More New Zealand children are killed by diseases linked to cold, damp, and overcrowded housing than in car crashes or drownings.
Disease casts a shadow over Parrs Park in West Auckland. It's there in the data: the children are getting sick. And when the women open their doors, they'll tell you.
"My granddaughter got bronchitis," says Talia*, on Selak Place. "She was just 5. We don't use the heater, it's broken. We use the oven to warm the house."
Aroha*, who lives in a state house next door, has four children. The two boys have asthma. The baby was also hospitalised with a respiratory disease.
"The doctor said it was because the house was too cold. We were only home three days and she got sick," Aroha says. "They gave her medicine. But there was nothing they could do about the house."
Across the road Azaryah, 1, has pneumonia. Her family took her to the doctor three times in three days. Eventually, they went to the emergency department and her illness showed up in an x-ray.
"Since then we've been running a dehumidifier and a heater all day. She just hasn't gotten any better," her mum says. "We have a good landlord but we're looking to move. It's pretty cold without the heater, it's freezing."
Upstairs, mould grows on the windowsills. Despite being a new house, it has no ventilation system.
Parrs Park, a low-income suburb with a diverse ethnic population, has some of the worst rates of preventable, poverty-related child diseases in Auckland. The area counted more than 140 potentially avoidable hospitalisations among its 2000 children during 2016 alone - six times that of a suburb like Remuera, across town.
The statistics do not make Parr's Park unique. In fact, every town around the country has areas just like it - and worse - where children are getting sick largely because of cold, damp, overcrowded homes.
Health data shows that each year 20 children are killed by diseases linked to unhealthy housing - more than 350 since the millennium. Half of those were from pneumonia. Asthma and wheeze took 33. Bronchiolitis claimed 15.
The deaths peak in winter, hospitals flooded as soon as it gets cold. Maori and Pacific children die at twice the rate of Europeans. The very poor die at 14 times the rate of the very rich, with a recent report from the Asthma and Respiratory Foundation describing the effect of deprivation as "near exponential".
"Across all respiratory health indicators, by far the most relentless and disturbing pattern was the high degree of inequality," the report said.
Hospitalisations caused by poverty-related conditions have increased since 2000 - up to 43,000 last year. Respiratory diseases, in particular, are growing at much more severe rates.
Doctors argue the hospitalisations are a result of embedded child poverty levels combined with a relentless housing crisis.
"In New Zealand we have created a triple jeopardy for poor health," says expert paediatrician Professor Innes Asher. "Poverty, unhealthy housing and inadequate basic health care puts health at risk, but when the three are combined...poor physical health is almost inevitable, as in Dickens' times."
On the ground in West Auckland, Te Whanau o Waipareira social workers have the anecdotes behind the data. Their clients come both from private rentals and state housing, from Kelston to Massey.
"We have workers who are taking mums and their babies to the doctor four times a week with respiratory illness," says Alisha Tamepo-Pehi, a lead clinician.
"The majority of our whanau can't afford heating. They don't have the basic necessities - beds, clothing, blankets. There are people sleeping on the floor, it's damp, it's dusty, there's drafts coming up."
Dr Cass Byrnes, a respiratory paediatrician at Auckland's Starship hospital, sees the impact of those living conditions every day. On a single day last week there were 40 children on the general ward with respiratory illnesses. In summer, those children would fill only two or three beds.
"We have waves of kids coming in the minute it gets cold," Byrnes says. "We try to delay discharges but the wards are packed. The problem is, the kids just can't get symptom free - they go home with antibiotics to the same environment that cause the problem."
A recent Otago University study found 53 per cent of children hospitalised with preventable, poverty-related diseases would be readmitted. For children with a smaller subset of conditions linked more strongly to housing and crowding, that figure jumped to 80 per cent.
Byrnes says not just the number but the severity of cases are getting worse. Rates of bronchiectasis, an irreversible, life-threatening lung disease caused by repeated chest infections, have tripled in just 15 years.
"It's a Third World disease, the kind of thing that if you were going to see it, the patients would be in their eighties. Now we are diagnosing it younger and younger," Byrnes said.
"Internationally people are astonished at the numbers we have here. It's completely terrifying."
A small silo for a big problem
Less than 10 years ago, clinicians were raising the same concerns about another poverty-related disease: rheumatic fever.
In 2011, New Zealand's rheumatic fever rates were 14 times higher than any other OECD country.
It was labelled a "national disgrace". Eventually, the pressure got too much and the government allocated $65 million to combat its spread.
