Gout in M ori

Rheumatology Advance Access published September 24, 2013 RHEUMATOLOGY Editorial 266 doi:10.1093/rheumatology/ket299 EDITORIAL Gout in Māori Modern affliction or ancestral trait? there were reports of gout in Māori men in regional newspapers (http://paperspast.natlib.govt.nz/cgi-bin/paperspast). For example, the northern chief Paora (Paul) Tuhaere was repeatedly reported to suffer from gout. In 1879 he was part of an official party and was ‘mounted on a charger, as he suffer[ed] acutely from gout’ (http://paperspast.natlib.govt.nz/cgi-bin/paperspast), and in 1884 a further attack of gout forced him to abandon the notion of visiting England (http://paperspast.natlib.govt.nz/cgi-bin/ paperspast). This account states that the natives believed that the government prevented Tuhaere’s visit by employing other Māori to curse him and give him rheumatism and gout (http://paperspast.natlib.govt.nz/cgi-bin/ paperspast). This supports the idea that Māori may have perceived gout as caused by more spiritual means. Rose [1] argues that because gout was familiar to European colonists, they would have recognized it in Māori and the historical accounts denying its presence among Māori are therefore credible. However, since the perception at the time was that gout was a disease caused by affluent lifestyles, gouty pathologies observed in uncivilized countries may not have been regarded as the same disease and were described instead as rheumatism. Garrod, who was a contemporary authority on gout stated ‘among nations in an uncivilized state . . . gout . . . is entirely unknown . . . but in our own country [England], and in many other parts of the civilized world, the case is far otherwise’ [8]. In 1914 Wohlmann observed that ‘nowhere else in medicine is there such confusion of terminology. Thus the unqualified names gout, rheumatism and rheumatoid arthritis are almost without meaning, for they may bear absolutely different interpretations to different readers’ [9]. Indeed, this perceived link between gout and social status is evident in the contemporary literature from New Zealand; in a description of court proceedings published in 1865, the link between gouty pathology and social status was made in conjunction with a Māori chief, with the reporter commenting that the chief, Winiata, was probably ‘aware of this complaint being a sign of good blood’ (http://paperspast.natlib.govt.nz/cgi-bin/ paperspast). An attending physician, Dr Nicholson, was quoted as saying that ‘it was the only case he had ever met with among the natives, and is conclusive evidence that we can boast of the best blood among our Kaipara [region in northern New Zealand] natives’ (http:// paperspast.natlib.govt.nz/cgi-bin/paperspast). Newman stated that ‘not one of all the descendants of the ! The Author 2013. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com 1 Downloaded from http://rheumatology.oxfordjournals.org/ by guest on September 24, 2013 There is an established viewpoint originating from Rose [1] that the high prevalence of gout in contemporary New Zealand Māori is attributable primarily to modern diet. However, recent bioarchaeological studies of prehistoric Māori have identified bony lesions consistent with gout [2, 3]. Of the 42 individuals studied from a 13th century South Island site, Wairau Bar, six males (14%) possessed these lesions [2]. Eleven of the 53 (21%) adult individuals from a 17th century Ihumatao site in Mangere, Auckland, showed evidence of gout [3]. The tendency towards males possessing the lesions and the location of the lesions predominantly on the margins of the first metatarsophalangeal joint in both assemblages are consistent with gout. Urate has not been recovered from the lesions, however, this is probably a result of post-excavation treatment of the assemblages. For instance, the Wairau Bar remains were curated by the Canterbury Museum for years prior to analysis and repatriation. The individuals from Wairau Bar were likely part of an immigrant population, making them among the first New Zealanders [2], whereas the Ihumatao site dates to a period [3] when Māori populations were well established and had developed a horticultural diet. Recent evidence that the Māori suffered from gout prior to contact with Europeans challenges the view that the elevated prevalence of gout in modern Māori is a recent phenomenon. It is important that this is reconciled in order to better understand the causes of gout in Māori, both pre- and post-European contact. A confounding factor in the reporting of gout in New Zealand during the early 19th century could be co-existing schools of medical thought. Westernized medicine, placing the causation of disease on a biological basis and the pre-existing Māori perception that there was no natural