A Re p ort to the
Ministry of Health
HAUORA WAHINE MAORI
C RECENT DIRECTIONS FOR MA01U WOMEN s HEALTH 1984-1994
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STACK KOTUKU PARTNERS WA OCTOBER, 1994 I 1Oij3j HAW MOH Library 1994 IIIIIIff 101185M
A Report to the •Popul a t ion- H eal th x & a f Ministry of Health
HAuoRA WxHiNE MAom
RECENT DIRECTIONS FOR MAORI WOMEN S HEALTH 1984-1994
KOTUKU PARTNERS OCTOBER, 1994
•mon CiIre & y of iteTh wi^_"I ;ion (.k Introduction II
It,
3. lO999jc 13
This report has been prepared by Kotuku Partners for the Population Health Services Section of the Ministry of Health and the Ministerial Advisory Committee on Women s Health. This report covers hui, writings, consultations with Mãori, and Mãori views on Health and Health Services over the period 1980-1994. This extract specifically covers Mäori Women s Health.
Introduction III
TABLE OF CONTENTS
Table of Contents iii
Introduction••••••e••••••••s•••••••s•••s...... ix
Major Themes - 11ãori Women health •••••••e...ss...S..s...... Xjjj ManaWãhine ...... xiii HauoraMãon ...... xiv Highlights - Mãori Women s Health Status...... xv Leading Causes ofDeath...... xvi Leading Causes of Hospitalisation...... xvi Priority Ranking Diseases and Conditions...... xvii Directions - Health Services...... xviii Directions - Policy ...... xx Directions - Research...... xxiv Directions - Mãori and the Health Reforms...... xxv Treatyof Waitangi ...... xxvi GovernmentAgencies ...... xxvii Recent Mãori Affairs Policy Statements ...... xxx
Part
Chapter1 Overview ••.s...... SS..S.S.S..._...... nn. 1 1 .1 Methodology...... 2 1.2 Reports Analysed ...... 3
A Brief Chronology of Health Among Mãori and Pãkehã...... 6
Chapter Two The Treaty of Waitangi ...... 15
English Version of the Treaty of %S aitangi...... 16 Mläori Version of the Treaty of Waitangi ...... 17 L. non CiAre &. ry of Health We.nton
Introduction IV
2.1 Recognition of the Treaty of Waitangi...... 18 2.2 Principles for Crown Action on the Treaty of Waitangi...... 20 2.3 New Zealand Mãori Council - 10 Implicit Principles...... 21 2.4 The Treaty of Waitangi and Health Care ...... 21 2.5 Tino Rangatiratanga and the Treaty of Waitangi ...... 23
Government Agencies 24
2.6 Kawanatanga and the role of Government ...... 24 2.7 Ministry of Women s Affairs - Minitatanga mö nga Wãhine ...... 24 TeOhu Whakatupu...... 25 Government Outcomes for Women...... 25 2.8 Te ManatU Hauora - Ministry of Health...... 26 2.9Rangapfl Hauora Tumatanui - Public Health Commission...... 26 Whdia te ora mô te Iwi - Sfrive for the good health of the people...... 27 Government Outcomes for Health ...... 28 2.10 Te Pum Kökiri - Ministry of Mãon Development ...... 30 Government Outcomes for Mãori Development: Mdori Health...... 30
Chapter Three Recent Mãori Affairs Policy Statements ...... 31
3.1 Te Urupare RangapU ...... 32 The Development Decade 1984 - 1994...... 35 3.2KaAwatea ...... 36
3.3 Towards 2010 - The Next 3 Years ...... 38 FU
ChapterFour Consultation •...... S...... S...... U••••••S••••tS 41
4.1 Guidelines for Consulting Women and Mãori Women...... 42 4.2 Consultation Guidelines ...... 42 4.3 A Guide for Departments on Consultation with Iwi ...... 43
Chapter Five Significant Health Hui 1984 - 1994...... 45 5.1 Hui Whakaoranga ...... 46 Details...... 46 Kaupapa...... 46 Proceedings/Recommendations ...... 46 5.2 Hui Taumata ...... 53 Details...... Kaupapa...... 53 Proceedings...... 53 5.3 Hui-a-Iwi: Nursing Education and Services...... 54 Details...... 54 Kaupapa...... 54 Introduction V
Proceedings.54 5.4 Cultural Considerations in Health...... 56 Details...... 56 Kaupapa...... 56 Proceedings...... 56 5.5 Hui - Te Ara Ahu Whakamua...... 58 Details/Kaupapa ...... 58 Proceedings1...... 58 Proceedings2...... 60 Analysis of Hui Te Ara Ahu Whakamua - Kotuku Report...... 60
Chapter Six Significant Health Research...... 63
6.1 Rapuora...... 64 6.2 Hauora: Mãorj Standards of Health: 1970-1984...... 76 6.3 Te Kohikohinga: A Mãori Health Knowledge Base...... 80
Ilauora iI lAori literature Review •••••••S••SSS••••••S••••S•••••...... fl.flflfl... 81
MentalHealth, Hearing and Asthina...... 85
6.4 Mental Health - Nga la o te Oranga Hinengaro Mãori ...... 85 Details/Kaupapa ...... 85 Proceedings...... 85 6.5 Whakarongo Mai ...... 88 Details...... 88 Proceedings...... 88 6.6 He Mate Huango - Mãori Asthma Review ...... 91 Details...... 91 Proceedings...... 91
Chapter Seven The Health Reforms and Mãori ...... 93
7.1 Treaty and the Health Reforms ...... 94 7.2 A Summary of Mãori Concerns ...... 94 7.3 Core Health & Disability Support Services ...... 95 7.4 Guiding Principles...... 96
Introduction A
PARTj ••••••••••••••••••••••••• ...... S... 99
Chapter Eight \\ ãhine Pvlãori...... 99
8.1 Historical/Political ...... 100 8.2 The Reasons for Change...... 103 8.3Mana Wahine ...... 105 8.4Whaia Te Iti Kahurangi ...... Ill 8.5 Maori women and social policy ...... 113
Chapter Nine The Health Status of Mãori Women...... 117
9.1 Achieving A Better Health Future For Maori Women...... 118 9.2 National Perspective of Mãori Women s Health ...... 120 Leading Causes of Death...... 120 Leading Causes of Hospitalisation ...... 121 Priority Ranking Diseases and Conditions ...... 122
Chapter Ten MAori Women s Perspectives ...... 123
10.1 Mãori Women s Perspectives on the Treaty of Waitangi...... 124
Chapter Eleven Mori Women and SmokingfHousing...... 127 ilVlãoriWomen and Snioking...... 128
11.1 KiaManawanui ...... 128 11.2 Te Taonga Mai Tawhiti ...... 132 11.3 Mãori Women and Smoking...... 137
ri Iãori Women and Housing •...... •••••••••••••••••••••••••••••••• 138
11.4 For the Sake of Decent Shelter...... 138
Chapter Twelve Mäori Women and Health Services ...... 145
12.1 Maori Women s Health Services: Case Studies ...... 146 Details/Kaupapa ...... 146 Proceedings...... 146 12.2 Screening for Maori ...... 152 Details/Kaupapa ...... 152 Proceedings...... 152 12.3 Cervical Screening ...... 153 12.4 Mammography ...... 155 12.5 The Needs of Maori Women in Maternity Services ...... 156 Details/Kaupapa ...... 156
Introduction V11
Proceedings . 156 12.6 Parenting Programmes...... 158
Chapter Thirteen Significant Mãori Women s Hui ...... 163
- 13.1 Runanga Kuia...... 164 - RunangaKuia: 1987...... 164 RunangaKuia: 1991 ...... 165 13.2 Putea Pounamu ...... 169 13.3 The Prevention of Early Death ...... 170
Introduction ix
INTRODUCTION
19 8 4 was heralded as the beginning of a new Development Decade for Mãori.
The Hui Taumata, at the beginning of the decade, marked the first of a number of events and hui at which Maori signalled their intentions for development in health, education, welfare and Maori community development. Many of the recommendations remain unfulfilled, yet the principles expressed at the hui continue to guide Maori aspirations.
The Hui Whakaoranga in 1984 provided an opportunity to re-examine a Mãori health philosophy. Recommendations from the many workshops held supported the funding of marae and Maori community initiatives "to meet local needs" defined or promoted through local Maori organisations such as the Maori Women s Welfare League.
Even before 1984 the Maori Women s Welfare League had established a health research unit and conducted a significant research project among Maori Women - Rapuora. In fact, no account of the developments in the health of Maori women would be complete without acknowledging the contribution of two women s organisations - the Women s Health League and the Maori Women s Welfare League.
19 9 4 is upon us, and as we look back at the hui, conferences, meetings, papers, and activities concentrated at furthering Mãori health, and Mãori Women s Health, one is struck with both the clarity and consistency of the calls from Mãori. These calls are for responses from both Maori and the health sector as the representative of the Crown.
The Hui Te Ara Ahu Whakamua held at Rotorua in 1994 has provided the opportunity to assess progress over the last 10 years. A significant publication, Whaiora, has also been released by Professor Mason Durie who has also looked at Maori Health Development over the last ten years.
This document, although necessarily selective, attempts to organise a huge volume of information which has been presented at the various hui and meetings and within the multitude of reports and research papers. Major themes are identified and considerable background information intended to provide context for these themes is also presented. I
Introduction x
This report relies on the principles of Maori Development which have been espoused as a framework for the presentation of the views of Maori (and in some cases the Crown) on Maori Health and Mãori Women s Health.
Part I of this report concentrates on Maori Health generically. Part II of this report concentrates on Wahine Maori.
Chapter 1 provides an overview to the report and provides some background information. The methodology, range of reports/hui analysed and a brief chronology of health among Mãori and Pãkehã is given.,
Chapter 2 presents the English and Mãori versions of the Treaty of Waitangi. The various attempts to seek recognition for the Treaty of Waitangi are also listed. The "Principles" of the Treaty heave been identified by representatives of both parties and some of these are identified. The Treaty is also discussed in relation to health care.
Chapter 3 identifies three recent policy statements of the last two successive Governments on Maori Development and Maori Health.
Chapter 4 gives three brief sets of guidelines which have been developed for consulting with Maori and Maori Women.
Chapter 5 describes five significant health hui which have been held over the - last decade. These hui represent a range of hui which have been held and is not intended to be an exhaustive account. The proceedings of the hui represent the views of the participants.
Chapter 6 details the findings of three significant seminal research papers on Mãori Health produced in the 1980s. A review of Mãon Health Research undertaken by the Department of Health is also summarised. The findings of three reviews addressing Maori Mental Health, Maori Hearing and Maori Asthma are also summarised.
Chapter 7 discusses the health reforms since 1991 and Maori views. A number of papers have been published and these have been summarised.
Chapter 8 describes some significant events for the period 1980-1994 which contribute to the collective published health knowledge of Maori Women.
Chapter 9 gives a description of the factors thought to influence Mãori women s health status. A brief summary of health status indicators for Maori women is also given.
Chapter 10 briefly presents a Maori women s perspective on the Treaty of Waitangi.
Introduction XI
Chapter 11 presents the findings and recommendations of several reports which have been produced on Mãon Women and Housing and Mãori Women and Smoking
Chapter 12 presents some qualitative findings on Mãori Women and Health Services,.
Chapter 13 presents the findings and recommendations of a number of significant Mãon women s hui which have been convened by the Ministry of Women s Affairs.
The material covered is far from exhaustive, but it is hoped that the major themes identified will assist in the development of polices consistent with kaupapaMãori in the context of the development of the reformed health sector.
Kotuku Partners October 1994 Introduction iii
HE Kuu WHAKAMIHI
E ngã mana, e ngã reo, e ngã karangatanga maha o te motu, tënã koutou. Tënã koutou me ö tAtou tini aituã e hingahinga mai nei i runga i ö tAtou marae. Kãti, e nga mate haere, haere, haere. Ka hold mai kite hunga ora; te pito ora tënã koutou, tënã koutou, tënã tãtou katoa.
E koa ana te ngakau o te hunga mahi ngãtahi o Kötuku kite hoatu të ripoata nei ki tëtahi wahanga o te ManatU Hauora, ãra, "Nga Mahi Oranga o Nga Tangata Tokomaha o Te Ao".
Ko tã te ripoata tuatahi nei he whakaatu i te ãhua o te oranga wãhine Mãori. Ki a mAtou nei, he tuhinga kimi möhio whaikiko tënei ma rãtou e ãrô ana ki ngã take oranga Maori. Na tënei pukapuka nei anö i whakaatu mai ngã körero-ã- waha e pa ana ki ngã wahine Mãori mai i te hainatanga o te Tiriti ö Waitangi tae noa ki tënei wa, a, i whakamarama mai te ripoata nei te ãhua o te td ö te oranga wãhine Mãon i tënei wa.
E mihi kau ana mãtou ki a Chris Cunningham mO töna kaha kite awhi mai ki ngã kairangahau o tënei ripoata. Na töna kaha, na töna aroha ki ngai tAua te iwi Mãon i whakaputa mãtou te ãhua pai mö tënei ripoata.
No reira, wãhine ma, te tãngata whenua 0 tënei motu, ãnei tO taonga hei oranga, hei whãriki mö tAtou te iwi Mãori, a, mo 0 tAtou mokopuna.
ACKNOWLEDGEMENT
Greetings to the rangatira and the iwi of Aotearoa. Greetings to those who have passed on, to our ancestors. Greetings to everyone.
Kotuku Partners are very happy to submit this report to the Population Health Services Section of the Ministry of Health. This report brings together in one document the wide variety of data pertaining to Mãori women s health. We believe that this report will prove to be an invaluable source for all people interested in Mãon women s health. This report also highlights important events in relation to Mãon women s health from the signing of the Treaty of Waitangi to the present climate which may explain the current health status of Mãori women.
We would like to thank Chris Cunningham for the support, strength and time he willingly gave to the researchers of this report and for the commitment he has to Mãori health. Tënã koe Chris.
Finally to the Maori women, the indigenous women of this country, this report is a gift to you, a mat spread for the use of Maoridom and future generations.
Kotuku Partners
Introduction ;iii
EXECUTIVE SUMMARY
This Executive Summary gathers together the main themes identified in the body of this report.
Major directions for Mãori Health Policy, Mdori Health Research, Mãori Health Services, and the State Sector are identified. The reader should, however, refer to the main text to capture the context for these directions. Introduction xiii
Al MAJOR THEMES - MAORI WOMEN & HEALTH
The striking aspect of the themes identified in this report is the clarity and consistency of the calls from Mãori and from wãhine Mãori over the last decade or so for improvement and involvement in decision-making, resourcing and servicing for Mãori in health services and the health sector generally.
In the context of the contemporary development and, perhaps, the re- establishment of Mana Wdhine, the calls for action in the health sector and the Mãori sector are a challenge to which the reformed health system must respond.
A2 MANA WAHINE
Te Mana Wãhine is the concept which symbolises and defines the status, power and authority of Maori women.
It is the vital source of Mãori women s contemporary power and it is the recommendation of wãhine Mãori that.
• Papatuanuku is nurtured and preserved, and that her resources are maintained and distributed equitably among her descendants; • Mãori women s autonomy is restored throughout society in Aotearoa and that she is granted resources to assist this process; • Mäori women be given access to participate in the management of resources of the country and the opportunity to develop their own corporate (whanau) structures to ensure the welfare of all; • decision-making processes with respect to the economic and social development of Aotearoa persues a partnership, under the Treaty of Waitangi, that promotes whanau, hãpu and iwi decision-making processes.
Introduction xiv
A3 HA UORA MA OR!
"In traditional Mãori terms, health is an all-embracing concept which emphasises the importance of the wairu.a (spiritual), whanau (family), Hinengaro (mental) and tinana (physical aspects). Modern terminology refers to this concept as "holistic" which contrasts with the traditional western model in which the physical aspects of health and sickness are emphasised. From the Mãori viewpoint issues involving te whenua (land), te reo (language), te ao turoa (environment) and whanaungatanga (extended family), are central to the Mãori culture, central to health and deeply rooted in the principles of the Treaty of Waitangi."
"Briefly, the whare tapa whã model compared health to the four walls of a house, all four being necessary to ensure strength and symmetry, though each representing a different dimension: taha wairua (the spiritual side), taha hinengaro (thoughts and feelings), taha tinana (the physical side) taha whãnau (family)."
Taha Taha Taha Taha Wairua Hinengaro Tinana Whãnau
Focus Spiritual Mental Physical Extended family
Key Aspects The capacity for The capacity to The capacity for The capacity to faith and wider communicate to physical growth belong, to care, communion think and to feel and and to share development
Themes Health is related Mind and body Good physical Individuals are to unseen and are inseparable health is part of wider unspoken necessary for social systems energies optimal development From "Whaiora", Mason Dune, 19942.
1 Hauora: Mãori Standards of Health, Em Pomare and Gail de Boer, 1988. 2Whaiora, Mãori Health Development, Mason Dune, 1994. xv
B Highlights - Mori Women s Health Status
B 1 Mãori Genera!:
• variation in definitions of "Mãori" be included in health. status and the use of these definitions markers creates problems in the collection, use and significance of Mãori • mortality: the most significant health data causes of death for Mãori are neoplasms, circulatory diseases, • "under-counting" of Mãori is respiratory diseases and accidents. known to be a significant problem • morbidity: the most significant • poor Mãori health status reflects causes of hospitalisation for Mãori poorly on the health sector, not on are pregnancy (birth, birth Mãori complications and newborns), injury and accidents, • 433,080 people belong to the New bronchitis/asthma and digestive Zealand Mãori ethnic group1 disorders.
• 511,278 New Zealanders • disproportionate conditions acknowledge descent from Mãori ranked in order include chronic rheumatic heart disease, • two thirds of Mãori live in the schizophrenia disorders, cot death, northern half of the North Island diabetes and hypertensive disease
• the age structure of Mãori in each • health risks for Mãori: the very RITA is remarkably similar young and very old make the greatest call on health services; • the Mãori population has more the risk taking lifestyles of younger and fewer older people adolescents and young adults brings a temporary but high • the Mãori population has two contact with health service; for main age groups where a distinct Mãon women the process of health status disadvantage is child-bearing and its exhibited: 0-1 (infants) and 40- consequences increases rates of 75 (middle and later working hospitalisation in the middle years and early retirement) years. • Mãori life expectancy is improving but is 4 years shorter for males and 5 years shorter for females than pãkehã
• Mãori fertility is slightly higher than replacement level
• Mãori have significantly different concepts of health which should
1 1991 Census data. xvi
B2 Mâori Women - Leading B3 Mãori Women - Leading Causes of Death Causes of Hospitalisation
death rates are higher for Mãori The following major causes of females than non-Mãori for all hospitalisation account for 63% age groups except females aged of public hospital separations in 15-24 years 1991. Separations are discharges, deaths or transfers. death rates increase with age (except for the youngest age Leading Causes group) • Pregnancy & Childbirth the smallest proportionate • Injury & Accidents difference between Mãori and • Bronchitis & Asthma non-Mãori occurs in the 65 and • Perinatal & Newborn over age group - particularly • Miscarriage/Abortions since there are many more non- • Otitis Media (Glue Ear, tamariki) Mãori in this age group than • Pneumonia & Pleurisy there are Mãori • D & C Conisation • Heart Failure & Shock the leading causes are: • Myringotomy •CORD • neoplasms • Dental • ischaemic heart disease • Uterine & Adnexa procedures • cerebrovascular disease • Skin & Breast Surgery • cord • lung cancer • other heart disease Causes Higher than non-Mäori • breast cancer • large bowel cancer • Pregnancy & childbirth • injury and poisoning • Injury & Poisoning • pneumonia and influenza • Neoplasms • Symptoms and Ill defined • CORD • Other heart disease
Causes Lower than non-Mãori
• Genital organ disease • Ischaemic heart disease • Perinatal conditions • Anthropathies
• The all-cause rate of hospitalisation in New Zealand is 41% higher for Mãori females than for non-Mãori females. xvii
B4 Mãori Women - Priority Ranking Diseases and Conditions2
Key conditions affecting Mãori women Mãori females have higher overall rates are: of death and hospitalisation relative to non-Mãori females. Ischaemic heart • heart disease: chronic disease, chronic rheumatic heart rheumatic, hypertensive and disease, lung cancer, cervical cancer, other forms of heart disease chronic obstructive respiratory disease and asthma were listed as the most • cancers: lung and cervical important health status areas in which cancer to effect reductions in incidence.
