Lower socio-economic groups are not only struggling to make ends meet, they are getting sicker and dying younger. Simon Collins reports on what needs to be done to redress the injustices faced by those at the bottom of the pile.

Life is harder in Mangere than in Remuera. Ask Eseta Lam Sam. It is 46 years since Eseta, 72, arrived from Samoa, leaving three children with their grandparents until she and her husband Sefo saved enough for the family to join them.

They raised four children in a Western Springs state house. But Sefo developed a lung disease caused by toxins in the mattress factory where he worked. He was laid off in 1986 and died the next year.

The family used his accident compensation to buy a modest house in Mangere where Eseta still lives with her eldest son, 50. Here she has developed her own health problems - an enlarged heart which leaves her short of breath, and severe head pain which has affected one eye.

Her son has breathing problems when water gets into his lung and he has to go to hospital to have it drained. He also suffers from gout. "It's like a rat that goes round your joints," he says.

The Lam Sams are not alone. Pacific people are almost twice as likely, and Maori more than twice as likely, as European New Zealanders to die before age 75. Low-income women are about 1.5 times as likely to die as high income women; low-income men are about 1.75 times as likely to die as men on high incomes.

The differences are shocking, but not unusual. In Australia, children and adults are both about 1.8 times more likely to die in the poorest fifth of households than in the richest fifth.

Even within the homogeneous British civil service, a famous study led by Sir Michael Marmot found men on the lowest grades were twice as likely to die of heart disease as men on the highest grades.

Hospitalisations of children with "diseases of poverty" such as skin infections and lung diseases are even more extremely skewed in New Zealand. Rheumatic fever, a severe throat infection which damages the heart, is 23 times more likely for Maori, and 49 times more likely for Pacific people, than for Europeans.

"Social injustice is killing and maiming our children on a grand scale," says Auckland University paediatrician Innes Asher.

The NZ Medical Association is calling for reducing social inequity, largely inspired by a review for the British Government led last year by Marmot. The association and the Heart Foundation are bringing Marmot here for seminars next week.

Dr Don Simmers, who heads the association's health equity subcommittee, has seen the effects of inequality after he and his wife moved from wealthy Queenstown to the low-income Wellington suburb of Newtown in 2002.

"I was struck by the high number of people who were affected by a whole range of diseases including the more predictable obesity, diabetes, and heart disease, but also asthma, thyroid disease, rheumatoid arthritis, gout, developmental delay, skin infections, drug addictions and congenital disease," he says.

He says many people in Newtown begin to age as early as their thirties. "People seem tired and worn out whether through the grinding drudgery of their mundane work, or trying and failing to make ends meet on benefits."

Tony Blakely of Otago University's health inequalities research programme says poorer families like the Lam Sams tend to suffer poorer health for four reasons.

First, low income directly affects material essentials such as housing, heating and food. The Lam Sams have used the Government subsidy to install insulation in their Mangere home, but Heart Foundation Pacific health manager Louisa Ryan says many Pacific families still live in cold, damp homes because they don't know the subsidy exists.

Eseta Lam Sam lives on her superannuation of $314 a week plus her son's earnings from selling Samoan pancakes and pies at the Avondale and Sandringham markets.

"I don't have enough when the bills and the rates come in," she says. "When the rates bill comes I pay it and don't go shopping; the next benefit is when I do the shopping. We just live on milk and bread for that week."

Second, these material problems can cause psychological stress.

"There is reasonable evidence that lack of control of your life, particularly your work life, is associated with higher cardiovascular disease rates," Blakely says.

Simmers sees three or four times as much anxiety and depression in Newtown than in Queenstown. He sees people coping by smoking, drinking and eating too much.

Blakely lists lifestyle factors such as smoking and diet as another route to ill health because they are not always due to stress.

Forty five per cent of Maori and 30 per cent of Pacific people smoke, compared with 20 per cent of Europeans and 11 per cent of Asians.

The Lam Sams don't smoke or drink, but their health problems are partly due to their diet. Ryan says gout can be triggered by canned corned beef, a popular food in the Pacific community.

Work issues have also affected their lifestyle Toxins killed Sefo Lam Sam, and his son has become overweight and developed high blood pressure and sleep apnoea, as well as gout, since being made redundant from a printing factory in the 1990s.

Blakely says healthcare itself can worsen inequalities when poorer people can't afford to go to a doctor, see doctors they can't understand, or don't know how to keep pressure on the system to get what they need.

The Lam Sams go to a Samoan family doctor in Mangere who charges only $15 a visit, but they deal with all kinds of doctors at hospital.

"You can tell what kind of person you're facing, the attitude," Eseta's son says. "Sometimes you're too scared to ask because they might give you the wrong treatment."

The Medical Association advocates a wide-ranging package to tackle inequality including banning cigarette sales, exempting "healthy food" from GST, and fixing welfare levels and the minimum wage in line with a "minimum income for healthy living".

In Auckland, a discussion document on the region's first spatial plan makes "reducing inequalities" a strategic priority. But public health physician Alex Macmillan says it has frustratingly few concrete targets.

It plans to support community gardens, reduce "local availability of alcohol and gambling outlets", work with other agencies to increase adult literacy and numeracy classes, ensure more "quality, affordable and mixed-tenure housing in targeted areas" and increase opportunities for walking, cycling and other physical activity. Yet its infrastructure section focuses on high-cost motorways and railways and barely mentions walkways or cycleways which are free to users - even though Blakely says they have helped the Netherlands achieve one of the world's lowest obesity rates.

It is only 25 years since New Zealand was one of the most equal OECD countries.

"Everything we look at in public policy we should look at in terms of whether it is going to bring the more disadvantaged people up more," says Heart Foundation medical director Norman Sharpe. "We are all living in an era of cost-constraint, but we can still find $50 million to reduce waiting lists for heart surgery for older people. There was also $12 million from the last Budget for rheumatic fever. There's the comparison."