366 days of gratitude

A text arrived from my GP’s surgery – I was due for a hepatitis A vaccine booster.

Injections aren’t something most people welcome and I wouldn’t say I enjoyed the experience today.

But I am grateful for medical science which means I’m protected from a disease which although not usually serious in most people can be fatal.

Nikki Kaye fighting cancer

Prime Minister John Key has announced that Nikki Kaye will be taking leave from her Ministerial portfolios after being diagnosed with breast cancer on Friday.

“I have spoken with Nikki and assured her she has the full support of her colleagues and I as she deals with this difficult diagnosis,” Mr Key said.

“Her medical team is working hard to ensure a full recovery. Nikki will be dedicating her energy towards getting well, and I wish her all the best.

“I appointed Acting Ministers to Nikki’s portfolios on Friday and this will continue until she is able to return to her role.”

Gerry Brownlee will act as Minister of Civil Defence. Nathan Guy will act as Minister for ACC. Anne Tolley will act as Minister for Youth. Ms Kaye’s Associate Education responsibilities will be taken by Hekia Parata.

I first met Nikki before she was elected, when she was campaigning to win the Auckland Central seat – which she did. I wasn’t surprised when the promise she showed then was rewarded with promotion to cabinet.

She is fit – she runs marathons – and determined and those will help her as she undergoes treatment and recovery.

Small failures

Hawke’s Bay District Health Board expects investigations will show a combination of small failures led to the gastroenteritis outbreak in Havelock North.

. . . The DHB’s chief executive, Kevin Snee, said he expected the government’s inquiry would show that there were small problems in the systems and processes used by the DHB, and by the district and regional councils.

He expected this to show that, when aligned, the problems allowed the water supply to become contaminated and people to get sick. . . 

This is so often the case, lots of small things add up to cause a big problem.

Earlier tests pointed to a ruminant animal as the cause of the outbreak.

Even before that was announced the usual suspects were blaming intensive dairy farming, in spite of there being none near the bore supplying the town.

. . . Federated Farmers president William Rolleston said the area near the aquifer was mostly lifestyle blocks and orchards.

He said people needed to take a step back from the speculation.

“We all contribute to bacteria in the environment, birds do, humans do and so do farm animals.

“Last week we saw a crescendo of finger pointing at agriculture, we heard that this was because of intensive dairy farms and the closest dairy farm we can find is 40 kilometres away.”

Mr Rolleston said while the indications did point to a four-legged animal as the source of contamination, that didn’t mean intensive agriculture was to blame.

He said the aquifer in question was a shallow aquifer, which had a greater risk of having its seals breached.

“We’re not saying that agriculture doesn’t create a risk, but those are the risks that the council needs to actually take cognisance of and mitigate.”

Last week the Green Party said any inquiry into the Havelock North water contamination should look at the role of intensive agriculture.

Mr Rolleston admitted agriculture was a risk for water.

“We’re not denying that and farmers have been up to the task. We’ve spent a billion dollars in the last decade fencing rivers and we’re playing our part.” . . 

Environment Minister Nick Smith also says speculation is unhelpful:

Questions have been asked about the culpability of cattle and chicken farmers, as well as a nearby mushroom farm, but Dr Smith says sometimes even the most basic failures could be to blame.

The campylobacter outbreak in Havelock North struck down 5100 people with gastro, closed schools and businesses and has left residents still boiling their drinking water weeks later.

It is a reminder of the E. coli contamination in Nelson where upstream farmers, birds and waterfowl were blamed before testing confirmed the true cause, Dr Smith says.

“It was embarrassingly found that most of the problem was toilets from the council’s library having been wrongly plumbed into the stormwater rather than the sewerage system,” he told crowds at a Lincoln University environment lecture in Christchurch on Tuesday night.

He said the lesson was to be cautious of jumping to conclusions too soon. . . 

He also addressed concerns about measuring water quality, limits on water takes and proposed strengthening of swimming requirements.

Dr Smith warned a goal of making all waterways swimmable, rather than wadeable, were “unworkable” and “impossible” without a massive bird cull.

But the Green Party has criticised that view as baseless.