Initiatives included school-based clinics to pick up sore throats; drop-in centres; awareness programmes and a housing service. The goal was to reduce the rate by two-thirds, to 1.4 cases per 100,000 people.
Six years later, that goal is still unmet. Health experts who were skeptical back then are furious now, saying targeting just one disease was never going to work, but instead diverted funds away from the wider issue.
"Rheumatic fever was a small silo for a big problem," says Otago University's Dr Nevil Pierse, deputy director of the housing research unit He Kainga Oranga. "In focusing on rheumatic fever alone, the government missed the big picture. Or, they're refusing to see it."
The rheumatic fever programme has not been evaluated in its entirety, but recent minutes from an Auckland District Health Board meeting lay out some of what went wrong. While the school-based sore throat clinics were considered a success, most other elements were flawed, the document said.
Messages about prevention did not reach vulnerable families or were not understood, it said. The same families kept getting sick. Some young people were not taking their penicillin injections, and were likely to get sick again.
Many of the community clinics were not up to scratch. "They were not rapid, drop-in, convenient or attractive to whanau and youth," it said.
And, crucially, the housing intervention did not always work. Partly, because there were no new houses available, but also because of problems in the design.
The housing referral and advice service began in 2013, with $3.75m allocated to and Auckland-Wide Healthy Homes Initiative. It was subsequently expanded to ten other districts, with $18m more.
The idea was to link families at high risk of rheumatic fever to "practical government and community interventions" that reduced household crowding. Nurses would visit eligible families and help them improve their homes.
To define eligibility, the Ministry of Health created a list of "risk" factors. This included children who were hospitalised for a group of nine specific illnesses thought to be caused by the same conditions as rheumatic fever. While conditions such as pneumonia and meningitis made the cut, critically, asthma, skin infections and ear infections did not.
The criteria also limited referrals to those on low-incomes, who reported overcrowding, and had more than one child. Later it was expanded to add "vulnerable" families, including pregnant mothers.
Pierse says the criteria were too strict, and estimates that of the 30,000 children each year with housing-related issues, only an estimated 6000 were eligible despite thousands more also arguably "at-risk".
Even when children were eligible, not all of them were referred, Pierse says. Many doctors were unaware of the programme, or too busy to fill out an extra form.
Documents show that in the three years since its inception, just 5800 families were referred. Of those, 4020 completed assessments with nurses at their homes.
However the "assessment" did not guarantee an intervention, such as the provision of insulation, or curtains, or carpet for the home.
This was because the funding provided by government only covered the nurse's visit and advice - not the cost of improvements. Charities or social services were supposed to fill the gap, with all alterations needing landlord approval and in some cases, the landlord to fork out.
Data from the programmes shows some interventions worked well. All families were given mould-removal kits. Curtains had a 68 per cent provision rate, floor coverings 66 per cent, and new bedding got to 75 per cent of those in need.
However, just 47 per cent of ventilation interventions were completed, and only 34 per cent of recommended insulation was installed. Just 25 per cent of families nominated for new houses were able to move.
"Basically, they're doing the right thing but they're doing it too cheaply. There's not enough kids, not enough criteria, not enough help," says Pierse.
"It's just ridiculous - if there was a new pill they would spend the money. If there was a pill as effective as good quality housing the health sector would spend the money so why don't they spend it on this?"
"We have been asking for a house for a long time"
Auckland District Health Board's latest rheumatic fever plan acknowledged the challenges with the housing supply. It said it was aware many families had been waiting "some time", and it risked some becoming disengaged.
In Auckland's Mt Roskill, the Herald met a family who had been on a housing wait-list for three years. The couple, who wouldn't give their names because they feared their landlord would evict them, have three school-aged children with bronchiectasis. Their house is uninsulated, cold and damp.
"We have been asking for a house for a long time," the father said. "We apply and hear nothing. We are at the point when we just can't be bothered with the service any more."
Nurses who work with the Health Housing Interventions see cases like the Mt Roskill family every week. Typically, families sleep in one room to save on heating. There's usually mould, and a lack of heating or ventilation, and limited insulation.
"That's one of our biggest challenges," says Vanessa Cameron, the project manager for the Wellington initiative. "We try and find various ways of working with them, but some landlords just don't understand the importance of insulation."
Cameron said the lack of funding was also extremely difficult to deal with, although they were extremely grateful for the support of charities and donations.
"For us, if we identity an issue then we're obligated to help find a solution. There's a lot of work trying to match need with supply."
