Health gaps: who's to blame? Claims a Maori failure to take individual responsibility for their health leads to a life expectancy lower than Pakeha are knee-jerk and simplistic, the authors of a new study write.

THIRD-CLASS passengers on the Titanic were twice as likely to die as first-class passengers. Why? Were poor people so stupid that they forgot to pack their wetsuits? Or were the parents of the poor people on the Titanic so neglectful that they failed to teach their children to swim?

Obviously, these are ridiculous explanations. The reasons were structural. There were only enough lifeboats available for the first-class passengers, and doors were locked, preventing third-class passengers from getting access to the lifeboats.

Our Decades of Disparity report shows disturbing trends in life expectancy for various ethnic groups in New Zealand. (l) Our results are new because we were able to adjust for the undercounting of Maori and Pacific deaths during the 1980s and 1990s.

We found that Pakeha life expectancy improved during these two decades but that Maori and Pacific life expectancy changed little. Put simply, the "gap" between Maori and Pakeha life expectancy widened from about seven years to 10 years in this period.

In stark contrast, Maori life expectancy increased dramatically during the 1950s, 1960s and 1970s, and was catching up with non-Maori. Had these trends continued through the 1980s and 1990s, there would have been little, if any, ethnic gap in life expectancy by 2000.

So why did the Maori life expectancy trend take a turn and flat-line through the 1980s and 1990s? Some commentators have blamed Maori and Pacific people for failing to take individual responsibility. This is knee-jerk and too simplistic.

The available data actually shows that while smoking rates remain higher among Maori, they did fall during this period for Maori men; that Maori and Pacific people exercised at least as much as Pakeha (Sport and Recreation New Zealand) and spent less on takeaway food (Household Economic Survey).

So what did happen about 1980 to cause previously strong improvements in Maori life expectancy to take a turn and flat-line? Did Maori call a hui about 1980 and decide to abandon individual responsibility for their health? No. Clearly, other things were going on.

In Decades of Disparity, we offer three (not mutually exclusive) possible explanations. If we look overseas, the death rate increased dramatically after the break-up of the Soviet Union and the resulting social and economic upheaval.

It seems plausible there was a similar, if more muted impact in New Zealand after the structural reforms during the 1980s and 1990s. Probably because of different employment patterns, the reforms had differing effects on different ethnic groups, with Maori and Pacific people hit hardest by unemployment and falling incomes.

Hundreds of studies internationally and in New Zealand have shown that low income and unemployment "get under the skin" to cause poor health.

Secondly, different patterns in cause of death point to a range of different explanations. Heart disease death rates fell dramatically among Pakeha during the 1980s and 1990s, but less so among Maori and Pacific people. Cancer death rates (both smoking and non-smoking related) actually increased among Maori and Pacific. Tobacco smoking will be one explanation for these varying trends, but it is far from a complete explanation. For example, smoking among 45-64-year-old Maori males decreased from 45.8 percent at the 1981 census to 35.4 percent at the 1996 census, but heart disease death rates among Maori males decreased only modestly.

Thirdly, Maori and Pacific people have poorer access to health care. Maori have higher rates of heart disease death than non-Maori, yet they receive lower rates of life-saving heart operations. Similarly, cancers unrelated to smoking (for example breast, bowel and prostate) now tend to occur at about the same rate in all ethnic groups, but the death rates among Maori and Pacific people tend to be higher. Why? Somewhere along the chain of events that might prevent someone dying of their disease, Pakeha are faring better.

The diverging mortality trends by ethnicity in the 1980s and 1990s are challenging and disturbing. A fundamental role of academics is to point out such trends, suggest explanations and initiate debate. It is inescapable that widening social inequalities during the 1980s and 1990s were associated with widening health inequalities.

It is misguided, condescending, and simply not useful to dismiss these diverging health trends as being due to Maori and Pacific people behaving badly.

REFERENCE

(1) Ministry of Health and University of Otago. (2003) Decades of Disparity: Ethnic mortality trends in New Zealand 1980-1999. Public Health Intelligence Occasional Bulletin Number 16. Wellington: Ministry of Health.

* This article was first published in the Dominion Post on August 1, 2003 and is reprinted with permission.

Tony Blakely and Bridget Robson are researchers at the Wellington School of Medicine and Health Sciences.