Dr Lawrie Knight: Fact checking Māori health claims that led to the Pae Ora
(Healthy Futures) Bill
Lawrie Knight is a doctor and former All-Black. The following is an abridged version of his submission to the select committee considering Pae Ora (Healthy Futures) Bill. The original version can be viewed here.
AdecisionhasbeenmadebygovernmenttocreateaseparateHealthServiceforMāori basedonWaitangiReport2575(Ref15)andtheTeOraReport(Ref1).
MāoridoctorsandhealthleadershavecalledtheNewZealandhealthsystem "systemicallyracist"primarilycontributingtopoorMāorihealthandreducedMāori longevity.
Thefourmostcommonclaimsmadeare:
1.MāoridiesevenyearsearlierthanotherNewZealanders
2.DecolonisingthehealthsystemwillimproveMāorihealthandlongevity
3.PrimarycontributingfactorsforMāoriillhealthare“systemicracism,”“white privilege,”and“unconsciousbias”intheNewZealandhealthsystem
4.Non–Māoriarenotaffectedbyinequitablehealthprovisionandservices
1. Māori die seven years earlier than other New Zealanders
ThedataonthelifeexpectanciesofpeoplelivinginNewZealandin2018are(Ref2,3):
Geneticshavebeenestimatedtoaccountforbetween7%and33%ofthevariancein longevity.Thestandardacceptedfigureforthisgeneticimpactis25%(Ref4,5). Comparisonsbetweendifferentethnicitiesregardingrelativelifeexpectanciesmust takethisintoaccount.
FromtheaboveMāorihavethelowestlifeexpectancy.However,itisnotaccuratetosay thatMāoridiesevenyearsearlierthanotherNewZealandersaseachraceinNew Zealandhasitsowngeneticallyinfluencedlifeexpectancy.
PakehadienearlysixyearsearlierthanChineseNewZealanders.
Dowealsoclaimthisisduetoa“systemicallyracist”healthsystem?Thelogicis missing.Ifgeneticsarenotconsidered,thenmistakesandfaultyanalysisoccur.
2. Decolonising the health system will improve Māori health and longevity
Thecommentthat“decolonisingtheHealthServiceisnecessarytoimproveMāori healthandlongevity"isnotsupportedbytheCookIslandexperience.
One way to estimate the impact of colonisation is to compare New Zealand Māori demographic data to a genetically similar population, namely Cook Island Māori still residentintheCookIslands.Thelatterhavealsobeensubjecttoadegreeofcolonisation buthavebeendecolonisedfor56years.
FemaleslivingintheCookIslandshavealifeexpectancyof79.2years(Ref6),whereas MāorifemaleslivinginNewZealandhavealifeexpectancyof78.2years.Formales,the relevantexpectanciesare73.3yearsand74.2years.Thesedifferencesarenot significantanddonotsupportanargumentthata56-yearperiodofdecolonisationhas hadeitherapositiveornegativeeffectonlongevityforCookIslandMāori.
Morehelpfultotheconsiderationofcolonisationanditseffectonlongevityisthatall PacificIslanders,irrespectiveoftheirorigin,havesignificantlyincreasedtheirlife expectancybymigratingtoNewZealand–despitelivinginlowersocioeconomicareas anddespitehavingtousetheallegedly“systemicallyracist”healthsystem.
Forexample,using2018censusdatafromSamoa(Ref7),Tonga(Ref8)andFiji(Ref9) thelifeexpectanciesforPacificpeoplelivinginthePacificIslandscomparedtolivingin NewZealandare:
TheaveragelifeexpectancyforPacificmaleslivinginFijiandTongais8.7yearslessthan PacificmaleslivinginNewZealand,andforPacificfemalesitis9.6yearslessthanPacific femaleslivinginNewZealand.
ThesedatashowverysignificantincreasesinlifeexpectancyforSamoans,Tongansand FijianslivinginNewZealand.Theyalsoshowthatimprovingkeysocialdeterminantsof health–poverty,unemployment,loweducationallevel,andpoorhousing-which presumablyhavebeenprevalentinthelesseconomicallydevelopedPacificnations,are theprimefactorsindeterminingbetterhealthandgreaterlongevity,alongwithahealth systemthatprovidesamorecompleteservicethanavailableintheIslands.
That77.2%ofPacificpeoplearechoosingtousetheNZhealthsystem-higherthanany otherethnicity(Ref10)-suggeststheydonotperceivethesystemtobe“systemically racist”orhavingan“unconsciousbias”againstPacificpeoples.
