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Matter of life and death

New Zealanders once had the highest recorded life expectancy in the world and now experts believe a few simple measures could put us back on top.

baby
Photo/Getty Images


The question mark in the title is provocative. Are we The Healthy Country?

“We’re not the healthy country if you compare us with Australians, and we do tend to be obsessive about comparisons with Australia,” says Alistair Woodward, professor of epid­emiology and biostatistics at the University of Auckland. “But it wasn’t always that way and the gap between New Zealand and Australia has closed in recent times.”

“Compared with the past, yes we are,” says Tony Blakely, professor of public health at the University of Otago. “Compared with most countries, yes we are. Are we the healthiest country at the moment? No. Could we be the healthiest country? Yes, if we chose to.”

In The Healthy Country? A History of Life and Death in New Zealand, Woodward and Blakely scan some 800 years of settlement to gauge this country’s overall health as told through our births, deaths and rapidly growing life expectancy statistics.

In 1960, men who reached 80 could expect to live another 5.5 years, women another 6.4 years. In 2012, 80-year-old men could expect another 8.5 years of life and women another 9.8 years.

Today, on average, a male born in 2011 will live to 90 and a female to 92. The number of people aged 100 and over increased tenfold between 1960 and 2010. If the rate of increase in life expectancy we saw in the 20th century continues, life expectancy in the year 2100 will be 100 or more.

“So now we have to engage with that conversation about what is a good innings,” says Woodward. “And that’s bound up with the quality question. Some people may live very good lives, very long lives, but it wouldn’t be acceptable if it was at the cost of others. These are questions we have to grapple with because the world has changed and changed profoundly.”

 

older couple
Photo/Getty Images

PROTEIN PLUS


The world encountered by this country’s first arrivals was heaving with protein: seals, sea birds, moa. These were rich pickings – a moa drumstick could weigh 30-40kg – but they lasted only 100-150 years. By the 1600s, nine species of moa were probably extinct and Maori were increasingly reliant on nutrient-sparse wild foods, cultivable plants and a diminishing quantity and variety of shellfish.

Before the Endeavour hoved into view, the estimated Maori life expectancy was 20-25 years. This was mainly the result of high infant and child mortality – those who made it to the age of 20 could live on average another 15-20 years.

For early European settlers, life was good. So good, claimed a local newspaper, that new arrivals “died only of drowning or drunkenness”.

Although the transitory population of sealers and whalers showed an alarming proclivity for death by drowning, injury, shipwreck, brawling and drunkenness, the early settler population benefited from the “healthy migrant effect”. Most were young and many came from rural regions (at a time when life expectancy in England’s agricultural districts was five to eight years greater than the national average).

Advertisements for new migrants called for married agricultural labourers and single domestic servants who were “sober, industrious, of good moral character, of sound mind and in good health”. Migrants who came out with the New Zealand Company or under Premier Julius Vogel’s assisted migration programmes had to pass health tests. As one commentator wrote in 1859, “the timid, the lazy and the sickly” remained in the old country.

Even the journey itself deterred those of frail disposition and depleted the virulence of diseases. As Woodward says, “New Zealand is a long way from trouble.”

 

GOOD SIGNS


Timing too was favourable. By the early 19th century, England was recovering from the long period of epidemics, famine and war that decimated 16th-century Europe. Typhus, smallpox and the plague were on the wane; sanitary conditions in towns and cities, although still appalling by today’s standards, had improved; agricultural production was on the rise; diets were more diverse; and mass manufacturing, although socially disruptive and polluting, made for cheaper household goods.

All good signs for the young colony. Despite the 1918 influenza epidemic (which claimed 7000 lives) and World War  I (17,000 lives), between 1870 and 1940 New Zealanders had the highest recorded life expectancy in the world.

