INDIGENOUS HEALTH IN NEW ZEALAND:

'by Maori, for Maori'Understanding

Maori culture andempowering Maori

nurses has helpedNew Zealand's

indigenous peopleimprove their

health, reportsDerek Hand.

WHEN THE WORLD HEALTHORGANISATION RELEASED AREPORT INTO THE HEALTH OFTHE WORLD'S INDIGENOUSPEOPLES EARLIER THIS YEAR, ITTRIED HARD TO FIND SOMEGOOD NEWS AMID THE HARSHREALITIES THAT IT OTHERWISEPAINTEDJ

Overall, the evidence pointed to hugeinequities in the health of indigenous peo-ples compared lo general populations.Destruction of their habitat, the source ofspiritual and material sustenance, threat-ened not only the health, but also the verysurvival, of the 200 million indigenouspeople globally.

Yet there were some encouraging stories.Where traditional ways of life and diethad not been severely disrupted, indige-

Ngaire Whata oitlslde the healthcentre in Rotorua.

nous peoples had low prevalence ofdiabetes, cardiovascular diseases andhypertension. At the same time, differentpictures emerged between different coun-tries, suggesting that some indigenoushealth initiatives were working.

The release of the report at an internation-al indigenous health workers' confereneein Aotearoa/New Zealand was designed toprompt the sharing of experiences, goodand had, and the pooling of informationon indigenous health. Ironically, the hostcountry itself has been the focus of atten-tion by others, including Australia,seeking answers to difficult questionsabout indigenous health.

In Australia, there have been calls for a"New Zealand-style revolution' inresponding to the poor health of indige-nous Australians.- A parliamentaryinquiry into Aboriginal health lastOctober also received evidence that theextent of participation of Maori people inthe social, political and economic life ofthe country flowing from the Treaty ofWaitangi was an important contributor tothe better health of Maori.'

The Treaty of Waitangi. signed in 1840by British settlers and Maori leaders, is apartnership agreement setting out howcoexistence in Aotearoa/New Zealandshould operate. Today, it forms an impor-tant legal and policy framework, settingthe tone and direction for health initiativesand other government activity thatimpacts on Maori well being. TheDepartment of Health, for example, buildsits Maori health policy around the Treaty,committing itself to improve Maori healthstatus so that Maori will in future have theopportunity to enjoy at least the samelevel of health as non-Maori.

However, sweeping statements about rev-olutions and the fine rhetoric of policydocuments hide some of the reality of thestate of Maori health, especially whencompared to the rest of the Aotearoa/NewZealand population. A comprehensiveseries of studies of Maori health producedby Te Ropu Rangahau Hauora a EruPomaie (the Eru Pomare Maori HealthResearch Centre) at the WellingtonSehool of Medicine, offers greater insightto the current state of affairs.

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In the third of its reports, cov-ering the period 1970-1991,-^the cetitrc notes that death ratesfor Maori from almost allmajor causes have indeed con-tinued to decrease, but withsome important exceptions.Among these arc high rates ofsudden infant death syndrotneamong Maori infants, youthsuicide (paiticularly amongyoung Maori males), homicideand violence, and motor vehi-cle accidents. Although lifeexpectancy at birth tor Maorihas certainly improved in thelast 50 years, it has notimproved as much as non-Maori. 'At present thedifference in life expectancyremains static,' the reportstates.

It also stresses the link betweenhealth and socioeconomic fac-tors such as income,employment, education andhousing. 'A review of theseindicators for the last decadeshow that Maori have becomerelatively worse off comparedto the non-Maori population,'it notes. This is evident in fig-ures from the 1996 census,which show that the medianannual income for Maori menaged 15 years and over wasNZ$16,000, eompared toNZ$22,000 for all men inAotearoa/New Zealand. Forwomen, the figures wereNZ$11.200 and NZ$12,600respectively.

GIVING VOICE TO MAORINURSES

Where there has been successin improving Maori health, agreat deal of credit can beclaimed by Maori health pro-fessionals themselves,ineluding nurses, despite theirrelatively small numbers. Ofmore than 28,000 RegisteredNurses working inAotearoa/New Zealand in1994. only 2.8% (780 nurses)identified themselves as Maori(another 1.1% identified them-selves as Pacific Islander, and92.1% were European/

Pakeha).^ A slightly larger pro-portion of Enrolled Nursesidentified as Maori (8% of theeounlry"s 6552 EnrolledNurses), but there were fewermidwives (1.97r of the coun-try's 3482 midwives identifiedas Maori).

