Health patterns in New Zealand: Class, ethnicity and the impact of economic development

So< Scr Med Vol 18. No Prmted m Great Brltam

II. pp 919-925. 19X4

0277-9536/X4 $3 00 + 0 O(I Pergamon Press Ltd

HEALTH PATTERNS IN NEW ZEALAND: CLASS, ETHNICTTY AND THE IMPACT OF ECONOMIC DEVELOPMENT PETER DAVIS Department

of Communtty

Health,

Umversity

of Auckland

Medical

School,

Auckland,

New Zealand

Abstract-In the broad sweep the experience of New Zealand tn health trends and patterns IS similar to that of other advanced mdustrial soaetles, yet there are some important differences that draw on the country’s colonial past and. more particularly, on rts locatlon in the South Pacific Of special note is the historical experience of the indigenous Polynesian minority-the Maon-m their passage through the demographic transition to their current position m the modern urban environment. It is this dual phase of development-industnahsation for the European majority. ‘westermsatlon for the Polynesians-that provides the special interest of the New Zealand setting, particularly m the analysis of class and ethmcity m the shaping of health patterns

LONG-TERM

lNTRODUCTlON

New Zealand is a small country of 3 million people, Just under 900/, of them of European migrant stock, that has established a high standard of living based on exports from the family farm and on heavily protected domestic industry [I]. In many respects it epltomises the economic and socio-political system of ‘dominion capitalism’ [2]; i.e. the transfer of a cultural and social ‘fragment’ of a metropolitan European country to an exotic climate, a period of settlement m which the indigenous people, the Maori, were subjugated, the establishment of an economy delivering primary products to the metropolitan market. the early and pragmatic use of the state in the interests of the settler community and the emergence of a classic ‘mixed’ economy with many of the mstltutions of the modern welfare state. It is this history of metropolitan influence-principally from Britain-of racial conflict and accommodation, of primary production followed by urbanisation and the establishment of secondary industry behind tariff and quota protection, together with the evolution of the institutions of the modern welfare state, that account for the principal patterns of health and health care in New Zealand. Many of the trends and patterns in the health area in New Zealand are similar to those recorded in other advanced industrial societies. Yet, there are also some quite distinctive aspects; in particular. there has been an early tradition of experimentation in the orgamsatlon and delivery of care, and there are also quite umque conditions for the analysis of the impact of ‘westernisation’ and of the development experience on the Maori and on the other Polynesian peoples of the South Pacific [3]. But more than this. concepts of health and health care m New Zealand have evolved In a chmate of egahtariamsm tinged by the ethos of self-help. It IS only now that the adequacy of these values as _guides to policy is being questioned and the whole basis of the health care system critically exammed as new evidence emerges on the persistence of mequahtles linked to differences of social class and ethnic group membership.

TRENDS IN HEALTH

The most striking long-term trends in health status are those that have commonly been recorded in the advanced industrial societies over the last century or more. In essence, this is the ‘demographic transition’, a transition of social and demographic structure from an equilibrium position of high fertility and mortality to the contemporary ‘stable state’ of low birth and death rates [4]. Associated with this is a long-term increase in life expectancy at birth and a rapid decline in the impact of the infectious diseases on mortality. These three long-term trends are, of course, interrelated, reflecting underlying changes in the social and economic structures of the industrialised countries. New Zealand has undergone much the same processes of change, though with some important differences. In New Zealand the demographic transition shows some significant discrepancies from the ‘ideal’ case [5]. In the first place, for the non-Maori population there is no preliminary ‘pre-industrial’ stage in which both birth and death rates were high. Fertility was high in the nineteenth century period of settlement, but the major decline in mortality had already taken place before the settlers came to New Zealand. Hence, there followed no further marked decline. Secondly, although a sharp decrease in the birth rate was recorded, it still remains higher today than it is in most comparable societies at the same stage of development [6]. Thirdly, while the Maori population has progressed through the full transition-from the very first stage of ‘pre-industrial’ levels of mortality in the late nineteenth century-this has followed at a variable period behind the advances in the non-Maori community. This lag has varied from a period of several generations in the early stages of the transition to a matter of years in the more recent phase. It is this variable lag that is also very much a feature of the data on the other two trends, the long-term increase in life expectancy and the rapid decline in the impact of the infectious diseases. As has already been demonstrated by McKeown and others for England and Wales. the United States, and other 919