One of the programmes the Healthy Housing Initiative was expected to match with was the government's Warm Up New Zealand initiative, which provides insulation subsidies. Launched in 2009, it offered grants covering up to 60 per cent of insulation costs both for low-income families and the general population.
It was immensely popular, with 241,000 homes insulated in the first phase. However, criteria were narrowed, with the current scheme only applicable to rental homes with low-income tenants. It's no longer so popular. Of the 20,000 grants available, just 3300 have been paid out.
"It's deeply disappointing," says Philippa Howden-Chapman, a professor of public health at the University of Otago. "There's a real reluctance of landlords, who are providing a service, to maintain that service. It's a reluctance I can only put down to the fact that most landlords aren't concerned about depreciation but only capital gains."
Howden-Chapman says with up to 800,000 uninsulated homes in New Zealand, she was staggered the government reduced such an important programme.
"It's both a social and a moral argument - children end up with compromised health for their whole lives, and they die."
Howden is part of a group of researchers who believe there should be an immediate investment in better housing, and more housing. She cites statistics highlighting New Zealand's inadequate homes- half of houses are damp and mouldy, half have bedrooms that are never heated. Five per cent of children live in severely crowded homes.
While the government had made some moves in the right direction - with the incoming Residential Tenancies Act mandating a certain level of insulation - the doctors say it's not enough.
New targets for the reduction of avoidable illnesses - 25 per cent by 2012 - were unclear in how they will address the burgeoning housing problems. In a statement, health minister Jonathan Coleman only said the Healthy Home Initiatives (and the Housing New Zealand equivalent, Warm and Dry) will continue "alongside other initiatives".
Further details on the housing side of the target were not provided, except to say the Ministry of Health would "work in partnership" with other agencies.
Ministry of Health spokesperson Dr Stewart Jessamine said the environment in which the interventions worked was "complex and challenging" with staff required to liaise with many agencies.
Sometimes it was hard to contact families as well as landlords, he said. Landlords were able to decline interventions.
Despite the difficulties, Jessamine said the ministry considered the project a success and many more thousands of families were expected to benefit in the coming years, particularly with "vulnerable" families included in risk criteria.
He said initially the number of indicator conditions were limited to let the ministry test the capacity of the service and its system design.
Back in West Auckland, Kelston MP Carmel Sepuloni has also been door-knocking in Parrs Park. The families tell her the same stories they tell us - they are cold, their houses are damp. But they are still grateful. Many in the area have no homes at all.
"We are seeing the full range of the homeless situation - I've had families living in tents, in boarding houses, lots of single men living on the street outside my office," Sepuloni said. "It's shameful."
A recent study from Otago shows 42,000 people now live in "precarious" housing such as garages, caravan parks and cars, with those families believed to be behind a solid swathe of the hospitalisation statistics. But none of the health initiatives are aimed at them.
The day we visit Sepuloni, she also gets a visit from a woman called Shelley Asesa. Shelley and her husband Ioane have six daughters. The youngest is 2, the oldest 10.
They have been living in motels since January, due to overcrowding at their family home. Currently, they're staying in Avondale, piled eight people to a single room. The bathroom is outside, shared with the rest of the camping ground.
Shelley has come to her MP's office in tears, with a doctor's note. Her second eldest, Fatulua, 9, has a skin infection - associated with overcrowding - that has gone into her throat.
It is the fourth time that year the GP has written to Work and Income on behalf of the family. It outlines their health issues - asthma, skin infections, boils, chest infections, diarrhoea, strep throat.
"Some of the children have had hospital admissions due to these problems," the doctor writes.
On top of that, the days off needed to look for housing and to care for the children has almost cost her Ioane his job.
"This is causing enormous stress for Shelley... please could you find suitable accommodation for them."
Although Ioane works full-time as a painter and they're prepared to pay up to $600 a week, Shelley says they simply cannot find a landlord to take them.
"They look and see a young couple with six kids, they're not exactly welcoming us in," she says.
All she wants - and all the girls want - is a place to call their own. The girls keep planning how to decorate their rooms, who will share with who.
Shelley says it's difficult to hear their plans when she can't promise they will find anywhere soon, as the housing crisis shows no sign of letting up.
"It's not what we planned. It's not what we wanted for our kids," she says. She is trying not to cry in front of her children, but it's hard. "It's not what we pictured it would be."
* Some names have been changed for privacy.
For more information about the data in this story, go here.