As COVID-19 restrictions ease on surgical and other procedures, principles of equity need to be upheld to prevent greater adverse outcomes for those who are already disadvantaged, surgeons are warning.

Dr Maxine Ronald, (Ngāpuhi/Ngātiwai), Whangarei surgeon and Chair of the Royal Australasian College of Surgeons’ (RACS) Indigenous Health Committee, says Māori and Aboriginal and Torres Strait Islander peoples have experiences of inequitable treatment with pandemic conditions.

“The Spanish Flu pandemic of 1918 resulted in a mortality rate for Māori at least seven times that of non-Māori, while the number of Aboriginal and Torres Strait Islander peoples lost to the pandemic will never be known as their deaths were not recorded by Australian health authorities. In some communities there were not enough people to remove the dead. Health care delivery was denied to Indigenous communities and Indigenous people were routinely turned away from hospitals.

In the context of the COVID-19 pandemic Māori and Aboriginal and Torres Strait Islander peoples have an acute sense of the threat of devastation of their communities, language, customs and particularly their elders as holders of Indigenous knowledge. They have lived experiences of current and historical impacts of colonisation and resultant social, economic and health disparities.

“We are seriously concerned that in these times of resource constraint and reprioritisation due to the COVID-19 pandemic, inequities will develop. Māori and Aboriginal and Torres Strait Islander peoples already experience significant health inequities in non-pandemic times. In a rapidly developing crisis and its recovery these inequities will be exacerbated. Not only will Indigenous groups experience inequities in terms of the virus itself, but also due to the secondary impact on non-COVID-19 illnesses and disease.

Dr Kelvin Kong, Worimi man and Ear Nose and Throat surgeon based in Newcastle, notes “that social isolation measures tend to be punitive and directed toward lower socioeconomic communities, particularly Indigenous people. This further marginalises our people and places them at higher risks of poorer health outcomes and financial stress, not to mention more unnecessary contact with the justice system. We strongly advocate for measures that help stop the spread of COVID-19, because of the devastating effects on our people, but managed in a sensitive way with co-design by Indigenous people.”

The Committee has issued some advice to RACS members to mitigate inevitable worsening of health inequities for Māori and Aboriginal and Torres Strait Islander peoples.

Dr Maxine Ronald says the advice includes ensuring principles of equity are embedded from the outset in all surgical initiatives, responses and systems.

“It’s also imperative to include Indigenous voices and perspectives in COVID-19 pandemic responses, initiatives and decision making at every stage of the crisis, but particularly as restrictions are lifted.”

She says the collection of high quality, ethnicity-based data is crucial. “Ethnicity data must be collected at point of testing for COVID-19. It must be of high quality and collected against nationally consistent criteria, to inform both the immediate response, and strategic directions to help Indigenous people recover from the potentially profound health, social and economic impacts of the pandemic.

“We’re also advising medical practitioners and decision makers to balance the risk of illness and spread of COVID-19 with the risk of cancer care not being treated optimally. Indigenous communities experience multiple and disproportionate barriers to access for cancer treatment and care. Consequently, these population groups are frequently diagnosed and receive treatment at a later stage, at a more advanced stage of disease and have worse cancer-related outcomes.

“Indigenous people have poorer access to early diagnosis of many forms of cancer and the types of cancer commonly diagnosed in Indigenous populations differ from that of non-Indigenous groups i.e. gastric and lung cancer is 3-6 times more common in Māori. Unless the risks of COVID-19 and optimal cancer care are balanced carefully, health outcomes for Indigenous cancer patients will worsen even more than before.”

“We are also encouraging the consideration of accelerated diagnostic and treatment pathways specifically for Indigenous patients. These will adjust for the delays in diagnosis and treatment so as to achieve outcomes comparable to non-Indigenous populations. Additional resources may be required to achieve equitable outcomes.

“As surgical leaders we have a responsibility and the ability to advocate for a response to COVID-19 which guarantees surgical conditions and procedures are delivered equitably to Indigenous people. Doing this will help ensure that all communities emerge from this global crisis as safe and as healthy as possible.”