920

PETER DAVIS LONG-TERM

Table I Male and female trends m years of hfe expectation at birth for Maon (195Gl972) and non-Maon (188&1972) Maon*

Non-Maon Female Male 188&1890 1901-1905 1921-1922 195&1952 1970-1972 *Reliable mformauon avadable. Source: Foster [8]

54.4 58 I 62 8 68 3 69 I for the Maort

Male

Female

57 3 --~~----60 6 65 4 72 4 54 I 75.2 61.0

55 9 65.0

population

before

1950 1s not

advanced industrial societies [7], so it can be shown for non-Maoris in New Zealand that much of the improvement in life expectancy took place before the major advances of modern medicine (Table 1). These data merely confirm the pattern elsewhere. What is of more interest in the second half of the Table is the way in which Maori life expectancy has rapidly improved from what one might call a ‘nineteenth century’ level to a standard closer to the European one within the space of 20 years. Much the same speeding-up of the demographic transition can be detected in the data on the pattern of mortality, with the decline in the infectious and respiratory diseases, and the age-specific increase m the classic life-style disorders of cancer and heart disease, taking place much later among the Maoris (Table 2). Again, as in the case of advances in life expectancy, the change in the pattern of mortality for the Maori population has been telescoped into the period since the Second World War, a period during which the population balance of the Maori people shifted from the rural areas of New Zealand to the growing urban and industrial centres. Clearly this process of urbanisation has had a dramatic impact on the life chances and life styles of the Maori people as they have become absorbed into the urban and industrial working class. Similar changes are now taking place among other Polynesian peoples, with the large-scale migration of Pacific Islanders to New Zealand, principally to the city of Auckland [9].

Table 2 Trends m mortahty

A@ group 15-24 1901 1930-1934 1950-1954 1975

IN HEALTH

Non-Maon

Bronchms and pneumoma Maon

Non-Maon

Heart disease

Cancer Maon

NA 56 8 I20

12 6 43 06

NA 38 08

I5 OX 01

NA

25-24 1901 1935-1939 195Gl954 1975

NA 41 0 15 I 09

134 56 16

NA 14.7 I6 0 3

33 25 0 3 02

45~ 64 1901 1930-1934 1951)~1954 1975

NA 41 8 26 7 37

I2 3 53 29 01

NA 22 I 13 2 12 6

14 5 54 22 37

‘NA = not avakible Rates .+K not calculated Sourw adapted from Foster [X]

CARE

The major themes that emerge m the analysis 01 the evolution of health care arrangements m New Zealand are, again, by and large typical of the development of health care systems in most other advanced industrial societies. As m the case of changing health patterns. these trends are closely mterrelated, reflecting much the same underlymg shift m social and political framework. The fundamental change-from which flows much else in the health area-has been the evolution of the welfare state provision of services. Linked to this are the issues of growing cost, the tendency towards technologyintensive and institution-based services, and a characteristic emphasis on the provision of personal medical services over broader public health initiatives. Although the early settlers saw themselves as pioneers breaking with the old order of industrial England, they were inescapably products of their time and brought with them the values and institutional arrangements of mid-Victorian society. Hence. the early organisation of medical care in New Zealand drew directly on the English Poor Law system. with its emphasis on private charity and the local authority provision of services for the indigent [lo]. Private charitable resources were limited and so local and central government resources funded basic hospital and medical services for Maorls and for indigent whites. Indeed, despite the espousal of the Victorian virtues of ‘self-help’ and despite an ldeological aversion to state intervention, the state became heavily involved in the funding and provision of health services from an early stage [ 111. It was this established involvement of the state in health care, together with a tradition of experimentation, the effects of the Great Depression and the political emergence of the Labour movement. that laid the foundations for the welfare state provision of health services in the 1930s. The first Labour government’s goal of a comprehensive. free and noncontributory health service was never achieved and strong private and voluntary sectors remain to this

rates per 10.000 for selected causes of death. by age group, for Maon (193C!- 1975) and non-Maon (1901~1975)*

