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| Journal of the New Zealand Medical Association,
27-October-2006, Vol 119 No 1244
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Asian health in New Zealand—progress and
challenges
Kumanan Rasanathan, Shanthi Ameratunga, Samson Tse
Recently, the Ministry of Health released the Asian
Health Chart Book 20061—a
comprehensive profile of the health of ‘Asian’ peoples in New
Zealand, utilising data from Statistics New Zealand, the New Zealand Health
Information Service, the New Zealand Health Survey, and the National Screening
Unit. This report follows similar chart books for Māori and Pacific peoples
and offers both implicit and explicit recognition of New Zealand’s growing
Asian population and the importance of considering this population’s
particular health needs.
The Ministry’s report is the culmination of almost a
decade of work establishing an ‘Asian health’ platform and
consciousness in the New Zealand health sector. Despite this progress, Asian
health arguably occupies a marginal space in the health system, outside the
frames of reference for the majority of professionals providing public and
personal health services. This paper reviews the current status of Asian health,
both in terms of the health of Asian New Zealanders and the responsiveness of
the New Zealand health sector, and considers the challenges to further work in
this field.
Who is ‘Asian’ in New Zealand?Statistics New Zealand estimates that 9.5% of New
Zealand’s current population is Asian, compared to only 3% in
1991.2,3 This proportion is expected to grow to
almost 15% of the national population by 2020. In some areas, the projected
increases are much higher. For example, it is estimated that 34% of the
population served by the Auckland District Health Board will be Asian by
2016.4
However, who gets defined as Asian in New Zealand raises
complex issues. Statistics New Zealand and the state sector use a definition of
Asian that is unique to New Zealand,5 differing
from that used in many other western countries, especially the United
Kingdom.6
The Statistics New Zealand definition includes peoples as
Asian if they have origins in the Asian continent from east and south of
Afghanistan (inclusive). It does not consider peoples from the Middle East, such
as Iranians and Iraqis, and Central Asia as Asian.
In contrast to the state sector definition, colloquial usage
of the term Asian in New Zealand—as reflected in the
media5—often specifically describes
Chinese and other East and Southeast Asian peoples. In this usage, Asian does
not include Indian or other South Asian New
Zealanders.7
In this paper, the Statistics New Zealand definition of
Asian is followed.
The Asian grouping in New Zealand is thus very heterogeneous
as it includes half the peoples of the World. Beyond this diversity in
ethnicity, the Asian grouping differs along many other axes, including
settlement history, socioeconomic status, English language ability, and
acculturation. For example, the grouping includes recent migrants together with
Indian and Chinese New Zealanders whose ancestors arrived in New Zealand over a
100 years ago. The socioeconomic profile of the Asian grouping roughly mirrors
that of the total New Zealand population, with an even distribution across the
deciles of the New Zealand Deprivation
Index.8
The health of Asian New Zealanders and the development of an Asian health sector in New ZealandFollowing the rapid increase of the Asian population in New
Zealand during the 1990s, the first major reports reflecting health issues
relating to these peoples began to
appear.9–11 Small studies revealed
concerns around access to health services, mental health, and settlement
difficulties.12–14 However, in the
absence of large-scale data, it was difficult to identify whether these concerns
applied to the whole population or specific Asian sub-groups.
The Asian Public Health Project
report15 published by the Ministry of Health in
2003 and the first Asian health conference16
held in Auckland in 2004 served as important steps forward, signalling the need
for a more systematic appraisal of the health of Asian peoples in New Zealand.
Alongside these developments, services and organisations
aimed at improving Asian health began to emerge in the context of healthcare
institutions (such as the Asian Health Support Service at Waitemata District
Health Board and the Asian Health Website hosted by Auckland Regional Public
Health Service), academic institutions (including university research centres)
and community groups.
During the past year, the first large-scale reports about
the health of Asian New Zealanders appeared:
These
three recent reports have recognised that Asian health is a useful banner for
organising and facilitating health research and services for Asian peoples in
New Zealand—whilst at the same time identifying that Asian is a
problematic category for analysis due to the diversity of peoples collected
under this grouping.5,19
As such, all three reports have focused on smaller
sub-groupings within the Asian category and have shown differences between these
sub-groupings. Interestingly, however, the three reports differ in the manner in
which they do this, although they all follow the principles of considering
Indian and Chinese peoples separately and attempting to consider the effect of
duration of residence in New Zealand.