• respiratory diseases: asthma, Finally, Mãori females tend to have chronic obstructive respiratory children at a younger age than non- disease (cord), pneumonia, and Mãori females and this is reflected in acute respiratory infections the higher rates of childbirth and (infants) pregnancy complications.
• diabetes
• sudden infant death syndrome (infants)
mental health conditions: total admissions to psychiatric hospitals and institutions licensed under the Alcohol and Drug Addiction Act, schizophrenic psychoses, and alcohol and drug dependence and abuse.
2Source: Maori Health Statistics in the Auckland Region, Triggs & Coulson, Department of Health, Wellington, 1992. xviii
C Directions - Health Services
The following directions for Mãori health services have been Women s Support Services recommended by Maori; • Mãori Women s Refuge • resources for marae-based services; • encourage use of Mãori personnel in Sexual and Reproductive Health existing services by: • establishing quota for training • Sexual Health for Women of Mãori • Education for the prevention of • promoting health vocations for STDs and AIDS Mãori in schools • establishing local/regional/tribal Preventing and Treating Abuse objectives for health; • integration of tikanga and kaupapa • Sexual and child abuse Mãori as fundamental to health • Social, psychiatric and family service delivery; planning services • Family violence and abuse C Service-specific areas Facilitating Support Services Development of the following services have been recommended: • Budgeting services • Rangatahi Health Information Addictions • Transportation • Plunket Car Seat Hire • Drug, Alcohol and Solvent Abuse • Accessibility of networks, liaise, communication Screening • Access resources • Massage • Basic screening for high blood pressure, cervical smear testing, Education and promotion breast cancer, instruction in self examination for breast cancer. • Asthma education • Hearing and vision • Smokefree education • Diabetes, screening and • Diabetes management Maternity and related services Research
I! • full or part maternity care • Research into Rangatahi health • antenatal classes • Mental Health Research • post-natal support • general medical care (particularly Mental health for maternity related services) • Parenting and Baby care • Long term Mãori Mental Health • Family relationships Services Other Health Services Health Service Development • Dental Care • Establishing Health Clinics. • Nutrition XIX
C2 Improvements to the System
If women are not well and healthy, Programmes are not provided then the whanau, hãpu and iwi can be for long enough for us to see affected. any constructive changes in our peoples attitudes and behaviour • Make Mãori women s health a patterns - a change needs to priority - when we look at the occur in the development and health of our women, we look long term planning strategies at the whole whãnau. for Mãori health. This should not restrict planning to short • look at increasing the number term, gap-filling methods only of Mãon Pan Tribal Groups who are providing health • Select health programmes that services to Mãori. are appropriate to our communities needs. • make available more money to employ Mãon to work in health • Restructure a lot of services to programmes. cater for the young Mãori population • give other than money resources, such as in peoples • The economy and position in it time and skills, providing for many Mãori whanau is equipment and materials when going to put many of our necessary. women and their whanau at risk especially their health • Many systems within government agencies have been • Increase and improve the set up for iwi development not provision of services in rural necessarily for Pan Tribal or areas Mãori development - both are vehicles providing for Mãori • Give Mãori the autonomy to development. decide what our heath priorities are without being told what Employ Mãori to train Mãori to others think is appropriate to work in the areas of Cervical our needs. Cancer, Breast Cancer, Smoking, Blood Pressures, • CRIEs, RHAs and PHC should Diabetes to train them to be publish a statement of intent mobile. enable Mäori organisations to negotiate possible contracting More Mãori Health Workers on opportunities. these programmes • need to empower our women to empower our people. xx
D Directions - Policy D 1 General recommendations: The following directions for Mäori The Directions for Mãori Health Policy health have been recommended; can be generally summarised under the following headings: • Treaty of Waitangi That there be: Treaty of Waitangi Participation • acknowledgement that many Cultural Acceptability Mãori believe health to be a Resources taonga Information • acknowledgement of the status Mãori Development of Mãon as tangata whenua • acknowledgement that the colonist patrician view D2 Aims for Mãori Health prevented more women from Policy signing the Treaty of Waitangi as a sign of the mana wahine • To promote an holistic view of held at the time health encompassing the interrelated physical, mental • Participation and spiritual aspects of being. That there be: . • To foster a renewed Mãori policies put in place that: pride in good health with • are developed by Mãori for Mãori tamarild and rangata Iii as the most important target groups. • are based on consultation and good information • raise the status of Te Reo To strengthen the whanau as a and Tikanga Mãon poutokomanawa of Mãon health. • ensure access on an equal basis • To attain parity with European • promote the unique qualities New Zealanders in life and talents of Mãori expectancy and incidence of • provide a support disease. mechanism for Mãori students [in training]; • To achieve proportional more Mãon women consulted representation in the health and involved in the planning professions. and provision of health services for women/children; • more Mãori women represented • To establish a Mãon Board of in decision-making processes Health which controls a share pertaining to health; of health care resources to cater for Mãori health needs. S recruitment/employment policies to enhance and maintain spiritual health; an emphasis on working with Mãori community health volunteers xxi
• formal links established programmes of schools and between Mãori communities tertiary institutions; and health services; • Mãori studies/language be • funding of Mãori health co- included as a component of ordinators; training • an emphasis on the use of • the philosophy of Te Whanau Mãori staff in hospitals in be promulgated amongst health consultative advisory capacity professionals; • better use of Maori-speaking • recognition and encouragement health professionals of a return to traditional Mãori • better use of Mãori nurses methods of preventing/treating • encouragement for the desire of diseases be enabled; kaumatua and Te Whanau to • [Government] give priority to share their expertise tribal and marae based health initiatives; • Cultural Acceptability • [Health and Mãori Affairs] That: support marae community health initiatives • taha Mãori be incorporated into • that Mãori language and culture every subject covered during be included in the training of all the three year nursing health professionals programme; • provision be made for a • Resources comprehensive and holistic That there be: health service with shared responsibility between health a review of resource allocation professionals and the mechanism so that health community; services may respond to locally • recognition that physical health defined needs will only improve with the strengthening of spiritual and • Information creative health through That: programmes which combine high levels of local innovation, • information be culturally participation and activity; appropriate, readily accessible • there be a fostering of concept and freely available; of total well-being which • [Health] to compile and corresponds to priorities of promulgate a register on Mãori Mãori communities. health initiatives; • there be acknowledgement of • [Health and Mãori Affairs] tohunga and traditional Mãori support further Mãori health healing practices; hui; • there be recognition of Mãori • attention be given to improving cultural/spiritual practices; health/sickness knowledge of • there be assistance for all health Mãori professionals in cross-cultural • attention be given to providing understanding, through: information and programmes •wananga using culturally appropriate seminars methods and modem media; • there be inclusion of Mãori • [Statistics] and health service spirituality in education providers record ethnic data better including hapu/iwi; xxii
• an information system be established to provide advice and knowledge on health initiatives • [Health] provide an estimate and analysis of expenditure from Vote:Health on Mãori
• Mãori Development
That there be policies developed which: • are in education • are in health • are in broadcasting • are on te reo • are in law/justice system • are in social welfare
That: • priority given to diseases (of Mãori) amenable to modem medical interventions • attention be given to improving access/use of health services by Mãori • a Mãori accountability structure to monitor funding from Government be established • Ministers of [Education, Mãori Affairs, Health] support Te Kohanga Reo movement • Te Kohanga Reo Trust and centres continue to promote health in its widest sense • [Education and Health] fund health education and promotion material appropriate for Te Kohanga Reo xxiii
E Directions: Rapuora, Hauora, Whaiora
The following are recommendations from 3 significant publications by Mãori on Mãori health:
El Rapuora Mãori health initiatives, particularly at a Marae, Hãpu or • that 1985-1995 be made a iwi level, be adequately decade of health with some resourced with people, measurable goals; information, skills and finance. • that Whare Rapuora be Culturally sensitive and established; relevant programmes be • that Mãori quote be established developed to target major for all health related health risk areas (smoking, occupations; alcohol, overweight, stress, • that the curricula of all health accidents, asthma, heart disease related training programmes and cancer) and to screen for contain compulsory modules on early disease (high blood taha Maori; pressure, diabetes, cervical • promote cuts in the cancer). consumption of fats, sugars and Special efforts be made to highly refined foods; improve Mãori women s health. • encourage marae committees to The National Health Statistics provide raw fruit/salads and Centre provide iwi and Hãpu fruit juices together with more health statistics as a basis for traditional food; the development of health • encourage young parents not to programmes with an Iwi or overfeed babies; Hãpu focus. • [MWWL] promote alerting Mãori to the dangers of alcohol E3 Whaiora and other drugs; • [MWWL] encourage The elimination of disparities between Smokefree initiatives; Mãori and non-Mãori through • seek the support of Churches in the Mãori health crusade; healthy socio-economic policies • promote production of health positive development education materials by Mãon; equitable distribution of resources E2 Hauora The health of future generations through It is recommended that: prevention The principles of the Treaty of promotion Waitangi be incorporated into primary health care/systems the constitutions and terms of reference of all groups and Active Mãori participation through organisations involved in health care. • a national focus for health • the Mãori health workforce • purchasers & providers • a Mãori development model XXIV
F Directions - Research
The following directions for Mãori health have been recommended;
That: • a Mãori wellness measure be developed; • [the Hui Whakaoranga] recorded an aversion to further resources being expended on scientific research on Maori; • a method of participatory developmental research with local Mãori be formulated; • an information system to provide advice and knowledge on health initiatives be established; • the next three censuses [after 1985] retain the question on smoking.
Rap uora
That: • Mãori kawa be a prime consideration in the design of any research on Maori; • the Mãori organisations be alerted when research on Mãori is being planned and then involvement invited; • a Mãori research council be established; • a complete compendium of Mãori herbal remedies and other healing practices; • all statistics and research use the definition of Mãori in the Mãori Affairs Amendment Act, 1984; • NZ Mãori Council research into Mãori men; • the Medical Research Council and ALAC facilitate the study of health and social well-being of Mãon. xxv
G Directions - Mãori and the Health Reforms
It should be noted that: • A Mãon Health Authority • To date, Mãori participation in should be given similar status to the reform process has been RHAs. limited.
• The principle of partnership is relevant to RHAs and iwi.
• There should be a clear agreed upon process for the disposal of all surplus Crown assets.
• Earlier understandings and arrangements between iwi and health authorities should be reflected in CHE policies.
• The relationship between funders and providers should be capable of facilitating iwi health development.
• Health entitlements should acknowledge health risks.
Any competitive advantages unique to RHAs should be matched with compensatory provisions for Mãori Health Care Plans.
• Guarantees beyond three years are needed for effective long term planning.
• Potential Mãon health providers will need assisted entry into the new system.
• Prevention and treatment should go hand in hand. The Public Health Commission must develop close and uncomplicated links with the funders and providers of treatment services. xxvi
H Treaty of Waitangi
• The Treaty of Waitangi is acknowledged as this country s founding document3. • the Treaty of Waitangi is a symbol which reflects Te Mana Mãori Motuhake • Te Tiriti o Waitangi, e tu moke mai ra, i waho i te moana e... • poor health of Mãori was a major factor for the establishment of a formal relationship between the Crown and Mãori • at least 5 Mãon women signed the Treaty of Waitangi • "principles" in relation to the application of the Treaty of Waitangi have been established by:
the Crown: Royal Commission • The Principle of Government The Kawanatanga Principle • The Principle of Self- identified two principles Management The particularly apposite to a Ran gatiratanga Principle discussion of health: partnership • The Principle of Equality and participation. Neither is • The Principle of Reasonable foreign to clinicians or health Cooperation administrators. • The Principle of Redress Partnership and participation • Mãori (see 10 Principles - in understanding health and New Zealand MOon Council) sickness; Partnership and participation in the development of health • the duty actively to (sic) protect to the fullest extent practicable; policy; Partnership and participation • the jurisdiction of the Waitangi health Tribunal to investigate in the delivery of omissions; services. • a relationship analogous to fiduciary duty, • the duty to consult; • the honour of the Crown; • the duty to make good past breaches; • the duty to return landfor land; • that the Mãori way of life would be protected; • that the parties would be of equal status; • where the Mãori interest in their taonga is adversely affected, that priority would be given to Mãori values.
3Path to 2010, Prime Minister, Wellington, 1994. xxvii
I Government Agencies
1IitT(f1gk.J& E.J.irh1Y1u11ITU
The purpose of the Ministry of Women s Affairs is to provide the The Ministry of Health is the Government with advice and Government s chief policy advisor on information on policy issues impacting health. It is also responsible for on women4. funding the purchasers of health services, and monitoring how they perform. TO Ohu Whakatupu
Te Ohu Whakatupu was established to help look after Mãori women s needs and generate resourcefulness and creativity based on our origins as women and Mãori. The PHC s functions are:
Government Outcomes for • to monitor the state of the Women5 public health and to identify public health needs; The Government seeks to make • to advise the Minister of Health on progress towards the following matters related to public health. outcomes for women, and especially This includes personal health for Mãori women as tangata whenua: maters, and regulatory matters, relating to public health; • opportunity and choice in all • to purchase, or arrange for the aspects of their lives; purchase, of public health services. • fulfilment of their aims and aspirations Whãia te ora mö te Iwi - Strive • full and active participation in for the good health of the society people6 • adequate resources of their own. This document established the following directions for Mãori health:
• greater participation of Mãori at all levels of the health sector; • resource allocation priorities which take account of Mäori health needs and perspectives; • the development of culturally appropriate practices and procedures, as integral requirements in the purchase and provision of health services. 4Corporate Plan 1993-94, Ministry of Women s Affairs, Wellington. 5Corporate Plan 1993-94, Ministry of 6Whaia te ora mo te iwi, Department of Women s Affairs, Wellington. Health, 1992. xxviii
Government Outcomes for HealTh7
Each year in the Estimates, the Government describes the outcomes which it is seeking for health. The following outcomes for health have been sought by the Government in recent years. They apply to both public health services purchased by the PHC and personal health services purchased by RHAs.
• All New Zealanders have • The public is protected from access to an acceptable range, malpractice and unsafe products level and quality of health and or processes disability services • Government departments and • Improvements are achieved in Crown agencies have adequate Mãori health status so that in information to allow them to the future Mãori will have the meet their obligations as health opportunity to enjoy the same and disability services policy level of health as non-Mãori advisers and monitors of the sector • Individuals and families are encouraged to take care of and • There is an adequate database improve their health and well- to support research and analysis being concerning the health and disability services system • Government assistance for the purchase of health and • There is appropriate investment disability services is directed to in the future health and well those who are least able to being of the population through make provision for themselves public health measures: health promotion, health protection • People with disabilities can and disease prevention. gain access on fairer terms to services which offer improved support
• Health service structures, regulations and funding mechanisms are in place which encourage the efficient provision of health and disability services responsive to the preferences of users
7Policy Guidelines for Mäori Health 1994/95, Minister of Health, Wellington, 1994. xxix
Government Outcomes for Mâori Development: Mãori Health9
The Ministry of Mãori Development The Ministry has a Health Portfolio has as its purpose: which gives policy advice to the Minister of Health which has the "to assist in developing an environment following outcomes: of opportunity and choice for tangata whenua, consistent with the Treaty of • Increased effectiveness of Waitangi " health institutions in designing, targeting and delivering appropriate health services to Mãori. • Increased effectiveness of access to an acceptable range of health services by Mãori. • Raised health profile of Mãori to that of the Tauiwi population in New Zealand. • An environment that is sympathetic to increased participation by Mãori in health services and that does not compromise Mãori cultural integrity. I
8Corporate Plan, Te Puni Kökiri, Wellington, 1992. 9Corporate Plan 1993-1994, Te Puni Kokiri, Wellington. xxx
J Recent Mori Affairs Policy Statements
F1t1IJ1 II.I1J.Ilr!jj.1IM,
honour the principles of the to actively participate, on Treaty of Waitangi through jointly agreed terms, in such exercising its powers of policy formulation and service government reasonably, and in delivery good faith, so as to actively encourage Mãori participation protect the Mãori interests in the political process. specified in the Treaty . eliminate the gaps which exist between the educational, personal, social, economic and cultural well-being of Mãori ron. people and that of the general PA. population, that disadvantage Mãori people, and that do not The document identifies two over- result from individual or riding goals: cultural preferences
. provide opportunities for Mãori • maintaining our current strong people to develop economic economic growth activities as a sound base for • building strong communities realising their aspirations, and and a cohesive society. in order to promote self- sufficiency and eliminate • Mãori Development attitudes of dependency • Settling Treaty claims S deal fairly, justly and • Tackling Mimi disadvantage expeditiously with breaches of • Health Care the Treaty of Waitangi and the grievances between the Crown Important priorities include: and Mãon people which arise • mental health out of them • child health S provide for the Mãori language • Mãori health and culture to receive an • a healthy physical environment equitable allocation of resources and a fair opportunity to develop, having regard to the contribution being made by Mãori language and culture toward the development of a unique New Zealand identity S promote decision making in the machinery of government, in areas of importance to Mãon communities, which provide opportunities for Mãori people
10Te Urupare Rangapu, Hon. K T Wetere, 11Towards 2010: The Next 3 Years, Prime 1988. Minister, Wellington, 1994. Introduction
I Chapter 1 - Overview 1
PART I
CHAPTER 1
OVERVIEW
This Chapter provides an Overview to the Report and includes some background information.
The methodology, range of reports/hui analysed I and a brief chronology of health among Mdori and Pdkehd is given. Chapter 1 - Overview
1.1 Methodology
This report provides the results of a survey of the last 15 years of hui, conferences and significant reports on Hauora Mãori: Mãori Health. This report has been produced for the Population Health Services Section of the Ministry of Health. This report, which concentrates specifically on Mãori women, has been compiled to assist the Ministerial Advisory Committee on Women s Health (MACWH) which has identified Mãori Women s Health as a priority for the committee for 1994.
A consultant was engaged to review a series of Mãori health publications, reports of hui and proceedings of conferences, and to extract themes and recommendations from the sources examined. This report summarises those main trends from a Mãori viewpoint and in relation to the Mãori view of health. The extracts from the health publications, reports of hui and proceedings of conferences are also presented.
The goal of any historical sketch is to understand the events which have occurred in order to gain an insight into the underlying thinking, philosophy, politics and directions prevalent among Mãori over this time. This report seeks to identify major events and happenings which influence both Mãori health and the health sector. This report also specifically seeks to identify what Mãori have said, sometimes repeatedly, over the recent past.
One must acknowledge the importance of all hui to the well-being of Mãori. As Sam Rolleston states in "He Kohikohinga: A Mãori Health Knowledge Base"1:
Another important source of information and contact was regular attendance at the many hui that are part of the normal calendar in the Mdori year - tangihanga, weddings, unveilings, learning wananga, reunions, committee meetings and other events. These gatherings, although not held specifically for health topics, were very important in observing those things that Mãori people do to maintain and strengthen their Mãoriness ".
1Te Kohikohinga, A Mãori Health Knowledge Base, Sam Rolleston, Department of Health, 1988.
