Three-year-old Te Awhenga leans into her mother’s lap and coughs a wet, phlegmy cough, delivered from lungs permanently damaged by repeat infections.
Just before Christmas last year, after 2½ years of GP and emergency department visits with upper respiratory tract infections, Te Awhenga had a CT scan under general anaesthetic. She was diagnosed with bronchiectasis, a disease that will afflict her for life.
Te Awhenga and her mother, Rarangi Matiaha, are with nurse Nora Dunphy, a specialist in childhood respiratory disease at Hawke’s Bay Hospital, when they welcome me into the consultation room. Dunphy explains the damage that has been sustained by the little girl’s lungs: “The bronchi – the tubes in the lungs – get infected, and become saggy and enlarged, and that becomes an area where mucus builds up. That creates a cycle of infection that goes around and around.”
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Te Awhenga will need ongoing treatment – two-week courses of antibiotics probably three or four times a year, daily chest physio at home to help clear the build-up of mucus in her airways, three-monthly check-ups by paediatricians until she is 18, and ongoing care into adulthood. It’s likely she will need intravenous antibiotics at times.
Last month, Matiaha was told she would need to take Te Awhenga to Auckland’s Starship Hospital for a bronchoscopy. The procedure involves another general anaesthetic so a specialist can insert a scope down her windpipe and into the lungs to investigate the state of her airways, wash out secretions and check what infections may be lingering.
Childhood bronchiectasis is regarded as a Third World disease. Rates increased significantly in New Zealand in the years following the deep benefit cuts and state housing policy changes of the early 1990s, which bit hard into the living standards of low-income families. A 2005 study found the rate here was 7-18 times higher than in other developed countries. Nationally, children under 14 with bronchiectasis were hospitalised more than 1000 times in the five years to 2021. Here in Hawke’s Bay, Te Awhenga’s paediatrician, Dr Sarah Currie, has 30 cases on her list.
Unhealthy housing
It is a disease of poverty and its twin sibling, bad housing. Those who suffer are disproportionately Pasifika and Māori. Exposure to smoking makes it worse, but no one in Te Awhenga’s household smokes.
She and her two siblings live with Matiaha in an uninsulated two-bedroom Kāinga Ora house in the suburb of Flaxmere. In winter, they have kept themselves warm by living and sleeping together in one room.
Te Awhenga’s repeated chest infections triggered a referral to the Child Healthy Homes service in 2021. The house was inspected and declared cold, damp and mouldy. Decent curtains were installed, but the ceiling and underfloor couldn’t be insulated. Late last year, heaters were put into each room – a significant improvement, provided Matiaha can make her sole-parent benefit stretch to cover the power bill.
But Te Awhenga has already sustained lifelong harm from an illness that’s causing her to miss preschool and will probably continue to impede her education, affect her ability to play sport, and severely restrict the options for Matiaha to improve the family’s income through paid work.
On top of that is the stress and worry. “It’s mamae [painful] that my baby is sick,” says Matiaha. “It hurts me. Me and her, we are very close.”
Yet, as Currie’s paediatric colleague Dr Russell Wills says, Te Awhenga’s illness is “95% preventable”.
“We see [bronchiectasis] here almost exclusively among Māori and Pasifika families living in poverty and in crowded housing. It’s a condition that we just don’t see in [nearby] Havelock North … It’s not fair, and it’s not right. And it’s not their fault.”
It’s a similar story for two-year-old Margaret, mercifully sleeping in her hospital cot after a feverish night when I visit. She has severe asthma, and eczema lesions have created a pathway for infection that has led to cellulitis.
Margaret’s mother explains through a Samoan translator that she and her extended family of five have moved three times since the child was born – emergency accommodation in one Hastings motel, which was too small, then into another emergency motel, which was cold and damp. Everyone slept in one room to keep warm. It was while they were living there that Margaret developed asthma.
Their third move was late last year, into a transitional housing unit – a decent three-bedroom house, but still temporary. The family are on the waiting list for a permanent Kāinga Ora house – along with 696 other households in the district. They have no idea how long it will be before they have a home.