The three reports identify significant concerns that require
action. Key issues include access to health services, in particular for Chinese
peoples; cardiovascular disease and diabetes for Indian peoples; levels of
physical activity; and mental health, particularly in young people. The reports
also indicate that whilst Asian peoples in New Zealand are relatively healthy
overall, much of this effect is due to the high health status of recent
migrants—the ‘healthy immigrant
effect’.20
Asian New Zealanders born in this country are in general
less healthy than recent migrants across a range of indicators including
cardiovascular disease mortality, cancer mortality, and prevalence of health
promoting behaviours.1,18 This is not
surprising given that most migrants to New Zealand need to be in good health to
be allowed to emigrate and many have high socioeconomic status in their
countries of origin. These migrant groups also have high levels of education
which are correlated with better health
status.21 This positive effect on health abates
with increased length of settlement in New
Zealand.1,18
The high levels of cardiovascular disease and diabetes in
Indian New Zealanders illuminate many of the challenges in considering Asian
health in New Zealand. If the Asian grouping is considered as a whole, levels of
diabetes and cardiovascular disease do not seem especially high. However, when
Indian peoples are considered on their own, they show the highest rates of
self-reported diabetes of any ethnic group in New
Zealand,17 a finding supported by other
surveys.22 They also show high levels of
cardiovascular disease, similar to Māori.
The obscuring of this finding when considering the whole
Asian grouping shows the clear potential for the diversity of the category to
mask areas of need through
‘averaging’.5 In this case, the
relatively low levels of diabetes and cardiovascular disease currently in
Chinese New Zealanders averages out the high levels in Indian New
Zealanders.19
Despite high levels of disease, Indian New Zealanders rarely
figure as a priority group in current diabetes strategies. For example, the
otherwise excellent Let’s Beat Diabetes Strategy by Counties
Manukau District Health Board fails to mention Indian peoples, only considering
Asian peoples in a relatively undefined
way23—despite a range of studies (some
based in South Auckland) confirming Indian peoples’ (as discussed above)
high levels of diabetes1,22,24,25 with low
levels of general practitioner consultations.24
In contrast, Indian peoples in New Zealand are identified as a high risk group
for cardiovascular disease in New Zealand screening
guidelines.26
The pattern of low levels of healthcare service utilisation
is seen across most areas for Asian peoples in New Zealand, particularly for
Chinese New Zealanders. The Ministry of Health chart book shows particular
concerns around primary healthcare and cancer screening, with no evidence that
this gap is filled by traditional
practitioners.1 In the Youth2000 study, 15% of
young Chinese New Zealanders reported accessing no healthcare at all—over
three times the rate reported by their European
peers.18
Factors outside the traditional boundaries of the health
sector, but of important relevance to the health and wellbeing of Asian New
Zealanders, are difficulties in finding employment and experiences of racism.
The importance of these associations is not unique to this population but there
are important nuances in the experience.
Asian peoples in New Zealand are more likely than non-Asian
New Zealanders to have tertiary qualifications, but have higher levels of
unemployment and lower incomes as a group.1
This is partly due to a lack of effective settlement strategies for migrant
Asians to New Zealand as well as failure to appropriately utilise these
migrants’ potential. Lack of (or under-) employment and difficulties
settling into the host community are associated with negative health effects,
particularly in terms of mental health—with Chinese migrants appearing to
fare worse than other migrants to New
Zealand.27
Recent evidence shows that Asian New Zealanders are less
likely to be interviewed for vacancies than other New Zealanders (despite
similar qualifications and experience, and regardless of duration of residence
in New Zealand) if they have non-European
names.28 Indeed, other studies note that the
experience of racism by Asian New Zealanders is common, with particularly high
levels in the employment sector.29
Challenges in advancing Asian health in New ZealandAt a time when several reports and an emerging research
literature have identified specific health issues for Asian populations in New
Zealand, the apparent policy void for Asian peoples in New Zealand is
concerning.30 Furthermore, no clear mandate
exists to consider or monitor Asian peoples when undertaking health research or
formulating health policy.
Indeed, operational capacity and clear policies to address
the health of Asian peoples are yet to be developed by the Ministry of Health.