Tony Blakely: reducing social inequalities is key to increasing the country’s life expectancy. Photo/Hagen Hopkins
Tony Blakely: reducing social inequalities is key to increasing the country’s life expectancy. Photo/Hagen Hopkins


This was due in large part to the dramatic decrease in infant and child mortality. Unlike the early missionary families – according to historian James Belich the 14 couples who came to New Zealand before 1833 had 114 children between them – by the 1890s, New Zealand women were marrying later (or not marrying at all), bearing children later and better educated, resulting in more resources per child and delayed infection rates. As forests were cleared, New Zealand became a nation of “unrestrained meat eaters (and milk drinkers)” – good for surviving childhood, if not for longevity.

“When you have high child mortality and infectious diseases, protein is very good at improving your immune system and making you more robust,” says Blakely. “So back then, a whole lot of saturated fat wasn’t holding life expectancy back. Fast forward to the 1970s and that sort of diet is an impediment.”

By the early 1900s, New Zealand had instigated the sanatorium movement (and compulsory notification of tuberculosis), a school medical service, health camps for children, Plunket and accident compen­sation. Under the 1938 Social Security Act, New Zealand became the first country in the Commonwealth to establish the principle of public responsibility for health services and to provide free care for all.

 

MAORI TURNAROUND


When James Cook landed in New Zealand in 1769, the life expectancy of Europeans and Maori differed by about 10 years. By 1900 non-Maori in New Zealand had a life expectancy 30 years longer than Maori. Measles, whooping cough, dysentery and tuberculosis took their toll. Land loss and trade opportunities pushed Maori to low-lying coastal regions rife with overcrowding, poor sanitation and illness. Tradeable foods – tea, bread, potatoes, salted meat – replaced healthier traditional diets, and alcohol and tobacco waged their war on the human body. On the battlefront, the musket wars of the 1810s-30s killed a fifth of Maori.

In 1837, first British resident James Busby wrote that unless action was taken, the country would be “destitute of a single aboriginal inhabitant”. From the turn of century, however, Maori life expectancy began to improve.“This at a time when the dominant government policy was assimilation and land loss was continuing,” says Woodward. “So Maori were still operating in a culturally alien landscape, yet we see these remarkable improvements in health.”

This dramatic turnaround, Blakely and Woodward say, was the result of increasing involvement of Maori communities in public health programmes, better education, improvements in housing, sanitation and infant nutrition, and the influence of Maori leaders such as Maui Pomare, Apirana Ngata, James Carroll and Peter Buck.

At the same time, in a seesaw pattern that continues to characterise health statistics in this country, improvement in the European life span faltered. Despite the advent of antibiotics and blood transfusions, by the 1960s tobacco and heart disease, coupled with increasing rates of road crashes and suicides, were exacting their price.

 

AUSTRALIA'S GAIN


A diet rich in meat, dairy products and protein quickly elevated cardiovascular disease as the No 1 cause of death. As a meat- and dairy-producing nation, New Zealand was slow to act, particularly compared with its closest neighbour.

Alistair Woodward
Alistair Woodward: we’re now running marathons into our seventies and eighties. Photo/Simon Young


Woodward: “After World War II, the major migrant groups in Australia were from southern Europe; they brought with them a diet that was very heart-healthy. The only European migrants we took were from the Netherlands – Yugoslavia, Spain, Italy and Greece weren’t regarded as suitable sources for new New Zealanders – so we didn’t have that diversity of cultural practice that served Australia very well in the 1960s, 70s and 80s. As a result, we’ve been five to 10 years behind Australia in moving from mainly red meat to mainly white meat consumption and in moving to olive oil.”

Reductions in smoking and a move to healthier diets eventually slowed coronary heart disease, but the structural reforms of the 1980s bore down on low-income families and again on Maori. User charges for health and education, the targeting of income support, market rentals for housing and the restructured labour market widened the ethnic health gap. From 1981-84 the mortality rate for Maori women was 2.6 times that of their European/Other counterpart. For Maori men it was 1.8 times.

 

CANCER AND INEQUALITY


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Source/The Healthy Country?, by Alistair Woodward and Tony Blakely


By this time, cancer was claiming more lives. Rates of breast cancer doubled after World War II. Male lung cancer rates peaked in about 1980. In the past decade, early diagnosis, improved treatment and the increasing scarcity of some cancers (stomach cancer, for example) have all reduced cancer-related mortality rates. The death rate from breast cancer for non-Maori fell 20% between 2000 and 2010 through better screening and treatments, and screening programmes and drops in smoking are cutting the number of cervical cancer cases.