The workload of paediatricians at Hawke’s Bay Hospital is dominated by the plight of infants such as Margaret and Te Awhenga. At morning handover during my February visit, nightshift registrar Aaron Weston runs through the status of the dozen or more kids on the ward and the Special Care Baby Unit (SCBU): severe pneumonia, upper respiratory tract infections (three cases), cellulitis, atypical pneumonia, respiratory syncytial virus (RSV).
All this in the middle of a Hawke’s Bay summer, before the devastation and displacement caused by Cyclone Gabrielle. But this is just a normal day at work for doctors and nurses serving communities with high levels of deprivation. A huge number of the sick children they are treating fall into the category of “potentially avoidable hospitalisations” – hospital stays that would be prevented by good housing, decent incomes, early detection and public health initiatives.
Nationally, there were 235,000 such admissions of children under 15 in the five years to 2021 – nearly half for respiratory diseases – according to the 2022 Child Poverty Monitor. Kids from the most deprived areas are twice as likely to be hospitalised for these conditions as those from well-off areas.
“Children under five are the canaries in the coal mine,” says Wills, who was Children’s Commissioner from 2011-16. “When poverty increases, the first affected are young children, particularly with respiratory and skin infections. That’s the first indicator, and then that flows through into increased behavioural and developmental problems.”
The first 1000 days
About 3000 kids a year are admitted to Hawke’s Bay Hospital’s children’s ward, and 450 to the SCBU for premature babies and very ill newborns. All the professionals treating these children know about the “first 1000 days” – shorthand for the mountain of research showing that family poverty, bad housing, maternal stress and depression, poor nutrition, family violence and drug and alcohol abuse within the first three years of a child’s life can inflict lifelong health, behavioural and neurological harm.
Wills and clinical nurse manager Michelle Robertson run me through the myriad frontline health innovations that have been tried in the region in recent years to reduce that harm. Increasingly, these take a multidisciplinary approach to working with the families of sick children.
It wasn’t always this way in child health, says Wills. “The baby was just the baby. Now it’s the whole whānau.”
And so the families of babies in the SCBU are supported by a team of nurses and social workers who assess living conditions. Sometimes, the families are in motels, sheds or cars, says associate charge nurse manager Di O’Connor. They try to get families pushed up the monumental waiting list for social housing, deliver immunisation and anti-smoking education, and look at children’s sleeping arrangements.
If a child from one of the district’s low-decile suburbs presents at the ED with a preventable illness, there is follow-up within 48 hours by a nurse to arrange a home visit and offer guidance on the likes of inhalers and eczema creams.
School principals are encouraged to refer directly to the paediatric team if they are concerned about a child’s wellbeing or development. “We want to see these kids as soon as possible, before the damage increases,” says Wills. Particularly if there are signs of fetal alcohol spectrum disorder, addiction or if mental health services are involved.
Outreach health teams include kaitakawaenga – Māori intermediaries – who know local whānau and make initial contact and build trust.
Dozens of child-health nurses working in the community have been trained to prescribe a limited range of medicines, so whānau with sick kids don’t have to go to a GP.
The results so far are mixed – hospitalisations for pneumonia have worryingly increased among Pasifika children since the Covid lockdowns, but admissions for asthma among Māori children have fallen. The standout success is in the decline in hospitalisations for cellulitis, thanks to intensive community-based work by nurses, kaiawhina and social workers.
Causes and cures
Health teams, says Wills, are working differently and more effectively. But there is only so much they can do when economic and social structures keep causing harm. “Long-term, reducing high rates and inequities in rates of admission with preventable disease in young children requires improvements in the underlying drivers of disease: poverty, crowding [and] poor-quality housing.”
Around the time Te Awhenga was born in 2019, Hastings and the wider Hawke’s Bay area were booming. House prices were up 12% in a year; retail, car sales and tourism were surging. Economists at ASB Bank gave the region five stars for performance.
What they didn’t mention, or couldn’t see for the bright glare of property and sales data, was that the district was in the grip of an acute housing emergency. Rents were rising 8-9% a year. The number of families waiting for state houses in the Hastings district had nearly tripled in three years.
