on about how Maori communities are keen to work with health providers, given appropriate information and resources. He mentioned that two decades ago, the late Eru Pomare wrote about Maori concepts of health focusing on health promotion and disease prevention.
The problem is that Nigel Wilson's version of solving these breaches of rights, lies in primary disease prevention by supplying information on disease treatment, and to rectify the "confused messages" about treating sore throats, and secondary prevention by expensive monthly injections of penicillin for two decades.
Nowhere is there any suggestion that the primary breach of Maori rights under the UN declaration, or the Waitangi Tribunal, is that the medical profession is not sharing with them, the fundamental dietary information in their own medical literature, which has the potential to not only prevent acute rheumatic fever and its complications, but a host of other infectious diseases which affect Maori and Polynesians far more than other ethnicities. Including - wait for it - obesity!!!!
How do we know this is so? As stated above the study, published in October 2010, lays out exactly that problem.
So why concentrate, as the rhematic fever article did, on "overcrowding"? On "housing"? If too many people in one house was the driver of rheumatic fever, that fact would be the same world wide, and it's not. Take Australia as an example. Which is the group in which rheumatic fever is the worst? Aboriginal and Torres Strait Islanders people living in regional and remote areas of central and northern Australia. None of those people suffer from overcrowding in tiny houses, but ALL of them suffer from serious nutritional issues, because they live on white flour, sugar, tinned food and alcohol.
The medical literature clearly shows very high rates of rheumatic fever in Fiji, American Samoa, Tonga and Hawaii, and none of their key factors there relate to overcrowded houses either. Again, the elephant in the room that no-one wants to talk about, is the same reason behind fact that polynesian countries now have the biggest infection and obesity problems in the world. The amount of zero-nutrition food eaten, has escalated hugely, and the increase in rheumatic fever in the Pacific Islands, and New Zealand, is just the canary in that mine.
Interestingly, Sri Lanka is a slightly different case study. Most of the acute rheumatic fever there does concentrate in the cities. There is no acute rheumatic fever there, out in the wops. Why? As anyone who has been to Sri Lanka can attest to, out in the countryside, there is an amazing variety of very cheap fresh fruit and vegetables available. Children in the Sri Lankan countryside, who may have a certain degree of protein malnutrition if they are landlocked or have no access to fish or chicken, have no deficiency of fresh fruit and vegetables, which as it turns out, is one of the keys in prevention of secondary rheumatic heart disease. Sri Lankan city children do not have free access to the abundance of fruit and fresh food that their country counterparts do, and that is probably the key to understanding why Sri Lanka has an intercity rheumatic fever focus.
The key to prevention of serious streptococcal A infections in the first place is that all children should be fed properly with an emphasis on adequate protein , fresh fruit, vegetables etc, and have healthy stores of Iron, vitamin C, vitamin D, zinc, magnesium and all the other important micronutrients including selenium. Sounds basic doesn't it. But a one month study of trolley contents in the various stores in rheumatic fever areas will show you that this isn't happening, ... and we know it's not happpening. Bad nutrition is a huge problem in the very areas of New Zealand which suffer Rheumatic Fever. Ask any school teacher walking around the grounds watching what Maori and Pacific Island children eat. It was a problem when my husband was a school principal in 1981, and it's an even worse problem now.
Mr Ryall, I have a serious problem with the current rheumatic fever emphasis on providing more information, swabbing children, and treating any child with bacteria in their throat with antibiotics.
Why? Because Streptococcal bacteria are ubiquitous in the environment, and undetected carriage rate within the community is very high.
A swab showing bacteria in the throat, has no relationship as to whether or not the person with bacteria in their throat will get an infection at all; ".. a positive throat culture for group A streptococci cannot distinguish between the perplexing streptococcal upper respiratory tract "carrier" state and an acute infection. Such carriers may even asymptomatically harbor the organism in their upper respiratory tract. These individuals are not truly infected and they appear to have a much lower risk of developing complications of group A streptococcal infections. Carriers do not by definition experience a rise in streptococcal antibody titer when acute and convalescent sera are compared. Often during episodes of upper respiratory tract illness, nasopharyngeal cultures obtained from these streptococcal carriers confirm a viral etiology for their upper respiratory symptoms."
Yet, a positive throat swab in this country, results in an automatic prescription of antibiotics "to prevent rheumatic fever? In spite of the fact that we know rampant antibiotic use is the driver of superbug development. And I've not even started talking about the long term health implication on individuals constantly napalmed with antibiotics in terms of permanently trashing their gut flora and increasing their chances of cancer later in life.
All that could be prevented in the future, and stopped in it's tracks right now, by Maori and Polynesians seriously learning and applying key, healthy nutritional principles.
This same article states that , "The incidence of pharyngeal infection is greater in the winter and spring months." Very interesting. A thorough read of early medical literature in the 1900s, shows repeatedly, that children with the most severe acute rheumatic fever, had had influenza around a month before.
Those who follow the medical literature on susceptibility to all respiratory infections, will know that Pubmed is full of articles showing that people with good levels of vitamin D, are unlikely to get influenza or ANY respiratory infections. That includes colds, the flu, pneumonia AND... presumably rheumatic fever. I say presumably, because there has only been one 2008 study linking low vitamin D levels in people with rheumatic fever.
But given that the New Zealand medical literature amply and repeatedly shows that there is an epidemic of vitamin D, and other deficiencies in New Zealand Maori and Polynesians, why aren't the real dots being joined here?
Contrary to Nigel Wilson's belief that lack of antibiotic treatment for sore throats to prevent rheumatic fever, and lack of information on disease treatment is a major breach of Maori rights, the biggest breach of Maori rights is the refusal to address nutritional issues which Starship have been known for over ten years, which are the primary drivers in so much of what Starship still sees and treats every day. Broad spectrum nutritional deficiencies are the problem, and would be the real fence at the top of the cliff, instead of sinking millions into school swabbing and antibiotic treatment at the bottom of the cliff for rheumatic fever, which when children are fed properly, just shouldn't even happen.
Dealing with nutritional issues, will not only reduce the incidence of rheumatic fever, as has happened in the European community (who in 1920, had the same rates as Maori did), ... educating Maori and Pacific Islanders on nutritional issues, will reduce all infectious diseases, and chronic diseases such as obesity, diabetes, strokes, heart disease, asthma and hugely reduce how much of the taxpayer's money has to be devoted to totally preventable diseases.
That should be the key message. To focus on food family nutrition in spite of house overcrowding, rather than just swabbing, and hitting everyone indescriminately with both short and long term antibiotics.
But dealing with key primary health issues like core nutrition, is just shoved in the "too hard basket" isn't it. If it's not, then why has Starship done nothing about this, other than "talk" for the last ten or more years?
