Intended for healthcare professionals
New Zealand’s praised zero covid approach is faltering in the face of variants. And its shift to endemic acceptance and vaccine strategy ignores the risk to its indigenous population. Katrina Megget reports
“There’s been a lot of lip service to equity in New Zealand’s pandemic response but the fine words have not always been matched to action on the ground.” So says Amanda Kvalsvig, an epidemiologist at New Zealand’s University of Otago, Wellington.
Her statement reflects the findings of a high ranking inquiry that concluded the New Zealand government breached its legal responsibilities to the indigenous Māori population in the country’s vaccine rollout and shift away from covid-19 elimination to living with the virus. Following a week long hearing in December 2021, the tribunal found the government not only failed actively to protect Māori people but failed to include equity in its pandemic decision making.
“New Zealand likes to think of itself as a progressive nation that’s facing up to its colonial past,” Kvalsvig told The BMJ. However, she added, the government’s covid-19 response “is an instance where actions speak louder than words.”
“Māori are well aware these decisions have exposed them to significant and preventable risk.”
New Zealand had been hailed as a prime example of how to deal with covid-19, initially opting for an elimination strategy with some of the world’s toughest restrictions. It needed to protect not just its population of five million but the country’s fragile healthcare system. New Zealand has one of the lowest numbers of intensive care beds per capita of the Organisation for Economic Co-operation and Development nations at four per 100 000 people (for comparison, the UK has 7.3, which is considered low by European standards).
The tactic paid off—until August 2021 there had been just over 2800 cases and only 26 deaths—and, closure of international borders aside, life continued as normal for the country’s citizens.
But August brought the delta variant. A seven week lockdown and hard border around the Auckland epicentre followed but failed to stamp out the virus or its spread to other regions. By mid-October, there were 2099 cases of delta. The government signalled it was moving away from its elimination strategy to “suppression mode”—in effect, acknowledging the virus would be endemic. At the time, Prime Minister Jacinda Ardern said, “Elimination was important because we didn’t have vaccines. Now we do, so we can begin to change the way we do things.”
It’s not that simple for Māori and Pacific Islander or Pasifika populations, which together make up less than 30% of the total population. Vaccination rates in these groups have lagged New Zealand European inhabitants.
The rollout started in February 2021 with border workers, essential workers, and their families, and those in high risk groups or settings such as senior care facilities. It continued based on age. Towards the end of October 2021 the coverage gap was clear: 49% of Māori were fully vaccinated compared with 72% of the entire eligible population.
This matters because Māori and Pasifika are disproportionately affected by the risk factors for covid-19 including obesity, diabetes, and cardiovascular disease, as well as poor access to health services.
Research from Te Pūnaha Matatini (the New Zealand Centre of Research Excellence for Complex Systems), published in the New Zealand Medical Journal, showed Māori are 2.5 times more likely to be admitted to hospital than non-Māori and 50% more likely to die.1
“Te Pūnaha Matatini research shows the risk of hospital admission from covid-19 for a 40 year old Māori and a 35 year old Pasifika is approximately equivalent to the risk of hospital admission for a 60 year old European,” says Polly Atatoa Carr, public health physician and associate professor of population health at New Zealand’s University of Waikato in Hamilton.
“If we look at outbreaks of the past it doesn’t take a crystal ball to see what a pandemic would do to our existing health inequity,” Atatoa Carr notes. The 1918 flu pandemic, for instance, killed one in 20 Māori—a mortality more than eight times higher than the general population.
With covid-19, in early November, more than 70% of cases and more than 70% of hospital admissions were from Māori and Pasifika communities. By mid-December, following a vaccine drive and a drop in covid-19 cases coinciding with summer, these figures were closer to 50%. The youngest New Zealander to die with covid-19 was a Māori boy under the age of 10.
Warnings over the potential impact had been expressed by Māori leaders as early as May 2020, while public health experts, Māori leaders and service providers, and even the government’s director general of health recommended the government prioritise Māori over the age of 50 in the vaccine rollout.
But this didn’t happen. The tribunal heard the government rejected calls to prioritise younger Māori and Pasifika in the age based rollout. Why the advice was rejected was not made clear. The government claimed they adopted a “whanau centred” approach (a culturally collective approach), which they believed was enough to protect Māori communities. It has continued to assert that equity has been considered at every step.
But according to Atatoa Carr, the vaccine rollout ignored both the health inequity and the predominantly youthful Māori and Pasifika populations. A quarter of the Māori population is under the age of 12, with the median age for Māori and Pasifika being 25 and 23, respectively, compared with 41 for New Zealand’s European population. So, until lower age limitations were lifted on 1 September, Maori and Pasifika populations were disproportionately missing out.
Rawiri Jansen, clinical director of Māori primary health organisation National Hauora Coalition, says the vaccine rollout “didn’t follow the science” and is a “complete failure” in its disregard of prioritising Māori ages. He quit the government’s expert immunisation advisory group after the government rejected the prioritisation advice. “Despite evidence that Māori and Pacific communities would be at greater risk from covid-19, the government has not been guided by this. Instead, we are seeing deepening inequity and a vaccination rollout in which inequity is hard baked.”
In addition, clinics are more commonly based in cities, a difficult trip for many Māori, and the online booking system proved a stumbling block for communities without internet access.
The tribunal also found that decision making to move to a different covid-19 response framework did not adequately account for Māori health needs and there was a lack of consistent engagement with Māori on key decisions.
“If health equity was prioritised in the vaccination rollout, including specific attention to Māori and Pacific leadership, resourcing, and vaccination access, then it is likely the way the impact of covid is now affecting Māori and Pasifika populations could have been reduced,” says Atatoa Carr.
When the delta variant first arrived it spread through marginalised communities in cities, hitting hardest people with a history of alcohol and drug dependencies, mental health problems, long term poverty, and overcrowded and transitional living conditions—communities in which Māori and Pasifika are overrepresented.
The strict lockdown had limited benefit in this community where people largely worked jobs that couldn’t be done from home and in an economic situation where they had no choice but to work and where social distancing and self-isolation was harder, says Michael Baker, professor of public health at the University of Otago, Wellington, and member of the government’s covid-19 technical advisory group. In these communities, which also have a long running distrust of authorities, cases are harder to detect, and contact tracing is difficult.
The government has scrambled to boost vaccination in Māori and Pasifika in recent months as it has moved to suppression. This has included deploying mobile vaccination buses to deliver jabs to communities with low uptake that have struggled to access the main clinics, and greater engagement with Māori leaders to boost vaccine rollout in local communities with additional funding from government. Jasen says, “this is far too little, far too late.”
The tribunal itself recommends additional funding, resourcing, data, and other support to Māori providers and communities, as well as strengthened engagement and calls to “expressly prioritise Māori” in the paediatric vaccine and booster rollout.
In response, the government welcomes the recommendations, which it will “very carefully study and consider.”
Commissioned, not externally peer reviewed
No competing interests to declare
This article is made freely available for personal use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.
Respond to this article
Register for alerts
If you are unable to import citations, please contact technical support for your product directly (links go to external sites):
Thank you for your interest in spreading the word about The BMJ.
NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. 
Read related article
See previous polls