So,ifshortenedlongevityforMāoriisattributedtoa"systemicallyracist"system,as claimedbytheWaitangiTribunalandTeOra,howisthephenomenonofhigher utilisationbyPacificpeoplesexplained?
Also,whatexplainsthesignificantlyincreasedlifeexpectancyofMaorilivinginthe MarlboroughregionwhereMāorimaleshavealifeexpectancyof79.9years(a5.7-year increase)andMāorifemaleshavealifeexpectancyof83.4years(a5.2-yearincrease)? (Ref11)
Perhapsthehealthsystemisnot“systemicallyracist“inthatregion.
Itdoesnotmakesensethat80,000healthworkersareracistforMāoributnotracistfor Tongans,FijiansandSamoans,orthehealthworkersinMarlborougharenotracistbut theworkersintherestofNewZealandare.ThelogicintheWaitangiTribunalandthe TeOrareportregardingsystemicracismisnotrational.
Thethirdofthecorestatements-that“systemicracism”,“whiteprivilege”and “unconsciousbias”inthehealthsystemarekeycontributorstoreducedMāori longevity,islistedastheprimarycauseintheTeOrareport.
Whatis “asystemically racisthealth system”?Itis asystemofhealthdelivery in which services are separated, financed, and delivered on the basis of race. It existed in South Africaunderapartheid.
Underapartheid,inhistoricaltribalhomelandsvarioustribesadministeredtheirown healthsystemsincludinghospitals.IntheremainderofSouthAfricathepublichealth systemwasdividedintotwo–onesystemfor“whites”andonesystemfor“non-whites.” Therewereseparatehospitals,separateambulances,separateservices,andseparate fundingprovidedfor“white”and“non-white”patients.Therewasvastlydifferent governmentfundingperheadofpopulationinthehealthbudgetsforthevariousraces aspergovernmentpolicy.Thestandardofmedicalcareonoffervariedsignificantly betweenthe“white”and“non-white”groups.
Thesearethecharacteristicsofa"systemicallyracist"healthsystem.
Until now,noneofthesebasiccriteriaforasystemicallyracistsystemexistsintheNew Zealandhealthservice.
Thus,fortheChairmanoftheNewZealandMedicalCouncil,thetwoAssociateMinisters ofHealth,andtheCEOoftheMinistryofHealth,tostatethatwehave“systemicracism” intheNewZealandhealthsystem,isjustnotfactuallycorrect.TheNewZealandsystem doesnotcomparetotheinternationallycriticisedSouthAfricanhealthsystem, legislatedtobecompletelysystemicallyracist.
UndertheCodeofDisabilityandConsumerRights,NewZealandhasahealthsystem legislatedforequalservicesandaccessforallraces,asrequiredbytheUNDeclaration ofPrinciplesonHumanRights,theDeclarationofCommonwealthPrinciples,andthe NewZealandBillofRights.Hadtherebeenanydiscriminationonracialgrounds,there wouldhavebeenprosecutions.Therehavebeennone.
TheaccusationofracismintheNewZealandmedicalcontexthasbeenlevelledwhen culturalnormsofthepatientwerenotadheredtoinprimarypracticeorinthehospital environment.However,alackofculturalknowledgeisnotracism,andgiventheNew Zealandhealthworkforceissodependentonimmigranthealthworkers(44% accordingtoNZMCandNursingCouncildata)accusationsthat80,000workersof diverseethnicitiesarecollectivelyracistarewrongandhavecausedsignificant resentmentamongstmedicalandnursingstaff.
3. The primary contributing factor for Māori ill health is “systemic racism,” “white privilege,” and “unconscious bias” in the New Zealand health system
Thephrase“whiteprivilege”impliesthattherearefewerobstaclesinthewayofnonMāoripeopletoaccesshealthcare.Whereistheevidence?Pakeha,andothernon-Māori racesaffectedbyunemployment,poverty,pooreducation,poorhousingorlivingin ruralareas,haveasmuchdifficultyinaccessinghealthasMāoriinthesame socioeconomicorgeographicalsituation.In2018therewereapproximately90,100 non-Māoriunemployedcomparedto40,300Māori.Thatthesepeoplehave“white privilege“isnotcorrect.Allthesepeoplebattleandneedassistanceirrespectiveoftheir ethnicity.
