Asians in New Zealand have long felt ignored in health policies, despite being our fastest-growing minority. Is it time we had another think about Asian health? Naomii Seah investigates.
Asian people live for a really long time. Asian people have less heart disease. Asian people are less likely to be alcoholics. Asian people eat low-carb, low-fat, low-sodium diets and we should all eat like them. Asian people are healthy.
Articles touting the superior health status of Asian people are a dime a dozen. We’ve all seen clickbait headlines about someone’s grandmother in rural Japan who’s lived to 112. Follow this link to learn her secret.
Though some may characterise this as a positive stereotype, it too comes with consequences. Because Asians overall are thought to have good health outcomes, there’s a distinct lack of attention paid to Asians’ needs in the healthcare sector.
But who cares? I hear you ask. Didn’t you just say Asians are generally healthy?
It’s true: Asians as an aggregate group have statistically good health outcomes in comparison to other major ethnic groups. However, when you disaggregate that group, some Asian ethnicities are more prone to certain conditions than others. For example, a 2012 report on the Asian population in Auckland showed that the Indian population has higher rates of cardiovascular disease, with mortality rates landing above Pākehā, but below Māori and Pasifika. Asians as a whole also have a higher rate of diabetes than the Pākehā population, and the Indian population has the highest rate of diabetes in New Zealand. Mortality rates for diabetes again land above Pākehā, but below Māori and Pasifika peoples. The 2012 report also found risk of stroke to be higher in all Asian populations than Pākehā, but lower than Māori and Pasifika. It seems a trend is emerging.
We may not even be getting the full picture of Asian health in New Zealand. A 2015 report commissioned by Runanga Whakapiki Ake i te Hauora o Aotearoa, the Health Promotion Forum of New Zealand, notes that “stereotypes and the ‘averaging effect’ may have boosted the health status of Asians in New Zealand beyond reality”.
Additionally, the last major review of Asian health in New Zealand was done in 2016, which included data from 2002-03, 2006-07, and 2011-13. Over that time, the Asian population in New Zealand almost doubled, from 6% to 11% of the total population. As of 2018, Asians make up 16% of the total population. That number is only set to grow. Current projections show that Asians will become, as an aggregate, the second largest ethnic group in New Zealand by 2030, and are likely to make up a quarter of the population by 2043.
Although Asians are set to make up a quarter of New Zealand’s population, we have the lowest rates of engagement with the health system out of any ethnic group. The 2016 review found “Asian adults were less likely to have a usual health practitioner or service to visit when unwell, compared to non-Asians”. Additionally, “Asian groups generally were less likely to use all types of public hospital services.”
The 2021 New Zealand Asian wellbeing and mental health survey, led by Asian Family Services (AFS), further found 47.9% of Asians “cannot access language and/or cultural support regularly when they use health services in New Zealand”. That’s over 338,900 people.
A recent study led by Dr Roshini Peiris-John at the University of Auckland further highlights this issue – it found one in five Asian youth were forgoing healthcare. In other words, they did not access healthcare even when it was needed.
In New Zealand, this systemic inequity for Asian New Zealanders exists in the broader landscape of a health system created by and for Pākehā people, using models of care that alienate vulnerable and already marginalised groups. This is reflected in the health outcomes of the total population. Pākehā people consistently report the best health outcomes in New Zealand. It begs the question – why is everyone else being left behind?
Barriers to access
“Imagine trying to tell a complete stranger what you’re thinking, your deepest thoughts, but in a language that’s not your native tongue. It’s incredibly stressful.”
Denzel Chung is a PhD student carrying out research into Chinese health in New Zealand with the Otago School of Medicine. From interviews with health professionals and the Chinese community, Chung says the biggest problems with access to healthcare are language barriers and a lack of culturally appropriate services.
“Cultural issues around stigma, awareness [of available services] and language barriers make people reluctant or less likely to access those services,” says Chung. He notes that language barriers predominantly affect the older Asian population, and recent migrants.
A “very, very common” phenomenon, especially in the Chinese community, is “getting family friends, [or] your own children, to interpret, which opens up a whole new set of problems”, says Chung. This includes privacy issues, and the fact that one might not necessarily want to share one’s health problems with friends or children. When that’s your only access to a health service, your health needs may remain unaddressed. A number of DHBs do fund interpreting services, but Chung says they’re “poorly resourced”. which means they tend to work more “in theory” than in practice. This means the reality for many Asians speaking English as a second language is that health services are simply inaccessible.