Chapter 1- Overview 3
1.2 Reports Analysed
• Te Kohikohinga, A Mãori Health Knowledge Base, Sam Rolleston, Department of Health, 1988. • Hauora: Maori Standards of Health, Eru Pomare and Gail de Boer, 1988. • The Treaty of Waitangi and Social Policy, Royal Commission on Social Policy, Wellington. • Path to 2010, Prime Minister, Wellington, 1994. • The Treaty of Waitangi and Health Care, M H Dune, NZ Med Journal, 1989, 102: 283-285. • Circular Memorandum No. 1988/79/61/24, Department of Health, Wellington. • Corporate Plan 1993-94, Ministry of Women s Affairs, Wellington. • Putea Pounamu, Ministry of Women s Affairs, 1989. • Corporate Plan, Ministry of Health, Wellington, 1993. • Whaia te ora mo te iwi, Department of Health, 1992. • Policy Guidelines for Maori Health 1994/95, Minister of Health, Wellington, 1994. • Corporate Plan, Te Puni Kökiri, Wellington, 1992. • Corporate Plan 1993-1994, Te Puni Kokiri, Wellington. • Te Urupare Rangapfl, Hon. K T Wetere, 1988. • Ka Awatea, Report of the Ministerial Planning Group, Wellington, March, 1991. • Checklist - How to Analyse Policies and Programmes to Ensure That They Meet Women s Needs, Ministry of Women s Affairs. • Consultation Guidelines, Public Health Commission, Wellington, 1994. • A Guide for Departments on Consultaion with Iwi, Te Puni Kokiri, Wellington, 1993. • Hui Whakaoranga, Maori Health Planning Workshop, Department of Health, 1984. • Hui Taumata, Maori Economic Devlopment Conference - He Kawanata, Wellington, 1984. • Nursing Education and Services, Proceedings of Gisborne Hui, National Council of Maori Nurses, 1987. • Cultural Considerations in Health, Advisory Committee on the Medical Workforce, Proceedings of the Rotoiti Hui, 1989. • Te Ara Ahu Whakamua Draft Action Plan, Te Puni Kokiri, Wellington, May 1994. • Te Ara Ahu Whakamua Analysis, A Comparative Analysis of Maori and Government Priorities for Health Services for Maori, Kotuku Partners, May 1994. • Rapuora, Mãori Women s Welfare League, 1984. • Women s Health, Review of Statistics, Bunnell, 1987. • Maori Health, Review of Statistics and Research, Pomare and de Boer, 1988. • General Health, Collection of Statistics and Research, NHSC, 1989. • Child Health Statistics, Review of Statistics and Research, de Boer et al., 1990. • Child Health - Plunket, Survey in South Auckland and use of Census and NHSC Data, Barnett, 1990.
Chapter 1- Overview 4
• Community Health, Survey of 439 Households in Porirua, Reinken et al., 1980. • Community Health, Literature Review, de Lacey, 1984. • Primary Health Care, Survey of Workload of 6 Public Health Nurses in Northland, Flight, 1984. • Psychiatric Hospital Services, Ethnography of 6 Hospitals, Dowland and McKinlay, 1985. • Primary Health Care Initiatives - Women s Health, Multiple Qualitative and Quantitative Methods, Norris etal., 1989. • Primary Health Care Initiatives, Multiple Qualitative and Quantitative Methods, McGrath, 1989. • Health Workforce, Multiple Qualitative and Quantitative Methods, Scotney, 1989. • AIDS, Interview Survey of 310 Intravenous Drug Users, Lungley, 1988. • AIDS, National Survey of 1000 People, Kilgour et al., 1990. • AIDS, Interview with 423 Intravenous Drug Users, Postal Survey of Pharmacies participating in the Needle Exchange Scheme, Lungley and Baker, 1990. • Preventative Health Care, Literature Review, Hodges, 1990. • Women s Health, Survey of 1390 Women in Manawatu, Trim and Perry, 1981. • Women s Health, Review of Statistics, Bunnell, 1987. • Women s Health, Bibliography, Wing and Curry, 1988. • Women s/Child Health - Preventing Low Birthweight, Literature Review, Morrell, 1990. • Child Health Statistics, Review of Statistics and Research, de Boer et al., 1990. • Child Health - Plunket, Survey in South Auckland and use of Census and NHSC Data, Barnett, 1990. • Adolescent Health - Smoking, National Survey of 2302 Students and Classroom Discussions, McClellan, 1987. • Maori, Health and the State, M.H. Durie, Annual Conference of the Public Health Association, 1992. • "The Treaty of Waitangi and Health Care"; NZ Med.J 102:283-285. • Maori Development, Maori Health and the Health Reforms, M.H. Dune, Hui Hauora a Iwi, Takapuwahia Marae, April 1992. • Submission on the Definition of Core Health Services, Te Roopu Maori Takawaenga Tohutohu kite Minits Hauora, January 1992. • Up from under, Women and liberation in New Zealand, 1970-1985, Christine Dann, 1985. • Women in NZ • Whaia Te Iti Kahurangi - Maori Women Reclaiming Autonomy, Vapi Kupenga, Rina Rata, Tuki Nepe & Alison Robins, November 1988. • Prognosis for the Socio-Economic Future of Maoridom, Submission to the Royal Commission on Social Policy, Marsden, Rev M, 1987. • Maori Women and Social Policy, The Royal Commission on Social Policy. • Final Submission to the Royal Commission on Social Policy, Department of Health. • Economic and Organisational Factors In Achieving A Better Health Future For Maori Women, Laurence Malcolm et al., Paper prepared for the Ministry of Women s Affairs, June 1991.
Chapter 1- Overview 5
• Maori Womens Health Statistics 1986-1991, Hineringa Trust, A report for Population Health Services, 1993. • Source: Maori Health Statistics in the Auckland Region, Triggs & Coulson, Department of Health, Wellington, 1992. • The Treaty of Waitangi, Claudia Orange, p 90,91; 1987. • Kia Manawanui, Nga Wãhine Maori me te Kai Paipa, John Broughton & Mark Lawrence, University of Otago, 1993. • Te-Taonga-Mai-Tawhiti, Te Rahori Trust, Paparangi Reid & Robert Pouwhare, 1991. • Policy Discussion Paper 2: Women & Smoking, Ministry of Women s Affairs, Wellington, May 1990. • For The Sake of Decent Shelter, Mãori Women s Housing Research Project, 1991. • Maori Women s Health Service, Hmennga Trust, 1993. • Women s use of health services in New Zealand, Department of Health, Penny Brader, Justine McFarlane, Judy Paulin & Tere Scotney, 1992. Background Papers on Cervical Screening and Mammography, Charlotte • Paul & Ann Richardson, Hui Whakamarama: A Consensus Hui for Screening for Maori, 1992. • Government policy for national cervical screening, National Cervical Screening Unit, Department of Health, 1991. • Whakatupu, Management Training Programme, Auckland Area Health Board, Sam Rolleston, November 1991. • Runanga Kuia, Takapuwahia Marae, Porirua, March 1987, Ministry of Women s Affairs, 1988. • Runanga Kuia, Takapuwahia Marae, Ministry of Women s Affairs, 1991. • Putea Pounamu, Ministry of Women s Affairs, Wellington, 1989 • The Prevention of Early Death, Ministry of Women s Affairs, Wellington, 1990. • Parenting Programmes, L Middleton, D Fuli et al., Department of Health,
Wellington, 1993.
I
Chapter 1- Overview 6
A BRIEF CHRONOLOGY OF HEALTH AMONG MAORI AND PAKEHA2
This section gives a brief chronology of Maori Health from Pre-Eurpoean times to the 1970s.
"In traditional Mãori terms, health is an all-embracing concept which emphasises the importance of the wairua (spiritual), whanau (family), Hinengaro (mental) and tinana (physical aspects). Modern terminology refers to this concept as "holistic" which contrasts with the traditional western model in which the physical aspects of health and sickness are emphasised. From the MJori viewpoint issues involving te whenua (land), te reo (language), te ao turoa (environment) and whanaungatanga (extended family) , are central to the MJori culture, central to health and deeply rooted in the principles of the Treaty of Waitangi. "3
Pre- Mãori were described by early European observers as "strong raw European boned well made active people rather above than under the common Times size especialy (sic) the men".4
There was no reason to believe that the Mãori population was declining before European contact. Apparently, few common epidemic diseases were indigenous, sanitation was carefully controlled, the population was isolated and, although there were villages, there were no really dense congregations. It is possible to think of a consistent growth of 0.5% to 1% per annum from. .around 1350 until about 1800 and thus account for the distribution of the population reported in the early 19th century.
2Waitangi Consultancy Group Hauora: Maori Standards of Health, Eru Pomare and Gail de Boer, 1988. 4The Oxford History of New Zealand, W.H. Oliver, et at., 1987. 5The Maori Population of New Zealand, 1769-1971, D.I. Pool, 1977. Chapter 1- Overview
1769-1840 New diseases introduced with Europeans included measles, dysentery, sexually transmitted diseases, tuberculosis, influenza, and whooping cough.
1830s Measles epidemic among Ngai Tahu.
1840 Treaty of Waitangi signed. At the same time first New Zealand Company settlers reached Wellington.
1841 Civil Servants were designated as Colonial Surgeons or Health Officers - appointed to meet the needs of "the imprisoned, the insane, the impoverished and the indigent". 6 The wealthy were cared for at home.
1840s Colonial hospitals established in Auckland, Wellington, Wanganui and New Plymouth - Mãori were treated free, although this was opposed by the settlers.
1846 Lunatics Ordinance set up asylums - psychiatric services are the only hospital services that have consistently been provided for all classes of pãkehã society.
1846 Some evidence of major whooping cough epidemic among Mãori.
1850 Influenza pandemic among Mãori population.
1852 New Zealand was divided into six provinces under the NZ Constitution Act. The Provincial Councils were made responsible for schools, hospitals and charitable aid. Colonial hospitals were transferred to provincial governments and voluntary contributions were encouraged. This gave donors a say in hospital administration.
6A Health Service for New Zealand, AJT4R, H-23, 1974. Chapter 1- Overview
1853 The Crown negotiated with Ngai Tahu for the sale of the Murihiku Block. The chiefs were promised that schools and hospitals would be set up as part of the deal. But schools and hospitals were a provincial responsibility and, since Mãori were not usually ratepayers, the provincial governments refused to take responsibility for these Crown promises unless they got extra money for it. This did not happen - and neither did the schools or hospitals.
1860s Land Wars led to confiscation of Mãori land. Legislation was then brought in to facilitate the acquisition of Mãori land for the settlers. Liquor was used extensively to encourage Mãori to go into debt and then mortgage their land.
As land was alienated from the iwi, so health and population of the iwi worsened. In the 1860s and 70s Ngati Kahungunu and Nga Puhi lost much of their land and suffered a decline in population - this began to reverse by the 1880s and 90s. Tuhoe registered a drop in population in the 1890s as their land was alienated - this was the last big iwi to be broken from their land. Those areas which shunned contact with the pakeha fared better: "The difference between the Kingites and the Maoris that Europeans are accustomed to see is very marked. The men and women are healthy looking, while the number of children playing about, and of fine stout infants to be seen in the arms of their mothers, is remarkable. It is sad to think that those natives who have least to do with Europeans are in every respect the best of their race; but so it j5•117
1875 Measles epidemic among North Island iwi.
1880s Mãori prophetic movements - Te Whiti, Tawhiao, Rua Kenana all discouraged contacts with pãkehã and were particularly against any further land sales. They all condemned and prohibited the use of alcohol among their followers.
1876 Lunatic Asylums Department created - first social service department in New Zealand.
7cit Land Purchase Methods, M.P.K. Sorenson, p 195: New Zealand Herald, 9 May 1878. Chapter 1- Overview 9
1883 Dr Alfred Newman maintained that New Zealand was the healthiest country in the world. His statistical evidence failed to take into account the poor levels of health of Maori, which is not altogether surprising, since he had argued two years earlier for the demise of the entire race: "the disappearance of the race is scarcely a subject for much regret. They are dying out in a quick, easy way, and are being supplanted by a superior race.8
In the latter part of the 19th century, life expectation for the non- Maori population was considerably higher than for either their Mãori or English counterparts [eg in 1876 non-Mãori life expectancy was 53.1; in 1881 English life expectancy was 45.9 and in 1891 Mãori life expectancy was 24.9 years].
1885 Hospital and Charitable Institutions Act - brought hospital management under the aegis of local committees. Proportion of expenditure met by government.
1890s "[Mãori] living conditions were appalling. Most of them lived in makeshift camps, without sanitation. They were afflicted by a host of infectious diseases and there was a very high rate of infant mortality. Traditional remedies were of no use for treating European diseases which were frequently fatal. Mãori received little medical aid other than periodic inoculations and handouts of medicines. They were seldom treated by doctors, let alone admitted to hospitals. For the most part they had to fend for themselves."9
At the same time there was still pressure from the Liberal Government to obtain more Mãori land.
1. 891 Influenza pandemic.
1896 Mãon population fell to 42,113 - lowest point in 19th and 20th century.
1898 Old Age Pension Act - provided for pensions for deserving persons . Mãori seldom qualified for a pension, because of their shares in their ancestral land - even though they received no income from the land.
8A Study of the Causes leading to the Extinction of the Maori, A.K. Newman, Transactions & Proceedings of the New Zealand Institute, 14, 59-77. 9The Revival of a dying race: a study of Maori health reform 1900-1918 and its nineteenth century background, R.T. Lange, MA Thesis, Auckland, 1972.
Chapter 1- Overview 10
Around the turn of the century, the philosophical struggle on the provision of pãkehã health services began to turn around. Throughout the 19th century, hospitals had operated within the framework of English Poor Law philosophy - providing a safety net for those who lacked means to fend for themselves. The poor were divided into deserving and undeserving and services reflected these categories. Supporters of the status quo argued that the hospitals should be provided through local charity and controlled by the donors - any change to the system would jeopardise the ability of the wealthy to show Christian concern and would make the poor lazy. Others believed that health care should be nationally provided and available to all. As early as 1882, Sir Harry Atkinson had proposed a national insurance scheme to replace private saving by national co-operative and compulsory insurance. Gradually the latter view began to predominate and the social stigma of attending a hospital began to disappear.
1900 Bubonic plague scare. This led to the establishment of the Department of Public Health and laid down much of the public health structure which persists today.
At the same time the Maori Councils Act was brought in which set up district councils in 19 tribal districts to improve sanitation and living conditions through local committees and local Maori sanitary inspectors. The councils powers were similar to local government authorities.
Apirana Ngata was the Organising Secretary from 1902-04. Maui Pomare became the first Maori Medical Health Officer and from 1905 he was assisted by Peter Buck. They worked to improve health conditions, including housing, sanitation and access to medical and nursing care.
"These Maori medical practitioners had devised programmes which would fit the criteria for primary health care delivery as outlined by the Alma Ata Declaration of the WHO in 1978, three quarters of a century later. Their measures were at times somewhat extreme, but perhaps they alone amongst the group who have delivered health care to the Mãoris in major programmes throughout this century recognised the overwhelming importance of cultural values and norms, and their impact both on the giving and on the reception of health care delivery."0
These men became the leaders of the Young Maori Party and all of them went on to become members of Parliament.
101s New Zealand a Healthy Country?, D.I. Pool, New Zealand Population Review, July 1982. Chapter 1 - Overview 11
1900s Health continued to be a major concern. In the first decades of the twentieth century, Mãori health improved, but tuberculosis, typhoid fever, dysentery, diarrheal and respiratory diseases persisted.
At the same time Grace Neil was lobbying for better health services for women and children. She established St Helen s hospitals for the training of midwives and maternity facilities for the wives of men of small means . They have catered predominantly for the pãkehã population.
1907 Tohunga Suppression Act - passed on grounds of concern for health of Mãori, but had the convenient political effect of hounding Mãori prophetic leaders, especially Rua Kenana.
1907 Plunket Society formed. It has catered mainly for pãkehã mothers and children.
1909 Hospital and Charitable Institutions Act - brought hospitals under the supervisory control of the Department of Public Health.
Mãori Nursing Service established - initially pãkehã nurses, but increasingly Mãon nurses trained to work with Mãon communities. Went into rural areas - work ranged from health education and maternal and child welfare to care for those dying of infectious diseases. In 1930 the Mãori Nursing Service came under the Public Health Nurse Service.
1913 Smallpox scare - may have been a virulent form of chicken pox: Ca. 2000 Mãori affected - 55 died; Ca. 100 pãkehã affected - none died. Dr Makgill, Auckland Health Officer was given carte blanche to control the epidemic - all Mãori gatherings were forbidden, meetings of the Native Land Court were suspended and travel by Mãori was first forbidden, then only allowed if a certificate of vaccination could be produced. (Dr Makgill also advocated that Mãori should be put in reservations under supervision).
1916 55 policeman marched into Maungapohatu in the Urewera ranges to arrest Rua Kenana for sedition and on 4 breaches of the licensing laws - he was found guilty of offences under the liquor laws and sent to jail. The trial broke his followers financially and they had to sell land cheaply to meet legal costs. Chapter 1 - Overview 12
1918 Influenza pandemic - caused crude death rate of 22.6 per 1000 for Mãori against 4.5 for non-Mãori. This is the only epidemic that is remembered by most pãkehã people in New Zealand, probably because it affected the pãkehã population also.
1930s Economic depression caused widespread unemployment. Maori males did not usually qualify of unemployment relief, unless they were living in the same manner as Europeans . It was also considered that Maori could grow their own food and therefore needed smaller benefits.
1935 Native Housing Act - provided housing finance for Mã()ri for the first time. Thus the connection between poor housing and ill-health among Maori was finally acted upon. The scheme was resumed after World War II with more emphasis on urban houses.
1938 Social Security Act - was intended to provide free health care for all. The Labour Government was forced to compromise because of opposition from the New Zealand branch of the British Medical Association which campaigned against the Bill. This led to the establishment of a dual public/private system which still operates today.
One effect of the Social Security Act was that, for the first time, Maori people began to receive the same health benefits as pãkehã. The increase in de facto eligibility is shown in the following figures:
1931 1534 Maori received old age pensions 1939 3096 Maori received old age pensions
193 1-5 335 Mäon widows received pensions 1935-9 569 Maori widows received pensions
Similar increases were recorded in the number of Mãori receiving family allowance and invalid pensions.
It is an irony that, although the Labour Government s introduction of social security improved the health and living conditions of Mãori people, it did so for individuals, but at the expense of Mãori tribal organisation. Chapter 1 - Overview 13
By 1951 Shacks and overcrowded houses had been reduced from 71% to 32% of Maori housing. But again, the official policy was to "pepper pot" Mãori families among pãkehã families, in order to assist in the process of integration . This further undermined social and cultural cohesion among Maori people in the cities.
Many aspects of physical health, however, continued to improve among Maori population. Tuberculosis death rates dropped from 37 per 1000 in 1841-5 to 10.06 in 1951-5. The incidence of typhoid dropped from 14.2 per 1000 in 1932 to 2.6 in 1948.
1950s Mãori people encouraged to migrate to the cities. Rapid change from being a rural based population to an urban base. In 1936 only 10% of Mãori population was urban; by 1961 this had increased to 40% (80.7% in 1986)
1950-52 Mãon life expectancy reached the same level as the non-Mãori population had reached in the 1880s (55 years).
1955-74 Mãori health indicators improved - deaths due to diseases which might be attributed to habits of modem living (smoking, alcohol and over-eating) were on the increase.
Chapter 1- Overview 14
1970s- Most physical health indicators continued to improve for both Mãori and non-Mãori, but the disparity between the two groups was still a problem. Mãori death rates from rheumatic and hypertensive heart disease were 4-5 times higher than non-Mãori rates, yet both are highly preventable and treatable. This suggests that Mãori people may be unaware of preventive measures or else access to appropriate medical care is deficient. 1
Also of concern was the excessive number of coronary deaths in Mãori females, particularly in the younger group aged 25-44 years. Mãori women have a higher mortality from this disease than women in all other countries. Yet coronary heart disease did not feature in the top five major causes of admissions for females in the 25-44 age year group or the 45-64 year group. This would suggest that Mãori females are receiving different health care than their non-Mãori counterparts.12
Mãon youth aged 15-24 years have a mortality rate of rheumatic heart disease 10 times that of their pãkehã counterparts. Acute rheumatic fever and rheumatic heart disease have been virtually abolished in all but third world countries, probably due mainly to improving living conditions and health care. The continued high incidence of acute rheumatic fever in Mãori is a serious comment on both New Zealand society and the health care system.
1tHauora: Maori Standards of Health, E.W. Pomare and G de Boer, Department of Health, 1988. 12Prevention of Cardiovascular Disease, Advisory Committee to Minister of Health, 1986, p8.
Chapter 2- Treaty of Waitangi 15
CHAPTER Two
THE TREATY OF WAITANGI
This Chapter presents the English and Mdori versions of the Treaty of Waitangi.
The various attempts to seek recognition for the Treaty of Waitangi are listed.
The "Principles" of the Treaty have been identified by representatives of both parties and some of these are identified.
The Treaty in relation to Health Care is also discussed.