Tuberculosis Maon

TRENDS

Non-Maon

Maon

Non-Maon

I.0 43 06

NA 25 32 0 5

20 IO 03 02

NA 32 54 53

33 3 I 33 37

NA 70 IO 2 71

44 31 24 24

NA II 2 35 9 43 I

24 6 22.9 24 I 28 5

NA 36 0 77 I 64 3

I4 I I

where the number

of draths

27 26 35 35

IS too low

8 8 9 3

Health

patterns in New

day, providing a patchwork of state. state-subsidised and private agencies in the delivery of care. Yet the state is still by far and away the dominant force, accounting for about 80:; of health expenditures [ 121. CURRENT

ISSUES IN HEALTH HEALTH CARE

AND

From these early foundations of the modern health care system New Zealand has followed much the same pattern as other advanced industrial societies: i.e. a growing volume of expenditure on health [ 131, the increasing importance of institution-based and technology-intensive services in the allocation of resources and the minimal commitment to health expenditure outside the traditional area of persona1 medical services [l4]. It is against this background that there have emerged some major issues in the organisational and philosophical underpinnings of health care delivery in New Zealand. One set of issues concerns the allocation of resources to health. In part this is merely a question prompted by a wider fiscal crisis of the state in which available resources are being squeezed between the growing demands of the health sector and a contracting tax base [ 151. But also, more broadly than this, it is a wider economic question concerning the efficacy and efficiency of allocating resources to traditional forms of health intervention. Although over the broad sweep life expectancy has improved, the record for New Zealand is less impressive than it has been for most other advanced industrial countries since the Second World War [ 161. In comparison with the more successful countries of Scandinavia, for example, the New Zealand mortality rate is significantly higher, especially among infants and children, among young males and in the years around retirement. This is so even for non-Maori rates (Table 3). In particular, there has been virtually no improvement in life expectancy for males aged 35 and over since 1951 [I 81, although this may now gradually be changing. The second set of issues that this raises concerns the changing pattern of ill-health and the new priorities of resource allocation that this suggests. With an agemg population. and with the impact of the chronic, degenerative disorders, the growing burden on the health care system is that of social dependency.

Table 3 Rano* of non-Maon to Swedish rates of death per 10.000 by age group. for males and females (I 979) A@ group Cl Ikl S-14

15-24 25-34 3s-44 45-54 55-64 65-74 ?5+

Males

FWl&S

17.5 176 292 Ibh 103 96 II8 127 II9 106

152 168 255 145 100 III 130 136 130 10s

*Sweden = 100 Source adapted from New Zealand health sources [ 171

and world

921

Zealand

Yet, the common response has been to emphasise mstitutional services rather than prevention and commumty support; in New Zealand, for example, well over half all health expenditure is allocated to institutional care, and over two-thirds of those in institutions are either over 64 or in psychiatric care [l9]. In broad terms these two sets of issues in resource allocation-the one concerned with scarcity, the other with priorities-prompt further questions about the distribution, selectivity, efficacy and social impact of health intervention. This IS an issue both of effectiveness and of equity. If resources are scarce and if there is some question as to whether their allocation conforms to the distribution of need, then the concern is not just about ‘value for money’ in a broad sense, but more specifically about social equity and the selectivity and efficacy of impact. The largest single item of health expenditure is accounted for by hospital services, and here the evidence is that there is considerable inequity in the allocation of resources. Indeed, while the demonstrated relationship between resource distribution and ‘need’ is not inverse-as ‘the inverse care law’ would have it [20]-it is certamly only a tenuous one. The funding system has been an incremental one and the main determinants of allocation levels appear to have been existing bed numbers, political pressures, and the built-in inertia of the system [2l]. The distribution of genera1 practitioners is more clearly in inverse relationship to ‘social need’, with a marked skew towards white, affluent suburbs [22]. This has real consequences for the allocation of services and scarce resources [23]. This principle of cumulative disadvantage-&the inverse care law’-is also repeated in the distribution of maternal and infant care services [24]. ETHNICITY

