Health inequalities were a major public health concern in the 21st century. Low-income people have had consistently higher death and illness rates than those on higher incomes. They are more likely to engage in behaviours that have a negative impact on health, such as smoking and eating unhealthy food.
The situation is starker when ethnicity is considered. Māori are likely to be ill more frequently and die younger than non-Māori of the same socio-economic status – even those who do the same unhealthy activities. Pacific Island people experience higher death and illness rates than other ethnic groups apart from Māori.
Important studies on social inequalities in health were published from the early 1980s. One of the first investigated male mortality rates by occupational class. Men in higher occupational classes – professions such as medicine and law – had significantly lower death rates than men in lower occupational classes such as cleaning and labouring.
The New Zealand Deprivation Index, which measures deprivation by small areas or neighbourhoods, was developed in the 1990s. Census data was used to create a socio-economic scale from decile 1 (least deprived) to 10 (most deprived). This tool has conclusively shown that health inequalities exist on a continuum – the more deprived communities are, the higher the death and illness rates. This trend is repeated when examined by gender, age and ethnicity.
From 2005 the New Zealand Census Mortality Study linked census and death records. Researchers measured socio-economic position before death – this approach showed that low socio-economic status caused ill health, rather than the other way round.
The economic reforms of the 1980s and 1990s were seen by some as increasing social inequalities in health. In the 2000s the government developed specific policies on inequalities in response to this. District health boards (established in 2001) had a statutory obligation to reduce inequalities. The Department of Health published a series of reports on this topic from 2002. Reducing inequalities was at the heart of many public health initiatives.
Concern about inequalities was not confined to the health sector. Because socio-economic position is determined by factors including employment, income and housing, a ‘whole of government’ approach was advocated. This meant that sectors such as social welfare, education and housing, as well as local government, were seen to have a role in reducing health inequalities.
Statements made by health practitioners in the late 1960s and early 1970s about the health-status disparity between Māori and Pākehā would sound familiar to people living in the 21st century. In 1969 the New Zealand Medical Journal editor described Māori health as ‘our particular problem with underprivilege in the midst of plenty,’ and in 1972 wrote ‘nothing can conceal the unpalatable fact that for the most part the Maori is at much greater disadvantage healthwise than the European.’1
The Māori population was devastated by new diseases brought to New Zealand by visitors and settlers, and declined for most of the 19th century. This, combined with significant land loss, set the scene for poor Māori health compared to other ethnicities into the 21st century.
In the 20th century improvements did occur in the wake of rising living standards and public health programmes that addressed particular illnesses such as tuberculosis. However, in the 21st century Māori still had higher death and disease rates than non-Māori.
A series of reports highlighting the disparities between Māori and non-Māori from the late 1950s contributed to the eventual rise of Māori health providers and culturally specific health programmes in the 1980s. The Department of Health started to support traditional Māori healers. By the early 21st century Māori health-provider groups contracted to district health boards, mainly based around tribal areas. It was hoped that treatment by Māori for Māori would reduce ethnic inequalities.