Covid-19 lays inequality in NZ bare

Covid-19 has laid bare our underlying systems of inequality. Victoria University of Wellington's Dr Anna Matheson asks if will we learn from evidence this time.

Repeating the same actions over and over again and expecting the outcome to be different has long been considered the height of absurdity. And what is more absurd is doing this while equipped with knowledge showing us a better way.

This is how it has been with our collective societal response to addressing health inequities that the Covid-19 crisis is now exposing in very clear ways. Just as individuals with underlying conditions are more vulnerable to the pandemic, so too are many of our communities.

In Aotearoa New Zealand, we have known for more than 40 years that socioeconomic position determines how sick you will be and how long you will live. Put simply, if you are poor, your life expectancy is lower than someone with wealth – six years for men and five for women. If you are also Māori or of Pacific Island descent, you can expect to be sicker and die even sooner.  

This pattern is mirrored globally, where the gap in life expectancy between richest and poorest countries is about 30 years. These starkly different outcomes for people are unfair and also avoidable.

The causes of differences in life expectancy are complex – but we know a lot about them. We know they are the result of systemic interactions, like institutional racism. Causes compound at both ends of the inequality spectrum – influencing both disadvantage and privilege. We also know inequality is relative, existing within countries as well as between countries, regardless of absolute material circumstances.  

We know how inequality ‘gets under the skin’ through stress induced by a lack of control experienced more frequently by some social groups, and that it is a known risk factor for a number of chronic diseases. And while there are significant inequalities in access to, and people’s journey through, the healthcare system, the system has been estimated to account for only 30 percent of health outcomes. Social, commercial and political determinants of health, which play out unequally for different social groups, contribute to the rest.

For all this we know, Aotearoa has been unable so far to fix formative social malaise such as our intolerable numbers of children living in poverty. Similarly, the Waitangi Tribunal Health Inquiry last year found that, despite years of substantial intention and investment, Māori health inequalities remain almost unchanged.  

Why has all we have learned not made an impact?

One answer lies in how we think about social intervention. Understanding health inequalities are reproduced through our social systems is important. 

Currently, our systems flow away from the local – away from the intimacy that drives empathy and compels action. Part of this flow is determined by history and its impact on power, knowledge and resources. Part of it is about what is valued and what is not – such as workforces or local eco-systems. And part of it is that we are good at gathering data, evidence and information to define and understand problems, but less good at acting to implement effective solutions.  

The Government has been lauded for its Wellbeing Budget, a welcome shift in focus away from predominantly economic growth. But if collective wellbeing is about the strength and flow of relationships with each other and the environment, solutions need to recognise this.  

Power, resources and voice need to be returned to local communities and policies need to be developed that foster local self-determination and innovation. We haven’t seen the health and social gains from whole-of-government and intersectoral strategies we would have expected. This is likely because communities and policy makers also need to be more joined up.   

It is against this background of inequality, inherent in our underlying systems, that the Covid-19 pandemic is happening. Despite the very necessary ‘first aid’ the Government is attempting to provide, we can predict which social groups will be most affected. 

We know the consequences of the pandemic will be substantial and long-lasting, similar to those we saw through the 1980s and 1990s with economic restructuring. Profound health and social consequences will once again fall heavily on those in already difficult and precarious circumstances.

Reviews last year of the health and disability, mental health and primary health care systems all theorised that dominant western models of health are not entirely fit for purpose. This crisis shows, in no uncertain terms, that our underlying systems are not fit for purpose.  

Let us learn from this moment and get more sophisticated and humane about addressing the large-scale outcomes of our social systems. 

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