AND THE ‘WESTERNISATION’ THESIS

It is questions of this sort-about the selectivity and efficacy of impact of the health care system-that have to be seen in the light of growing evidence of quite marked social variations in health patterns in New Zealand. One of the strongest of these is ethnicety. Whether it be hospital services, general practitioners or maternal and infant care, ethnicity is seen to be a crucial variable affecting-and affected bythe allocation of resources. Indeed, it is in this area of racial variation and ethnic difference that some of the most distinctive aspects of the New Zealand health scene are to be found. In the first place, there is the impact of the demographic transition on the Maori people. It is estimated that by the end of the nineteenth century the Maori population totalled 40,000, marking the low-point m a decline of possibly 60% since the beginning of the century. Since this period the Maori people have passed through the entire demographic transition, with very rapid changes in both the level and the pattern of mortality, especially in the period of the population shift to the cities since the Second World War [25]. Despite this rapid change m the health circumof the Maori people, major ethnic stances differentials on most health indicators still remain.

922

PETER DAVIS Table 4 Ratto’ of Maor to non-Maor rates of death per 10.000 populatton for mayor causes. 15-64 >ears (1975) Cause of death

15-24

Infectwe and parastnc Respiratory Accidents Circulatory Neoplasms DIgestwe Endocnne All causes

Age group 25-44

45-64

72 60 ?.I 2.s 16 2.2 38 23

72 40 26 21 I.6 23 68 2.2

42 13 14 I4

I3

*Non-Maon = I. Ratto not calculated too low. Source: adapted from Pomare [26].

where rates are

Table 4 outlines some of the causes of death that reveal strong differentials between Maoris and nonMaoris. Many of these differentials are for conditions that fall into the category of the classic ‘diseases of poverty’ [27] and inequality; e.g. accidents and death from respiratory causes. Others conform more to an alternative etiological pattern of life style, stress and broader socio-cultural factors; e.g. heart disease and lung cancer where Maori women feature among the highest rates in the world. It is this second etiological pattern that has drawn the strongest interest in the research community. In essence it is a variant of the ‘westermsation thesis first propounded by Burkitt [28]. It is argued that much the same forces that Burkitt identified in the impact of affluence and ‘westernisation’ on the populations of the advanced industrial societies have now come to shape the health chances of the Polynesian peoples of the South Pacific. In the case of the Maori these trends seem to have progressed to a further stage. If at one time the pattern and level of mortality characteristic of the Maori people conformed to the

Table 5 Compartson European populations

Condltlon Definrte hypertension per 1000

of Pa&c Island. New Zealand Maw and for selected condltlons, age-adJusted rates. males only (1962-1964) Pacdic Isolated

Island Urbamsed

41

343

“:, Dlabeuc

04

“,, Obese

7

21

2.1

156

‘I,, Varicose vems Source

adapted

New Zealand Maorl European

266

55

from Prior and Tasman-Jones

288

15 7 I9 6

87 37 33 4

131

Table 6 Age-standardlsed male mortahty for all causes per 100.000 population 15-64 years. by Registrar-General’s aoclal class for England and Wales (1970-1972) and New Zealand (1975--1977) Social class level

I II IIINM IllM IV V Source

Pearce er ul 1291

England

and Wales 36X 3X6 463 498 53x 660

New Zealand 425 422 470 524 54x 955

profile of a group that was at an intermediate stage on the path to ‘westernisation’. it now appears that they have reached a crucial stage that has taken them beyond the non-Maort population m the Impact of the ‘diseases of affluence’ like cancer and heart disease. Plausibility 1s lent to this variant of the ‘westermsation and ‘diseases of affluence’ thesis by the evidence that other Pacific Island peoples are going through much the same processes of social and epidemiological change. Table 5 outlines ‘I number of key health indicators contrastmg Pac~tic Island populations, affected to varying degrees by ‘westernisation’, and New Zealand Maori and European groups. In most instances the figures show ‘1 clear trend running from relatively untouched and isolated commumties in the Pacific Islands to New Zealand Europeans and Maoris.