Thephrase“unconsciousbias”referstoastronglyheldbeliefthatexistsinmemoryand influencesdecisionmaking.Thesebeliefsarisefromchildhoodconditioningand becausetheyseemsonormal,weareunawaretheyareaffectingourdecisions.
Allpeople,fromallraces,includingMāori,haveunconsciousbias–itispartofbeinga humanbeing.Somepeople(inallraces)willhaveanunconsciousbiasagainstmembers ofadifferentrace-thisistheracialbiasreferredtoinTeOra.Somepeoplebelievethat theircultureisbestorthattheircultureisnotbeingtreatedfairly-thisisthe commonestunconsciousbiasthatexistsandisverymuchpresentinthisdiscussion abouthealthinNewZealand.
Asanexampleofthis,thecurrentlowvaccinationrateamongstMāori,thelowestofany ethnicity,hasbeenblamedon“systemicracism”and“governmentincompetence”by bothAssociateMinistersofHealth(Ref14)
Theirunconsciousbeliefinthecompleteresponsibilityofthegovernment,andinherent racisminthehealthservice,stopsthemfromconsideringthatthesamefactorscausing poorvaccinationratesinothercommunitiesandcountries,maybecontributingto vaccinehesitancyinMāori–e.g.antivaxsentiment,fearconcerninggenetic engineering,concernretheinjectionofforeignparticlesintothebody,problemsin gettingoffwork,rumoursofinfertility,rumoursofDNAissues,religiousissues,needle phobia,tapuissues,concernreadverselong-termeffects,andother misinformation/sideeffectsetc.WhywouldtheseconcernsnotbeaffectingMāoriinthe samewayastheyareaffectingasignificantnumberofNewZealandersandmillions worldwide?Theyareoffcourse,andevenDerekFoxhascommentedrecentlythata significantminorityofMāorirefusetotakethevaccinationfortheirownreasons.
TheMedicalCouncilchairhasstatedthatdoctorshaveanunconsciousracialbias againstMāori.ThebiaspresumablymeansthatdoctorsbelieveMāoriaresomehow inferiorandthereforearenottreatedaswellaspatientsfromnon-Māoriraces.Where istheevidenceforthis?Thefactthatthehighestutilisationbyethnicityofthehealth servicesisbyPacificpeoples(Ref10)suggeststhattheydonotthinkthatan unconsciousbiasexistsforthem.
WehavehadaHealthandDisabilitysupportsystemforpatientsforover20years.If specificexamplesexist,whereMāorihavebeentreatedwithaninferiorservicedueto theirrace,whyhavetheynotbeenprosecuted?
Throughoutthereports,thepoorMāorihealthoutcomesdocumentedintheWaitangi Report2575andtheTeOrareport,arestatementsonlyofpoorerhealth outcomes.
Thereisnodocumented,factualevidencepresentedregardingthe causes.
Forexample,theTeOraReportstates,withoutevidence,thatthefollowingarethe causesofpoorMāorihealthoutcomes
-"Systemicracism,""whiteprivilege"and"unconsciousbias"inthehealthsystem -theneedforlongerconsultations
-theneedforthedoctortogettoknowthepatientbetter
-lackofMāorispiritualknowledge
-nothavingonedoctoronanongoingbasisinPrimaryHealthClinics
-Māoriknowledgenotbeingincorporatedintotheconsultationanddiagnosis -effectsofcolonisation
Asidefromcolonisationcontributingtopoverty,whichhasthegreatestimpactonhealth, theothernominatedcausesarenotconsistentwithinternationalmedicalopinionwhich statesthatdiseaseprevalenceandpresentationisstronglyrelatedtotherangeofsocial deprivation factors which exist external to the health system, and for which thehealth systemisnotresponsible.
TheWorldHealthOrganisationmakesthefollowingstatementaboutsocialdeterminants ofhealth:
“World Health Organisation - Social Determinants of Health (SDH)
TheSDHhaveanimportantinfluenceonhealthinequities-theunfairandavoidable differencesinhealthstatusseenwithinandbetweencountries.Incountriesatall levels of income, health and illness follow a social gradient: the lower the socioeconomicposition,theworsethehealth.Thefollowinglistprovidesexamples ofthesocial determinantsofhealth,whichcan influencehealthequityin positive andnegativeways:
- Income and social protection
- Education
- Unemployment and job insecurity
- Working life conditions
- Food insecurity
- Housing, basic amenities and the environment
- Early childhood development
- Social inclusion and non-discrimination
- Structural conflict
- Access to affordable health services of decent quality.