But social inequality still skews overall life expectancy figures. From 2001-04, Maori mortality from cancer was roughly twice that of European/Other. Maori rates of lung cancer for men are nearly three times greater than that for European/Other males and over four times greater for women.

Why? According to Blakely, Maori tend to get more fatal cancers, such as stomach, liver and lung cancer. Later presentation or delayed diagnosis gives the cancer more opportunity to progress before treatment and there is less care, less “transit through health services”, for Maori.

“And the fourth [reason] is a wretchedly hard one. If you have a population that has higher rates of other disease, your treatment options are limited and your chance of getting ideal treatment and good survival from your cancer is less.”

Although all social groups are showing strong reductions in mortality rates, thanks in large part to increasing gains in the 65-plus age bracket, by the beginning of the 21st century, being wealthy, being a woman, living in spacious housing and working in a high-status occupation were all associated with low mortality and a long lifespan.

At the same time, a growing proportion of the New Zealand population cannot routinely afford sufficient and healthy food and is more likely to eat cheap, high-density, fatty food. The implications are more diabetes, obesity and cardiovascular disease, increased risk of some cancers and greater wear and tear on bones.

“Reducing those social inequalities,” says Blakely, “would be enough to possibly nudge New Zealand back to having one of the highest life expectancies in the world.”

There have been major improvements in our health record. Restrictions on coal for home heating, more efficient wood burners, the removal of lead from petrol, reductions in sulphur content in diesel and stricter emission standards for motor vehicles have all reduced air pollution, although in 2011 man-made pollutants were still responsible for about 100 premature deaths and 600 hospital admissions.

Although we sit around the middle of the OECD pack for alcohol consumption, the beneficial impact of moderate consumption on diabetes, ischaemic stroke and heart disease at older ages is outweighed by injury at younger ages, road crashes, liver disease, cardiovascular disease and breast cancer.

 

WEIGHTY ISSUES


The average body weight has increased since the 1980s, but this hasn’t affected life expectancy. Thus far. Obesity increases the risk of cardiovascular disease, diabetes, high blood pressure, high blood cholesterol, osteo­arthritis, asthma and sleep disorders, and although medication can control conditions such as hypertension, Blakely says the full impact of increasing body weight is yet to unfold.

“There may be a long-run cohort where childhood obesity plays out in disease rates at 60 or 80 years, but the obesity epidemic has not matured to that extent. Obesity is a handbrake on mortality reduction – in New Zealand about 5% of cancers can be attributed to people being more than normal weight – but in terms of reducing life expectancy, it’s overwhelmed by all the other things that are causing life expectancy to go up. It’ll probably play out as much if not more through morbidity. Obesity gives you hip problems and musculoskeletal problems. In surveys on how people assess their quality of life, it’s lower for obese than non-obese people.”

In the 21st century, smoking remains the single largest preventable cause of premature death. Per-capita consumption of tobacco has fallen two-thirds since the 1970s, but the decline has stalled in the 2000s. Up to 5000 deaths a year, of a total of 30,000, would be avoided if nobody smoked.

And this is where the growing inequity in New Zealand’s health statistics is again apparent. Although higher socio-economic populations and European and Asian populations have the lowest smoking rates, Maori smoking rates have not changed since 2006-07, with 41% of Maori adults still smoking.

 

SIMPLE MEASURES


There is a note of exasperation in the conversation around such figures. Tobacco, diet and alcohol are still undoubtedly the big risk factors at the moment. That will change in 30 years’ time when we move more into cognitive functioning and dementia, but right now, says Blakely, we could make significant gains by acting on those risk factors without breaking the budget.

A few simple measures, they say, can put New Zealand back at the top of the league tables in life expectancy: halve the amount of salt in the food chain; reformulate energy-dense, nutrient-poor foods; provide more informative nutritional labelling on food; and ban or tax sweetened beverages.