SOCIAL

CLASS-CULTURE INEQUALITY

AND

Analysis in terms of ethnic variations almost inevitably leads to explanations couched in terms ol broad cultural factors and life style. This IS encouraged in the New Zealand setting by the evidence which clearly supports some variant of a ‘westermsation’ thesis adapted to the ethnic diversity of the South Pacific. Beyond this ethnic diversity there may also be a place for a racial interpretation smce certain Pacific Island populations and the New Zealand Maori appear to be more disadvantaged than New Zealand Europeans on key health indicators. even while they may otherwise be considered to be at an intermediate stage along the path of ‘westernisation’. Yet, while there IS this evidence for a racial, Polynesian/European difference on certain key ‘disorders of affluence’-such as diabetes and hypertension-it IS more likely that this just reflects an interaction of specifically Polynesian cultural traits with the conditions of social and economic disadvantage characteristic of the urban working class m an advanced industrial society. It IS considerations ot this kind-i.e. class structure and the special interaction of class and ethmcity-that suggest the importance of analysing the impact of social class m determining health chances in New Zealand society. Social class IS a primary source of social identification and group formation m advanced mdustrial society. Social classes are strata sharing similar levels of resources and styles of hvmg, and this IS reflected as much in the health area as it is elsewhere. Conventional wisdom has long held that New Zealand was somehow exempt from the impact of social class on health. but recent research shows that much the same pattern of class inequality m health holds in New Zealand as it does elsewhere [29]. For example, in Table 6 social class mortality rates for working males m the age group 15-64 are outlined. contrastmg the figures for England and Wales with the data that are now available for New Zealand. Using the same classification scheme-the British Registrar-General’s scale-the distributions turn out to be much the same. showing a clear inverse ‘gradient’ In both cases.

Health patterns m New Zealand Table 7 Age-standardtsed male mortahty for ma,or causes per 100.000 New Zealand populatton 15-64 years. for RegstrarGeneral’s social class levels I and V. and ratio V.1 (1975-1977) Cause of death

I

Infecwe and parastttc Resptratory Acctdents Ctrculatory Neoplasms Dlgestrve Endocrtne All causes

41 17.5 566 219.0 91.5 9.2 X6 424.5

Source

adapted

Regtstrar-General’s V

soctal class VI

165 76 6 197 5 361 I 171 1 54 5 24 9 955 4

40 44 3.5 16

from Pearce er al [30]

Of further interest is the pattern that emerges when total mortality is broken-down Into the major diagnostic groupings, as outlined in Table 7. What the information suggests is that, while the gradient continues to be strong for those causes of death linked to social and economic disadvantage-the so-called ‘diseases of poverty’ like the infectious and respiratory diseases and accidents-for those disorders that have come to be linked with conditions of living characteristics of the advanced Industrial societies-like heart disease, cancer-the gradients are not so marked. What Table 7 confirms IS the impression that members of the working class in the advanced industrial societies+specially unskilled manual workers-are at greater risk from almost any cause of death. Nor is the evidence on the impact of the so-called ‘disorders of affluence’ restricted to mortality. One of the classic early conditions identified by Burkitt as distmctive of the effects of ‘westernisation’ was dental caries. Yet, while this may initially have been an affliction of the affluent-like cancer and heart disease-there is evidence that, like these other two conditions, it may now have become a ‘problem of the poor’. In New Zealand this story has been given a further twist with evidence of dramatic social variations in tooth loss and denture-wearing (Table 8). While there does not appear to be any strong gradient in the level of dental caries across social class, the pattern of treatment-as reflected m the wearing of dentures and m the ratio of teeth missing to teeth either filled or untreated-shows a clear gradient. What the data on denture-wearing suggest is that, even where risk factors and other epidemiological determinants of health status are held constant, the differential impact of the delivery system can itself result in marked social class variations. Therefore, any assessment of the impact of social class has to go Table 8. Average number of decayed (D). nussmg (M) and filled (F) Teeth. rauo M ‘DMF and percentage wth no natural teeth. by social class for New Zealand population 15 and over (1976) Soctal class level

DMF

I 2 3 4 5 6 Source

Cutress

19 5 21 2 20 7 20 9 20 4 20 2 er a/

[3l]

M ‘DMF 0 0 0 0 0 0

35 55 56 60 61 65

beyond conventional explanations couched m terms of life style and environment to accommodate the effects of the delivery system itself. Research suggests that, in the United Kingdom at least, the health care svstem actuallv works to reinforce--rather than to erode-existing social class differentials [32].