Researchshowsthatthesocialdeterminantscanbemoreimportantthanhealth careorlifestylechoicesininfluencinghealth.Forexample,numerousstudies suggestthatSDHaccountforbetween30-55%ofhealthoutcomes.Inaddition,
estimatesshowthatthecontributionofsectorsoutsidehealthtopopulation healthoutcomesexceedsthecontributionfromthehealthsector.
AddressingSDHappropriatelyisfundamentalforimprovinghealthandreducing longstandinginequitiesinhealth,whichrequiresactionbyallsectorsandcivil society.”
WorldHealthOrganisation(Ref12)
Since2000,mostMāorihealthservicesforMāorienrolledontheMāorielectoralrollin bothruralandurbanregionshavebeenprovidedbyseventy-sevenMāoriHealth providers(Ref13).Theyhavebeenfundedbythestatebutcompletelymanagedbyiwi throughoutNewZealandduringthistime.Theywerecreatedovertwentyyearsagoto providea“byMāori,forMāori”healthserviceasasolutionfortheMāorihealth problems–theidenticalreasonasforthiscurrentbill.
Whilesomeofthehauorahaveprovidedanexcellentrangeofpublichealthmeasures andpersonalhealthservices,othershavenotbeensosuccessful.Overall,thenetworkof hauorahasnothadthebreakthroughinimprovingMāorihealthstatisticsthathadbeen hopedwouldoccurwitha“byMāori,forMāori”serviceprovider.Thereasonsforthis aredebatedwithMāoriclaiminginadequatefundingasthecause,andthefunding agencystatingfailuretoreachagreedhealthtargets,poormanagement,andincorrect spendingprioritiesaretoblame.TheWaitangiTribunal,whenstartingtheir investigationintoMāorihealth,refusedtopublishtheirfindingsintowhythishealth servicedeliverysystemfailed,statingitwas“sensitive”(WaitangiReport2575).Thisis irrationalastheinformationiscrucialtoassistingwiththesuccessofthisnewAct.
4. Non–Māori are not affected by inequitable health services
TheTeOrareportstatesthatthreemeasurementsconfirmMāoriarereceivingan inferiorhealthservicetootherNewZealanders:
1.MāorihaveahigherASHfigurethannon-Māori
2.Māorihavepoorersurgicalrecoverythannon-Māori
3.Māorihaveahigherdeathratefromarangeofmedicalcausesthannon-Māori
Thenumberofhospitaladmissionsthatcouldhavebeenpreventedbyaccesstotimely andcompetentgeneralpracticecare(AmbulatorySensitiveHospitalisation-ASH)were 2,171/100,000forthenon–Māoripopulation,and3,686/100,000fortheMāori populationbetweentheyearsof2007and2018.
TheTeOrareportneglectstomentionthe2016ASHrateforPacificadultswas 8,787/100,000–afigureovertwiceashighasMāori,andtherateforPacificchildren aged0-4was12,079/100,000(Ref10).Thesefiguresarenotseenwhensubsumedby the83.5%ofthepopulationcomprisingPakeha,Asianandothernon-Māoriethnicity groups.TherearealsonoASHfigurescollectedforthedisadvantagedsectionofthe Pakehapopulation.
ThatMāorihavealongerpostoperativestayinhospitalisindicativeofapoorersurgical outcomeforthesameprocedure.However,thisoutcomeisconsistentwithgreater comorbiditiesinthepatientatthetimeofsurgeryand,inacutemedicalsituations,a laterpresentationathospitalduetonotseeingaGPearlyintheillnessprocess(plus significantdistancetotraveltothehospitalcomparedtothenon-Māoripopulation.)To automaticallystatethatthelongerstayisduetoinferiorsurgicalserviceiswrong.
ThatMāorihaveahigherdeathratefromarangeofcausesisagainconsistentwiththe presenceofco-morbiditiescoupledwithgeneticsandpoorprimaryhealthcareas outlinedinSection1and3.
AsthevastmajorityoftheseMāorihavehadtheirgeneralpracticehealthprovidedby oneoftheseventy-seven“byMāori,forMāori”primaryhealthproviderssince2000, and,astheASHfigureisameasureofapoorlevelofaccessingandutilisinggeneral practiceduringthistime,thenthereasonsthatMāoridonotaccessprimaryhealth servicesmustbeclearlyidentified.Withoutclarityaroundthereasons,therewillbea repeatofthefailureofthesystemofthelast20years,whereserviceshavebeen providedby"Māori,forMāori",buthavenotsignificantlyimprovedMāorihealthas hoped.
