Good health is not just a matter of biology and genes. The time, place and conditions people live in, and their life experiences and choices, all help determine their health status. In New Zealand, people’s health may be affected by household income, employment status, working conditions, education, diet, housing, environment, family and cultural networks, and tobacco smoking, as well as age, gender and hereditary factors. Socio-economic and ethnic inequalities are closely related to health.
Traditionally, good health was viewed as the absence of illness. In the 1940s the World Health Organization defined health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.1 This definition was still used in New Zealand in the 21st century.
Life expectancy and mortality trends are key measures of health status in the 21st century. However, increasing emphasis is placed on quality of life. Independent life expectancy indicators measure how many years people can expect to live free of limitations on daily activities, and without needing assistance. In 2013 the average independent life expectancy at birth was 65.2 years (compared to 79.5 years of total life expectancy) for New Zealand men, and 66.5 years (compared to 83.2 years of life expectancy) for New Zealand women.
In the 21st century doctors sometimes write out ‘green prescriptions’, which advise patients to be physically active. Research has found that green prescriptions are a cheap way of increasing activity and exercise levels and improving quality of life.
Though lack of illness is only one way of defining health, changes in the types of disease that cause illness and death remain an important way of understanding changes in the health profile of New Zealanders. Infectious disease as a cause of death declined from the late 19th century. This was associated with decreasing child death rates in that period. Deaths from non-communicable diseases such as cancer increased as the population aged and lifestyles changed. For Māori these changes occurred decades later.
Socio-economic status (based on factors like income, occupation and education) is a key determinant of health. People living in favourable circumstances continue to experience better health than people living in poverty, within a context of rising living standards, improvements in life expectancy, changing causes of illness and death, and developments in medical technology since the 19th century. Health inequalities between rich and poor are found in every area and for almost all diseases.
Researchers have argued about how socio-economic factors affect health, but accept that there is a connection. It is likely that a combination of material poverty (such as poor housing and nutrition) and stress caused by low social status results in health inequalities.
The New Zealand Index of Deprivation uses census data based on income, family status, employment status, qualifications, accommodation, communications and transport to create a scale of socio-economic status. This is applied to neighbourhoods. Decile one is the least deprived and decile 10 the most deprived. There is a strong correlation between deprived areas and the health status of their residents.
Life expectancy and mortality trends are common ways of measuring health status and monitoring inequality. Life expectancy is lower in more deprived areas. In the early 2010s there was an eight-year life-expectancy gap for males and a six-year gap for females between the least and most deprived neighbourhoods.
While all-age mortality rates fell at much the same rate for all income groups in the 1980s and 1990s, the gap between the rates for low- and high-income earners (which researchers call the ratio of mortality) widened over this period. While the overall drop in mortality rates was a positive change, the widening relative gap was not. However, the gap did not increase in the 1990s and early 2000s.
Researchers have suggested that increased income inequality in the 1980s and 1990s (associated with structural reform of the economy) contributed to increased inequality in mortality rates. However, they point out that this inequality also increased in other comparable countries at the same time, and the change was no faster in New Zealand than in countries that did not reform their economies.
Ethnicity is a critical component of health inequalities. Māori and Pacific people have had consistently poorer health than other ethnic groups since the 19th century. Though this is linked to socio-economic status, both populations still have poorer health when factors like income, occupation, education, neighbourhood and personal behaviour are accounted for. Explanations for this include institutional racism (where organisations and structures discriminate against certain ethnic groups, either overtly or unintentionally) and for Māori, the ongoing effects of colonisation.
In the 2010s Māori and Pacific people were over-represented in negative health statistics, but under-represented in health-sector employment. In the 2013 census 14.9% of New Zealanders identified themselves as Māori and 7.4% as Pacific people. However, in 2013 only 2.7% of doctors were Māori and 1.8% were Pasifika. In 2015 6.5% of nurses and 9% of midwives were Māori, while 2.6% of nurses were Pasifika.
Life expectancy for Māori improved dramatically over the 20th century, and the considerable gap between Māori and Pākehā life expectancy narrowed rapidly after the Second World War. Non-Māori life expectancy increased rapidly in the 1980s and 1990s, but the increases for Māori were small. However, the gap narrowed in the early 21st century. In 2012-14 life expectancy at birth was 83.9 years for non-Māori women, 80.3 for non-Māori men, 77.1 for Māori women and 73 for Māori men. Life expectancy at birth was 78.7 years for Pasifika females and 74.5 years for Pasifika males.