Additionally, Chung notes that for many in the Chinese community there’s a lack of understanding of the New Zealand health system, especially around access to specialist care. The referral system is unfamiliar to many new migrants, and the steps involved can be overwhelming for patients when English is their second language.
Dr Carlos Lam Yang, a GP in the Auckland suburb of Flat Bush, has seen this first-hand. “I’ve had lots of experience personally, assisting family members and relatives through the healthcare system,” says Lam Yang.
He cites an incident that occurred when he was working at an urgent care practice, where a young patient came in with her father in the evening; they spoke a dialect of Cantonese. Lam Yang, who speaks Cantonese himself, found it difficult to understand, saying he only got “bits and pieces” of their conversation. He managed to make out that the girl was having a psychotic episode, and he had to refer her to Middlemore hospital.
“They weren’t familiar with the healthcare system,” says Lam Yang. “They didn’t even know where Middlemore hospital was.”
He accompanied them to psychiatric services once his shift had ended. Once they arrived, Lam Yang found all the forms were in English. “There wasn’t anything there in any other languages, not even in te reo Māori for that measure,” says Lam Yang, who adds that the Pākehā receptionist wasn’t forthcoming. Lam Yang helped them translate their forms. They then had further issues finding the emergency department – again, all the signage was in English.
“This is an example of where the system fails,” says Lam Yang, who notes that although there are many Asian healthcare providers, “the actual system itself is not geared to deal with cultures who don’t speak English”.
“The government is not really paying attention to population groups that are burgeoning in size; they have healthcare needs too. That definitely needs to be urgently addressed, otherwise, we’re going to have a very underserved population.”
Experiences of healthcare
“When accessing health services, a lot of Asians’ first experience is that they don’t feel they are being heard or understood.”
Ivan Yeo is the deputy director and public health lead for Asian Family Services. He notes that for the younger generation in particular, cultural differences might present a larger barrier to accessing health services than is recognised.
He points to the growing proportion of second-and-above-generation Asian-New Zealanders, many of whom speak perfect English in a New Zealand accent, yet may not be able to articulate their cultural needs.
“The first impression [to a healthcare professional] is, aw, you’re a Kiwi,” says Yeo, “so their cultural needs may not be taken into consideration.”
“There’s an individualistic approach in the Western health system which actually conflicts with a lot of Asian cultures, which [are more] collective.”
Yeo says that he’s seen this lead to an alienation of young Asians from the healthcare system. When family members’ views conflict with individual advice, they “won’t want their kids to go back and see that GP again”.
Chung agrees, noting that “the bigger issue [with the younger Asian population] is trying to get their family on board. It’s not as simple as going off and doing your own thing, going to get your own diagnosis. It’s a lot more collectivistic. With family involvement, there’s a lot more clash with different cultural views, and how to seek help, and when you shouldn’t be seeking help as well.”
Lovely Dizon, a PhD candidate at the Auckland medical school researching Asian health, has also seen this cultural dissonance pop up in her research. She notes that many healthcare practitioners may make “assumptions about family” when treating the younger Asian community. “In our culture, you can’t exactly stand up to our parents and grandparents… Eurocentric systems and thinking about families don’t work for Asians.”
“The population is changing,” Yeo continues, “but a lot of health practices aren’t catching up.” He says he’d like to see the system responding to younger Asians in New Zealand in “a more culturally appropriate way”.
Arshveen Hora, a student at the University of Auckland, says that in their experience “the lack of cultural understanding in health professionals is really appalling.” Additionally, they note that their health issues have often been dismissed.
Indira Fernando has had similar experiences with health professionals dismissing her symptoms, although she notes she doesn’t know “how much of this is that I’m brown, how much of this is that I’m a woman, or how much of this is just back luck”. Recently, she developed kidney pain and was taken to Dunedin Public Hospital, where she was told “there’s nothing wrong with you, the blood in your urine is just your period, go home”. She said the experience made her hesitant to go back to the hospital, and caused her to delay seeking medical treatment for three days. When she finally visited the hospital in Wellington, they found three kidney stones.