Chapter 2- Treaty of Waitangi 16
ENGLISH VERSION OF THE TREATY OF WAITANGI
The Treaty
HER MAJESTY VICTORIA Queen of the United Kingdom of Great Britain and Ireland regarding with Her Royal Favour the Native Chiefs and Tribes of New Zealand and anxious to protect their just Rights and Property and to secure them to the enjoyment of Peace and Good Order has deemed it necessary in consequence of the great number of Her Majesty s Subjects who have already settled in New Zealand and the rapid extension of Emigration both from Europe and Australia which is still in progress to constitute and appoint a functionary properly authorised to treat with the Aborigines of New Zealand for the recog- nition of Her Majesty s Sovereign authority over the whole or any part of those islands - Her Majesty therefore being desirous to establish a settled form of Civil Government with a view to avert the evil consequences which must result from the absence of the necessary Laws and Institutions alike to the native population and to Her subjects has been graciously pleased to empower and to authorise me William Hobson a Captain in Her Majesty s Royal Navy Consul and Lieutenant Govenor of such parts of New Zealand as may be or hereafter shall be ceded to her Majesty to invite the confederated and independent Chiefs of New Zealand to concur in the following Articles and Conditions.
Article the First The Chiefs of the Confederation of the United Tribes of New Zealand and the separate and independent Chiefs who have not become members of the Confederation cede to Her Majesty the Queen of England absolutely and without reservation all the rights and powers of Sovereignty which the said Confederation of Individual Chiefs respectively exercise or possess, or may be supposed to exercise or to possess over their respective Territories as the sole Sovereigns thereof. Article the Second Her Majesty the Queen of England confirms and guarantess to the Chiefs and Tribes of New Zealand and to the respective families and individuals thereof the full exclusive and undisturbed possession of their Lands and Estates Forests Fisheries and other properties which they may collectively or individually possess so long as it is their wish and desire to retain the same in their possession; but the Chiefs of the United Tribes and the individual Chiefs yield to Her Majesty the exclusive right of Preemption over such lands as the proprietors thereof may be disposed to alienate at such prices as may be agreed upon between the respective Proprietors and persons appointed by Her Majesty to treat with them in that behalf.
Article the Third In consideration thereof Her Majesty the Queen of England extends to the Natives of New Zealand Her royal protection and imparts to them all the Rights and Privileges of British Subjects. W HOB SON Lieutenant Governor. Now therefore We the Chiefs of the Confederation of the United Tribes of New Zealand being assembled in Congress at Victoria in Waitangi and We the Separate and Independent Chiefs of New Zealand claiming authority over the Tribes and Territories which are specified after our respective names, having been made fully to understand the Provisions of the foregoing Treaty, accept and enter into the same in the full spirit and meaning thereof: in witness of which we have attached our signatures or marks at the places and dates re- spectively specified. Done at Waitangi this sixth day of February in the year of Our Lord One thousand eight hundred and forty.
Treaty of Waitangi Act 1975, First Schedule Chapter 2 - Treaty of Waitangi 17
MAORI VERSION OF THE TREATY OF WAITANGI
Te Tiriti
KO WIKITORIA, te Kuini o Ingarani, i tana mahara atawai ki nga Rangatira me nga HApu o Nu Tirani i tana hiahia hoki kia tohungia ki a ratou o ratou rangatiratanga, me to ratou wenua, a kia mau tonu hoki te Rongo ki a ratou me te Atanoho hoki kua wakaaro ia he mea tika Ida tukua mai tetahi Rangatira hei kai wakarite ki nga Tangata Mâori o Nu Tirani-kia wakaaetia e nga Rangatira Mäori te Kawanatanga o te Kuini ki nga wahikatoa o te Wenua nei me nga Motu-na te mea hoki he tokomaha ke nga tângata o tona Iwi Kua noho ki tenei wenua, a e haere mai nei. Na ko te Kuini e hiahia ana kia wakaritea te Kawanatanga kia kaua ai nga kino e puta mai ki te tangataMaori ki te pkeha e noho ture kore ana. Na, kua pai te Kuini Ida tukua a hau a Wiremu Hopihona he Kapitana i te Roiara Nawi hei Kawana mo nga wahi katoa o Nu Tirani e tukua aianei, amua atu kite Kuini e mea atu ana ia ki nga Rangatira o te wakaminenga o nga hãpu o Nu Tirani me era Rangatira atu enei ture ka korerotia nei. Ko te Tuatahi
Ko nga Rangatira o te Wakaminenga me nga Rangatira katoa hoki ki hai i urn ki taua wakaminenga ka tuku rawa atu kite Kuini o Ingarani ake tonu atu-te Kawanatanga katoa 0 0 ratou wenua. Ko te Tuarua
Ko te Kuini o Ingarani ka wakarite ka wakaae ki nga Rangatira ki nga bApu-ki nga tângata katoa o Nu Tirani te tino rangatiratanga o o ratou wenua o ratou kainga me o ratou taonga katoa. Otiia ko nga Rangatira o te Wakaminenga me nga Rangatira katoa atu ka tuku kite Kuini te hokonga o era wahi wenua e pai ai te tangata nona te Wenua-ki te ntenga o te utu e wakaritea ai e ratou ko te kaj hoko e meatia nei e te Kuini hei kai hoko mona. Ko te Tuatoru
Hei wakaritenga mai hoki tenei mo te wakaaetanga kite Kawanatanga o te Kuini-Ka tiakina e te Kuini o Ingarani nga tangata Maori katoa o Nu Tirani ka tukua ki a ratou nga tikanga katoa rite tahi ki ana mea ki nga tângata o Ingarani. (signed) WILLIAM HOBSON Consul and Lieutenant-Govemor Na ko matou ko nga Rangatira o te Wakaminenga o nga hapu o Nu Tirani ka huihui nei ki Waitangi ko matou hold ko ugaRangatira o Nu Tirani ka kite net i te ritenga o enei kupu, ka tangohia ka wakaaetia katoatia e matou, koia ka tohungia ai o matou ingoa o matou tohu. Ka meatia tenei ki Waitangi i te ono o nga ra o P.epueri i te tau kotahi mano, e warn rau e wa te kau o to tatou Ariki. Ko nga Rangatira o te wakaminenga. I Treaty of Waitangi Amendment 1985, Schedule. /
Chapter 2 - Treaty of Waitangi 18
2.1 Recognition of the Treaty of Waitangi13
The standing of the Treaty in statutes and history books of New Zealand remains a matter of dispute. Mãori attempts to invoke the Treaty have often had negative results, up until very recent times when some change in official attitude has been discernable.
The inclusion of the principles of the Treaty in the Terms of Reference of the Royal Commission on Social Policy, for example, is indicative of a new understanding and approach where Mãori rights and Crown responsibility are concerned.
A chronology of events summarises some of the effort to have the Treaty s status determined.
1882 Deputation of Ngapuhi chiefs under Parore petition the Queen over grievances under the Treaty. Access denied.
1877 Wi Parata v The Bishop of Wellington: The Treaty of Waitangi, without the passage of subsequent legislation, is not able to confer particular Mãori (land) rights.
1884 Deputation led by King Tawhiao to England but unable to get access or supporting action over their grievances.
1890s Kotahitanga mo Te Tiriti o Waitangi attempted to introduce a Mãori Rights Bill into Parliament in 1894. The Bill sought Maori control over their own lands, fisheries, oyster beds, shellfish beds, tidal estuaries and other Mãori food resources. When the Bill was tabled European members walked out of the House and in 1896 Parliament rejected the Bill.
1924 Ratana took a deputation to England but on advice from New Zealand, audience with the King is blocked.
1932 A petition was tabled by Tirakatene in the House (based on Ratana s plan to have the Treaty ratified). The petition was held over for 13 years. Meanwhile facsimiles of the Treaty were sent to schools throughout the country - with little benefit to Mãon.
13from The Treaty of Waitangi and Social Policy, Royal Commission on Social Policy,Wellington.
Chapter 2- Treaty of Waitangi 19
1938 Hoani Te Heuheu Tukino v The Aotea District Mãori Land Board in the Court of Appeal. While the appeal was dismissed, and the Treaty was regarded as enforceable only when it became part of municipal law, the Court did not decide against the Treaty as a fundamentally important document.
1975 Waitangi Tribunal formed to make recommendations on claims relating to the practical application of the Principles of the Treaty of Waitangi (but excluding grievances arising prior to 1975).
1985 Waitangi Amendment Act passed, allowing the Waitangi Tribunal to recommend on claims dating back to 1840.
1986 High Court decision in favour of Tom Te Weehi being able to "exercise a customary Maori fishing right" (as promised in the Treaty of Waitangi).
1987 Court of Appeal find in favour of the New Zealand Mãori Council that the transfer of Crown lands to state enterprises without consideration of Mãori land grievances would be inconsistent with the Principles of the Treaty of Waitangi and therefore unlawful in terms of the State-Owned Enterprises Act.
The Treaty of Waitangi is acknowledged as this country s founding document14. A number of principles in relation to the Treaty and its application to the health and other sectors have been defined and these are given below.
14Ph to 2010, Prime Minister, Wellington, 1994. I
Chapter 2- Treaty of Waitangi 20
2.2 Principles for Crown Action on the Treaty of Waitangi
In 1988, Government approved the publication of the Crown Principles. The document received some criticism from Mãori because it seemed to be an attempt by Government to re-write the Treaty or at least re-interpret Treaty principles unilaterally - by one of the Treaty partners.
Principle 1
The Principle of Government The Kawanati
The Government has the right to govern and make laws.
Principle 2
The Principle of Self-Management The Ranatiratana Princ
The iwi have the right to organise as iwi, and, under the law, to control their resources as their own.
Principle 3
The Principle of Equality
All New Zealanders are equal before the law.
Principle 4
The Principle ofReasonable Cooperation
Both the Government and the iwi are obliged to accord each other reasonable cooperation on major issues of common concern.
Principle 5
The Principle ofRedress
The Government is responsible for providing effective processes for the resolution of grievances in the expectation that reconciliation can occur.
Chapter 2 - Treaty of Waitangi 21
2.3 New Zealand Mãori Council - 10 Implicit Principles
The Royal Commission on Social Policy reported the following 10 principles which have been identified by the New Zealand Mãori Council
i) the duty actively to (sic) protect to the fullest extent practicable; the jurisdiction of the Waitangi Tribunal to investigate omissions; a relationship analogous to fiduciary duty; iv) the duty to consult; V) the honour of the Crown; vi) the duty to make good past breaches; vii) the duty to return land for land; viii) that the Maori way of life would be protected; ix) that the parties would be of equal status;
X) where the Maori interest in their taonga is adversely affected, that priority would be given to Mãori values. 2.4 The Treaty of Waitangi and Health Careis
PRINCIPLES
Having received scant attention for over 100 years, the Treaty of Waitangi is now vey much a focus for race relations in New Zealand and a context for Mãori economic, social and cultural development. Most debate about the Treaty has centred on its application to property rights and its relevance to past grievances. But the Treaty s other dimensions have been progressively identified including its implications for contemporary issues and the maintenance of Mãori wellbeing.
It appears that deteriorating health was a major factor leading Busby, the British Resident, to press for a formal relationship between the British Crown and the Mãori tribes. In 1837 he promised a British Protectorate because of the "miserable condition" of the Mãori people "especially their high mortality rate" resulting from "total European impact" and concluded that the Maori had "some claims of justice upon the protection of the British Government". The Treaty that followed in 1840 made clear the Crown s protective role and the conferment of individual citizenship rights (article 3) but did not remove Mãori control and management over Mãori resources (article 2). These provisions are regarded as pivotal to the Treaty s implications for health care and health services.
In 1985 the Board of Health s Standing Committee on Maori Health Recommended that "the three articles of the Treaty of Waitangi be regarded as the foundation of good health in New Zealand." A Department of Health circular memorandum 16 similarly set out the Department s view that the Treaty
15The Treaty of Waitangi and Health Care, M H Dune, NZ Med Journal, 1989, 102: 283- 285. 16Circular Memorandum No. 1988/79/61/24, Department of Health, Wellington.
Chapter 2 - Treaty of Waitangi 22 of Waitangi should be integrated into the health services. "For the Department of Health the Treaty has special significance. Concepts of health are firmly based in Mori culture (which, according to the Treaty, has a right to official recognition and protection) and Maori people have a right to appropriate services - funded through our health system. The Department accepts that this view is in accord with the WHO principles set out in the Alma Ata Declaration of 1978 on Primary Health Care."
Two principles identified by the Royal Commission on Social Policy are particulalrly apposite to a discussion of health: partnership and participation. Neither is foreign to clinicians or health administrators.
Three areas of application are pertinent:
Partnership and participation in understanding health and sickness;
2 Partnership and participation in the development of health policy;
3 Partnership and participation in the delivery of health services.
CONCLUSION
The Treaty of Waitangi is not a blueprint for good health or a prescription for all ills. Nonetheless, good health is clearly an objective of the Treaty. Statistical disparities between Mãori and non-Maori are sufficiently serious to introduce the possibility that inferior standards of health might merit examination by the Waitangi Tribunal in a similar manner to land grievances or the loss of Maori language. Although the variables are complex, the issues infinitely more speculative and measurements ill defined, the principles underlying Mori health and Treaty obligations may not be vastly different to those underlying environmental pollution, access to fisheries or the retention of tribal lands.
But regardless of efforts to redress the past, two Treaty principles, partnership and participation, have positive implications for the future. Those same principles are inherent in the Ottawa Charter for Health Promotion and underline the need for health experts to welcome the active involvement of communities and to work comfortably with them.
The Treaty of Waitangi was written for the future. At a time when health services are being redeveloped and reorganised, there is a need to consider those Treaty principles and to incorporate them into health philosophies, policies and practices.
I
Chapter 2- Treaty of Waitangi 23
2.5 Tino Rangatiratanga and the Treaty of Waitangi
Over the past 15 years, and indeed over many years before that, Mãori have actively voiced their opinions, views and concerns on the concept of tino across the spectrum of social policy issues. Mãori have rangatiratangaarticulated these concerns through a number of fora, from making recommendations at hui, to undertaking comprehensive studies and lobbying successive governments. Collectively these "views" contain a number of significant and common themes which Mãori identify as critical to achieving a (Maori) sense of well-being.
In particular, improving the well-being of Mãori is dependent upon the Treaty of Waitangi. As stated at the 1984 Treaty of Waitangi Hui, Turangawaewae Marae:
"The Treaty of Waitangi is a symbol which reflects Te Mana Mäori Motuhake ".
The Treaty is the document which acknowledges the status of Mãori as tangata whenua, provides for the principle of partnership between the Crown and Maori, and is the basis for equitable treatment.
Mãori require a greater share of resources so that they can devise strategies which will enable them to achieve tino rangatiratanga.
Recognition of taha Mãori (values, cultural and Maori beliefs) as an integral part of society.
Mãori will continue to discuss and debate amongst themselves and with tauiwi their needs and aspirations. These discussions contribute to a growing resurgence amongst Mãori people today that must be viewed as being positive for their future development.
Mãon will continue to discuss, debate and refine their needs and aspirations in the context of contemporary society with reverence and respect to those who have gone before.
Chapter 2 - Treaty of Waitangi 24
GOVERNMENT AGENCIES
The significant players at a central level of the health sector in relation to Mdori and Mãori health are:
• the Ministry of Health; • the Public Health Commission; • the Ministry ofMaori Development; and, • the Ministry of Women s Affairs.
A brief description of each is given below together with major policy directions and government outcomes identified for each.
2.6 Kawanatanga and the role of Government
There can be no denying that government have played a significant role in contributing to the many fora within which Mãon have participated. Often it has been in the form of providing necessary resources, both human and financial, "listening" to what has been said and in introducing policies that have been seen to assist Mãori in achieving a sense of well-being.
However, at many fora Mãori have been critical of the pace at which successive governments have gone about assisting them. Many social and economic statistics reveal that, while the position of Mãori is improving, in many spheres Mãori are still fairing poorly. The hearings of the Waitangi Tribunal also indicate the importance Mãori place on the need for immediate redress of past injustices.
2.7 Ministry of Women s Affairs .- Minitatanga mö ngâ Wähine.
The purpose of the Ministry of Women s Affairs is to provide the Government with advice and information on policy issues impacting on women17.
Policy Advice on Health and Disability Support Services includes:
• policy guidelines and regulations, and information and monitoring systems for regional health authorities and the Public Health Commission • specific health services for women • issues for Mãori health providers • mental health of Mãori women and their families
17Corporate Plan 1993-94, Ministry of Women s Affairs, Wellington. Chapterl - Overview 25
• disability support services: purchasing and provision including targeting, assessment, the needs of carers, and deinstitutionalisation • accident compensation legislation and regulations.
Te Ohu Whakatupu
Te Ohu Whakatupu is the Mãon Women s Policy section of the Ministry of Women s Affairs.
One of the most important roles of Te Ohu Whakatupu is to act as a catalyst for change18. Te Ohu Whakatupu was established to assess specific Mãori women s needs in areas including health, education, housing and employment.
Te Ohu Whakatupu was also established to help look after Mãori women s needs and generate resourcefulness and creativity based on our origins as women and Mãori.
Te Ohu Whakatupu advances Mãori women s interests in all aspects of the Ministry s work and provides advice to the Minister and government agencies on policies that have particular impact on Mãori women. Its work also includes consultation with Mãori women, publications and information services On Mãori women s issues, and Ministerial Services including work on specific projects.
Government Outcomes for Women19
The Government seeks to make progress towards the following outcomes for women, and especially for Mãori women as tangata whenua:
• opportunity and choice in all aspects of their lives; • fulfilment of their aims and aspirations • full and active participation in society • adequate resources of their own.
8Putea Pounamu, 1989, Ministry of Women s Affairs, Wellington. 19Corporate Plan 1993-94, Ministry of Women s Affairs, Wellington.
Chapter 1 - Overview 26
2.8 Te ManatO Hauora - Ministry of Health
The Ministry of Health has as its mission20:
"Leading the health and disability sector in promoting health through skilled policy advice, health protection, funding management and monitoring."
The goal of the health sector is to ensure that New Zealanders have fair and affordable access to health and disability support services and that every dollar spent of health gets the best possible result.
The Ministry of Health is the Government s chief policy advisor on health. It is also responsible for funding the purchasers of health services, and monitoring how they perform.
The Ministry has a Maori Health Group which "advises on Mãori health issues and the development of Mãori health policy". The group is currently in the process of developing its Strategic Plan. 2.9 RangapU Hauora Tumatanui - Public Health Commission
The Public Health Commission was established on 21 June 1993 under the Health and Disability Services Act to improve and protect the public health; and to meet the Crown s objectives for public health.
Public health services are concerned with whole populations, or population groups such as children, or older people, rather than individuals.
The PHC s area of responsibilities include environmental health, nutrition and food, the prevention and control of communicable diseases, major lifestyle and public health problems as well as the public health needs of special groups, including Maori.
The PHC s functions are:
. to monitor the state of the public health and to identify public health needs;
• to advise the Minister of Health on matters related to public health. This includes personal health maters, and regulatory matters, relating to public health;
• to purchase, or arrange for the purchase, of public health services.
The PHC have developed A Strategic Direction to Improve and Protect the Public Health and are currently working on a Strategic Direction for Mãori Public Health.
20Corporate Plan, 1993, Ministry of Health, Wellington.
Chapter 1- Overview 27
Whãia te ora mô te Iwi - Strive for the good health of the people?,
In 1992 the Government published the document "Whaia te ora mo te iwi" as a response to Mãori issues in the health sector and the Health and Disabilities Services Bill.
The Government identified a number of "policy directions" in order to build on the momentum generated by Maori in the health arena and which recognise the potential of the health system to address Mãori health concerns:
They are:
• greater participation of Mãori people at all levels of the health sector;
• resource allocation priorities which take account of Maori health needs and perspectives; and,
• the development of culturally appropriate practices and procedures, as integral requirements in the purchase and provision of health services.
Key Points
The Government acknowledges:
(a) the active contributions made by Mãori people to the - health system over the years; (b) that major discrepancies still exist between the health status of Maori and non-Maori despite some improvements in Maori health status; (c) the potential of the health reforms to address Maori health C concerns. 2 The Government is developing a surplus land protection mechanism in consultation with Maori people to replace the mechanism presently operated by area health boards. A statement requiring the new health agencies, CHEs, the PHC and RHAs to utilise this mechanism will be inserted in the instructions covering the transfer of asstes to these entities.
3 Specific reference is made to the special needs of Mãon in Clause 7, Crown s objectives, of the Health and Disability Services Bill, in respect of which the Crown may give to a purchaser written notice of the Crown s social and other objectives.