In the early 21st century Māori had the highest all-age mortality rates, followed by Pacific people. The gap in mortality rates between these two groups and Europeans and others (mainly Asians) widened in the 1980s and 1990s. This was probably related to the economic restructuring of the time, which had a big impact on Māori and Pasifika employment and income. The gap narrowed from the late 1990s to the early 2000s, a time when the economy recovered and health policies began to address health inequalities.
The Asian population (which included a large proportion of recent migrants) had the lowest mortality rate over this period. This reflected the good health of most migrants.
Lifestyle and environment affect health and are shaped by socio-economic factors. The material circumstances of people’s lives and the behavioural choices they make are influenced by things like income, employment status and education.
Cancer has been the single biggest cause of death in New Zealand since the early 1990s. In 2015 it accounted for around 30% of all deaths. Most cancers are not strongly inheritable, and so are in theory preventable.
Lung cancer is mainly caused by tobacco smoking and exposure to second-hand smoke. It is one of the most common causes of death from cancer.
Tobacco consumption rose significantly in the 1930s and 1940s and stabilised from the 1950s to the 1980s, after which it dropped steadily. Male lung-cancer death rates peaked in 1965 but did not drop significantly until the 1980s. Female deaths peaked in the mid-1970s, but have not declined to the extent male rates have. Because women took up smoking later than men, female lung-cancer trends follow behind male trends.
Tobacco is the single biggest cause of preventable deaths in the world, as well as in New Zealand. In addition to lung cancer it is linked to bladder, liver, pancreatic, kidney, mouth, lip, throat and stomach cancer, leukaemia (blood cancer) and a growing list of other cancers. Tobacco contributes to heart and respiratory diseases and blindness, and is associated with infertility and foetal-development problems. Exposure to cigarette smoke is a major risk factor for cot death in babies.
There are socio-economic and ethnic inequalities in tobacco use and lung-cancer deaths. In the 2010s people living in the most deprived neighbourhoods were three times as likely to smoke as those living in the least deprived areas. Māori adults were 2.5 times as likely to smoke as non-Māori. Lung-cancer registrations and deaths increased with neighbourhood deprivation. Lung cancer caused 34% of Māori cancer deaths and 17% of non-Māori cancer deaths in 2015.
Other behavioural factors associated with cancer include excessive alcohol consumption, sun exposure, poor nutrition and obesity. 30–40% of work-related deaths through disease are due to cancer caused by exposure to toxic substances such as asbestos.
Cardiovascular diseases are also major causes of death. In 2015 coronary heart disease (mostly heart attacks) caused 16% of deaths and cerebrovascular disease (mostly strokes) caused 8%.
Coronary heart-disease rates peaked in the late 1960s and then declined steeply. The decrease was slower for Māori, who experienced higher rates of the disease than non-Māori in the early 21st century. Heart disease was overtaken by cancer as the single leading cause of death in the early 1990s.
The 7.1 magnitude earthquake which struck the Canterbury region on 4 September 2010 caused a big increase in recorded heart attacks. In the week after the quake, between eight and 10 people per day suffering heart attacks were admitted to Christchurch Hospital, compared to the usual two or three. Natural disasters cause a sudden and unusual surge of adrenaline in the body which can trigger a heart attack.
Though heart disease has an age and genetic component, major risk factors are associated with lifestyle – smoking, poor nutrition and low physical activity, which are in turn influenced by social factors. The decline in coronary heart disease is projected to slow in the 21st century, partly because of the emergence of an obesity (and type 2 diabetes) epidemic since the 1970s.
Unhealthy diet is a major cause of chronic disease in New Zealand. Researchers estimate an extra serving of fruit or vegetables per day would reduce deaths from coronary heart disease by 10%, and from strokes, oesophageal and stomach cancer by 6%.
Being overweight or obese causes ill health. The age-standardised obesity rate for the adult population increased from 19% in 1997 to 31% in 2014/15. New Zealand had a high obesity rate compared to other OECD countries.
Some New Zealanders have difficulty obtaining nutritious food for economic reasons. In a 2010 study, almost half of low-income households regularly ran out of food through lack of money.
Cold, damp houses and polluting indoor heating are associated with respiratory problems such as asthma. Studies in the 2000s found that insulating houses and installing non-polluting heating resulted in higher average temperatures, less mould and condensation, lower nitrogen-dioxide levels, improved respiratory health, fewer days off school and work, and fewer doctor visits.
A 2012 report found that air pollution (mainly caused by emissions from home heating, vehicles and industry) was associated with 1,175 premature deaths, 607 extra hospital admissions for respiratory and cardiac illness and 1.49 million restricted-activity days (when people cannot do activities they may have undertaken if pollution was not present) each year.