The Healthy Country?There are also opportunities in the “physical activity space”, says Woodward, to reduce unhealthy body weight and improve mental health and cardiovascular health. Simply by making cities more attractive and safer for people to walk and cycle will help put exercise back into people’s lives on a day-to-day basis.

“The whole area of processed foods is fraught because of all the players involved, but I’m confident we’ll win through. The cost of shifting to a different path is much lower than people fear – there are commercial opportunities, for goodness sake, in terms of producing food that doesn’t harm people.”

But a reduction in smoking would have the biggest gains. A tobacco-free New Zealand would bring an additional five-year gain in life expectancy for Maori by 2040 and three years for non-Maori. Is it achievable?

“Absolutely,” says Woodward. “We’ll be sitting here in 20 years saying, ‘Yes, we did do that.’ Public sentiment is changing. Most smokers tell you they want to quit. And we’ve made enormous progress in the past 20 years. Taking cigarettes out of bars and restaurants was thought to be political suicide – now it’s accepted as the norm. Plain packaging? The Government has cautiously headed down that direction and I hope it will hold its nerve.”

 

INCREASING LONGEVITY


With infant survival now sitting at around 99.5%, the attention of the health sector is inevitably focusing more on prolonging age at the far end of life.

The best advice might be to choose your parents well – about a quarter of the variability of lifespan is inherited – but new research into the biological basis of ageing and the lottery of cell division is well under way. Already, scientists are looking at ways to reduce the shortening of telomeres, the capping sequences at the end of chromosomes necessary for the replication of cells, to potentially reverse degenerative diseases.

But this constant push towards increasing longevity raises a bevy of social and economic issues. “We’ve already committed to increases in life expectancy,” says Blakely, “and no doubt the next 20 years will see a lowering of mortality rates. But the next question is how much we want to keep those increases going on.”

To get New Zealand back in the highest health rankings will require reducing social income inequality in health without losing high-income groups’ life expectancy; if the most deprived 20% of the population was only 15% worse off in health terms than the top 20%, New Zealand’s life expectancy would jump by two to three years.

To cope with increasing longevity, the age of retirement will need to rise if we want to keep super universal and tied to the average wage. New Zealand set 65 as the age of eligibility for the pension in 1898. Since then, life expectancy at birth has increased by about 25 years, while the number of extra years we can expect to live if we reach 65 has almost doubled.

Workforce expectations, too, must change to make better use of what older people can provide, says Blakely, “and models of living for all ages must adapt to a much smaller environmental footprint. Providing more food to more people has incurred substantial environmental costs.”

Climate change and environmental change will present challenges to an increasing, and increasingly aged, pop­ulation. The world population, currently more than seven billion, is likely to grow half as much again within the next 100 years. A global temperature hike of 4°C will threaten agriculture, reduce global labour productivity and increase extreme weather events.

“If temperatures go up as much as predicted, that will have a major impact on food systems around the world,” says Woodward. “And given the growing population and the ageing of that population, there will be limits as to how well you can feed the world population.”

 

Hip Op-eration
Members of Waiheke Island’s Hip Op-eration senior-citizen dance crew. Photo/Ida Larsson

TRIATHLONS, NOT SLIPPERS


But growing life expectancy is not necessarily a recipe for growing dependency or debilitating age-related disability. Already, as a result of earlier recognition of illness and treatment, years lived in good health are rising more rapidly than years lived with disability. In more scientific terms, as we live longer we’re seeing a “compression of morbidity”. In the US, for example, men aged 50-74 in the 1930s were twice as likely to have difficulty walking and impaired vision than they are now.

As a population, we’re also determinedly not ageing.

“People no longer see their retirement as a period when you sit down, put your slippers on and watch TV,” says Woodward. “Now, it’s an opportunity to make a dent in your triathlon time. Men and women are running marathons and cycling around Lake Taupo into their seventies and eighties. We’re changing our notion of what constitutes ageing. If we’re prepared to relook at the contributions that older people can make, we’ll see [ageing] as a resource for society. That is a very exciting prospect for New Zealand.”

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