21Whaia te ora mote iwi, 1992, Department of Health, Wellington.
Chapter 2- Treaty of Waitangi 28
4 The Government will ensure that all health sector agencies are required through the Statements of Intent and the contractual and administrative arrangements outlined in the Bill, to reflect its committment to improve Mãori health.
5 The Government will encourage the participation of Mãori in the health sector through the "Good Employer" provisions of the Health and Disability Services Bill. These require health sector agencies to recognise the aims and aspirations, employment requirements and need for greater involvement of Mãori as employees of the employer. (Clause 2, Interpretation of "Good Employer").
6 The Government will continue to seek suitably qualified Mãori people for appointment to Boards.
7 The Government will include a requirement in the Statements of Intent for the Regional Health Authorities and the Public Health Commission to consult with Mãori in the developing of their purchasing strategies.
8 The Government agencies such as the Department of Health, the Public Health Commission and Te Puni KOkiri, will work together with Maori national organisations to contribute to the achievement of the Government s outcomes for health.
9 The Government will seek to work with Te Waka Hauora o Aotearoa should this initiative come to fruition.
10 The Minister, and Associate Ministers of Health, will announce Government s general policy directions for Mãori health at a series of Health Reforms Communication Hui to take place in September-October 1992. t Government Outcomes for Health22
Each year in the Estimates, the Government describes the outcomes which it is seeking for health. The following outcomes for health have been sought by the Government in recent years. They apply to both public health services purchased by the PHC and personal health services purchased by RHAs.
• All New Zealanders have access to an acceptable range, level and quality of health and disability services
Improvements are achieved in Maori health status so that in the future Mãori will have the opportunity to enjoy the same level of health as non-Maori
22Policy Guidelines for Mäori Health 1994/95, Minister of Health, Wellington, 1994. Chapter 2 - Treaty of Waitangi 29
• Individuals and families are encouraged to take care of and improve their health and well-being
• Government assistance for the purchase of health and disability services is directed to those who are least able to make provision for themselves
People with disabilities can gain access on fairer terms to services which offer improved support
• Health service structures, regulations and funding mechanisms are in place which encourage the efficient provision of health and disability services responsive to the preferences of users
The public is protected from malpractice and unsafe products or processes
• Government departments and Crown agencies have adequate information to allow them to meet their obligations as health and disability services policy advisers and monitors of the sector
• There is an adequate database to support research and analysis concerning the health and disability services system
• There is appropriate investment in the future health and well being of the population through public health measures: health promotion, health protection and disease prevention.
Chapter 2- Treaty of Waitangi 30
2.10 Te Puni Kôkiri - Ministry of Mãori Development
The Ministry of Mãori Development has as its purpose23:
"to assist in developing an environment of opportunity and choice for tdngata whenua, consistent with the Treaty of Waitangi"
Government Outcomes for Mãori Development: Mori Health24
The Ministry has a Health Portfolio which gives policy advice to the Minister of Health which has the following outcomes:
• Increased effectiveness of health institutions in designing, targeting and delivering appropriate health services to Mãori.
• Increased effectiveness of access to an acceptable range of health services by Mãori.
• Raised health profile of Maori to that of the Tauiwi population in New Zealand.
• An environment that is sympathetic to increased participation by Mãori in health services and that does not compromise Mãori cultural integrity.
23Corporate Plan, Te Puni Kökiri, Wellington, 1992. 24Corporate Plan 1993-1994, Te Puni Kokiri, Wellington.
Chapter 3- Recent Mimi Affairs Policy Statements 31
CHAPTER THREE
RECENT M AFFAIRS POLICY STATEMENTS
This Chapter identifies three recent policy statements of the last two successive Governments on Mãori Development and Mãori Health.
Chapter 1 - Overview 32
3.1 Te Urupare Ran gapu
REAFFIRMING THE GOVERNMENT S OBJECTIVES
The Government reaffirms the principal objectives set out in He Tirohanga Rangapü. These are to:
• honour the principles of the Treaty of Waitangi through exercising its powers of government reasonably, and in good faith, so as to actively protect the Maori interests specified in the Treaty
• eliminate the gaps which exist between the educational, personal, social, economic and cultural well-being of Maori people and that of the general population, that disadvantage Maori people, and that do not result from individual or cultural preferences
• provide opportunities for Mãori people to develop economic activities as a sound base for realising their aspirations, and in order to promote self-sufficiency and eliminate attitudes of dependency
• deal fairly, justly and expeditiously with breaches of the Treaty of Waitangi and the grievances between the Crown and Mãori people which arise out of them
• provide for the Maori language and culture to receive an equitable allocation of resources and a fair opportunity to develop, having regard to the contribution being made by Maori language and culture toward the development of a unique New Zealand identity
• promote decision making in the machinery of government, in areas of importance to Mãori communities, which provide opportunities for Maori people to actively participate, on jointly agreed terms, in such policy formulation and service delivery
encourage Maori participation in the political process.
BACKGROUND
On 21 April 1988 the Government released He Tirohanga Rangapü. That paper proposed ways of improving the delivery of government programmes and services to Mãori communities and the Government stated then that the objective of any of its programmes should be to give people the best possible opportunity to develop according to their wishes and to realise their aspirations. The proposals for Maori people in He Tirohanga Ran gapi were based on this general objective, as well as on the Government s seven principal objectives in the Mãori affairs area.
25Te Urupare Rangapu, Hon. K T Wetere, 1988.
Chapter 3 - Recent Miori Affairs Policy Statements 33
The ideas set out in He Tirohanga Rangapü were to:
establish a Ministry of Mãori Policy
• establish a practical partnership with iwi organisations in the development and operation of policies
• improve the responsiveness of government departments to Mãon issues
. transfer Mãori programmes to other departments
• phase out the Department of Mãori Affairs and the Board of Mãori Affairs.
The reaction to He Tirohanga Ran gapü was mixed. There was widespread support for using traditional iwi structures to bring about appropriate policy development and delivery of services for Mãori communities. The idea of a ministry was generally well received though it was not necessarily seen as replacing the department. There was considerable scepticism that other government agencies would be able to respond sensitively to Mãori issues given their record over many years. There was a clear call for the retention of the Department of Mãon Affairs in a restructured form.
The Government has taken these concerns into consideration in producing this policy statement.
SUMMARY OF PROPOSALS
This policy statement proposes:
• measures to restore and strengthen the operational base of iwi
• a Ministry of Mãori Affairs to provide a Maori perspective in policy making
• the transfer of the Mãori Land Court s servicing to the Department of justice
• ways of improving the responsiveness of government agencies
• an iwi Transition Agency (for a five year period) to help iwi develop their operational base
• an independent review of the Mãori Trust Office disbanding of the Board of Mãori Affairs options for Pacific Island communities.
The success of the Government s proposals depends on strengthening the iwi and helping restore their independence. The Government is keen to see iwi develop their own structures with their own administrative procedures,
Chapter 3- Recent Mäori Affairs Policy Statements 34 negotiating skills and measures of performance so that they can make their own decisions about what is important to them. That is, it wants to see the iwi ultimately become independent and self-sustaining.
To enable this to happen, the Department of Maori Affairs will be restructured into an "Iwi Transition Agency". Its task will be to assist iwi to develop their operational base over a five year period. The Government expects that five years should be enough time to enable most if not all iwi to have their respective authorities fully operational and capable of entering into contracts with government agencies to take on any government programme. The need for the Iwi Transition Agency would cease at the end of these five years, and the agency would be disbanded. For those few iwi authorities which still need assistance to become fully operational, a limited amount of government funds will be available through the Ministry of Mãori Affairs. The principle function of the ministry, however, will be to provide advice on all matters of government policy making that affect Maori affairs.
These proposals are in line with a number of other changes which the Government has taken in reforming the state sector. In the education area, for example, the development of policy will be the task of a new and compact ministry, and responsibility for administration will be largely transferred to the community. The new Ministry of Mãon Affairs and the restructured Department of Mãori Affairs reflect this move towards separating operations from policy advice.
There are a number of benefits for Maori people in the new arrangements outlined in this policy statement:
. Iwi will be able to work towards self-reliance on their own terms.
• The future relationship between the iwi and government agencies will encourage iwi to determine their affairs in a way that accepts Maori perspectives and aspirations.
• The moves towards greater efficiency and effectiveness are aimed at • improving the way Mãori people are served by government agencies.
•. The new Ministry of Mãon Affairs will have a similar role and status to that of Treasury and the State Services Commission. It will review and comment on all government proposals where it believes a Mãori perspective is essential. The Ministry will also ensure that all government agencies are aware that policy proposals should be consistent with the Treaty of Waitangi and with the Government s seven principal objectives in the area of Maori affairs.
The proposals in Te Urupare Ran gapü provide an opportunity for Maori people to use their traditional institutions and structures for designing and delivering their own programmes and services.
Chapter 1- Overview 35
The Development Decade 1984- 1994
1984 Hui Taumata Te Mãori 1985 Extension of Waitangi Tribunal Te Mãori Te_Ohu Whakatupu established 1986 TeMãori Te Maru Whenua established 1987 Te Taura Whiri i te Reo Mãori Development Corporation Te Mãori 1988 He Tirohanga Rangapu Poutama Trust Treaty of Waitangi (State Enterprises) Act Treaty of Waitangi Amendment Bill Mãori Trust Board Amendment Bill Orakei Settlement Mãori Fisheries Bill Te Urupare Rangapü 1989 An iwi authorities bill Iwi Transition Agency Ministry of Mãon Affairs Transfer of Mãori Land Court Government agencies become more responsive
Transition period begins
Iwi choice begins
1990 150th Anniversary of the Treaty of Waitangi. 1991 Iwi development 1992 Iwi development continues 1993 Iwi development continues 1994 TARGET DATE • Iwi authorities fully operational • Iwi Transition Agency disbanded • Government agencies fully responsive
Chapter 3- Recent Mori Affairs Policy Statements 36
3.2 KaAwatea2o
Early in 1991, the Minister of Mãori Affairs (Hon. Winston Peters) appointed the Ministerial Planning Group to develop recommendations regarding the Government s Policy directions and objectives in the Mãori Affairs area by:
• describing the current position of Mãori in society; • formulating key strategies to achieve Government outcomes; • identifying the rationale and scope for Government responsibility which includes as assessment of the current policy and delivery system in the Maori Affairs area.
The report focussed on Education, Health, Economic Resource Development, Labour Market and Training and the Treaty of Waitangi (including the settling of grievances).
For Health, a description of Mãori health status was given together with an analysis of causal factors including:
• socio-economic status (and the strong correlation between the incidence of Mãori health and low income, high unemployment, poor housing and low educational attainment); • lifestyle factors (diet, smoking, alcohol and drug abuse); • an inappropriate health system and lack of access (ie. the health system has not been designed to take account of Mãori values and Maori social units such as whãnau, hãpu and iwi); • accidents and occupational hazards (young Maori adults are almost twice as likely to die from accidents. Mãori are over-represented in risky labouring occupations); • susceptibilities to diseases (including causal factors relating to the high rates of MAori mental illness).
Recommendations
22 That any future policy emphasis in Vote: Maori Affairs include a strengthened Health policy function;
23 That a health promotion programme be established within Vote: Maori Affairs;
24 That a health promotion unit be established within the operations function of the new specialist Mãori agency;
25 That a health promotion function have a regional presence in the proposed Regional Development Agency;
26Ka Awatea, Report of the Ministerial Planning Group, Wellington, March, 1991.
Chapter 3- Recent Mori Affairs Policy Statements 37
26 That community health initiatives continue to be enhanced and promoted as legitimate mechanisms for reaching and catering for the needs of Maori people.
It has never been clear whether Ka Awatea has been endorsed as Government policy. It is likely, therefore, that it has not been endorsed by the Government as policy and has been over-ridenby "Towards 2010".
Chapter 3- Recent Mãori Affairs Policy Statements 38
3.3 Towards 2010 - The Next 3 Years27
In 1993 the National Government adopted the Path to 2010 as a general statement of government policy and a vision of New Zealand into the next century. The Next 3 Years is a Government document setting out the National Government s policy and programme priorities for the current term of office.
The document identifies two over-riding goals:
• maintaining our current strong economic growth • building strong communities and a cohesive society.
These goals are self reinforcing.
Mãori Development
Maori as tAngata whenua hold a unique place in our country. The Treaty of Waitangi, as the nation s founding document, recognises this special place.
Despite this, Maori account for many of the long term unemployed, families under stress, and in general are participating less in education than the general population. The economic and social position of Mãon needs to be improved in the interests of New Zealand.
The government has two broad objectives for working with Maori to improve their position:
to reach fair settlements to claims under the Treaty of Waitangi to work on a broad front to tackle Mãon disadvantage.
Settling Treaty claims
Settling well-founded claims under the Treaty of Waitangi in a way that is fair and affordable is a high priority for the Government.
With grievances addressed by the Crown, an even stronger relationship can be developed between the Crown and Mãori. This will enable Maori to continue to move away from past grievances toward growth and development.
The Government s aim is to settle all major claims by 2000. The Government will continue to work with Maori to clarify the principles by which it will be possible to settle these claims.
Tackling Mãori disadvantage
Resolution of Treaty claims will have a number of economic and social benefits for Maori. For example, the settlement last year of the
27Towards 2010: The Next 3 Years, Prime Minister, Wellington, 1994.
Chapter 3- Recent MIori Affairs Policy Statements 39
commercial fisheries claim is now leading td the expansion of Maori enterprises and employment.
However, the Government recognises that settlement of Treaty claims alone will not address all the current needs of Mãori in our society, such as health, employment and education. Some of these challenges are addressed in the opportunities created by a growing and responsive economy:
• new employment provides more opportunity for Maori to take up work and secure better jobs
• the education sector is now more responsive to Maori needs, for example with the development of kura kaupapa Mãori (Mãori secondary schools)
• the new health system will now be more able to respond to Mãori needs - the Raukura Hauora o Tainui Trust is one example.
But there are other opportunities for meeting these challenges. Neither Government nor Maori are solely responsible. Each has an important part to play and neither can do it alone.
The Government s focus will be on providing more scope for initiative and opportunity for Maori to participate fully in the economy. This can be done by:
• targeting resources to those most in need, putting more emphasis on areas of low education, poor health and unemployment
• developing programmes to help the long-term unemployed and the disadvantaged.
Health Care
If we are to have strong communities, there must be access for all to good quality health care at reasonable cost. At-risk children and adults, in particular, should receive good quality health care so that they have the opportunity to build successful lives.
In the last year the Government has introduced into the health system a number of new features. The new features create opportunities to improve significantly over time New Zealander s level of health care by:
• enabling communities to be more involved in the setting of priorities for health care and in regional health initiatives
• developing more responsiveness and innovation in bringing health care to communities
Chapter 3- Recent MIori Affairs Policy Statements 40
• achieving better quality and value for money service through better management practices
These changes have created some uncertainty. But change is always difficult and health too important an area to be excluded from the benefits that more modem approaches and structures have to offer. The Government has already invested more resources into the health system, especially in areas where New Zealand needs to raise its performance. Important priorities include:
• mental health • child health • Mãori health • a healthy physical environment
Over the next three years the Government s priority will be to ensure the new features of the health system are firmly established and operate effectively for the benefit of communities.
This will require all the people involved - including individuals, health groups, the regional health authorities, the Crown health enterprises, private health providers and the Ministry of Health - to work together and work productively to deliver a modernised health service which offers the best that medicine can deliver.
Chapter 4- Consultation 41
CHAPTER FOUR
CONSULTATION
This Chapter gives three brief sets of guidelines which have been developed for consulting with Mãori and with Mdori Women.
Chapter 1 - Overview 42
CONSULTATION
4.1 Guidelines for Consulting Women and Mãori Worn
That departments should build their own links into women s networks.
2 That there is commitment to listen to women s views and include the views of women with an understanding of sexism and racism in the development of policy. If it is shown that the proposal does not meet women s needs, the department is committed to substantial revision, or rejection.
3 That processes which are designed to help women express their views will be used.
4 That staff at all levels have a clear understanding of why women and Mãori women should be consulted and how to use the information gained as a result of consultation.
4.2 Consultation Guidelines29
The Public Health Commission have recently published guidelines for consultation to assist the PHC staff develop consultation specifications.
The following is a summary of the suggested process. Further details can be found in the document and are not repeated here:
Duty to consult
Consultation requires that [those consulting]: • set out a proposal not finally decided upon; • adequately informs the parties of all relevant information upon which the proposal is based; • allows sufficient time for those parties to respond; • considers the responses that the parties have given with an open mind and without any element of predetermination; • reaches a decision in light of the consultation, that may or may not alter the original proposal.
28Checklist - How to Analyse Policies and Programmes to Ensure That They Meet Women s Needs, Ministry of Women s Affairs, Draft. 29Consu1ion Guidelines, Public Health Commission, Wellington, 1994.
Chapter 4- Consultation 43
• Decide the purpose of consultation • Select consultation networks • Establish ground rules for consultation • Consult with Mãori • Set objectives for effective consultation • Develop a timeframe for consultation • Examine the methods for consultation • Identify the information requirements for consultation • Distributing discussion documents • Third party registration of interest in consultation • Plan to record and analyse the findings • Identify possible barriers to effective consultation • Always evaluate the consultation process
4.3 A Guide for Departments on Consultation with lwi3o
Te Puni Kökiri have promulgated a guide for departments on consultation with iwi. Key elements of their suggested process are given below:
Essential Elements of Quality Consultation
• Clarification of Purpose • Sufficient preparation and lead-in time • Sufficient time for debate • Opportunity to participate for all those with an interest • It must be genuine consultation • There must be post-hui evaluation or feedback • A transparent process
Summary
These are the basic elements of a quality consultative process. How you choose to fulfil these basic requirements will vary considerably depending on the nature of the issue and the stated objective of the consultation. Successful consultation requires serious preliminary consideration of the objective of the consultation. The next step is to formulate a consultation process that presents the greatest potential for delivery of that objective.
30A Guide for Departments on Consultaion with Iwi, Te Puni Kokiri, Wellington, 1993. Chapter 4- Consultation 44
Chapter 5-Significant Health Hui 45
CHAPTER FIVE
SIGNIFICANT HEALTH Hui 1984 — 1994
This section describes 5 significant health hui which have been held over the last decade.
These /zui represent a range of hui which have been held and is not intended to be an exhaustive account.
The proceedings of these hui represent the views of the participants.
Chapter 1- Overview 46
5.1 Hui Whakaoranga Details The Hui Whakaoranga3 was held at Hoani Waititi Marae, Glen Eden, Auckland, from 19-22 March 1984, with a theme of promoting a positive view of Mãori health. The Hui was sponsored by the Department of Health and the programme was developed in consultation with the New Zealand Mãori Women s Welfare League, the New Zealand Mãori Council, the Hoani Waititi Marae Committee and the Departments of MAori Affairs and Education. It was held in recognition firstly, of the growing number of health initiatives that were developing in Mãon communities, and secondly, that despite the considerable improvements in recent years, there still exists a large disparity in health status between Mãori and non-Mãori people. Kaupapa
The objectives of the hui were:
To provide an opportunity and forum for organisations and individuals concerned with Mãon health to meet, discuss and share ideas, experiences and information related to health matters.
2 To promote a view of the positive aspects of Mãori health.
To develop a mechanism to plan, co-ordinate, monitor and evaluate intervention programmes related to Mãori health.
As health is an integral part of the culture of any group of people, the Hui Whakaoranga was an opportunity for Mãori people to defme health in their terms and to talk about the solutions that have been developed or might be developed to meet their needs. The Hui Whakaoranga was timely in that, it provided a focal point for the Department of Health to inform Mãori people, I health agencies and health providers that for 1984 and 1985, Mäori health had been identified as a priority area in terms of health intervention strategies, health education programmes and efforts to improve cross-cultural understanding between Mãori people and health providers. Proceedings/Recommendations
)i.1s.rj Ito r Note) ik.sO)s1IT1
The recommendations from the hui reflect the broad understanding of health taken by participants, and the importance of building and achieving a holistic perspective of health.
31HU1 Wbakaoranga, Maori Health Planning Workshop, 1984, Department of Health, Wellington.
Chapter 1- Overview IkA
I c r.)uhiti3sr.
1.1 That the primacy of Te Taha Wairua be recognised by institutions throughout New Zealand.
1.2 That support and special status be given to the tohunga and traditional health practices to facilitate their recognition and utilisation in the health services.