SOCIAL STRATlFlCATlON

18 59 29 2.3

O0 of natural teeth I5 3 30 5 30 5 33 9 34. I 36 5

923

AND ETIOLOGY

Two different strands of research, therefore, have illuminated quite distmct dimensions of social hierarchy in New Zealand and have unravelled rather different chains of etiological reasoning. The first, in the tradition of the ‘westernisation’ thesis, emphasises life style and culture, while the second-in the tradition of class inequality research-stresses the impact of the material circumstances of life [33]. In their different ways, both challenge the ability of the health care system to respond to social diversity and inequality. These two strands of research meet in the case of the Maori community. Evidence from the ‘westernisation’ tradition of investigation shows that there is a range of conditions for which the Maori are severely disadvantaged (Tables 4 and 5). This can plausibly be linked to the same trends of economic development and life style-but as these trends affect vulnerable minority groups in the ‘western’ societies. However, within the social class tradition of mvestigation that is more characteristic of research in the advanced industrial societies, these same disadvantages can be interpreted as part of that trend that has seen the working class become susceptible to the modern ‘disorders of affluence’. Therefore, there is special interest in the New Zealand context in the interaction of social class and ethnicity, and this is explored in Table 9. There are some difficulties in ensuring adequate cell sizes for the comparisons involving the two ethnic minority groupings, and this has been overcome to some degree by concentrating on overall mortality and by collapsing the middle class strata. The clear impression is that there exists a substantial ‘ethnic group effect’-even after social class has been taken into account. In other words, there is something further about the cultural, social and economic circumstances of ethnic minorities over and above their social class position that must be called into account to explain their special health disadvantages. There is also evidence of some further variation between the Maori and Pacific Island groups. Hence, it IS something more than a simple racial difference between European and Polynesian, Table 9 Age-standardtsed male mortahty for all causes per 100,000 populatton, 15-64 years, by Regtstrar-General’s soctal class for Maort, Polynestan and other* (19741978) Soctal class level I-IIINM IIIM JV V

Maorl

Polynesian

Other

816 687 863 1304

556 466 827 972

426 493 508 845

‘The great maJortry are of European ortgm Source adapted from Pearce cf al. (341

924

PETER DAVIS Table IO EXCESSdeaths atm~~g Mmrl males aged 15-64 standardmd Regtstrar-General’s soctal class. major cuses and total mortahty Age- class standardtsed ewess deaths (B)

for age and (197GlY73)

Clllss rtrect II-B A) I, < ,,)

Cause of death

Agestandardtsed excess deaths (A)

Infectwe and paras,t,c Resptratory Accidents Circulatory Neoplasms Dlgestw dtseases

53 0 133 3 166.9 269 8 78 8 41 3

49 III I08 233 65 32

7 7 0 3 I 0

62 16 2 35 3 13 5 I7 i ‘7 _< __

Endocrtne dtseases All CdUSeS

89 3 902 9

85 8 736 5

40 I84

Sources adapted

from

PedKe

cf ol

[34]

There are too few deaths among working Polynesian males to continue the analysis of all three ethnic groups. Therefore, Pacific Islanders are excluded and the analysis is restricted to Maori and ‘other’ groups in Table IO, where an attempt is made to record how much of the Maori disadvantage is accounted for by social class-both for overall mortality and for specific causes of death. Four-fifths of the excess of Maori over ‘other’ deaths is not removed when the comparison is standardised for social class. When the specific impact of social class is examined, it does not seem to conform to the ‘disorders of poverty’/‘disorders of affluence’ distinction. Taking three classic ‘problems of the poor’-accidents and respiratory and infectious diseases-while a third of the excess of deaths for accidents is accounted for by social class, the impact is much less for the respiratory and Infectious diseases. Similarly for the ‘disorders of affluence’; while very little of the excess of deaths for endocrine diseases is accounted for by social class, and not much more for circulatory disorders and neoplasms, digestive diseases reveal a slightly greater impact. What these results suggest is that there is no straightforward interpretation of the effects on mortality of the interaction of social class, ethmcity and the forces of social and economic development in New Zealand. To some extent it might be tempting to interpret these results as supportmg a cultural, life-style interpretation of differential mortality. That IS, one could look to diet. self-care, smoking, drinking and other aspects of life style to account for the Maori disadvantage and also to explain the social class gradients for the ‘disorders of amuence’. Yet it is also clear that racial and social class differences in life style are not independent of material condition (e.g. poorer diet, excessive drinking and smoking may just as plausibly be explained by stress and deprivation as by cultural difference). Nor can it be assumed that the recorded ethnic group differences are fundamentally cultural in nature and hence relatively unconditioned by inequality of circumstance: e.g. both unemployment and inequalitles of access to health care are greater for Maorls and Pacific Islanders than would be predicted from knowledge of their class position alone [35].