“The exact same thing happened with my mum,” Fernando continues. “She turned up to the hospital with kidney pain, was sent home, and showed up the next day because she was in agony – she had to have a procedure to have [her kidney stones] removed.”
Stigmatisation and mental health
“We don’t need to cost more lives to make a change,” says Dr Kelly Feng, national director of AFS.
Feng points to the worrying statistics in the organisation’s 2021 Asian wellbeing and mental health survey, which found 44.4% of Asian people in New Zealand were experiencing depressive symptoms.
“Mental health issues are so real, and people [are] realising they can’t really cope any more,” says Feng. “So they call us because we’re doing a lot of social media promotion. But we haven’t got increased capacity to cope with the demand.”
Feng notes that their service sees a lot of “late presentation”, which means that people have delayed seeking treatment until their mental health needs become urgent.
“Stigmatisation plays a huge part for our Asian people – there’s a culture and the shame [of wanting] to cope within the family as much as they can.” Feng further notes that a lack of understanding of how mental health services work is also a challenge for the Asian population.
And perhaps it’s not surprising that mental health services are stretched beyond capacity – discrimination against Asian people has risen in recent years. The 2020 Asian wellbeing survey by AFS found 16.8% of Asian people in New Zealand had recently suffered discrimination. This reflects the 2016 overview of Asian health, which found “Chinese and other Asians were most likely of all ethnic groups to ever have been a victim of an ethnically motivated verbal attack”.
From May to July 2020, the AFS helpline offered in seven Asian languages experienced a 150% surge in calls, and counselling sessions booked for Asian patients increased 138%.
Feng notes that AFS is currently able to provide three free counselling sessions, but then they need to refer patients on. “It’s very limited, there’s not many people we can refer them to, [especially] if they prefer to speak to a counsellor or clinician who knows their culture and speaks their language.”
The other service available is the AFS-run Asian wellbeing service, which offers multilingual and culturally diverse services. But it’s currently a user-pays service, and “that’s not good enough,” says Feng.
Feng says she’d like to see recognition that “Asians are a vulnerable population as migrants, and [we] need to do something about it”. She notes that some areas of Auckland have an Asian population of over 50%, “but if you’re looking at primary mental health services and mental health services in secondary care, there’s nothing matching with the population base at all”.
Additionally, the 2021 survey found that 98.7% of the Asian population believes the public holds negative stereotypes of people with mental illnesses, and that the stigma associated with mental health was one of the biggest reasons Asians didn’t seek support. Feng would like to see this stigma in the Asian community addressed.
Dr Roshini Peiris-John, who led the study on Asian youth forgoing healthcare, says she suspects another barrier to seeking help is stereotypes held about Asians. She says her sons spoke about the reluctance to seek help from school counsellors because “Asians are perfect, hardworking, clever, fastidious. And when they’re feeling down or not good about themselves there’s an aversion to go and talk to somebody, because of the approach in response.
“There’s a feeling amongst young people that seeking help is not really going to help. It sometimes makes things worse for them because of the discrimination that they face.”
The bigger picture
“The pain of one community doesn’t outweigh the pain of another community,” says Dizon. “What helps one community will help another.”
Because of course, when we have a discussion about the health needs of Asians in New Zealand, it’s important to recognise that our Māori and Pasifika whānau are also being left behind in a clear breach of Te Tiriti. But Dizon believes that these conversations about health can be had in tandem.
“Māori and Pasifika are significantly affected [by unequal healthcare],” says Peiris-John. “So [Asian health] has to be looked at within the broader context of New Zealand’s pattern of inequity.
“Each group will have their own racism-related issues,” she adds. But “there’ll be the common minority group versus majority group perception”. Peiris-John continues that race-based inequities affect all minority groups, and this is reflected in the fact that statistical health outcomes of minorities in New Zealand are consistently worse in comparison to the Pākehā population.
“I’d love to advocate for free healthcare for young people in New Zealand, irrespective of ethnic background,” Peiris-John says. Cost is also an issue for accessing care, she adds, and addressing that alongside the specific issues around ethnic discrimination would go a long way towards achieving more equitable healthcare for Asians.
Dizon says she’d like to see communities in Aotearoa working together to create appropriate approaches to healthcare that uplift all people. She notes that these conversations must be had in the context of “honouring Te Tiriti, and knowing we are tauiwi.
“We can care about one community without taking away what has happened in other communities.”