Theabsolutenumberofnon–MāoriwithavoidablehospitaladmissionsintheTeOra report-90,000-isthreetimeshigherthantheabsoluteMāorinumber.Thisisan enormousnumberofnon-Māoripatientswhohavenothadaccesstotimelyor competentprimaryhealthcare.
Theproposedrestructuringofthehealthsystemdoesnotrecognisethesedisadvantaged multi-ethnicnon-MāoriNewZealanderswhoarepatientsonthefringesofthenon–Māori society. The figures below from Stats NZ indicate the size of this non-Māori medical underclasslivinginpovertyin2019.
ChildPovertyfiguresforchildrenlivinginNewZealand,StatsNZ2020(Ref16)
Fromtheabove,therearetwiceasmanychildrenlivinginpovertyinthenon-Māori (Pakeha+Pacificgroup)–145,000children-comparedtotheMāorigroup-61,000.
AnalternativeviewofthesamefiguresisasignificantlygreaternumberofPakeha childrenarelivinginpovertythanthetotalnumberofMāoriandPacificchildren.
IntheopeningsubmissiontotheTribunalHauorasEnquiry,theCrowncounselaccepted that “there is no need for this Tribunal panel to enquire into the question of whether Māorihealthstatusissignificantlyworsethanfornon-Māoriatapopulationlevel;thisis wellestablishedandnotdisputed."
Thisstatementisincorrect.
Asshownabove,aspovertyistheprimedeterminantofhealthoutcome,thiswasa mistakeonbehalfofCrowncounsel,whoalsoappearstohavehadalimitedknowledge ofhealthstatistics.Atapopulationlevel,wedon'thavethedatatostatethatMāori healthissignificantlyworsethanthatofalargeportionoftheNewZealandpopulation wholiveinpoverty,asthelevelofhealthandlongevityofthiscohortofdisadvantaged Pakehahasnotbeenmeasured.Whynot?Inabsolutenumbers,asshownabove,itis biggerthanboththeMāoriandPacificacombined.
ThenewHealthActstatesitsroleisto
(a)protect,promote,andimprovethehealthof all New Zealanders;and
(b)achieveequitybyreducinghealthdisparitiesamongNewZealand’spopulation groups,forMāori;and
(c)buildtowardsPaeOra(healthyfutures)for all New Zealanders.
Tonotaddresstheneedsofthisexceptionallylargenon–Māorimedicalunderclass, twicethesizeoftheMāorimedicalunderclass,andselectivelyincreasethepercapita fundingforMāori,isaninfringementoftheUNDeclarationofHumanRights,the CommonwealthDeclarationofPrinciples,andtheNewZealandBillofRights.Eachof thesepiecesoflegislationrequireequalityofaccesstohealthcareforequally disadvantagedgroups,irrespectiveofrace,gender,sexuality,religion,ageetc.,asabasic humanright.
Discussion
WhileitisrightforMāoriDoctorsandMāorileaderstoadvocateforbetterhealth fortheMāoripeople,itisnotrightthattheyattributeallMāoriillhealthtoa “systemicallyracist”systemwith"unconsciouslybiased"doctorsandhealthservice staff.Theseaccusationshavecausedhugeresentmentamongsthealthworkers.
Ifthisbeliefcontinues,theproblemswillneverbesolved.
ItiswrongthathealthstatementsmadebyvariousMāorileadersandtheWaitangi Tribunalaretakenatfacevalueandnotchallenged.Māoridoctorsknowthefour statementsdiscussedarefactuallyincorrectbutpersistinstatingthem.Theyarealso awareoftheWHOsocialdeterminantsofhealth(Ref12)whichtheyignoreinthis discussion.TheWaitangiTribunalisawareofthereasonsforthelackofsuccessofthe current“byMāori,forMāorisystem,”butrefusestoreleasetheirfindingsastheyare “sensitive”(Ref15).
ThepointsImakearenotanargumentagainstaddressingequityissueswhichexistfor thelowersocioeconomicgroupsofallethnicitiesinNewZealand.Ifullysupportthe argumentthatasignificantlyincreasednumberofMāoridoctorsmustbeproducedon anannualbasistohelpsolvetheMāorihealthproblem.Itisexceedinglydifficultfora non-Māoridoctortoassistwithmentalhealth,spiritualorpsychiatricissuesin traditionalMāoripatientswholiveinthetraditionalMāoriworldThesepatientsrequire adoctorwithanunderstandingofthatworldview.Thesignificantlyincreasednumber ofMāorimedicalgraduates,nowapproaching120ayear–30%ofthetotalgraduateswillbethesolutiontothisproblem.