Other government agencies have made less progress in engaging the concerns of
Asian peoples. For example, the recent study on New Zealand living standards did
not report findings for Asian peoples.31
Further research, including qualitative analyses, is also
required to consider the contexts and drivers of the health needs and
inequalities identified and provide targets for action. It is, however,
important to consider whether there is a case for considering the health of
Asian peoples in New Zealand separately to the ‘mainstream’.
The New Zealand health sector has made significant progress
over the past decade in considering specific health issues for Māori and
Pacific peoples, especially in describing inequalities. This approach has been
justified on several grounds including the relatively poor health status of
these groups, and (for Māori) their constitutional status as tangata
whenua (people of the land). Despite this progress, much remains to be done
and wide inequalities remain. However, there is now an explicit recognition of
these groups in policy together with the acknowledgement that the health sector
must improve services and access for Māori and Pacific peoples in order to
reduce inequalities. These are important milestones.
For Asian peoples, in terms of crude mortality, no such
inequalities exist however. In fact, the broad Asian groups appear to have
similar or higher life expectancy to the rest of the New Zealand
population.1 If this is the case, is there then
any need or utility in attempting to cater for Asian populations beyond what is
available in the ‘mainstream’ health sector? And is there any need
for specific health policy and services aimed at Asian peoples in New Zealand,
given the apparent success of the health sector in ensuring their health?
Based on the recent reports, the current good health status
of Asian populations in New Zealand would appear to have little relation to
services provided by the health sector. As discussed above, over a range of
services, Asian populations show low utilisation from primary
care1,17,18 to cancer
screening1,17 to Accident Compensation
Corporation services32 and the favourable
health indices appear to primarily reflect the high health status of the recent
migrant constituencies of Asian populations.
As the ‘healthy immigrant effect’ wanes with
increased duration of settlement,33 it is
predicted that as migrant communities acculturate, they will begin to resemble
other New Zealanders’ risk status for major chronic illness (as shown by
New Zealand-born Asian populations).
Asian populations also show particular risk factors for
chronic illness, with low levels of physical activity and insufficient fruit and
vegetable consumption.1 Combined with low
levels of health services utilisation, the chronic disease burden in Asian
populations in New Zealand could thus increase dramatically. Such an increase
may be seen not just in Indian groups (whose elevated risk for cardiovascular
disease and diabetes has been demonstrated in many
countries34–36), but also in Chinese
groups who may mirror the increasing prevalence of obesity and chronic disease
in China.37–39
Improvements in health policy and service responsiveness for
Asian populations in New Zealand thus appear warranted by these risks which
could result in increasing morbidity and mortality, and furthermore, increased
health expenditure, for a large and growing proportion of the population.
It seems untenable for policy and services to continue to
broadly ignore one-tenth of the New Zealand population especially in the context
of inequities in access to the ‘mainstream’ health system for large
parts of this population. These inequalities are particularly challenging issues
for agencies serving areas with larger Asian populations, such as district
health boards in the Auckland region and some primary health
organisations.
ConclusionAsian New Zealanders now constitute a significant part of
New Zealand society. The recent advances in knowledge about health issues faced
by this diverse population provide an agenda for progress in building capacity
and policy to address these concerns. This agenda must build on the existing
work already achieved by a range of service providers, academic institutions,
and community groups. However, for this sector to make progress, greater
recognition of Asian populations by central government and large
‘mainstream’ organisations (such as district health boards) is
needed.
The challenge posed by the Asian Health Chart Book
2006 and other recent reports is whether there is sufficient will to
recognise the health needs of Asian peoples in New Zealand. If so, explicit
engagement, policy and service development are required to address these needs
in this significant and diverse part of the New Zealand population.
Author information: Kumanan Rasanathan,
Public Health Medicine Registrar, Section of International Health, School of
Population Health, University of Auckland; Shanthi Ameratunga, Associate
Professor, Section of Epidemiology and Biostatistics, School of Population
Health, University of Auckland; Samson Tse, Director, Centre for Asian Health
Research and Evaluation, University of Auckland; Auckland
Acknowledgements: We thank Alistair
Woodward (Head, School of Population Health, University of Auckland) for his
comments and critical review of the manuscript.
Correspondence: Dr Kumanan Rasanathan,
Public Health Medicine Registrar, Section of International Health, School of
Population Health, University of Auckland, Private Bag 92019, Auckland, New
Zealand. Fax: (09) 373 7624; email: k.rasanathan@auckland.ac.nz
References:
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