Waves of privatisation of state housing in the 1990s and again in the 2010s meant that, by 2019, there were 248 fewer occupied state houses in the Hastings district than in 1991. The population had meanwhile grown by a third.
Those without homes were crowding in with whānau or living in emergency accommodation, in garages or cars, or on the streets.
The impact of the crisis was becoming increasingly apparent in the hospital emergency department and paediatric ward. In 2018, an estimated 994 children under 15 had been hospitalised for preventable housing-related diseases, up from an already-shocking 653 in 2016.
When career public servant Nigel Bickle arrived in early 2019 to become chief executive of the Hastings District Council, the first thing Mayor Sandra Hazlehurst said was, “We’ve got a housing crisis here and I am sick of Wellington turning up to tell me what they think they will do in our community.”
Hazlehurst determined that housing was a top priority for her council. The goal was not just to build houses and address the critical shortage, but to build strong communities. By the end of 2019, Hastings – and in particular Flaxmere, statistically one of the most economically deprived areas in the country – was the focus of a locally driven, multi-agency plan to rebuild the broken housing system.
A team of analysts from the council and the Ministry of Housing and Urban Development (MHUD) were tasked with untangling the causes of the housing crisis. They found multiple compounding factors, starting with state house sales. The booming horticulture industry was importing rising numbers of seasonal workers and putting them in motels, backpackers, hostels and rentals. The resulting shortage of beds for tourists made the Airbnb market highly lucrative for residential landlords. “They could get $1000 a week instead of $500 a week [from long-term tenants], and no one is taxing them,” says Bickle.
In 2016, in response to the increasingly desperate nationwide housing crisis, the government started putting homeless people up in motels. This further reduced tourism accommodation and stoked the incentive for landlords to turn to Airbnb.
By 2019, the district had 1000 fewer houses available on the residential rental market than in 2016, says Bickle. Throughout that year, the number of households living in emergency motels bounced between 81 and 141. The majority were Māori.
“Our whānau were being displaced left, right and centre,” says Chrissie Hape, chief executive of Ngāti Kahungunu Iwi Incorporated.
On top of all this, the council hadn’t been zoning enough land for housing, and planning rules were getting in the way of orchardists building onsite accommodation for their seasonal workers. And although private houses were being built, they were at the top end of the market. There was also the ripple effect of Auckland’s crisis driving homeowners there to cash up and move to the Bay.
Home-ownership rates among Māori and Pasifika in the district had plummeted since the mid-1980s and were now among the lowest in the country. Half of all working households who were renting couldn’t afford to buy a house, even in the lowest quartile of the local housing market.
Everyone knew bits of this story, but the analysts had for the first time pulled those bits together to show the underlying drivers of the district’s dysfunctional and harmful housing system.
Thanks in part to Bickle’s connections in Wellington, powerful actors got behind the idea of a bespoke local solution, including ubiquitous government fix-it man Sir Brian Roche – a son of Hawke’s Bay and at that time the establishment chair of the Housing and Urban Development Authority – and Andrew Crisp, then newly appointed chief executive of the MHUD.
Also there were Ngahiwi Tomoana, Ngāti Kahungunu’s chair at the time and the longest-serving iwi leader in the country, and Te Taiwhenua o Heretaunga, which had grown over more than three decades from operating out of a Flaxmere shed into a sophisticated provider of kaupapa Māori social services, including transitional housing provision. Kāinga Ora, the Heretaunga Tamatea Settlement Trust (which holds treaty settlement assets), the Hawke’s Bay District Health Board (now Te Whatu Ora), Te Puni Kōkiri and the Ministry of Social Development were also brought into the net.
If the idea of bringing everyone with resources and knowledge together to respond to an emergency sounds blindingly obvious, when it came to housing, this was all completely new. So much so that when Housing Minister Megan Woods got behind a new collaborative strategy for Hastings in late 2019, it was tagged as a pilot “place-based” project. And so rare was it for local government to take a lead on the housing crisis that the Hastings District Council got an award for the initiative.
