A collaboration between health geographer Jesse Whitehead and illustrator Jean Donaldson. Edited by Jonathan Burgess.
22 January 2025
“Dad, when are you going to die?”
I slowly open my groggy eyes to see my six-year-old daughter staring at me with a look of concern on her face. It’s 6am on a Monday morning, and I’m not ready for this.
But it is kind of my job. And not just as a parent who is supposed to somehow have an answer to all life’s impossible questions.
As a demographer and health geographer, it’s my job to think about how environments impact our health. I like maps, and use data to understand more about people and place – and how environments impact our health.
We can’t live forever, and none of us know when we’ll die. But some of us will live longer, healthier lives than others.
In Aotearoa New Zealand, health inequities are stark, persistent, and avoidable. These inequities, defined as unfair and preventable differences in health outcomes, challenge our perception of Aotearoa as a fair society. The social determinants of health – factors like housing, employment, education, and access to health services – play a significant role in these disparities.
For instance, the average life expectancy for pākeha men in Aotearoa is about 81 years, while for Māori men, it’s 73 years. This gap has widened since 2014. People living in the poorest areas of Aotearoa have a life expectancy nine years lower than those in wealthier areas.
A 1998 report from the National Health Committee clearly linked poverty to ill health, noting that the financially worst-off have the highest rates of illness and early death. Despite the passage of time, these findings remain relevant. Recent data reveals that young people under 30 living in remote areas are up to three times more likely to die than their urban counterparts.
We only found this out in 2023. What’s changed in rural Aotearoa? It turns out that health outcomes haven’t changed, but the way we look at data about people and place has. Historically, definitions of rurality in Aotearoa grouped small towns together with large urban centres based on their urban form – basically having streets, footpaths and suburbs – and lifestyle blocks on the edges of cities were considered rural. This led to misleading health research outcomes.
Under the leadership of Professor Gary Nixon, we developed a new classification system for rurality that better reflects health realities. This new system revealed that previous classifications underestimated rural health outcomes, particularly for preventable deaths.
Definitions were masking inequalities.
The conditions in which we are born, grow, work, live, and age create health differences. Rural populations in New Zealand tend to be older and poorer, with lower incomes, fewer formal qualifications, and less access to technology. These conditions are worse for Māori, especially in remote areas where 73% live in high-deprivation zones.
Poor access to health services further exacerbates these disparities. Rural communities consistently highlight access as a key issue, and the government aims to improve this through its rural health strategy.
The Covid-19 pandemic provided a stark example of how access to services impacts health outcomes. During the vaccine rollout, urban areas had numerous vaccination centres, while rural areas were often left with few options.
In the most vaccinated suburbs in Auckland, Wellington and Queenstown, the longest drive time to a vaccination centre was just five minutes. In Murupara, labelled the nations “slowest town”, the median age was 29 years – meaning that people had only just become eligible for the vaccine – and the nearest clinic was almost an hour’s drive away.
This led to significant disparities in vaccination rates, highlighting the need for a more equitable approach to health service delivery.
Looking ahead, Aotearoa faces significant demographic changes. By the 2050s, one quarter of the population could be over 65, with the number of people over 85 doubling. This ageing population will stretch health resources, with older individuals already occupying a significant portion of hospital beds. At the same time, the Māori population is young and growing, with a median age of just 27. Balancing the needs of these two demographic groups will be a major challenge.
Climate change adds another layer of complexity, bringing new health challenges such as extreme heat and more frequent severe weather events. Cyclone Gabrielle, for example, caused $14 billion in damage and significant disruption to health services. Building resilient and equitable health systems that can withstand these challenges is crucial.
Addressing health inequities in New Zealand requires a multifaceted approach. We need to improve living conditions, ensure fair access to health services, and prepare for future demographic and environmental changes.
These are complicated, intersecting and interrelated issues that nobody has a simple solution to. But research can play a part. If we can better understand the complex nuance of these problems, we can work together to create better solutions.
“Daaaadd! When are you going to die!??”
Ahh, that’s right – it’s Monday morning. How do I explain all that to a six year old?
“Well darling, nobody knows exactly when they’ll die. But if we work together to create a fairer society, we can all live longer healthier lives.”
Jesse Whitehead is principal investigator with Te Pūnaha Matatini, who focuses on impact and equity through health geography and demography.
Jean Donaldson is a designer and illustrator who works with Toi Āria: Design for Public Good. She is based in Te Whanganui-a-Tara. You can see more of her work at https://jeanmanudesign.com/.