ItisalsoundeniablethatmanyMāoriinremoterural,lowersocioeconomicgroupshave poorerhealththanotherslivinginurbanNewZealand.Theneedforimprovementfor thesepeopleisunquestionable,asitisforthenon-Māoriwhoareinthesamesituation, However,theargumentthat"systemicinstitutionalracism"isresponsibleforMāori livingrelativelyshorterlivesthanotherNewZealandersisincorrect.
ThecausesforallgroupswithinMāoriandnon-Māoriethnicitiesnotaccessingprimary healthprovidersinatimelymanner,andthereforescoringhigheronASHfigures,are multiple.IbelievethattheMedicalCouncil,theMāoriMedicalPractitionersgroup,the WaitangiTribunal,andtheMinistryofHealth,areafraidtoproperlycalloutthereal causesofnotonlyMāoripoorhealth,butthepoorhealthofalargepercentageofall racialgroups,Pakehaincluded.Pakehaandallotherethnicitiespresentwithobesity, hypertension,addictions,smoking,coronaryarterydisease,depression,anxiety disorders,gout,cancers,diabetes,respiratoryproblems,geneticdisordersetc.,onan ongoingbasis.ThefactthatPakehamales,thecreatorsofthehealthsystem,andthe sectorofsocietyaccusedofprivilege, are in the lower half of life expectancy when compared to the other ethnicities in New Zealand (seetable1)doesnotfitatallwith any“whiteprivilege”or"systemicracism"theory.Itdoesfitwellwiththe internationallyacceptedmedicalopinionthatdiseaseprevalenceandpresentationis stronglyrelatedtomultiplesocialdeprivationfactorsoutlinedabove,towhichPakeha andPacificaarenotimmune,andthatthesefactors‘sit’outsidethehealthsystemand requiretheirownresearchandsolutions.TheNewZealandexperienceofvery significantlyimprovedlifeexpectanciesforallPacificpeopleswhonowliveinNew Zealandconfirmsthis.
Conclusion
1. Systemic racism is not the cause of Māori health issues, but without clarity around the actual causes of the problems there can be no targeted solution
2. Funding the Health System without dealing with the Social Determinants of Health will not solve the problem
3. The government can allocate any amount of funding it wishes to Māori health but must also fund other equally medically underprivileged groups with the same per capita amount. Not to do so is in breach of New Zealand and international law and the stated aim of the Pae Ora (Health Futures) Act.
Dr L. Knight MSc (Hons) MBChBReferences:
1.https://www.mcnz.org.nz/assets/Publications/Reports/f5c692d6b0/CulturalSafety-Baseline-Data-Report-FINAL-September-2020.pdf
2.https://www.statista.com/statistics/719397/new-zealand-female-life-expectancyforecastby-ethnicity/
3.https://www.statista.com/statistics/719375/new-zealand-male-life-expectancyforecastby-ethnicity/
4.https://medlineplus.gov/genetics/understanding/traits/longevity/
5.https://immunityageing.biomedcentral.com/articles/10.1186/s12979-016-0066-z
6.http://www.geoba.se/country.php?cc=CK&year=2018
7.https://countryeconomy.com/demography/life-expectancy/samoa
8.https://countryeconomy.com/demography/life-expectancy/tonga
9.https://countryeconomy.com/demography/life-expectancy/fiji
10.https://www.nzdoctor.co.nz/sites/default/files/2019-09/Tofa%20Saili%20A%20review%20of%20evidence%20about%20health%20equity%20for%20Pacif ic%20Peoples%20in%20New%20Zealand.pdf
11.https://www.stats.govt.nz/information-releases/national-and-subnational-periodlife-tables2017-2019
12.https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1
13.https://www.health.govt.nz/your-health/services-and-support/health-careservices/maorihealth-provider-directory
14.https://www.nzherald.co.nz/kahu/covid-19-coronavirus-delta-outbreak-peenihenaredisappointed-with-vaccine-uptake-among-maori-admits-systemisracist/OU4UCX2NWCU27T66KXR3GH5VZI/
15.https://waitangitribunal.govt.nz/inquiries/kaupapa-inquiries/health-services-andoutcomesinquiry/
16.https://www.stats.govt.nz/information-releases/child-poverty-statistics-yearended-june2020
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