“He knows, as we all do, that the real and lasting damage to our rivers is from stock in waterways, farm run-off, sewage and intensified dairy farms among others – he just won’t admit it,” Green Party water spokeswoman Catherine Delahunty said. . . 

Tests above and below a dam on our farm confirmed birds were at the bottom of poor water quality.

The Otago Regional Council also proved seagulls were to blame for high levels of E.coli in the Kakanui River.

Up until recently, ORC staff and local farmers alike had been baffled about the cause of such high concentrations in the upper Kakanui, particularly during summer.

ORC staff have been concerned about the concentration of the bacteria, as high levels indicate a risk of people swimming becoming ill. The council enlisted the help of local farmers, who provided access to their properties and the nearby river for inspection.

ORC scientists went into the gorge to investigate by helicopter when this inspection failed to identify the source of the bacteria. The culprits − a large colony of nesting gulls − were found in rugged terrain, about 5km above the Clifton Falls bridge. Water quality samples were taken immediately above and below the colony, with divergent results.

Upstream of the colony, the bacteria concentrations were 214 E.coli/100ml, whereas immediately downstream, the concentration was far greater at 1300 E.coli/100ml.

The levels peaked on January 3, at 2400 parts per 100ml of water. ORC manager of resource science Matt Hickey said that according to Government water quality guidelines for recreational swimming areas, those with less than 260 E.coli/100ml should be safe, whereas water with more than 550 E.coli/100ml could pose a health-risk.

Mr Hickey said six colonies of gulls were found in total, on steep rocky faces, where they clearly favoured the habitat for nesting. While they had gone undetected up until now due to their inaccessibility, it was likely the gulls returned each year to breed.

“Unfortunately, these nesting gull colonies are likely to continue to cause high E.coli concentrations in the upper Kakanui River, particularly during the breeding season,” Mr Hickey said.

These are only two examples which show Delahunty is wrong to say birds aren’t a problem.

That doesn’t mean farming, especially when it’s intensive, is blameless.

There are many causes for poor water quality but many have happened over time and it will take time to get the improvements we all seek.

That is much more likely with the collaborative approach the Minister seeks:

New Zealand had a habit of turning environmental issues into a battle ground with winners and losers where farmers are seen as environmental vandals and environmentalists as economic imbeciles, Dr Smith said.

“I have been trying to lead a culture change at both a national and local level where different water users and interest groups work together on finding solutions that will work for the environment and the economy,” he said.

It doesn’t have to be either a healthy environment or a growing economy.

A collaborative approach, based on science, can achieve both.

Science must also be applied to the cause, and response to, Havelock North’s problems to ensure that a series of small failures doesn’t lead to large-scale gastroenteritis again.

What about the doctors?

Proponents of euthanasia argue that people have autonomy over themselves which includes the right to die.

They rarely look at the debate from the point of view of doctors who would prescribe lethal doses of medication or administer them.

At The Spinoff, Medical Association chair Stephen Child gives that perspective:

For many, the key discussion point is whether it is possible to write and administer perfect legislation that permits someone autonomy at the end of life without the secondary negative consequences of:

• inappropriate deaths
• reduction in quality of palliative care
• normalisation of suicide.

Both sides of this debate will emphasise anecdotes, surveys or “research” demonstrating cases of potential intolerable human suffering, or cases of coercion/inappropriate decision making, resulting in potentially unnecessary death. . . 

The ethical standards of a profession often go beyond public opinion, the law and market demands, and may also differ from the personal values held by some individuals within that profession. The role of professional ethics, however, is not only to prevent harm and exploitation of the patient but also to protect the integrity of the profession as a whole. This often requires the professional body to fulfil a leadership role to ensure clarity and provide direction.