Giving a voiee to these nurses"views on Maori health is theNational Council of MaoriNurses. Formed in 1982 andnow representing more than1000 members, the council isgoverned by a national execu-tive, and its work is framedwithin a fomial constitution.Members sit on special sub-committees that bring togethernursing and midwifery exper-tise across a range ofportfolios, including mentalhealth, family health, childhealth, care of the elderly, mid-wifery, smoking and healthpromotion.

'Our job is to work at the coal-face," said Ngaire Whata. thecouncil's national president,during a break from volunteernursing duties at the indige-nous health workers'

Ngaire Whata (left) and Millie Heke undertaking volunteer nursing duties at theinternational indigenous health workers conference

argued that prescribing rightswere particularly important fornurses working with rural iwi(tribes), where they needed tobe equipped to deal with abroad range of health prob-lems.

More broadly, within the nurs-ing profession itself there isacknowledgment of the needfor greater understanding of

With our old poople behind us, itgives us a powerful force thatallows us to reach Maori.conference. 'The council isowned and controlled by Maorinurses and for Maori people, sowe can make our own deci-sions and set our own policieson the health of Maori. It hasgiven us the opportunity wherewe can set the scene for thefuture health directions ofMaori."

Working at the coalface is alsoabout lobbying governmentsover changes that might lead toimproved health Ior Maori. Forexample, the council has givenits support to a push for nurseprescribing rights, and metwith the health minister to pre-sent a Maori perspective. It

Maori culture and traditionalvalues. This is reliected in arevamped nursing curriculumthat requires all nurses to betutored in the Treaty ofWaitangi and in Maori culturalinterpretations of "health". Thisso-called "cultural safety'(whakaruruhua) component ofthe national nurse educationcourses was introduced in 1992and is taught in 15 nursing andfive midwifery colleges aroundthe country.

KOROWAI AROHA

Aoteaioa/New Zealand hasembraced the idea of applyingfree market principles to health

and other community services.It operates a 'purchaser/provider' split, where fundingauthorities (the "purchaser")contract with clinics and otherprograms (the "provider') forhealth services. In someinstances. Maori act as co-pur-ehasers in this system,effectively allowing themgreater autonomy in decidingthe shape of health care forMaori within fixed budgets.

Of the different 'providers' ofhealth care to Maori people,some are described as being'by Maori, for Maori" (a termused by Maori groups to under-line their strengths, and bygovemment funding agenciesas a category in their formalaccounting and reporting sys-tems). The Korowai Aroha("Cloak of Love") health centrein Rotoma is an example of aservice opeiated by Maorinurses lor Maori people.Catering for a Maori popula-tion of about 22.000 in the areaaround Rotorua. the clinic wasset up with government fund-ing in 1992 by a group of localMaori nurses. It provides 'cul-turally appropriate' ciue andservices and is committed toworking with traditional prac-tices. The centre has a full-timestaff of 15 people, includinglour nurses, five midwives. a

MAY 1998 - VOLUME 5 NO 10 AUSTRALIAN NURSING JOURNAL 19

traditional spiritual healer anda geneiLiI practitioner. It alsoacts as coordinator for a teamof 50 community-based, part-time, paid carers. KorowaiAroha is overseen by a Boardof Trustees, all of them Maori,except an accountant member.

Ngaire Whata. herself aRegistered Nurse, is the cen-tre's manager. 'We see Maorihealth as having many dimen-sions,' she said, adding that thecentre's strength lay in its abil-ity to view the notion of'health' through the lens ofMaori culture and tradition.'''Our people are comfortable indealing with us.'

Staff at the centre see about11,500 clients a year, and offera wide range of services,including checks for asthma,diabetes and cervical screen-ing. While deaths from heartdisease have graduallydeclined, cancer has becomethe leading cause of death forboth Maori and non-Maori.Cancer of the breast, lung andcervix are the most commoncancers for Maori women.Cervical cancer is three timesas common in Maori women asin non-Maori women, a situa-tion which has in tum beenlinked (at least in part) to thehigh prevalence of smokingamong Maori women.