1.3 That the employment of "Mirnta Maori" in all major hospitals and institutions in New Zealand be encouraged. These governing bodies should invite Mãori District Councils, New Zealand Mãori Women s Welfare League, Tribal Authorities and Te Runanga Whakawhanaunga i ngã Hahi o Aotearoa to help them in their selection process.
1.4 That the employment policies of New Zealand institutions recognise and reflect the spiritual and cultural values of Maori people.
1.5 The institutions be encouraged to recruit and train employees who will guide and develop policies for the needs of Mãori people so that they can maintain and enhance spiritual health.
Mrs MWIMM-1 M.- 2.1 That health and educational institutions recognise MAori culture as a positive resource, and Te Taha Hinengaro as an essential part.
2.2 That support be given to establish marae based community initiated projects/programmes to meet needs which have been identified by local people or promoted through local Maori organisations.
2.3 That support be given to identifying and encouraging the use of Maori personnel in existing health service agencies.
2.4 That the lack of Mãori personnel in the health services be readdressed by: (a) the promotion of the concept of a Maori preference quota in training schemes. (b) promoting in schools and on marae health services vocational opportunities. (c) establishing local, regional, tribal, marae health personnel objectives. Chapter 1- Overview 48
2.5 That the wider ramifications of the care of Mãon people in existing long and intermediate care institutions such as rest homes and geriatric units be explored.
2.6 That the feasibility of including Maori spirituality in health education programmes in schools and in tertiary educational institutions be investigated.
2.7 That assistance be given to health workers and professionals with an interest in MAori health to improve their cross-cultural understanding and communication skills through: (a) ongoing education wãnanga, seminars, workshops; (b) incorporating Mãori studies and language as an integral component of their training curriculum; (c) working and sharing their skills with Maori volunteers and community-appointed persons.
3.1 That the concepts and philosophy of Te Whanau espoused by Mrs Rose Pere be available to all those who participated at the hui and be promulgated amongst health care provider groups. 3.2 That support be given to Matua Whangai and/or whãnau support/resource groups be set up by Maori people where: (a) none are available, for example in hospital; (b) a need is demonstrated; (c) MAori families don t have links with a marae; (d) to work, communicate and liaise with other services, health professionals and Mãon groups.
3.3 That formal links be established between Maori communities and health service organisations. A liaison co-ordinating group be established to identify local health issues, priorities and to plan and implement programmes.
3.4 That Mãori people be encouraged and supported in standing for hospital boards, advisory/management committees and executive positions in professional organisations.
MsJ. s1siti its ml.) d-. r 1I h
4.1 That the Department of Health: (a) compile a register and guidelines of "community health initiatives" so that it can be made available and used by other Maori groups; (b) fund Health Co-ordinators to marae-based projects to aid the training of voluntary health workers; Chapter 5- Significant Health Hui
(c) with the Department of Mãori Affairs, support further health hui on a regional/tribal basis; (d) recognise and encourage a return to traditional Mãori methods of preventing and treating health problems.
4.2 That priority be given to important diseases/sicknesses that are amenable to modem medicine treatment, e.g. diabetes, kidney, heart and chest diseases, hepatitis and ear disease.
4.3 That attention be given to improving the access and use of modem health care services by MAori people by activities such as: (a) supporting the Department of Health s Priority Programme; (b) provision of health education and disease prevention programmes; (c) running marae courses, seminars on the use of health services.
4.4 That attention be given to improving the health/sickness knowledge of Mãori people by: (a) using simple language and avoiding medical jargon; (b) using services of bi-lingual resource people; (c) improving cross-cultural communication skills.
4.5 That attention be given to providing information and programmes using the appropriate cultural, audio-visual facilities, targeted to focus on certain life-style behaviour factors, e.g. smoking, accidents, alcohol and drugs.
4.6 That hospital boards and other volunteer agencies be encouraged to: (a) provide advisory and support services for disabled persons in a marae-based community setting; (b) use MAori staff in an advisory consultative capacity in relation to the care of Mãori people; (c) allow voluntary workers to work alongside hospital board- based health professionals in a supportive capacity.
(t.Is)ii1 .. .TL it i
That this hui recommends to Government:
"That priority be given to tribal and marae-based initiatives in terms of capital development and on-going salary maintenance."
Recommendations from the Raukawa Tribal Planning Experience of Health Workshop
6.1 That the Department of Statistics and Health Service Agencies record:
Chapter 5- Significant Health Hui 50
(a) a person s ethnic/cultural affiliation; (b) the hãpu, iwi, marae affiliation of all New Zealand residents on existing and future data collection systems.
6.2 That a "Mãon well-ness" measure be developed covering for example: - weekly hours of exercise - number of contacts with marae in a given period hours in spiritual, whanau, cultural, language activities per week etc.
6.3 That the hui record there is an aversion to further resources expended on scientific research on Mãori people.
6.4 That a compromise method of "participatory" development research be formed which allows: (a) a gradual, intelligent and progressive use of gathered data in keeping with local Mãori needs as expressed by them; (b) a shared learning and development experience in which there is a continuing interaction between people and those whom they have engaged so that goals, changes, programmes and directions can be negotiated.
Wm 1W
7.1 That the Department of Health and Mãori Affairs support Marae Community health initiatives. 7.2 That policies on community health centres be aimed at networking people and agencies so that they work together.
7.3 That existing mechanisms of resource allocation be reviewed with a view to providing flexibility in resource use and allocation by health service agencies so that they can respond to locally defined needs. 7.4 That the triple S scheme proposed by the Review Committee on Primary Medical Care should be examined as a possible source of funding for community initiatives.
7.5 That the possibility of other sources of funding such as Accident Compensation Commission and voluntary agencies, Internal Affairs Department should be investigated.
7.6 That where the need for a particular community health service has been established and partial funding has been
Chapter 5- Significant Health Hui 51
provided by either private or voluntary groups, the balance of funds be provided by government as soon as possible.
7.7 That where warranted, central government provide on- going funds for community health centres/clinic services.
7.8 That an accountability structure be established to monitor funding from government, and other agencies.
7.9 That an information system be established to provide advice and knowledge on health initiatives.
7.10 That hospital boards be encouraged to make use of provisions under the Hospital Act to assist individuals who cannot afford to pay for items essential to their health e.g. vision glasses.
7.11 That provision be made for community health centre/clinic services to be implemented on a trial pilot basis e.g. the Foxton Nursing/Counselling Clinic operated on an experimental basis by nurses.
7.12 That provision be made for the ownership of community health clinic facilities to be given to local communities.
8.1 That Hui endorses the considerable health component and strongly commends the Te Kohanga Reo Trust Programme and its workers.
8.2 That the Ministers of Education, Mãori Affairs and Health: (a) support the Te Kohanga Reo Programme with increased funding and administrative support for its continued development; (b) implement the Te Kohanga Reo concepts, objectives and teaching methods throughout the education system; (c) recognise the considerable teaching skills of resource persons such as kaitiaki by on-going salary support.
8.3 That the Te Kohanga Reo Trust and Centres: (a) continue to promote health in its widest sense through its disease prevention and health promotion activities; (b) utilise non-MAori speaking health professionals and Mãori nurses in: - an advisor - a supportive - a teaching role or function (c) encourage the desire for Kaumatua and Te Whanau to share their expertise. Chapter 5-Significant Health Hui 52 I 8.4 That the principle be accepted that health is something that is done with people and not to them.
8.5 That the Minister of Labour increase the voluntary organisation training programme for trainees in Te Kohanga Reo from one to two years.
8.6 That the Department of Health support and assists the Department of Education in finding health education material nationally and internationally suitable for the promotion of health through Te Kohanga Reo Whanau centres.
:(TT
9.1 That the Department of Health provide an estimate and analysis of the expenditure from Vote: Health on Maori people.
9.2 That the Minister of Health acknowledge the establishment of the National Council of Maori Nurses and recognise the need for a National base with full-time nursing personnel.
9.3 That the half-way houses for the rehabilitation of psychiatric patients be established.
9.4 That the Department of Health fund a family therapist in the Mangere Community.
Further Recommendations that have been proposed through the evaluation questionnaire of the Hui Whakaoranga:
10.1 That in the organisation of the new Area Health Boards, MAori people be appointed to each committee concerned.
10.2 That the Maori language and culture be included in all medical and nursing training programmes, taught by Maori people.
10.3 That increased time be given to Maori language, Maori News and programmes of interest to Maori people on Television.
10.4 That Health Department and Hospital Boards should not exploit Mãori people willing to provide voluntary services; remuneration should be given possibly in the form of a koha.
Chapter 5-Significant Health Hui 53
5.2 Hu! Taumata32
Details
The Hui Taumata, which was held in Parliament Buildings in Wellington in 1984, shortly after the coming to power of the Lange Labour Government, was a MAon Economic Development Summit. Kaupapa
Although specifically aimed at addressing Maori economic development, part of the hui addressed Mãori poor health. Participants acknowledged that Mãori health is amongst the worst in the world. The causes stem from a number of factors including low economic status, educational under-achievement, low self-esteem and lack of access to positive health care systems. Proceedings
The hui recognised that physical health will only improve with the strengthening of spiritual and creative health through programmes which combine high levels of local innovation, participation and activity.
The hui further fosters the concept of total well-being which corresponds with the priorities of the Maori community.
The hui marked a change in the direction of Maori policy to an iwi Idevelopment emphasis (see Te Urupare Rangapu).
32Hui Taumata, Maori Economic Devlopment Conference - He Kawanata, Wellington, 1984.
Chapter 5- Signijfcant Health Hui 54
5.3 Hui-a-Iwi: Nursing Education and Services33 Details
In July 1987, a hui on Nursing Education and Services was held by the National Council of Maori Nurses at Rongopai Marae, Gisborne.
About 600 people attended. Kaupapa
The kaupapa was to meet to discuss a proposed submission to the Royal Commission on Social Policy. A number of Maori indicators emerged which required further discussion, development aand research. These encompassed Mãon health and the Treaty of Waitangi, Biculturalism, Mãori Women s Health, Primary Health Care, Institutional Care and the formulation of a national health policy with Mãori input. Proceedings
Key Recommendations
1 Treaty of Waitangi and Mãori Health
a) That the NCMN (through the proposed cultural unit for the NZ Nursing Workforce) prepare and present a direction paper to the Waitangi Tribunal in order to have health recognised as a taonga and that it be given the same protection under the Treaty of Waitangi as are our lands, fisheries, language etc.
b) That this report/submission from the NCMN also be included as a paper for consideration in the Treaty of Waitangi phase because throughout it reference is made to the Treaty of Waitangi and to various aspects of health which are of concern to the Maori people.
2 Mãori Women and Mãori Health
a) That Maori women must be consulted and involved in the planning and provision of health services that affect them and/or their children.
b) That information such as health education material concerning Mãon women and children must be culturally appropriate, readily accessible and freely available to them.
c) That funding be made more readily available for both researching and implementing strategies for Maori health initiatives such as
33Nursing Education and Services, Proceedings of Gisbome Hui, National Council of Maori Nurses, 1987.
Chapter 1- Overview 55
establishing marae-based health centres as culturally appropriate community development models.
d) That the use of IUDs and DEPO PROVERA be banned in New Zealand.
e) That funding be made available for increasing preventative health measures starting with greater provisions for cervical screening, hepatitis B immunisation programmes and the whole area of violence and abuse.
f) That Mãori women must be represented in decision making processes pertaining to health care and delivery, eg. on health committees, groups, boards, authorities and commissions etc.
g) That acknowledgement be given by the medical profession in this country, that to have control over her life and body including her reproductive functions is the right of every woman but especially that of the poor, indigenous and colonised women of Aotearoa. I 3 Rangatahi
a) That Taha Mãon be incorporated into every subject covered during the three year nursing programme.
b) That the Royal Commission on Social Policy recommend that things MAori be given through the Education system.
c) That affirmative action in recruitment and appointment of Mãori tutors be taken in all Technical Institutes or Polytechnics.
4 Health Benefits Review
a) That there be a redistribution of funds and resources from within the current health system to meet the needs of the Mãori community.
b) That provision be made for a comprehensive and holistic health service with shared responsibility between health professionals and the community in planning the allocation of funding and resources.
Chapter 1- Overview 56
5.4 Cultural Considerations in HeaItiv4 Details
A hui was held at Waikohatu Marae, Rotoiti, from 8-10 February 1989. Approximately 60 people attended the hui which was held as a result of a 5-day residential workshop on "The Future Deployment of the Medical Workforce" which had been convened by the Advisory Committee on the Medical Workforce in 1987.
This hui was recommended by Mãori participants at that workshop.
Kaupapa I Ngã Kaupapa i) to improve the cultural sensitivity of doctors through their teachers; ii) to address the Treaty of Waitangi and bi-cultural issues; I iii) to introduce appropriate solutions to Mãori health problems; iv) to define on-going actions to follow from the Hui and evaluate outcomes; v) to highlight the value of the whanau community system of health care; vi) to learn to value the Mãon people through the experience of marae living.
At the conclusion of the hui the following recommendations were made for subsequent action: Proceedings
Priority Recomendations
That the Mãon perspective should be incorporated into the curriculum. This would involve the appointment of a lecturer in Mãori Health (who would be Mori) and the establishment of a formal process of consultation with the Mãori community through the development of a permanent advisory group.
2 That a staff development programme be instituted for all academic staff as a means of encouraging an increase in cultural awareness.
34Cultural Considerations in Health, Advisory Committee on the Medical Workforce, Proceedings of the Rotoiti Hui, 1989.
Chapter 5-Significant Health Hui 57
3 That a support system for Mãori students be developed to provide social support and act as a focus for community contact. Such a system would also provide a forum for academic discussions by encouraging mature students and by liaison with schools. Chapter 5-Significant Health Hid 58
5.5 Hui - Te Ara Ahu Whakamua
Details/Kaupapa
In March 1994 at Papaiouru Marae in Rotorua, speakers and delegates at the hui Te Ara Ahu Whakamua were asked to consider five questions:
• What constitutes a healthy Mãori? • How should Mãori health be measured? • How can Government agencies contribute to Mãori health? • What policies should be put in place to achieve health for Mãori? • What objectives should be set for the year 2000?
Over three days of the hui, 600 participants including 26 guest speakers offered their views on these issues.
The views of the participants at the hui are represented below 35. These views have simply been categorised.
Proceedings 1
What constitutes a healthy Mãori?
• a sense of identity - knowledge and understanding of the whakapapa • self esteem, confidence and pride • control of own destiny • a voice that is heard • intellectual alertness; physical fitness; spiritual awareness • personal responsibility; co-operative action • respect for others • knowledge of te reo and tikanga • economic security • whanau support
How should MAori health be measured?
• number of Mãori in positions of influence • value of resources in Mãori ownership • increase in lifespan • drop in the crime rate • increase in educational achievement • rate of business success/employment • use of te reo/cultural strength
35Te Ara Ahu Whakainua Draft Action Plan, Te Puni Kokiri, Wellington, May 1994.
Chapter 5- Significant Health Hui 59
How can Government agencies contribute to Mãori health?
• by handing over resources to Mãori • working together avoiding overlap and duplication - "tatau, tatau" • clearly defining their roles, responsibilities • employing and involving Mãori at all levels • being accountable for the effectiveness of their programmes for Mãori .. listening and keeping people informed
What policies should be put in place to achieve health for Mãori?
Policies that:
• are developed by Mãori for Mãori • are based on consultation and good information • raise the status of Te Reo and Tikanga Mãori • ensure access on an equal basis • promote the unique qualities and talents of Mãori • are in education • are in health • are in broadcasting • are ontereo • are in law/justice system • are in social welfare
What objectives should be set for the year 2000?
• strong Mãori structures • power and influence • health • skill • tereo • employment • equality
Chapter 5- Sign ficant Health Hui 60
Proceedings 2
Analysis of Hui Te Ara AN Whakamua - Kotuku Report36
This conference attracted Maori and non-Maori who worked in the area of Maori health or whose positions of employment impacted on Mãori health.
EXECUTIVE SUMMARY
In summarising the findings of this project it was evident during the process of the hui that Mãori health community workers were not given the opportunity to present keynote addresses at the conference. The majority of the speakers who gave presentations were mainly those from middle and top management positions in the public service. This approach for whatever reasons did not fully explore the impact of Government policy on the health delivery service and the health sector on Maori people. In respect, Maori health community workers were only given the opportunity to discuss issues affecting them in workshops and Government employees were not present to respond to questions asked. As a result, the conference did not involve the full participation of the Mãori health community workers who would have been helpful in advising Government officials about the policies that have already been put into place for Mãori at various levels of the health sector.
The Maori priorities of health services and the health sector for Mãori included Government s ability to accept a holistic approach to Maori health and that Mãori seek to establish Mäori health services for Maori by Maori. Greater accessibility to health services which were culturally appropriate were highlighted as well as having a Mäori influence in middle and top management of the public sector. Also discussed was the Treaty of Waitangi and having a constitutional review on the Treaty of Waitangi and its application to Mãon health in terms of the structural changes and implementation of Government policy. By undertaking such a review would satisfy the needs of Maori and it seeks Government to refocus on the Treaty of Waitangi and to understand fully what it really means in policy development. The problems facing Mãon in the current health sector will be resolved when Government is able to constitutionally position Mãon adequately in terms of the Treaty of Waitangi in the health sector.
Furthermore, from a Maori perspective, whanau development, the empowerment of women, and employment were issues emerging from the Mãon guest speakers and workshop participants. The move towards whanau development and seeking to re-educate Mãori parents in child rearing practices was highlighted. Also the use of whanau development in terms of catering for all Maori was expressed. For the past few years the focus has been on iwi development and yet many Maori live in urban environments minus their
36Te Ara Ahu Whakamua Analysis, A Comparative Analysis of Maori and Government Priorities for Health Services for Maori, Kotuku Partners, May 1994.
Chapter 5- Significant Health Hui 61 language and culture. A shift to catering for these Mãori in terms of Government funding to health services was signalled.
The empowerment of Maori women was also a focus and by restructuring and stabilising our whanau structures many of the problems that effect Maori today would be solved. It was also felt that Mãori women should also be included in the decision making process of society concerning Mãori health primarily as they were the ones at the forefront of change for Maori health.
Government priorities concerning the health services and health sector for Maori involved mainly what was outlined in Maori Policy Guidelines for Mãon health. It was emphasised that Mãori health was a Government priority. Government was more concerned with policy rather than what was really occurring in the community and this was evident in the data presented. Although Government had policy in place to ensure that they are meeting their obligations in terms of the partnership outlined in relation to the Treaty of Waitangi, there were questions emerging about the implementation of these policies, and who they were to be implemented by, and how culturally appropriate will these services be? As a result Maori consultati6n and informing Mãon about these policies was an area that Government did not think in depth about in relation to policy formulation. It was evident as well that Government would heavily rely on the skills of Te Puni Kökiri, the Mãori Health Group of the Ministry of Health for Maori policy advice not taking into account the valuable advice of those Maori currently working at the cutting edge of Government policy.
Finally, it is noted that Maori health transverses other areas of government decision making process in Parliament i.e. education, employment, justice and social welfare, and that Government needs to think seriously about implementing the Maori Policy Guidelines in a way that is culturally safe for Mãori and which will truly benefit Mãori in the current climate. The future for Maori health lies at the community level as stressed by Dr Pat Ngata. Chapter 5- Sign ficant Health Hui 62
Chapter 6- Significant Health Research 63
CHAPTER Six
SIGNIFICANT HEALTH RESEARCH
This Chapter details the findings of three significant seminal research papers on Mäori Health produced in the 1980s.
A review ofMdori Health Research undertaken by the Department ofHealth is also summarised.
The findings of three reviews addressing Mãori Mental Health, Hearing and Asthma are also summarised.
Chapter 1- Overview 64
THREE SEMINAL RESEARCH PAPERS RAPUORA, HAUORA, TE KOHIKOHINGA
This section documents three significant Mãori health research papers which were produced in the 1980s.
6.1 Ropuora37
The first paper is a research project undertaken by the Mäori Women Welfare League in 1984.
As a result of the research a number of "are Rapuora were set up.
The major findings and recommendations of the work are given below.
The Mdori Women s Welfare League are intending to repeat the exercise again after a decade has elapsed to assess the changes which have occured.