The NZMA, along with the World Medical Association and 53 national medical associations, holds the following positions on voluntary euthanasia and assisted dying:

• We recognise the rights of patient autonomy, so we recognise the right for society to have this discussion. We also acknowledge that people currently have the right to end their own life and that this legislation focuses on third-party assistance with this act.
• We recognise the rights of patients to refuse treatment or for the removal of lifesaving treatment, and that the natural consequences of an illness may progress to death.
• We recognise the rights of patients to have good access to high quality palliative care services and we passionately advocate for improved resources, education, workforce and facilities to achieve this goal. We strongly oppose the current necessity for our major hospice facilities in New Zealand to have to raise half their funds themselves.
• We recognise the patient’s right to have administered analgesia and sedation to relieve pain and suffering – even if a secondary consequence of this is the shortening of life. Morphine is not an agent of euthanasia, and will not by and of itself reliably end the life of a patient. These agents are administered to relieve suffering, applying a risk/benefit analysis similar to all treatments, with a shared understanding of the potential risks in their prescription.

It might look like dancing on the head of a pin but there is a difference between giving something to alleviate pain and suffering in the knowledge it could hasten death and giving to deliberately kill.

. . .  Many people, however, still find confusing the difference between the concept of administering terminal analgesia/sedation to a dying patient, and that of administering voluntary euthanasia to a patient with concurrently stable physiology. The difference between palliative care and assisted dying is well documented and clear. The World Health Organisation definition of palliative care includes the statement that palliative care “intends to neither hasten nor postpone death”.

In jurisdictions where euthanasia and assisted laws exist, concern is growing about the impact on palliative care, where those seeking euthanasia are referred first to palliative care for assessment. This has led to confusion in patients as to the role of palliative care and – in some instances – patients who are opposed to euthanasia declining palliative care services.

The profession as a whole has also echoed concerns about the accuracy of diagnosis and prognosis, as well as the lack of certainty around measuring the capacity of patients facing terminal illness, who often also have reactive depression, altered brain physiology from medications or metastases, as well as potential external coercion factors.

For the profession, as well as ethical considerations, physician-assisted dying raises issues of:

• potential impacts on palliative care delivery
• potential changes to a doctor-patient relationship
• difficulties with adequate training, assessment and regulation of the profession
• potential negative impact on health providers participating in such acts.

Principles of autonomy and self-determination are, of course, central to this debate. The NZMA respects and supports patient autonomy but is concerned about relying on these principles to enact euthanasia or assisted suicide. Principles of autonomy demand full knowledge of risks and alternatives, and consent must be free of coercion, duress or undue influence.

An absolute guarantee that those who choose assisted dying are doing it voluntarily would be extremely difficult to establish in legislation and ensure in practice. Doctors are often not in a position to detect subtle coercion – as is also the case when trying to identify signs of emotional or financial abuse of elders more generally. Coercion also extends to assumptions of being a burden, giving rise to a sense of an “obligation” to die.

Given the gravity of the risk involved for individuals where autonomy is claimed but cannot be guaranteed, the belief that autonomy should trump all should be viewed with caution. . . 

 

I gave doctors permission not to keep trying to save the life of our first son and seven years later asked them not to call the crash team when our second son stopped breathing.

Both had degenerative brain disorders and any treatment would have only prolonged their suffering and postponed their inevitable deaths.

If I faced the same decisions in the same circumstances I’d do the same thing.

That isn’t euthanasia though.

It’s also very different from an adult in full control of their minds who requests the right to die and I understand how the fear of  what might be ahead could lead someone to that decision.

But legalising euthanasia isn’t only about fully competent individuals who want the right to control their lives and deaths.

It’s also about others who might feel pressured to choose a premature end or who might forgo high quality palliative care for fear euthanasia will be an inevitable consequence.

And it’s about medical professionals and what it asks of them too.

In abridging the article from which I’ve quoted, I missed a paragraph on surveys carried out in Canada, New Zealand and the United Kingdom. Each survey showed while roughly 30% of doctors agree “in principle” with the concept of assisted dying only 10% would feel comfortable in participating.

That’s what is often missed in the debate. It’s not just about the right to die and the patients, it’s also about the right to kill and the doctors.

P.S.

There’s an assisted suicide table-talk in Auckland tonight:

Broadcaster and comedian Jeremy Elwood hosts the Ika-Spinoff.co.nz current affairs cabaret, Table Talk, on the subject of Assisted Suicide. Join panelists David Seymour MP, promoter of the End-of-Life Choice Bill; Dr Jan Crosthwaite, University of Auckland Proctor and formerly Department of Philosophy; and Dr Stephen Child, Chair of the NZ Medical Association for a free-ranging discussion of a topic that defies politics.