Because health status is largely determined by socio-economic factors, improvements are mainly influenced by things like income levels and housing quality. These are related to the society-wide distribution of resources. Nevertheless, health services are an important way of addressing health problems and inequalities.
Until the 1940s most people had to pay for all health services. Poor people received free treatment at public hospitals, which were also part-funded by user charges. General practitioners (GPs) and other doctors set their own fees. Friendly societies subsidised health care for their members, who paid regular subscriptions.
Under the Social Security Act 1938, public hospitals became free in 1939 and prescription medicines followed in 1941. From 1941 doctors received a set fee for service from the government, which they could top up by part-charging patients. Patient fees rose over time because the government subsidy did not increase in line with inflation. Prescription fees were reintroduced in 1985 and could be as much as $20 per item by the early 1990s. Hospital care remained free.
In the 21st century GPs and other health professionals grouped together as primary health organisations (PHOs). PHOs with high-need enrolled populations (Māori and Pacific people and residents of deprived neighbourhoods) received more funding per person than those with less needy populations. The formation of PHOs resulted in lower fees for most people, though some low-income people living in better-off areas paid more. Prescription charges were reduced to $3 per item for most people in the 2000s, and then raised to $5 in 2013.
Because New Zealand’s primary health service was partly funded by patient fees, cost still limited access to GPs in the 21st century. Between a quarter and a third of people put off visiting doctors or collecting a prescription because of cost. Women were more likely to defer visits than men because they had less disposable income.
While Māori, Pacific and Pākehā people had similar rates of registration with a primary health practitioner in the early 21st century, Māori and Pacific adults were more likely to put off going to a doctor when ill. Cost was the major factor, but studies also cited actual or perceived racism, and family and work commitments coming before personal health. Deferred visits sometimes meant people ended up in hospital when their health problem could have been solved by a GP at an earlier stage.
Some health services in areas with significant Māori and Pacific populations tried to make clinics more culturally friendly. In the 1980s the Plunket rooms in Kingsland, Auckland, were decorated with tapa wall hangings and Samoan mats on the floor. Plunket nurse Robin Griffiths sometimes referred Pacific mothers to traditional healers and older women in their communities.
Asian people had better health status than other ethnic groups, and their use of health services was much lower. This reflected good health, but also barriers to access such as language differences. Asian migrants’ health declined the longer they lived in New Zealand.
Health disparities between Māori and Pākehā were written about from the 19th century. Health researchers published major reports on social inequalities in health from the 1980s. Activity in this field increased in the 1990s and 2000s. Reducing inequalities was a major part of government health policy and a statutory obligation of district health boards in the 21st century.
From the 1980s the government and health authorities took more account of Māori perspectives on health. The number of Māori and Pacific health providers increased from the early 1990s, when the government began allowing private-sector groups to tender for health service contracts. These groups provided culturally specific services on marae and in other community settings in an attempt to improve Māori and Pacific health. However, the 2002/3 New Zealand Health Survey reported that only one in seven Māori and one in 11 Pacific respondents had used these services in the last 12 months, emphasising that mainstream providers remained important to all social groups.
Cultural beliefs about the human body can influence the extent to which people use health services such as breast-screening programmes. Vaifagaloa Naseri Moepogai of Health Star Pacific Trust in Auckland said: ‘The topic of breasts, especially in the public arena, is a subject considered taboo for our women, and as such, emotions can be frail. You have to take this into consideration and be delicate and sensitive about overcoming these beliefs.’1
Major public-health programmes promote immunisation against infectious diseases, and breast- and cervical-cancer screening. They are advertised in different ways for different sections of the population. Programmes targeting individual behaviour promote healthy food, exercise and stopping smoking.
Targeted programmes have not reached all eligible people. Māori and Pacific women have lower breast and cervical screening rates and higher death rates for these cancers than other women. Child immunisation rates are low in New Zealand compared to other developed countries. Māori children have lower immunisation rates than other ethnic groups.
Dew, Kevin, and Anna Matheson, eds. Understanding health inequalities in Aotearoa New Zealand. Dunedin: Otago University Press, 2008.
Dew, Kevin, and Peter Davis, eds. Health and society in Aotearoa New Zealand. 2nd ed. Auckland: Oxford University Press, 2004.
Gauld, Robin. Revolving doors: New Zealand’s health reforms, the continuing saga. Wellington: Health Services Research Centre; Institute of Policy Studies, 2009.
Shaw, Susan, and Bron Deed, eds. Health & environment in Aotearoa/New Zealand. South Melbourne: Oxford University Press, 2010.