29 May 2025
A collaboration between complex systems researcher Anna Matheson and illustrator Hanna Breurkes. Edited by Anna Brown.
Imagine you’re watching a river flow through a beautiful valley. At first glance, the river seems peaceful, carrying water gently downstream. But if you look closely, you’ll notice the current shaping everything it touches — carving paths, altering landscapes, and influencing every living community it flows through.
The reality of health inequality is much like this river — it isn’t just an outcome you measure at a single point in time, but an ongoing process constantly shaping people’s lives. Just like a river’s path is determined by terrain, rocks, and weather, health inequality is created and sustained by complex societal factors — economic policies, historical injustices, environmental conditions, and unequal power dynamics.
Picture a family living near the banks of this metaphorical river, stuck in overcrowded housing, juggling multiple low-paying jobs, struggling to access nutritious food and quality healthcare. These conditions don’t exist in isolation; they intertwine and reinforce one another, pulling the family deeper into hardship, much like powerful currents pulling everything in their path downstream.
The evidence for this dynamic is clear. Studies around the world show a social gradient in health: the lower you sit on the socioeconomic ladder, the poorer your health outcomes tend to be. Consider the famous Whitehall studies from the UK, where even civil servants with stable employment showed significantly worse health if they occupied lower-ranking jobs. Their limited control over work and life created constant stress, wearing down their health just as relentless currents erode the riverbank.
In New Zealand, this pattern is starkly evident, with people in the poorest neighbourhoods living about a decade less than those in the richest areas. Globally, too, this pattern of inequality is profound — life expectancy in materially poorer countries is roughly 33 years shorter than those with high incomes.
The data shows us a consistent pattern. But its regularity masks the twists and turns and constant movement of the people and artefacts it represents. It also masks the ease and strength of water that flows downwards. But rivers begin their existence at the height of mountains, where the action of water vapour has defied gravity to rise and help fill and refill trickles and torrents. A slower, dispersed and generative journey upwards.
Traditional solutions to health inequalities often resemble building small dams or bridges, addressing more immediate and singular issues like encouraging healthier eating or increasing health screenings. While valuable, these measures seldom alter the source of the river’s underlying current.
To change this flow, it is helpful to understand that our measurements of health inequality are simplifications, removed from their rich and constantly moving context. This reality is a complex interconnected web of ecosystems where changes in one area have potential to ripple outward, altering future outcomes. For inequality, ‘power’ is the rising vapour that can connect the downstream with the source of the flow upstream. And for health, the power-to-act is most impactful when people closest to the issues possess it.
Imagine local communities as expert guides intimately familiar with their unique stretch of the river. Even with plentiful information and evidence, they still need their rich local insights and lived experiences, as only they know exactly where currents are strongest and how to navigate hidden obstacles. When communities hold genuine power, they can steer resources and interventions to protect and nurture the environments and social conditions critical to their wellbeing, creating the foundations to withstand sparse or turbulent waters.
Yet the influence of empowered communities extends beyond their immediate surroundings. Local norms, practices, and innovations that serve community needs can send ripples upstream and vapour skywards — reshaping distant systems that perpetuate health inequalities. Just as water evaporates and rises, only to replenish mountain streams, the grassroots actions of communities can ascend, influencing policies and where resources are put, that in turn can remake relationships of trust and power. Local knowledge and actions become powerful currents of change, capable of even transforming economic and governance systems.
Health inequality is about more than a pattern of outcomes; it is the result of a dynamic and ongoing process, continuously shaping and reshaping the circumstances in which people live — across generations. To truly alter the river’s course, solutions must leave communities with the power to act collectively, not only to navigate the currents but to rise and influence the sources upstream themselves. Engaging with the connected flow of real relationships is where there is potential for disruption that can lead to system change.
Instead of cycles of inequality, we can foster cycles of regeneration, creating healthier and more resilient futures for everyone along the river’s path.
Anna Matheson is a principal investigator with Te Pūnaha Matatini who leads the research project Ki te toi o te ora: System change to reverse health inequality and environmental degradation.
Hanna Breurkes is a designer and illustrator who is passionate about designing to improve wellbeing and is inspired by nature.
Anna Brown is a principal investigator with Te Pūnaha Matatini who believes that design has a role to play in delivering public good.