Enjoy the full & delicious Ika menu, join a table or book for a group. Doors open and bar and dinner service from 5.30 pm, the discussion will start at 7.30 pm.

Follow the discussion on the TheSpinoff.co.nz

WHEN
August 30, 2016 at 5:30pm – 10:30pm

WHERE

Ika Seafood Bar and Grill
3 Mt Eden Rd
Auckland 1023

Anti-farming bias won’t wait for facts

Contamination of Havelock North’s water supply is a serious health issue which has prompted the government to undertake an inquiry.

In announcing the draft terms of reference for it, Attorney General Christopher Finlayson said:

“It is important that New Zealanders have confidence in the quality of our drinking water, and the independent inquiry will ensure we have a clear understanding of what happened in Havelock North,” says Mr Finlayson.

“Cabinet has today agreed to initiate a Government inquiry which will report to me as Attorney General.

“The inquiry will look into how the Havelock North water supply became contaminated, how this was subsequently addressed and how local and central government agencies responded to the public health threat that occurred as a result of the contamination.

“The terms of reference are very wide and will include any lessons and improvements that can be made in the management of the water supply network in Havelock North and, more broadly, across New Zealand.”     

Cabinet will consider over the coming weeks who will lead the Government inquiry.

The inquiry will be undertaken under the Inquiries Act 2013. This will ensure it follows a clear statutory process and will have a range of powers such as the ability to call witnesses.

The need to wait for facts hasn’t stopped the usual anti-farming suspects rushing to blame farming in general and dairying in particular for the contamination and using it as an excuse to call for the end to irrigation development.

Federated Farmers’  Hawke’s Bay president Will Foley said while there was some livestock farming in the area it wasn’t intensive:

. . . Basically in terms of the area around Havelock North there just isn’t intensive livestock farming.

He said farmers were watching the situation but there had not been any discussions yet.

“Really we’re just waiting to see some more clear evidence as to how the contamination occurred. And then if it was something related to farming livestock, then we can react to it then and I guess change practises if that’s what it turns out to be.”

IrrigationNZ points out that a focus on science and proven solutions is needed in the response to the Havelock North water crisis.

“IrrigationNZ is very concerned, as is everyone else, about the situation in Havelock North. However, we are surprised by some of the accusations now being made around intensive livestock and irrigation, particularly as the area surrounding the water supply well is dominated by orchards, cropping and low intensity livestock.”

“Before jumping to conclusions we first must understand the facts. A thorough inquiry will establish how groundwater in the area has become contaminated but this will take time. In the short term we should be moving towards best practice when it comes to protecting public water supplies from contamination,” says Andrew Curtis, IrrigationNZ CEO.

Fact 1;

Pathogen contamination almost always results from a point source or a preferential flow scenario.

“The issue will likely be either a preferential flow scenario down the side of an old well case (particularly around older bore casings), a poorly constructed or sealed well head or backflow (contamination making its way directly into bores). Another scenario could be point source from the stock piling of manure. During periods of heavy downpour, contaminants can move through the soil and then there is a risk,” says Mr Curtis.

Fact 2;

Grazing livestock or irrigation are unlikely to be the cause.

“The Havelock North end of the Heretaunga plains is an area of low intensity livestock. Dominated by orchards and seasonal cropping, with sheep grazing in winter there is no dairy or intensive livestock,” says Andrew Curtis.

Livestock grazing is extremely unlikely to have caused this issue – the pathogens don’t make it through the soil, the soil acts as a filter – research work undertaken by ESR has previously shown this to be true.”

Solutions to prevent contamination of groundwater?

Proven solutions include good management practice at both the supply point and any nearby wells.

“Well head protection is essential for all bores and this needs to be better enforced for older bores. Additionally, we need to be looking at requiring back flow protection where applicable. INZ has produced guidelines for backflow prevention that are based on international best practice for agriculture. On top of this, the council needs to be managing nearby point sources where, if heavy rain occurs, leaching could result. Basically all wells near public water supplies should be properly protected.”