In a sense the New Zealand health care svstem has emerged from an ‘age of innocence’. a period when it was thought sufficient merely to spend more money on existing medical services to secure the public health. But the data on ethnic group and social class differentials give the he to this easy assumption. Furthermore, data on the wider context of health suggest that not only will greater attention have to be paid to the distribution of services. but the very mechanisms of intervention are themselves in question. MacDonald has suggested linkages between the state of the economy-as measured by the rate of unemployment-,and various health mdicators including the post-neonatal mortality rate. levels of suicide and self-harm, and hospital admissions for alcoholism and alcoholic psychosis [36]. In a sense this information merely confirms research findings from elsewhere [37], but in the New Zealand context it is a far more potent finding. When it 1s taken together with the data on ethnic group and social class differentials in mortality, this research calls into question the direction. efficacy and claims to social legitimacy of the entire health care system. In this respect such a cumulation of findings raises the kinds of questions about the New Zealand health care system that have been prompted by the Black report in the United Kingdom [38]. As in the case of other advanced industrial SOCIetles, then, the New Zealand health care system 1s going through a period of reassessment. To some degree this is prompted by the requirements of fiscal stringency. But more than this. growing social diversity, the growth of private medical insurance [39], and evidence of continuing inequalities in health are beginning to call mto question both the adequacy of the health care system and the fruitfulness of ex,istmg theories about trends in health patterns. It may well be that New Zealand provides a unique testing ground for the analysis of the interaction of social class and ethniclty in the dynamic health clrcumstances of modern social and economic development. Acknowledpmmfs-I

wtsh to thank Neil Pearce for extractmg the data for Tables 6-10 and Robert Beaglehole and Lawrence

Malcolm

for comments

on an earlier

draft

REFERENCES CONCLUSION

What the figures on differential mortality illustrate 1s the extraordinary resilience of fundamental social Inequalities in health.

For a recent revtew of the New Zealand polltlcal economy and Its relatIonshIp !o developments m rhe health care system. see Fougere G The state and me&Cal care dellvery In In 1/1c Ptrhl~ fnrerrtrHeulrh.