Fabulous Flaxmere
The immediate and urgent need was to reduce the number of families living in motel units – 120 in early 2020. Arms were twisted up backs at Kāinga Ora to get it to see beyond the crisis in Auckland and start building state houses in Hastings; planning rules were fixed to make it easier for growers to build onsite worker accommodation.
A medium- and long-term plan was laid out. Despite being stripped of most of their land by colonisation, Ngāti Kahungunu was able to identify enough ancestral whenua around the district to support a pipeline of 600 houses – provided the finance and planning hurdles that had historically stopped whānau building on their own land were removed.
The council looked at its own land holdings, identified four blocks in Flaxmere, and pounced on “shovel-ready” government infrastructure money to start development. It also ramped up public amenities in the suburb – parks, playgrounds, a new skatepark, basketball hoops. A suburb better known for its high deprivation statistics and gang presence now had a flamboyant champion in Mayor Hazlehurst, who took to calling it “Fabulous Flaxmere”.
The state house portfolio in the district had been shrinking for a decade, but now it started to grow, with 216 homes built or bought between 2020 and 2022. Another 145 new builds will be finished this time next year.
Council land in west Flaxmere was sold to Te Taiwhenua o Heretaunga, where the first sod on the 120-house Waingākau development was turned in mid-2019. The vision is to help Māori whānau into home ownership, using a mix of tenure types including full ownership, shared equity and rent-to-buy.
Ngāti Kahungunu obtained $45.3 million under the government’s Whai Kāinga Whai Oranga Māori housing fund to build 131 long-term rentals and papakāinga in Hastings and Wairoa. The plan is to develop off-site manufacturing and use the project as a training ground for workers.
And the Heretaunga Tamatea Settlement Trust bought land in 2020 on Flaxmere’s eastern fringe for 400-500 homes, with consenting being fast-tracked.
A long-term plan has been laid out to meet demand for 7000 new houses in the next decade. Moves are afoot to shift the racecourse out of its prime urban location and use the land for hundreds of homes. The suburb of Camberley, a tight knot of old state houses with a strong Mongrel Mob presence, is due to get the “place-based” treatment next.
Turning the Titanic
In the three years after the place-based housing collaboration was officially launched, things got worse. Over the June 2022 quarter, 219 families including 921 children spent time living in motels. By then, the government had paid $21.5 million to local motel owners in six years. The social housing waiting list kept growing.
But by the end of last year, there were signs of improvement. Five motels were retired from emergency housing, with the number of households in motels over the December 2022 quarter down to 111. The waiting list for a state house hit a peak and started to fall.
It was nowhere near enough, but it built confidence that with co-ordinated action and strong relationships between key local players and central government, it was possible to start turning the Titanic and provide secure homes for families and children.
Setbacks were inevitable, but no one expected that to include a devastating cyclone. Although the epicentre of the housing initiative – Flaxmere and other low-income pockets of Hastings city – was unharmed by Gabrielle, the damage to hundreds of homes throughout the district, including 216 that can’t be rebuilt, has flowed through the housing system. Throughout Hawke’s Bay, 145 affected families are reliant on temporary accommodation; among the displaced are the residents of five marae communities.
Everything will be stretched as the cost of fixing roads and bridges is counted, and the impact on jobs and incomes from the $1.4 billion hit to the horticulture sector becomes apparent. As ever after a natural disaster, there are huge risks that existing inequities will be amplified.
The district council’s Nigel Bickle says equity remains “front and centre” in the response to the cyclone, as it has been throughout the collaborative response to the housing calamity.
“These issues can’t be solved by any one party on their own and what we have learnt to do over the past three years is create deep relationships – a coalition of the willing to deliver better outcomes for our place … Cyclones come along, economic conditions change. But fundamentally, you get things done through a genuine commitment to partnership.”
It’s too late for Te Awhenga, who already carries the lifetime scars of inequity, but there’s a glint of hope for those who come next.
Rebecca Macfie received research funding for this story from philanthropists Scott and Mary Gilmour. Part 2 of “Hardship & Hope” will appear in next week’s Listener.