“A best practice approach to managing the threats to public water supplies needs to be implemented across New Zealand. There will always be risks from avian, ruminant and human sources so we need to be identifying all the contamination pathways. We need to let the experts get on with their jobs and not take cheap shots with un-informed accusations,” says Mr Curtis.

It’s understandable for the people of Havelock North to be upset about their water and everyone wants to know what caused the problem and what can be done to prevent it happening again in the area or anywhere else.

But that’s not an excuse for the usual suspects to use the issue for their own political agenda without waiting for the facts. In doing so they’re show their anti-farming bias.

We could forget about feeding people and earning the export income we need for a happy, healthy, well functioning country as those of a very dark green persuasion would have it.

We could produce a lot more food and seriously degrade the environment with no concern for the future, a path for which I haven’t heard anyone advocate.

Or we could use science to produce food sustainably which requires good environmental practices based on science.

If poor farming practices are degrading the water we can do something about it but let’s wait for the inquiry and base any required action on the facts.

 

Shunning science shameful

A nurse has been given a suspended sentence after pleading guilty to recklessly causing grievous bodily harm and failing to provide for a child.

A Sydney mother who put her baby in danger of starvation by breastfeeding while on a raw food diet has been handed a 14-month suspended sentence.

The 33-year-old woman, who cannot be identified, was last year trying to treat her six-month-old son’s severe eczema and sought the advice of a naturopath who allegedly first put her on the diet and later convinced her to consume only water.

The woman’s son nearly died of starvation and dehydration as a result.

The Director of Public Prosecutions (DPP) lawyer, Alex Brown, told the Campbelltown Local Court that the woman “was a nurse who decided to blindly follow a naturopath she had only just met” and that her child came within days of death. . . 

Severe eczema is horrific and difficult to treat.

When you’re sleep deprived, desperate to help your baby and conventional medical solutions don’t help it’s not unusual to seek unconventional solutions.

But it’s difficult to understand how a nurse could shun science and her own training by following such dangerous advice and fail to recognise her baby’s failing health.

News reports don’t mention the baby’s father or other family. Perhaps the mother had no other support and no-one else to help her or who would have observed the baby’s deteriorating health.

The naturopath has pleaded not guilty to the charges. How on earth can she defend the indefensible?

Alternative practices sometimes do no harm and some alternative advice might work.

I use Lavish Soap’s goats milk and flax seed oil cream for eczema. It can’t be advertised as a treatment because it hasn’t gone through the necessary scientific research but it stops the itching and even if it didn’t it wouldn’t kill me.

But some alternative practitioners let their own unfounded beliefs blind them and they’re particularly dangerous when giving advice to new parents and those expecting babies.

Earlier this year, Waitemata DHB had to investigate a staff member who handed out “dangerous” advice to pregnant women.

. . . Lesson handouts advised women to take castor oil or acupuncture to bring on labour and compared medical induction to forcing a butterfly out of its cocoon early. “A ‘helped out’ butterfly may never fly,” it reads. . . 

Shunning science when it could endanger lives is shameful.

Green’s red roots showing

Does the Labour Party know about the Green’s proposal to socialise all health services?:

. . . Green Party health spokesman Kevin Hague said he would get rid of private healthcare altogether. 

“I think that distorts the health sector completely and produces a two-tier system.” . . .

This not only shows the Green’s red roots, it also shows a woeful understanding of how the health sector works.

Medical specialists usually work in both public and private hospitals. The work they do in private hospitals, paid for by individuals or insurance companies, takes pressure off public services.

ACC also uses private specialists to get people back to work sooner than if they had to go on public waiting lists.

But private healthcare isn’t just medical specialists in private hospitals. It’s general practitioners, dentists, orthodontists, optometrists, physiotherapists, radiologists, laboratories  . . .

Does Hague really think all these services should be publicly owned and funded?

The Memorandum of Understanding between Labour and the Green Party included a no surprises clause.

Last week Metiria Turei announced the desire to slash the value of houses by 50%. This week Hague is planning to socialise all health services.

I suspect both came as a surprise to their would-be coalition partner.