Health

patterns

Work and Housrng m Neti, Zeulund Socket> (Edtted by Shtrley I. and Wtlkes C ) Ross. Auckland, 1984. 2. Armstrong W Land. class. colomahsm, the ongms of dommton capttahsm. In New Zealand and the World: Essu~s m Honour o/ Wolfgang Rosenberg (Edited by Wilmott W.). Universtty of Canterbury. Chrtstchurch. 1980. 3. For a recent review of the ‘westermsatton’ thests in New Zealand and the South Pa&c. see Prtor I. and TasmanJones C New Zealand Maort and Pacific Polynestans. In Wesrern Dwuses. Their Emergence and Prwentlon (Edited by Trowel1 H C. and Burkttt D P.) Edward Arnold, London. I98 I 4 Nevtlle W. R. J Trends and sources. In The Population of New Zealand. Intrrd~sc~plrnur~ Perspectnes (Edited by Nevtlle W R. J and O’Netll C. J.). Longman Paul, Auckland. 1979 5 The ‘Ideal’ IS based on the European and North American experience 6 O’Neill C. J. Fertthty, past. present. and future. In The Populutwn of New Zralund. Inrerdwlplmury Perspecrnes (Edited by Neville W R. J. and O’Neill C. J.). Longman Paul. Auckland. 1979. 7 McKeown T. The Role of Mednme: Dreum. Miruge or Nemesis Nuffield Provmctal Hospitals Trust, London, 1976. McKmlay J B. and McKmlay S. M The questionable contribution of medical measures to the decline of mortality m the United States m the twentieth century. Mdbank Meml Fund Q. 55, 1977 8 Foster F. H. Trends in Heulrh and Health Servrces. Department of Health. Wellmgton. 1979. 9 While nearly three-quarters of the Maort population lived m rural areas m 195 I, this had declined to less than a thud by 1976 (ibzd.. p. 39). The proportion of Pacific Islanders m the New Zealand population has more than doubled to 3”,, m the 10 year mtercensal period since 1971 Two-thirds live m Auckland (Department of Stattsttcs mformatton release no. 83!139). 10 Ohver W. H The ortgms and growth of the welfare state. In Socral Welfare und New Zeuland Sorter) (Edited hy Trim A. D.) Methuen. Wellmgton, 1977. Il. It is estimated that m 1925 over 40”;, of all health expenditure m New Zealand came from pubhc sources (Smith A. G. and Tatchell P. M. Heulrh Expendnure m Ivelc Zealand-Trends und Gron,th Parlerns Department of Health. Welhngton. 1979). 12. Ihrd. p I 1 I3 Ibid.. p. I?. 14. Ibrd.. p I9 J. Evaluating medical technology m the 15 McKmlay context of a fiscal crisis. the case of New Zealand. Mdhunk Meml Fund Q. 58, 1980. B The structure of a health servtce and its 16 Easton performance, the New Zealand case. N.Z. J/ Pub/. Admrn. 35, 1976. Health Stattsttcs Centre. Morrolrt~ and DeI7 National mographrc Dura IY7Y. Department of Health. Wellmgton. 1982: World Health Orgamsation World Health Srarrsrrcs Annual. World Health Organisatron. Geneva. 1981. 18 Zodgekar A V Mortality In The PopularIon of .V~II Zculund~ hrerd~scrplmar~~ Perspectices (Edited by Neville W’. R. J and O’Neill C. J.). Longman Paul, Auckland. 1979 19. Davis P Health and Health Care m Nelew,Zealand. Longman Paul. Auckland. 1981. 20 Tudor Hart J The inverse care law. Lancer i. 1971. resource allocatton in ‘I. Ross Barnett J. ei ul Hospital New Zealand Sot Ser. Med. 14D. 1980

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22. Ross Barnett J and Newton P Intra-urban dtspartttes In the provision of primary health care- an exammatton of three New Zealand urban areas. Atr.r(. N.Z JI Socrol 13, 1977. L e/ ul. The avatlabthty. distribution and 23. Malcolm utilisatton of general practitioners in New Zealand. A study based upon GMS clatms. N Z med. J. 91, 1980. G. Social needs for medical services the 24 Salmond inverse care law in New Zealand. N.Z. med. J. 80, 1974 25. Neville R J. W. op cn 26. Pomare E. W Muon Siundurds o/ Heuhit: A Sluha of the 20 Yeor Period IY55-75 Medical Research Counctl. Wellmgton. I980 27. Blaxter M Social class and health inequahttes. In Equuhrles und Ineyuulr~~~ m Heulih (Edited by Carter C. and Peel J.) Academic Press, London, 1976 28. Burkitt D. Dtseases of modern economic development In Encwonmental Mrdnine (Edited by Howe G. and Lorraine J.) Heinemann. London. 1973. 29 It IS still the exception rather than the

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36. MacDonald M. Health and unemployment, are the effects of recent unemployment m New Zealand becoming apparent m national health statistics? Unpublished paper, Department of Community Health. Auckland Medtcal School. 37. Colledge M. Economtc cycles and health: towards a sociologtcal understanding of the Impact of recession on health and illness. Sot. Sci. Med. 16, 1982. P. and Davidson N., op. cu. 38. Townsend 39. For an analysis of this and other policy issues, see Davis P Policy outcomes m health and health care. In In the Pubhc Inreresr: Heallh. Work and Housrng in Neu Zealand Socierv (Edited by Shirley I. and Wilkes C.). Ross. Auckland, 1984. Probably a third of all New Zealanders now have private medical insurance. For an analysts of the flight to private cover. see Fougere G. Medtcal insurance, the market’s quiet counterrevolution. In The Future of Net%,Zealand Medrcine-A Progressne Vlelt, (Edited by Beaven D. and Easton B.). Peryer. Christchurch, 1974.