Improved testing and follow-up is regarded as the best wayof reducing the incidence andmortality from cervical cancer.Korowai Aroha underlines theimportance of incorporatingMaori values into the structureof services such as cervicalscreening. 'Our women treatthe cervix as very sacred. It is abit different from the Pakeha[Europeans],"she explained.The difference, she said, playsitself out in the greater reluc-tance of Maori women to comeforward for cervical screening.Recognising the importance ofprivacy, a Maori women's cer-vical screening register hasbeen compiled and the infor-

mation it contains is protectedby a guardian. Access to theregister ean only be granted bya panel of caretakers.

Another important faetor inwhether people access primaryhealth care is its cost, especial-

exercises. That avoids a lot ofinjury and is an excellenthealth gain for us in that area.'

Another of the clinic'sstrengths is its strong links tothe Maori community's elders,who offer their support. 'With

Ngaire Whala with a framed copy ot the Treaty ot Waitangi

ly when the 'user-pays'principle is dominant. 'Wehave to charge people whocome to see our nurses,' saidMs Whata. 'We used to onlycharge a kauhau [donation].Now we charge NZ$5 for eachvisit to the nurse or doctor topeople with a community ser-vices card." The clinic does noteharge for children under sixyears, and for others, the fee isNZS15. It may not be free, butit compares favourably to a feeof up to $40 that is otherwisecharged for a standard visit to aGP. Although its primary focusis on Maori people, the centredoes not exclude non-Maori.'We are also prepared to workoutside our region, but onlywhen we are invited," she said.

Millie Heke. a nurse at the cen-tre, said education was a largepart of the day-to-day work,such as holding stop-smokingclinics on local marae. the tra-ditional Maori meeting places.'In sports, we see that a iot ofpeople are now doing warm-up

our old people behind us. itgives us a powerful force thatallows us to reach Maori,' MsWhata said. Staff recentlyreported a drop in the numberof older people attending theclinic. 'They were busy doingline dancing!" Millie quipped.'We had told them not to sit athome thinking they were goingto get sick. We told them to getout and walk and dance and dothings.'

Acknowledging the particularskills and insight that theybring to their work, the WHOhas called for a swelling of theranks of indigenous healthworkers. In Australia, that sen-timent is echoed by theCouncil of Aboriginal andTones Strait Islander Nurses(CATSIN). which was formedin the wake of a forum heldlast August to fmd ways ofrecruiting and retaining indige-nous nurses. CATSIN hasendorsed the Aotearoa modelof cultural safety, and hascalled for its implementation in

Australia.

CATSIN chair Sally Gooldsaid she was optimistic thatnursing education in Australiawill successfully take onnotions of cultural safety, inturn rectifying the absence of astrong indigenous presence innursing. 'It would pave theway for reconciliation, fornurses to really examine theirfeelings and take on the philos-ophy of reconciliation.'•

AUTHOR

Derek Hand is a Sydney-basedjournalist. He travelled toAoteaora/New Zealand iviththe 199"^ annual award of theAustralian Medical Writers'Association.

REFERENCES

1 World Health Organisation TheHealth of Indigenous People. WorldHealth Organisation, Geneva, January1998,

2 In a press statement dated 15September 1997. the president of theAustralian Medical Association, DrKeith Woollard, described the need fora New Zealand-style' revolution inindigenous health. He added: 'Injustthree short decades, the health statusof the Maori has improved dramatical-ly. In contrast, the health of AustralianAboriginal people has, if anything, gotworse.'

3 Australian Medical Association andPublic Health Association of Australia,Submission to the House ofRepresentatives Standing Committeeon Family and Community AffairsInquiry into Indigenous Health 1997.

4 Pomare, E., et al,. Hauora: MaoriStandards of Heaith III. Wellington:Wellington School of Medicine, TeRopu Rangahau Hauora a EruPomare, 1995,

5 New Zealand Health Workforce1994, New'Zealand Health InformationSen/ice, Ministry of Health, 1996,Wellington.

6 For a discussion of Maori healthperspectives, see Durie, M,, Whaiora:Maori Heaith Development. Auckland,Oxford University Press, 1994,

For more information, contactSally Goold of the Council ofAboriginal and Torres StraitIslander Nurses on (07) 34088199 or Robyn Coulthard, ANFNurse Advisor, on (03) 94822722.

20 VOLUME 5 NO 10 AUSTRALIAN NURSINO JOURNAL • MAY 1998