0 KIT61 P1 1 (I)LhI J a DE416175 k I DWI 1XV 9 (S)F1
THE ROLE OF THE LEAGUE
As the largest Mãon women s organisation and with a record of a third of a century as a watchdog for the welfare of Mimi women and their families the League must now spearhead action to raise health standards. We should have as one long-term aim the elimination of current disparities between Mãon and non-Mãori in health statistics so that all New Zealanders have life expectancies that do not differ between ethnic groups.
RECOMMEND THAT:
Aprogrammeforpositive action on health be presented at the National Conference in 1985.
In retrospect the eighties may be seen as one of the peaks in the renaissance which began with the Young Mãori Party at the turn of the century and has gathered momentum in the past 20 years. Mãori unity of purpose is manifesting itself in action on land and preservation of mahinga kai, language, identity and economic well-being. A health crusade is an appropriate part of the resurgence of Mimi identity. It is a natural extension of the spirit manifest in Tu Tan gata, Kökir4 Matua Whangai and Kohanga Reo.
37Rapuora, Mori Women s Welfare League, 1984.
Chapter 6- Significant Health Research 65
While the League has made its commitment to health, it should support the efforts of Maori Doctors who have been actively promoting good health among Maori. It should applaud the health initiatives already taken to establish marae health centres such as the one at Waahi Pa, Huntly and the Maaka Clinic at Ruatoki.
It should seek united Mãon action on health in the widest sense. In this way it will contribute immeasurably to the emergence by the twenty-first century of a vital, culturally secure people.
RECOMMEND THAT:
All Mdori organisations plan united action on health under the umbrella of the Minister of Maori Affairs who should be requested to convene such a hui.
MAORI HEALTH YEAR AND DECADE
When the League announces its health action programme it should urge the Government and all Maori organisations to combine in a decade of Health with the designation of 1985 as Te Tau Rapuora. Objectives could be set, for example to ensure that the censuses of 1991 and 1996 reveal a significant improvement in Maori health.
RECOMMEND THAT:
1985 be declared Te Tau Rapuora (Rapuora Year).
1985 to 1995 be made a Decade of Health with some measurable goals.
For the next three Censuses, the Department of Statistics retains the question on smoking so that at least one measurable health goal can be observed.
WHARE RAPUORA
The data indicate that too many young and middle-aged women are at risk because of tribal dislocation. They have only tenuous links with the whanau and, at best, a fragmentary knowledge of te taha Mdori. Determined leadership is required in order to halt the insidious decline of a culture i tuku iho i nga tupuna, as well as the seepage of Maori confidence and self-esteem.
There was a marked disparity between the incidence of current symptoms of ill-health and the seeking of professional advice. If in some instances Rapuora women or other members of their families do not have skilled diagnostic and remedial attention it may be because of financial pressure, whakamaa or distance from services. Chapter 6- Significant Health Research
Ideally every area should have a W}{ARE RAPUORA and, where possible, they should be marae based. This Health House could be regarded as an integral part of the marae as are the wharekai and the Kohanga Reo.
RECOMMEND THAT;
WFL4RE RAPUORA be established in areas of significant Mãori population.
They be established in cooperation with the Mdori community and the local health authorities.
These health houses be built on marae to plans acceptable to the Department ofHealth but of an interior and exterior design that will complement the marae.
Where a Kohanga Reo is already established on a marae the WLL4RE RAP UORA be sited nearby.
The house be equipped with diagnostic hearing booths and facilities for blood sampling and urine tests.
The W[IARE RAPUORA be open regularly with a doctor or a public health nurse available at set times.
Kaumatua and other people recognised by local Mdori communities as cultural resource contacts be available at WHARE RAPUOR4.
WJL4RERAPUORA be aplace where people can discuss any topic in a relaxed atmosphere.
The League, the New Zealand Mdori Council, the Mdori Women s Health League, and other Mãori organisations support the re- establishment of the Mãori healing experts.
The WHARERAPUORA be a centre of activity for Mãori herbal treatment.
The League petition the Government to establish five WHARE RAPUORA annually with the Departments of Health, Mãori Affairs and Labour working with local Mäori Committees. The building of the health houses would be excellent work skills development projects for Mãori youth.
The League seek the support of the Government and the doctors and nurses professional associations for the establishment of a training scheme for Mãori Community Health Assistants.
In recommending training we have in mind candidates like the interviewers who did the Rapuora survey. Our interviewers empathy with their own women and their aroha was not only appreciated by the respondents but also
Chapter 6- Significant Health Research 67
inspired and heartened them. A course of further study is desirable because skills such as the taking of blood pressure, urine testing, infant care, basic nutrition and first aid should be available at the WHARE RAPUORA.
Block courses at Technical Institute Schools of Nursing could provide the training but it is imperative that the Institutes find a way to encourage entry by women like the Rapuora interviewers who might not think of themselves as tertiary students. Certificated Mãori Community Health Assistants would be salaried to service the WHARE RAPUORA. The aim would be to provide a check point for health.
FUTURE RESEARCH
The Rapuora survey has shown that Mãori can play key roles in research. Despite what at the start seemed an insurmountable handicap of lack of training in research techniques and an inexperience of the terminology used in the planning and in the processing of results, an amateur non-professional organisation has proved a point. Mãon can carry out research on Mãori.
Throughout the development of this project the League has been guided and supported by professionals at all stages. This was essential to ensure that the survey was scientifically well-grounded. But the survey was fundamentally the work of Mãori women.
We have already commented on the advantage of having Mãon women doing the field work. Their knowledge of the social structure led to the division of almost 1200 women interviewed into seven homogeneous groups. This intimate knowledge proved to be a valuable asset.
Motivation was a mainspring from the start. Concern about the people meant that enthusiasm was quickly aroused. Despite the time taken - inevitable in a big research project even when a full-time paid team is available - interest and action was maintained. As the list of acknowledgments testifies this was an exercise involving almost a hundred field workers, many not League members. They voluntarily gave their time, talents and energy to further the research.
For those taking part it has been a valuable growth experience. Many have gained in skill and confidence; a high proportion of the 1177 women at home experienced a sense of euphoria with the opportunity to talk about themselves with women like themselves. All derived satisfaction from knowing that they were working for the benefit of their people.
Rapuora could be a trail blazer for future research. This research provides only basic information on the health of Mãon women. It is a guide to action and an affirmation that the Mãon can conduct valid scientific research projects successfully.
When future research is planned the question may be asked: "Who is a Mãon?" The definition introduced in the 1974 amendment to the Mãori Affairs Act should apply and be used for all statistics relating to the Mäon. This wider
Chapter 6- Significant Health Research 68 definition recognises cultural identification as the key element in ethnic classification.
RECOMMEND THAT:
Further research arising from the Rapuora survey be developed only in consultation with the League.
The League seek additional funding for the establishment of a League Research Unit based at its headquarters.
The Director of the Research Unit should be a culturally secure Mdori with research experience.
For the conduct of research generally experience with the Rapuora research has confirmed the paramount importance of observing kawa in all phases of the work.
RECOMMEND THAT;
In the designing of any research project on the Mãori that kawa be a prime consideration.
As a greater guarantee of a culturally sensitive approach and an open response, investigative
interviewing be carried out by people of the same cultural background is those who are being interviewed.
The Mãori organisations be alerted when research on the Mãori is being planned and their involvement invited. This will give a wide support base and greater assurance that research findings will be used positively to meet Mdori needs.
The Mãori be involved in the planning and direction of health promotion programmes relating to the Mäori.
A Mäori Research Council be established.
A programme of research projects be drawn up with priority being given to those areas where research is likely to lead to the greatest benefits for the people.
A complete compendium ofMdori herbal remedies and other healing practices be compiled.
In all statistics and research the definition of Maori should be in accord with the Mãori Affairs Amendment Act 1974 which includes any person ofMaori descent.
Chapter 6- Significant Health Research 69
For the next three Censuses the Department of Statistics retains the questions on smoking so that at least one measurable health goal can be observed (as noted above).
HEALTH OF MAORI MEN
The survey has confirmed the League s belief that the health status of Mãori women is inextricably interwoven with relationships within the home. The most significant relationship is with partners. This was evident in the objective identification of the seven sub-populations in this survey when from the fourteen variables the two on marital status and age became the dominant ones.
The partnered status was perceived by Rapuora women as desirable and it was evident that the women who had achieved a stable partnered relationship, Young Mother and Partnered Mother, were more secure and better able to counter stress.
Urban Young and Lone Mother did not have male support in their lives and report a high level of depression. The League believes that the heavy smoking and drinking reported by these young women are the distress signals that arise from the unpartnered women s position.
Almost two-thirds of the Rapuora women were partnered and eight often of the partners are themselves Mãori. From the important stance of "identity" this can be regarded with some degree of satisfaction. On the other hand there is reason for concern. Although the situation that follows is not a common one the League believes that one woman subjected to these conditions is one too many. Asked about being treated differently as a Mãori one respondent volunteered:
"We have 6 girls in our family. Are you interested in hearing why we chose to marry pdkehd men? We lived in. . . and the majority of married men beat their wives. My father beat my mother and we hated it, so we chose to marry pdkehd men."
There were many Rapuora daughters, wives and sisters who reported instability, abuse, arguments and violence in their homes. Usually, but not always, overuse of alcohol was a concomitant factor.
In addition to their role as partners to our women the Mãori men have a leadership role in tribal affairs. This is another compelling reason why their health status and social well-being should be studied.
RECOMMEND THAT;
The New Zealand Mãori Council initiate research into the self- perceived health status and social well-being ofMäori men.
Chapter 1- Overview 70
The League support the Mdori Council in any research proposal.
The Medical Research Council and the Alcoholic Liquor Advisory Councilfacilitate the study of the health and social well-being ofMdori men.
A Mdori contact service be set up in the main urban centres for women subjected to emotional or physical battering or to feeling "alone." This might be a telephone link or "hot-line".
DEPARTMENT OF MAORI AFFAIRS
Although the Department does not have a direct administrative concern for health matters it can have an exemplary and supportive role in any campaign to raise standards. Several senior officers including Dr Tamati Reedy, Neville Baker and Tom Parore are good examples of physical fitness.
RECOMMEND THAT;
The Department ofMaori Affairs continue to help promote health awareness and fitness regionally and nationwide.
The Department ofMaori Affairs appoint at senior officer level a Health Liaison Officer in each District and that such an officer belong to the tribes of the District.
The Department ofMaori Affairs allocate some of its vocational training budget to sponsoring students in comprehensive nursing training courses and in other health-related disciplines such as physiotherapy, occupational therapy, nutrition, radiography, podiatry.
The Department ofMdori Affairs continue to hold regular Introduction to Nursing courses at Technical Institutes.
A MAORI PRESENCE IN THE HEALTH PROFESSIONS
Mãori are poorly represented in the health professions. For example only 3 per cent of nurses are Mãori as are only 3 per cent of student nurses. More Mäon doctors, nurses and health professionals would lessen Mãori diffidence about seeking treatment and increase respect for Mãori values in matters of sickness and death.
RECOMMEND THAT;
Mãori training quotas similar to the places reserved at the Medical Schools be set for all health and health-related occupations.
The League encourage Mãori to enter the comprehensive nurse training programmes which are open to entrants up to ages 40 to 47.
Chapter 6- Significant Health Research 71
The League establish Rapuora scholarships for nurse trainees to be awarded annually.
League branches in the 13 areas where comprehensive nurse training courses are held establish links with Mdori trainees, perhaps adopting one or more students experiencing financial or other difficulty.
The League promote Mãori representation on hospital boards and other committees and boards concerned with health.
The curricula of all health and health-related training programmes contain compulsory modules on Te Taha Mäori and cross-cultural understanding as well as sensitivity training. Mdori lecturers and tutors besides being part of the teaching team must contribute to the course structure.
LIFESTYLE TARGETS
The Rapuora survey highlighted some life-style topics: alcohol, nutrition, smoking, weight control and fitness. While our recommendations are addressed primarily to the League they are also desirable guidelines for other Mãori organisations and individuals seeking an improvement in Mãon health status.
WEIGHT CONTROL AND NUTRITION
Being overweight is a common condition among Rapuora women but few were following the most effective remedy which is to cut calorie intake. Obesity in itself may not be a killer but it predisposes the carrier of excess weight to skeletal problems, and many of the older women complained of their lessened vitality, and the difficulty in carrying out simple tasks because of their overweight.
An excess of calories is usually the result of eating too many of the fats and sugars which figure prominently in the New Zealand diet.
RECOMMEND THAT;
A substantial cut in the consumption offats, sugars, highly refined cereals and salt be promoted.
A "Food for Health" booklet, similar in its graphic appeal to the recipe book published in 1976, be prepared.
A diet of wholesome unrefined food at League functions in place of the pavlova, cheese cake, calorie-rich food, be supported.
Marae committees be encouraged to further the trend to provide raw foods (fruits, salads) and fruit juices as alternatives to the traditional cooked meals and fizzy drinks offered. Chapter 6- Sign ificant Health Research 72
The League branches conduct their own weight-watcher or holistic health groups as branch activities.
Young parents be encouraged not to overfeed babies and young children so that over-eating habits are not set early in life.
ALCOHOL
Few Rapuora women see alcohol as a personal health problem for a high proportion are light or occasional drinkers. Several reported being the victims of others who drink, usually their partners or fathers.
A high proportion of the young women perceive alcohol as a social lubricant affording the drinkers the opportunity to meet their mates in a relaxed accepting atmosphere. It appears that the pub is the urban marae for many where drinking is a group event and where the members regularly affirm their membership.
The Rapuora study certainly indicated the significance of peer pressure in establishing a habit and highlighted the need for leadership from the community to help young people select more positive and creative activities.
We commend the study on "Alcohol and the Mãori People" by the Alcohol Research Unit and suggest that action be taken on some of the issues raised in this report.
RECOMMEND THAT:
The Alcoholic Liquor Advisory Council be commendedfor its study, on "Alcohol and the Mãori people."
The League at branch level discuss this document with other Mãori community groups.
The League support schools and other agencies in campaigns to alert the young to the dangers of alcohol and other drugs.
The League endeavour to see that each branch ofAlcoholics Anonymous has at least one Mdori willing and able to counsel and support Mãori problem drinkers.
The League where possible ensure that non-alcoholic beverages are available at Mdori hui.
SMOKING
Because smoking is the major preventable cause of death in New Zealand and as the proportion of Mãori smokers is double that of the non-Mãori population, deterrent action on the habit is urgent. Sixty per cent of Rapuora women smoke and a third of these are either not aware or do not want to acknowledge that smoking is harmful. Most begin to smoke as teenagers or earlier, and
Chapter 1- Overview 73 although many give up the habit, for most the addictive nature of nicotine results in lifetime bondage to the cigarette.
A campaign against smoking has to be aimed at two target groups; the young between the ages often and twenty who are particularly susceptible to peer group pressure to start smoking and the confirmed smoker who is impairing her own health and often setting a pattern for her daughters.
RECOMMEND THAT:
MA S H - Mäori Action on Smoking and Health be promoted.
Mothers and grandmothers be encouraged to act as an example to the impressionable age group from ten to twenty.
We work with schools to discourage smoking.
"STOP SMOKING" Clinics be run along the lines of the Seventh Day Adventists five-day course.
We declare all League meetings smoke free - as practised at National Conference.
The Government be urged to increase substantially the tax on tobacco and to channel the additional revenue into health promotion and the subsidising of sport.
We support the banning of cigarette advertising and the sponsorship of sport by tobacco firms.
We actively support the organisations ASH (Action on Smoking and Health) and GASP (Group Action on Smoking Pollution).
We prepare slogans and propaganda to counter the ever-present advertising by tobacco companies; for example:
"MASH THE ASH, BEFORE YOU CRASH"(from the 1984 National Conference of the League.
"rMA HEALTHY MIORI NOTA FAG END ONE."
"TOBACCO COMPANY PROFITS DO NOT BENEFIT THE MAORI
"WHAKAMUTUA TEKAIHIKARETI"
THE CHURCHES
The reaction to this sub-heading may well be that the Church is concerned only with spiritual health. Churches have considerable influence and they can assist our campaign by proclaiming an holistic view of health. Opportunities to remind adherents of
Chapter 6- Significant Health Research 74 the interdependence of tinana, hinengaro and wairua arise at hui such as those of 18 November and 25 January at Ratana and the annual Hui A Ranga, Hui. Toopu and Hui Tau.
RECOMMEND THAT:
The support of all Churches be sought for the Rapuora Decade.
The Ratana, Ringatu and Mdori sections of other Churches participate in the Mdori Health Crusade.
GOVERNMENT AID AND COMMUNICATIONS
The state of the economy precludes any substantial government financial support for Te Tau Rapuora but it is hoped that before the Rapuora Decade is too far advanced an improvement will allow a greater allocation of state resources. Meanwhile more than moral support is required. Spending on preventive medicine is an investment which will reduce later demands not only on the Department of Health but also on the Departments of Social Welfare and Justice. As a bonus, a healthier New Zealand should be a more productive nation.
A modest grant administered by a Rapuora Trust under the control of a Mãori, Health Board should cover the production of videotapes, audio cassettes and printed material. The same grant could subsidise MAori self-help through, for instance, regional allocations to assist with seeding hui. Local bodies which fund community development projects are another source of assistance for these activities.
To promote good health practice full use must be made of the electronic developments which have revolutionised the giving and receiving of information. There will always be a place for the talk and the printed word, but for many the image on the screen, besides arousing interest more readily, makes a deeper impression. Audio-visual material, both slide-tape cassettes and videotapes, should be prepared for and by Maori and made available to marae committees to League branches and to other Mãori organisations. Videotapes on smoking, weight control, nutrition, alcohol and drug abuse, fitness and stress could be much more effective, as Dr Peter Tap sell suggests, than written material on these vital topics. Such materials, and similarly programmes for broadcast, should be by Mori for Mãori with Mãori producers and film makers, doctors and nurses. For example, there was the excellent "Koha" film of Cy McLaughlin the ex-Mãori All Black, who at 66 years still runs a marathon..
Prominent young Mãori sportsmen and entertainers who are non-smokers could feature in Health Department posters and advertisements and appear on television to deliver a health message urging their peers to join them as non- smokers.
Chapter 1- Overview 75
"Te Karere" and "Koha" and Radio Aotearoa are excellent vehicles for promoting health and during Rapuora Year regular features and snippets would keep the topic continually in the limelight. If the present tokenism on television were replaced by a time and resource allocation reflecting much more closely the tãngata whenua presence in Aotearoa, then there would be greater opportunities to foster Tu Tan gata, Te Reo Ran gatira and Te Oranga whanui o te Iwi.
This is particularly true of the young for many of whom television is the major source of information as well as entertainment. Impressionable teenagers are having attitudes and values shaped in the living room not so much by parents as by the ceaseless stream of images and sounds from the box.
RECOMMEND THAT;
Health education materials aimed at Mãori be produced by Mãori in consultation with the appropriate community groups and that a portion of the current appropriation for health education be set aside for this purpose.
That Radio New Zealand and the television channels be approached to give priority in programming to topics which provide young Mãori viewers with healthy Mãori role models.
AIMS FOR A MAORI HEALTH POLICY
1. To promote an holistic view of health encompassing the interrelated physical, mental and spiritual aspects of being.
2. To foster a renewed Mãori pride in good health with te ran gatahi as the most important target group.
3. To strengthen the whãnau as apoutokomanawa of Mãori health.
4. To attain parity with European New Zealanders in life expectancy and incidence of disease.
5. To achieve proportional representation in the health professions.
6. To establish a Mãon Board of Health which controls a share of health care resources to cater for Mãori health needs.
Chapter 1- Overview 76
6.2 Hauora: Mâori Standards of Health: 1970-198,438
The second report gives a statistical profile of Mãori over the years 1970 - 1984, co-authored by Professor Em Pomare and Gael de Boer.
This was the second time the research had been carried out and has been a milestone in the reporting ofMdori health status.
"Hauora ". is currently being updated by Te Pümanawa Hauora ki Whanganui-a-Tara.
Introduction
It is hoped that this report will be read and discussed widely, not only within the Mimi community but also by others interested in creating an environment in New Zealand which fosters the highest levels of health for all. Serious social, economic and cultural inequalities still exist between Mäori and non-Mãon people and are important reasons for the disproportionately high levels of sickness in MAori people which are reported within.
