Orr-Walker says at the current rate, it's only going to get worse. He stresses the urgency of the problem for Māori and Pasifika. 

"For a long time we've said that type 2 diabetes is a tsunami. It is a disaster in slow motion. But unfortunately, the 'slow motion-ness' of it means that it's just a little easy to forget about and not act with sufficient urgency."

"Mission million"

How did it get this bad? Well, racism.

Selah Hart is the chief executive of Hāpai te Hauora, an Auckland-based organisation that advocates for Māori public health outcomes. She says the current statistics show that the health system has continued to fail Māori and those in lower socioeconomic brackets. 

"The writing's clear as day on the wall that the system has been fragmented, it is what many are referring to as a postcode lottery. But I think we could go even deeper into that. It isn't just the postcode lottery, it isn't just based on where your residential address is, it's actually also based on the ethnic group that you belong to, because we know that there are inherent biases in the system."

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A University of Waikato study published in 2020 found that Māori patients receive fewer prescriptions of metformin, a common diabetes drug, than non-Māori patients and have worse blood sugar control as a result. It showed that while Māori received fewer prescriptions than non-Māori, there was no difference in adhering to prescriptions, likely due to access to prescriptions rather than the medication dispensing. 

"Māori were less likely to receive the five to seven prescriptions needed to maintain 100% medication cover; however, once prescribed, metformin dispensing was not different from other ethnic groups." 

This study backs up a 2018 Pharmac-commissioned University of Auckland report which showed that in 2012/13, Māori received pharmaceutical treatments at a rate 41% below what non-Māori would when presenting with the same health needs. The drivers of such inequities, it said, were "complex and entrenched" - the result of historical and contemporary social, political, cultural and economic processes. A "deeper understanding of systems and barriers" was needed to overcome medicine inequities. In the Māori health sector, this is known as the 'mission million.' 

While neither study addressed the reasons for fewer prescriptions in detail, Dr Lily Frazer says it's unconscious bias from doctors. She says doctors must consider their assumptions when treating each patient.

"Have I already decided for this person just based on their ethnicity or based on their name or based on their address that they're not going to take it and so I'm not even going to offer it? That definitely happens in health, from GPs from, all medical professionals, really."

When Roimata Smith recalls the day the doctor called her fat and didn't prescribe her diabetes medication, she says she knows why he treated her the way he did. 

"It's the colour of my skin ... but then they shouldn't be looking at the colour of your skin."

Good kai, bad kai

Over the last 200 years, Māori eating habits have undergone a significant transformation. Pre-colonisation, research shows that the traditional diet for Māori was typically low in carbs and consisted of meat, vegetables, and seafood that were either hunted or harvested. Wheat, potatoes, maize, and other vegetables were introduced by Pākehā settlers and quickly embraced by Māori. Since the US implemented low-fat, high-carbohydrate dietary recommendations in the 1970s, there has been an enormous rise in obesity and the comorbidities that go along with it globally.

Since 2015, Frazer's clinic has been recommending a low-carb, ketogenic fasting diet to treat type 2 diabetes patients, which she sees as similar to how her tīpuna (ancestors) ate. She says it's not fat causing insulin resistance; it's carbohydrates and sugars.

"I don't think our tīpuna were getting up and having a big breakfast or a breakfast, morning tea, lunch, afternoon tea, and dinner. ... and obviously, our kai was unprocessed, whole foods and the healthy fats that come with the bird or come with the fish.

"It's capturing the lessons of that style of eating and being more in tune with the environment."

Even over her lifetime, she says the way people eat and drink has changed significantly, impacting the rise in type 2 diabetes.  

"The access to sugary drinks, lollies not being just for a party, but just being a food, frequent takeaways, all those things have an impact."

She is hopeful that the new health system will recognise the role this way of eating plays in managing type 2 diabetes.

"I'm hopeful that in this revamp of the health system, that somewhere in there somebody is really looking seriously at the kai that we recommend for whānau who have type 2 diabetes."

But Hamilton-based Māori nurse, Hinemanu Kelly, says the patients she sees can't afford healthy foods.