disease, illness was a result of either transgression against an atua (god) by the breaking of tapu (law) or the result of makutu (witchcraft) [4]. Illnesses were considered either mate Māori (traditional Māori conditions) or mate Pakeha (European-introduced diseases), influencing who Māori consulted for treatment [5]. Gout was therefore less likely to come to the attention of British physicians because Māori considered it an inherent disease. The earliest enquiry into Māori health was by the physician Fairfowl in 1821 [6]. Gout was not mentioned in his report, although rheumatism was reported as prevalent [6]. This apparent high frequency of rheumatism was also commented on by others, including Thomson [7], but again, no mention of gout was made, with Thomson stating that gout was unknown among Māori [7]. However, Editorial canoes that came from Hawaiki ever suffered from gout. Imagine an old Māori Chief suffering from rich gout, when he had for food irregular and scanty allowances of fern root, dried eels . . .’ [10]. Clearly the Māori lifestyle did not align with British expectations of gout, thus they may not have diagnosed it on these grounds, ascribing any gouty episodes to the broader term of rheumatism. There is no way to determine whether the prevalence of gout in Māori has been previously understated due to misdiagnosis. However, the underrepresentation of gout as a serious pathology in Māori as reported in historic documents is likely related to a combination of factors, including a lack of comprehensive epidemiological studies of populations prior to the mid-20th century, the Māori viewpoint on the cause of gout and the perceived prerequisite lifestyle conditions for the development of gout, leading to a misdiagnosis of the condition as rheumatism in Māori. Therefore we argue that rather than being attributed primarily to the adoption of a westernized diet, Māori, like other Oceanic populations, have a long history of gout. While their diet has changed considerably since European contact, with the introduction of alcohol and, more recently, fructose-containing beverages, it is likely that the pre-contact Māori diet included seasonal consumption of high fructose foods such as the ti (New Zealand cabbage tree; Cordyline australis) rhizomes and the drupes of the karaka tree (Corynocarpus laevigata), as well as year-round consumption of purine-rich seafoods, all of which contribute to increased serum urate levels. The prehistoric presence of gout has implications in our understanding of the risk of disease, and wider recognition of this would allow better focus on the range of factors contributing to gout in Māori, including inherited genetic variants. University of Otago, Dunedin, New Zealand. Accepted 24 July 2013 Correspondence to: Anna L. Gosling, Department of Anatomy, University of Otago, 913 Dunedin, 9054 New Zealand. E-mail: anna.gosling@anatomy.otago.ac.nz *These authors contributed equally to this study. References 1 Rose BS. Gout in Maoris. Semin Arthritis Rheum 1975;5: 121–45. 2 Buckley H, Tayles N, Halcrow SE et al. The people of Wairau Bar: a re-examination. J Pac Archaeol 2010;1:1–20. 3 Campbell M, Hudson B. The NRD site community report. Auckland, NZ: CFG Heritage Ltd, 2011. http://www. cfgheritage.com/2011_36nrd_communityreport.pdf (23 August 2013, date last accessed). 4 Buck P. Medicine amongst the Maori in ancient times, the effect of civilisation and the present conditions of the race. Auckland: University of New Zealand, 1910. 5 Best E. Maori medical lore. Notes on sickness and disease among the Maori people of New Zealand, and their treatment of the sick; together with some account of various beliefs, superstitions and rites pertaining to sickness, and the treatment thereof, as collected from the Tuhoe tribe. Part I. J Polyn Soc 1904;13:213–37. 6 Fairfowl, McNab R. Evidence given before Commander Bigge. Wellington: John Mackey, Government Printers, 1908:550–8. 7 Thomson AS. On the peculiarities in figure, the disfigurations, and the customs of the New Zealanders; with remarks on their diseases, and on their modes of treatment. Br Med Chirurg Rev 1854;14:356–63. Disclosure statement: The authors have declared no conflicts of interest. 8 Garrod AB. Observations on certain pathological conditions of the blood and urine in gout, rheumatism and Bright’s disease. Med Chir Trans 1848;31:83–97. Anna L. Gosling1,2, Elizabeth Matisoo-Smith1,* and Tony R. Merriman2,* 9 Wohlmann AS. The mineral waters and spas of New Zealand. Wellington: John McKay, Government Printer, 1914. 1 Allan Wilson Centre for Molecular Ecology and Evolution, Department of Anatomy and 2Department of Biochemistry, 2 10 Newman A. Annual General Meeting—Wellington Philosophical Society. Trans N Z Inst 1879;12:432–8. www.rheumatology.oxfordjournals.org