Decreasing the life expectancy gap between Māori and Europeans in Aotearoa New Zealand

It is very impressive that Dr Ghafel and colleagues report that the life expectancy gap in Aotearoa New Zealand has lessened over two decades between Māori and Europeans.¹

Mortality data from the Aotearoa New Zealand mortality collection and population estimates from Stats NZ Tatauranga Aotearoa were used to calculate life expectancy at birth for Māori, Pacific, Asian and European and Other populations for the periods 2001–2003 and 2020–2022.¹ The life expectancy gap has gone from 8.0 to 6.5 years in Māori males and from 8.3 to 6.0 years in Māori females, i.e., 18.8% and 27.7% reduction respectively. There was no change in the life expectancy gap for Pacific people.

The authors are to be congratulated for analysing the data identifying the cause of death categories responsible for the changes in life expectancy and conveying this news. This is a magnificent achievement by all those working in preventative health and Māori themselves.

Classification of ethnicity

The authors used prioritised ethnicity as a measure of cultural affiliation, and identity is based on self-reported ethnicity from the Aotearoa New Zealand census.² However, as people are known to identify with multiple ethnic groups, this may have affected the count, as it would mask important heterogeneity within groups. Also, a person’s reported ethnicity can change over their lifetime as their personal and cultural perceptions evolve, and people can opt in or opt out from different ethnicity classifications over time. It would be very interesting to know how many people switch their ethnicity between censuses. It is possible that the latest data from the 2023 New Zealand Census may include relatively healthier people than it did 20 years ago.

Possible reasons for closing the life expectancy gap

Reductions in cardiovascular and cancer mortality accounted for more than half of the total improvements, reflecting their larger contribution to mortality. The authors comment on the declines in cardiovascular mortality likely reflecting a combination of long-term declines in smoking, improvements in population-level cardiovascular risk factors, advances in primary and secondary prevention—including wider use of antihypertensive therapy—lipid-lowering medications and improved acute and post-acute management of ischaemic heart disease and stroke.

The reduction in smoking in Aotearoa New Zealand is laudable and explains some of the fall in both cancer and cardiovascular deaths. However, the smoking prevalence in Māori remains unacceptably high at 17% compared with European and Asian rates of 6%.³

Māori continue to have higher rates of hypertension and elevated cholesterol levels as compared with Europeans. And the inequality with higher rates of admissions with acute coronary syndromes in Māori as compared with Europeans has increased.⁴ Furthermore, outcomes including mortality and morbidity have been worse in Māori as compared with Europeans after coronary artery bypass grafting (CABG).⁵

Other possible contributions to the fall in mortality in Māori could include improved nutrition; decreasing rates of obesity, resulting in decreased rates of diabetes; increasing exercise; and improved access to and adherence of cardiovascular drugs. Improvement in health literacy and improved access to percutaneous coronary intervention (PCI) and CABG with better outcomes may also have occurred, but we have little data about these possible changes.

Moving forward to close the life expectancy gap

Pharmac have had a major role in restricting quality-of-life-improving and lifesaving cardiovascular drugs that are readily available overseas. There are numerous life-changing drugs that also reduce death from cardiovascular causes; some reduce total mortality; some reduce hospitalisations and some decrease progression of kidney disease. We do not have access to the safest antiplatelet drug, apixaban, nor treatment for patients with heart failure with preserved ejection fractions, which make up half of the causes of heart failure, nor the 25,000 New Zealanders with familial hypercholesterolemia who may die in their 30s. They are simply not available.

Several recent actions by the Aotearoa New Zealand coalition Government are likely to increase inequity. Cost is a major factor affecting adherence⁶ and eliminating medicine co-payments have been linked with fewer hospitalisations for patients residing in regions of high socio-economic deprivation.⁷ The return to a NZ$5 co-charge for each prescription item will affect equity and adherence. The coalition Government has also deleted the Māori ethnicity criteria, which allowed increased access to some cardiovascular and diabetes drugs, which will also result in increased inequity.

Conclusion

For a life expectancy gap of 6.5 years in Māori males and 6.0 years in Māori females to remain is a shameful travesty. It reflects badly on all of us working in the health sector. The findings of this study will help inform the continued effort needed to close this gap, but we must do better.

“He waka eke Noa Noa.”

“A waka we are all in together.”