"All the time when I talk to people about making some changes to their menu, there are a good amount of them that will say 'oh we can't get fruit or veggies because they are too expensive'. Because at the end of the day they go and buy what is on special and right now fruit and veggies are just so expensive so it's definitely not a priority for our unwell whānau to be buying stuff they can't afford."

Roimata Smith is currently on the job seekers' benefit. After emergency housing payment deductions and other medical bills, she only has $150 each week to live on. 

She budgets $30-$50 for food each week, which, with the current cost of living crisis, doesn't go far, however hard she tries. 

"I can't afford veggies, meat. If I can't afford it, I don't buy it. I just stick with canned food ... not that I like it."

Opening a can of spaghetti or baked beans is a typical dinner for her. 

Whakawhanaungatanga

To help the lifestyle change needed to manage type 2 diabetes, Turuki Health in Māngere employs health coaches. 

"Lifestyle change is a journey, and It's not going to happen over a 15 minute consultation with a GP, because you just don't have the time, or the accessibility to the doctor to be able to make those sustainable changes." says Frazer. 

She believes their care method is working for Māori. It's a system based on whakawhanaungatanga, establishing and building relationships with the people she cares for.

"We always say that relationships are at the heart of successful change and so that's something we do focus on for everybody at Turiki."

Frazer also stresses that when whānau are diagnosed with type 2 diabetes, they should not be made to feel it is their fault. 

Clinical director of Waipuna at Waipareira Health in Henderson, Dr Zarah Allport, says healthcare practitioners must look at whānau with uncontrolled diabetes from a holistic point of view. 

"You have to say, 'what's going on for you that is making this a problem?' Is it a) that you don't have enough understanding around this that you haven't been getting enough support to understand your diagnosis? Is it b) you don't actually have the money to eat healthily and have a diabetes right diet? Or is it c) that you've actually had a really difficult experience with a health practitioner, and now you don't have any trust in that system."

She says it's usually all of the above.

'There's no quick fix to cure diabetes' - Te Aka Whai Ora CEO

In October this year, Te Whatu Ora and Te Aka Whai Ora (Health NZ and the Māori Health Authority) released Te Pae Tata, the interim New Zealand Health Plan, which sets out the priorities for the next two years and replaces 20 different district annual plans from the old district health boards. 

The plan has six key priorities, one of which is Māuiuitanga taumaha - people living with chronic health conditions, which includes diabetes. 

Chief executive of Te Aka Whai Ora, Riana Manuel, has some big aspirations when it comes to improving chronic conditions among Māori. But there's a catch - she says it will take time. 

"You can't just look at this problem and go: 'Oh it's a one-dimensional fix, we just need to apply more medication, or we need to have more access to GP services.' Actually, we need lifestyle changes. Chronic disease is about the big, gnarly, transformative things that take time. They're not often popular things. There's no quick fix to cure diabetes," Manuel says.

"We know that we can make a huge impact in chronic conditions, when our people are living in better housing, when they have better economic basis, that then allows them to buy good kai that is going to be better for them ... but that takes time."

She says the way they will do that is to drive better health literacy for Māori, better access to a range of services, increased screening for chronic conditions and improvement on social determinants, like housing and poverty.

"Poverty will always drive poor health outcomes. That's just a fact. If you cannot afford the things you need to live the kind of life that you need to lead, then that's going to be problematic."

How will Te Aka Whai Ora improve social determinants? 

"By working together across the sectors to make sure that we can actually implement things that are going to be really meaningful to turn that around."

The interim health plan says it will also "implement accessible and nationally-consistent clinical pathways for diabetes, cardiovascular diseases, respiratory conditions, stroke and gout, supporting specialist teams to integrate with primary and community care providers to create seamless pathways for whānau."

Back in Roimata Smith's living room, she is just starting to regain trust in the healthcare system after the shocking incident where a doctor called her fat. 

These days, she has a new GP, a Māori woman, and a Māori mobile nurse who comes and visits her in her whare.

As for the racist doctor she met, she says she hopes he's the last one that she comes across. 

"I don't want to go through that with any other doctor like that. I wouldn't expect anyone else would want to either."

Reporting by Ella Stewart

Photography and Video by Cole Eastham Farrelly

Executive Editor John Hartevelt