McNoe and Reeder’s paper1 on sun protection policy in New Zealand has an important flaw. Although data was collected on ethnicity the paper did not include ethnicity in the analysis of the data. While it is accepted that New Zealand as a whole has a high incidence of melanoma, this is largely within the New Zealand European population that account for 79.9% of cases with low levels reported in Māori 0.7% and Pacific 0.2%, and probably even lower levels in people from Africa and the Indian subcontinent (5.7% other and 13.5% unknown).2 Even these statistics in New Zealand are difficult to interpret. As Callister noted3 “In New Zealand, where there is a high rate of ethnic intermarriage and ethnicity is culturally constructed, there is likely to have been a weakening of the relationship between ethnicity and skin colour”. It is entirely possible that the 0.7% Māori who get melanoma are all fair skinned.

Adherence to the sun protection policy is more important in schools with large proportions of New Zealand European children, and of less importance in schools with a high proportion of dark-skinned children. They did not use the ethnicity data to test the hypothesis that adherence to the sun protection policy was lower in schools with a high proportion of children with dark skin.

The sun protection policies advocated in this paper are essential for children with fair skin, and of diminishing benefit as the child’s skin gets darker, to the point where for very dark-skinned children they provide no demonstrated benefit. However, such policies will have an unmeasured adverse effect by promoting vitamin D deficiency. In a study at our practice (enrolled population around 7,000) on pregnant women,4 87% of women were deficient in vitamin D and a review of records found 10 children under five years old having been diagnosed with rickets in the previous three years. The practice has just 18% New Zealand European.5 It seems counter-intuitive to walk past Newtown School to see the Somali children with sun hats on. For more detail on effects of sun exposure and vitamin D deficiency, see New Zealand policy statement.6 Protecting children at low risk of developing melanoma from the sunlight that will increase their vitamin D levels risks causing harm. The logistics and costs of arranging supplementation make it unlikely to be effectively implemented.We could learn the lesson from the Sudden Unexpected Death in Infants (SUDI) experience. The initial public health response was effective in dropping the rate in the New Zealand European population, but for 10 years Māori had a rate twice that of the non-Māori population. A team of researchers addressed the problem from a Māori perspective7 and devised the ‘pepe pod’ that led to a dramatic reduction of SUDI in Māori.8 An earlier appreciation that a different public health approach was needed for Māori could have saved lives.

We are an increasingly multicultural society. We need to be more sophisticated in our health promotion policy and take care not to use a one-size-fits-all.

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McNoe and Reeder’s paper1 on sun protection policy in New Zealand has an important flaw. Although data was collected on ethnicity the paper did not include ethnicity in the analysis of the data. While it is accepted that New Zealand as a whole has a high incidence of melanoma, this is largely within the New Zealand European population that account for 79.9% of cases with low levels reported in Māori 0.7% and Pacific 0.2%, and probably even lower levels in people from Africa and the Indian subcontinent (5.7% other and 13.5% unknown).2 Even these statistics in New Zealand are difficult to interpret. As Callister noted3 “In New Zealand, where there is a high rate of ethnic intermarriage and ethnicity is culturally constructed, there is likely to have been a weakening of the relationship between ethnicity and skin colour”. It is entirely possible that the 0.7% Māori who get melanoma are all fair skinned.

Adherence to the sun protection policy is more important in schools with large proportions of New Zealand European children, and of less importance in schools with a high proportion of dark-skinned children. They did not use the ethnicity data to test the hypothesis that adherence to the sun protection policy was lower in schools with a high proportion of children with dark skin.

The sun protection policies advocated in this paper are essential for children with fair skin, and of diminishing benefit as the child’s skin gets darker, to the point where for very dark-skinned children they provide no demonstrated benefit. However, such policies will have an unmeasured adverse effect by promoting vitamin D deficiency. In a study at our practice (enrolled population around 7,000) on pregnant women,4 87% of women were deficient in vitamin D and a review of records found 10 children under five years old having been diagnosed with rickets in the previous three years. The practice has just 18% New Zealand European.5 It seems counter-intuitive to walk past Newtown School to see the Somali children with sun hats on. For more detail on effects of sun exposure and vitamin D deficiency, see New Zealand policy statement.6 Protecting children at low risk of developing melanoma from the sunlight that will increase their vitamin D levels risks causing harm. The logistics and costs of arranging supplementation make it unlikely to be effectively implemented.We could learn the lesson from the Sudden Unexpected Death in Infants (SUDI) experience. The initial public health response was effective in dropping the rate in the New Zealand European population, but for 10 years Māori had a rate twice that of the non-Māori population. A team of researchers addressed the problem from a Māori perspective7 and devised the ‘pepe pod’ that led to a dramatic reduction of SUDI in Māori.8 An earlier appreciation that a different public health approach was needed for Māori could have saved lives.

We are an increasingly multicultural society. We need to be more sophisticated in our health promotion policy and take care not to use a one-size-fits-all.

‍