These facts are not new to most Mãori people, for similar gloomy statistics were presented in the previous report "Mãori Standards of Health" published in 1980. The present report issues a strong challenge to Mãon and non-Mãori alike, for substantial improvements in Mãon standards of health will only occur through the concerted efforts of both peoples. The previous report is now out of date, but nevertheless, there are important messages from that study which remain relevant today. Principally it was an assessment of the mortality experience in Mãori and non-Mãori over the 20 year period 1955 to 1975 and the present report extends that assessment for the decade to 1984. The 1980 report drew attention to the fact that the incidence and mortality from most of the common killing diseases in this country were still appreciably higher in the Mãori than the non-Mãori. Furthermore, the report stressed that the current poor health status of Mãon people was largely due to the adoption of adverse life-style factors and that these needed to be tackled if substantial improvements in health status were to be made. The report did not address itself to the important question as to why the Mãori and non-Mãori differences existed but it has certainly been the strong feeling within the Mãon community that socio-economic, self esteem and cultural factors are of major importance and that some of these differences are the inevitable result of the difficulties associated with monoculturalism. This report has therefore been extended to include information relating to socioeconomic, self-esteem and cultural factors.
38H Mãori Standards of Health A Study of the Years 1970 - 1984, Pomare & de Boer, 1984. apter 1- Overview 77 commendations
Important improvements in Mãori standards of health have occurred in the past decade, notably improved life expectancy from birth and reduced overall mortality. However, there still remain areas of major concern. Mãon people are grossly disadvantaged socially, economically and culturally, as evidenced by their high levels of unemployment, low earning capacity, poorer educational attainment, low home ownership, over-representation in penal institutions and high rates of physical and mental ill-health and accidents. The high level of stress experienced by many Mãori people is reflected in their prevalence of lifestyle risk- taking (cigarettes, alcohol and food), mental disorders and violent behaviour. Access to health care is less than adequate for many and relates to both cost and cultural factors.
If Mãori standards of health are to be improved in any substantial way in the short term, then jobs are required and access to health care improved. In the longer term however, the most substantial benefits to well-being will come about by reducing the level of lifestyle risk-taking and accidents and by improving the status of Mãori people socially, economically and culturally.
It is recommended that:
1. The principles of the Treaty of Waitangi be incorporated into the constitutions and terms of reference of all groups and organisations involved in health care.
This would allow major inequities in health that currently exist between Mãori and non-Mãori to be addressed by more effective involvement of Mãori people in health planning and delivery, by more realistic alloca- tion of resources to Mãori health, by more emphasis on health promotion and disease prevention and by recognising culture as a basis for health. The Treaty of Waitangi is not seen as the panacea for all Mimi ills but rather the basis for forward planning in health, with the aim that all New Zealanders should enjoy equal opportunities for well- being.
2. Urgent efforts be made to develop Rangatahi (youth) work schemes nationwide..
Unemployment causes severe stress and poor self-esteem and strikes right at the heart of many Mimi health problems. Employment oppor- tunities need to be improved urgently if levels of mental illness, lifestyle risk-taking and violence in the community are to be minimised.
3. Mori health initiatives, particularly at a Marae, Hipu or Iwi level, be adequately resourced with respect to people, information, skills and finance.
Chapter 1- Overview 78
Such initiatives will play an increasingly important role in promoting health and well-being, screening for early disease, and providing infor- mation about health services.
4. Culturally sensitive and relevant programmes be developed to target major health risk areas (smoking, alcohol, overweight, stress, accidents, asthma, heart disease and cancer) and to screen for early disease (high blood pressure, diabetes, cervical cancer).
Each of these risk factors exacts a high toll within the Mãori community in terms of death, sickness and anti-social behaviour. Whilst national efforts aimed at all New Zealanders will help, specific efforts targeted within the Mäori community are important and urgently required. Health education is the key and will involve many groups, both Maori and non-MAori, if attitudes are to be changed. It will be particularly important to promote culturally appropriate messages - for instance, smoking and alcohol should be discouraged as they have never been part of traditional Maori cultural activities. By contrast, traditional Mãori foods should be strongly promoted as excellent sources of suste- nance and Hauora (health).
5. Special efforts be made to improve Mlori women s health.
High levels of illness due to cancer, heart disease and lung disease are unacceptable and likely to become even worse in the next decade. Specific action is required to curb the high levels of smoking in young Mãori women; to screen for high blood pressure, cervical cancer, diabe- tes and overweight; and to provide parenting skills and support for the many young and often solo Mãori mothers. Initiatives may well be developed through lwi, Hãpu and WhAnau action or through networks such as the Kohanga Reo, Mãori Nurses Association or the Maori Women s Welfare League.
6. A MIori health resource unit be established with advisory, monitoring and research functions. The unit should have a MJori director and a research officer and be supported by the Medical Research Council of New Zealand and/or the Department of Health.
The unit would assist in the development and promotion of relevant research projects ensuring that Maori Kawa (protocol) was a prime con- sideration. The unit would be responsible for ongoing monitoring of Maori standards of health and publishing periodic reports. Emphasis would be given to areas of current concern such as Maori women s health, unemployment and health, culture and health.
7. Research be directed into areas highlighted in this report.
Chapter 1- Overview 79
These areas include the following: access and acceptability of current health care delivery; unemployment and health; antisocial behaviour and violence; lifestyle risk-taking (cigarettes, alcohol, food); accidents in the home and on the road; genetic factors in disease, especially of the lungs, kidneys and metabolism; infections such as rheumatic fever and sexually transmitted diseases; cot deaths; diseases such as diabetes and asthma.
8. The Department ofHealth s National Health Statistics Centre provide Iwi and Hapu health statistics as a basis for the development of health programmes with an Iwi or Hapu focus.
9. A further major report on Mãori standards of health be prepared in due course to cover Mãori health issues and health trends up until 1990.
Chapter 1- Overview 80
6.3 To Kohikohinga: A Mäori Health Knowledge Base
The third paper was written by Sam Rolleston for the Department ofHealth in 1988.
The research attempted to describe health from a Mdori perspective and covers a wide range of cultural views ofMãori in relation to Health.
A summary of the range of topics covered is given and the reader is referred to the base document for further information.
The concept of a "knowledge base" is founded on the idea of a researchers notebook. The report details a Mãori perspective on health and covers:
• Te Taha Mãon Early Considerations of "The Mãori Perspective" • Ic Kohl Toi Mãori Health Research • Ngã Mahn Tohunga The Role of the Tohunga • Te Tiro Whaiti Dale: A Case Study • Rongoa Wai Rakau Medicinal Use of Plants • Tikanga Mãori Mãon Values: Whanaungatanga and Whakapapa • Te Rongoa o Te Katakata Humour as Therapy • Te Awhi WhAnautanga me te Whakapakoko Midwifery and Embalming • Te Karo Mamae: Tangihanga: Coping with Grief • Te Tiriti The Treaty and Health
39Te Kohikobinga, A Mãori Health Knowledge Base, 1988, Sam Rolleston, Department of Health, Wellington.
Chapter 6- Sign ficant Health Research 81
HAUORA MAORI LITERATURE REVIEW
In 1990 the Health Research Services Section of the Department of Health published the Hauora Mãori Literature Review which reviewed the Research undertaken by the Department of Health Research Units which related to Hauora Mãon over the period 1980-1990.
Twenty research projects were carried out over the period and are briefly described in the report.
Themes in the Research
Research priorities and methods change over time and certain themes emerge throughout the research.
Publications in the early series of Special Reports were mainly statistical compilations of health data produced by the Medical Statistics Branch. The compilation of statistics is still carried out, but recent publications tend to be presented together with findings from related research40 41 4243• The internal report on establishing performance indicators for Plunket dealt with the development of appropriate statistics44.
In the early 1980s there were two publications by MSRU which specifically addressed health issues in the community45 46 The conventional health services (ie public health nurses and psychiatric hospitals) were also the subject of investigations47 48•
After the formation of HSRDU in 1985-86 and the move to client driven research, the work became much more varied. Evaluation research focussed on primary health care initiatives, such as the union health services and women s health centres49 50, and on the Health Workforce Development Fund 51 . New topics included research on AIDS52 53 54 and on preventative health care55.
40Women s Health, Review of Statistics, Bunnell, 1987. 41Maori Health, Review of Statistics and Research, Pomare and de Boer, 1988. 42General Health, Collection of Statistics and Research, NHSC, 1989. 43Child Health Statistics, Review of Statistics and Research, de Boer et aL, 1990. "Child Health - Plunket, Survey in South Auckland and use of Census and NHSC Data, Barnett, 1990. 45Community Health, Survey of 439 Households in Ponrua, Reinken et aL, 1980. Community Health, Literature Review, de Lacey, 1984. 47Primary Health Care, Survey of Workload of 6 Public Health Nurses in Northland, Flight, 1984. 48Psychiatric Hospital Services, Ethnography of 6 Hospitals, Dowland and McKinlay, 1985. 49Primary Health Care Initiatives - Women s Health, Multiple Qualitative and Quantitative Methods, Norris etal., 1989. 50Primary Health Care Initiatives, Multiple Qualitative and Quantitative Methods, McGrath, 1989. 51Health Workforce, Multiple Qualitative and Quantitative Methods, Scotney, 1989. 52A]DS, Interview Survey of3lO Intravenous Drug Users, Lungley, 1988. AIDS, National Survey of 1000 People, Kilgour etal., 1990.
Chapter 1- Overview 82
The theme of women s health has been consistent throughout the 1980s56 57 58 59 60 The MSRU also had input into the Mãori Women s Welfare League study of Women s Health. Some work on child6 6263 and adolescent health64 has also been carried out.
Over the 30 year period the research methods have developed, moving from an emphasis on the collection of statistics, to research which used both quantitative and qualitative methods. The multiple methods used in recent projects reflect a concern with process, impact and cost measures, including an attempt to look at access, equity and affordability. These more complex research questions require the use of more varied, innovative methods.
The ways in which Hauora Mãori has been included in research has also developed over time. Early work focused mainly on statistics. Five of the first six entries(1960-1972) were ongoing collections of statistics which focused specifically on Maori health through comparisons with Europeans.
The first half of the 1980s saw a move away from focusing on statistics, but few of the reports discussed Mãori health. Only five entries are included for the years 1980-86, and for the most part, the information relating to Maori was limited.
From 1987 there has been a greater effort to include Mãori as part of study populations. For example, in the follow-up survey on intravenous drug users65 conscious effort was made to locate and interview Mãori respondents.
In some reports the presentation of material allows for the information on Maori to be easily found. For example McClellan 66 discussed ethnic differences throughout the text, had a short section on ethnicity and included an appendix with ethnic data.
Some reports have included reflection on the research methodology and how this affects the information on Maori. For example, the evaluation of three women s health centres67 pointed out that qualitative methods (ie participant
54AIDS, Interview with 423 Intravenous Drug Users, Postal Survey of Pharmacies participating in the Needle Exchange Scheme, Lungley and Baker, 1990. 5Preventative Health Care, Literature Review, Hodges, 1990. 56Women s Health, Survey of 1390 Women in Manawatu, Trlin and Perry, 1981. 57Women s Health, Review of Statistics, Bunnell, 1987. 58Women s Health, Bibliography, Wing and Curry, 1988. Primary Health Care Initiatives - Women s Health, Multiple Qualitative and Quantitative Methods, Norris et al., 1989. 60Women!s/Child Health - Preventing Low Birthweight, Literature Review, Morrell, 1990. 61Chjld Health Statistics, Review of Statistics and Research, de Boer et aL, 1990. 62Child Health - Plunket, Survey in South Auckland and use of Census and NHSC Data, Barnett, 1990. 63Women s/Child Health - Preventing Low Birthweight, Literature Review, Morrell, 1990. 64Adolescent Health - Smoking, National Survey of 2302 Students and Classroom Discussions, McClellan, 1987. 65see ref 45. 66see ref 55. 67see ref 40.
Chapter 6- Significant Health Research 83
observation) probably would have been more suitable to assess the work of the Mãori health co-ordinator at one of the centres.
As researchers have become more sensitive to the concept of ethnicity, the language used to describe Mãori and non-Mãori has changed. At present the term ethnicity is used rather than race , as race refers only to common descent characteristics, whereas the term ethnicity , embraces the ideas that an ethnic group shares a common ancestry, culture and history, and acts to maintain that cultural identity.
Greater sensitivity and the growth of the Pacific Island population has led to the end of the practice whereby Pacific Islanders were included with the European population. Also, it has become more common for Pacific Islanders and Mãon to be considered as separate groups rather than combined together as part of the other ethnic category.
Despite these linguistic changes, the definition of Maori has remained remarkably constant throughout the 30 years. Most ongoing health statistics continue to be based on a biological definition of Mãori 68, whereas other types of research have tended to use some form of self-definition which is generally based on the cultural group with which people identify 69. Only one survey used a biological definition of Mãori70 and research o the women s health centres used a definition based on workers perceptions 71 . One project discussed the problems of ethnic statistics in detail, and used both Census statistics (self-identification) and NHSC statistics (biological definition) to come up with two different sets of Plunket contract rates for Mãori, Pacific Island and other ethnic groups72.
The way in which MAon is defined in health statistics is an important issue at present. To address this, a joint research project with Te Wahanga Hauora Mãori, HRS and HSS is being planned for 1991.
Implications for Policy
A number of research projects reviewed more general considerations of health status (including women s health research bibliography), which used ongoing statistics and/or research data73. Only one of these was exclusively about Maori health (see ref 32). This type of research tends to compare Mãon and non-Mãori rates on health problems, which in turn can suggest which areas need special attention. Recommendations one to five iii Hauora provide directions for policy.
Many of the research projects explored how health services are delivered 74. It has been suggested that social services should be delivered with considerations
68see refs 39, 31, 32, 33, 34, 51. 69see refs 36 47 55 43 41 and 45. 70see ref 38. 71see ref 40. 72see ref 35. 73see refs 36 3132 49 33 and 44. 74see refs 37 38 39 4140 42 35 and 46.
Chapter 6- Significant Health Research 84 to the principles of voice . mana o te reo, kia tu tãngata; choice - ida orite te tãngata; and safe prospect - hauora. These three themes emerged from sorting of a sample of submissions made to the Royal Commission on Social Policy., The authors stated that these themes transcended ethnic variations .
Chapter 1- Overview 85
MENTAL HEALTH, HEARING AND ASTHMA
6.4 Mental Health - Ngâ la o te Oranga Hinengaro Mâori Details/Kaupopa
This report, produced by Te Puni Kökiri is association with the Maori Caucus of the Mental Health Foundation, looks at health trends from the perspective of three different population groups: Mãori, Pacific Island and Pãkeh. Proceedings
The Rise of Mãori Psychiatric Admissions Maori rates of first admission to psychiatric services have increased dramatically over the past 30 years while the pakehã rates have remained stable.
The following factors lead to Mãori psychiatric admission:
• drug abuse and drug psychosis (increasing, and occuring at an early age - preventative programmes focus mostly o alcohol);
• the lack of culturally appropriate early detection and support systems in schools;
• the lack of community agencies working under kaupapa Maori in the mental health field;
• Mãori are more likely to be seriously ill before help is sought (admissions to hospital are more likely to be enforced);
• issues such as cultural alienation, poverty, unemployment and hardship, the breakdown of cultural traditions, the shift from rural to urban living and the failure of the education system for Mãon have not been taken into account in the design of health services for MAori.
The Failure of Treatment
When Mãori enter a psychiatric hospital or ward for the first time, what happens to them does not appear to work well and it is the consequent readmission rates that are particularly worrying. • once admitted, Maori are 40% more likely to be readmitted than pakeha; Chapter 1- Overview 86
• Maori readmission rates have risen 40% in the decade 1981-1990 while pãkehã rates have fallen 25%; • Maori readmissions are more likely to be for severe psychotic illnesses (schizophrenia and affective psychosis); • 37% of all Maori male admissions are for schizophrenia; 32% of all Mãori female admissions are for schizophrenia (compare 22% and 16% for pãkehã respectively);
The Difference Between Women and Men
• on average there is little difference between men and women, Maori and pakehA over the decade 1981-1990; • Mãori rates of first admission appear to be climbing especially for Mãori women; • Maori men have a 65% higher rate of admission for neurotic, personality and other disorders than Mãori women (compare pãkehã men 18% higher than pakehã women); • while there is a rapid decline in pãkehã readmission rates for NPO disorders, the Maori rates are rising; • as pakehã leave psychiatric hospital and wards, largely to (pakehã managed) newly created community services, Mãori, particularly Maori men, are finding themselves in hospital in rapidly increasing numbers and with a diagnosis of serious mental illness.
Recommendations Recommendations to a number of central agencies need to address the following issues: greater Mãon control of mental health services; • better funding of services with a specific Maori mental health focus; • the provision of accurate and up-to-date service information on Mãori mental health and treatment outcomes;
• the development of community based, hospital and advocacy mental health services that meet Mãori needs; • research identifying Maori mental health needs and effective treatments; • training programmes to rapidly increase the number of qualified Mãon available to work in Maori mental health services; • education programmes targeting specific areas for Maori such as drug abuse, young mothers and school aged children; and,
Chapter 6- Significant Health Research 87
• reviews of the impact of legislation on Mãori such as the Mental Health (Compulsory Assessment and Treatment) Act (1992) and the Criminal Justice Act (1985).
Chapter 1- Overview 88
6.5 Whakarongo Mal
Details
A review of Mimi Hearing impairment was undertaken in order to advise the Minister of Mãori Affairs on the most appropriate means to achieve the health needs of Mãori people in policy planning and service delivery.
The review report was submitted ml 989.
Proceedings
FiSi m II Y&I) 1161Y i m I :I I" i7 I (s)F1
The unacceptably high levels of Mãori hearing impairment require deliberate and active strategies aimed at prevention, early detection and effective treatment. Programmes of intervention should combine specialist skills and knowledge with active Mãori participation.
2 The full extent of Mãon hearing impairment needs to be determined and it is recommended that government support be given to the National Foundation for the Deaf to conduct a comprehensive survey.
3 The collection of ethnic statistics is essential for adequate planning and appropriate service delivery. It is recommended that ethnic statistics be routinely collected by Audiology clinics, the National Audiology Centre, Advisors on Deaf Children, Hearing Vision Testers, the Deafness Research Foundation and ear/hearing clinics.
4 Parenting programmes which include health education and health promotion are highly desirable and in particular, a recommendation is made for support for the programme on positive parenting being undertaken by the Mãori Women s Welfare League. (5.2)
5 Kohanga Reo could also provide an appropriate focus for health education and prevention. It is recommended that the Kohanga Reo Trust be funded to appoint a health education and liaison officer. (5.3)
6 A policy of active intervention is recommended in order to provide a focus for the prevention, detection and treatment of middle ear infections. Special well trained ear nurses, (nurse microscopists) should be deployed in high density Mãori areas, in association with MAori community groups and area health boards. Ten positions are recommended initially. While operating from an appropriate clinic, nurses would be mobile and able to bring specialist skills and knowledge directly to the Mãori community. (5.4)
Chapter 1- Overview 89
7 In line with the recommendation of the Hearing Report, specialist ENT services should be increased not reduced. The Manukau outpatient clinic should be adequately funded and the establishment of similar clinics encouraged. (5.5)
8 It is recommended that hospital waiting lists for audiology and ENT be regularly reviewed and provision made for alternate arrangements if a particular hospital cannot offer adequate services. Access to audiology services should be increased by greater flexibility in referral procedures (4.3.1).
9 The subsidy for hearing aids for adults is no longer adequate. It should be reviewed and increased to 100% for those who have been deaf since childhood and superannuants; and up to 50% for others.
10 A recommendation is made for the appointment of a Mäori Liaison Officer to the NZ Association of the Deaf in order to establish closer contacts with appropriate Mãori organisations and develop programmes with relevant cultural content. (5.6) 11 A senior Mãori Hearing Officer should be appointed to the National Audiology Centre so that the technical and professional aspects of hearing impairment can receive ongoing attention. (5.7. 1) 12 Better coordination of services should improve accessibility and efficiency. Area health boards should establish service development groups to provide a focus for hearing impairment as well as Mãori health.
13 It is also recommended that health boards establish formal relationships with the iwi authorities in their area. (5.7.2)
14 A Mãori Health Resource Unit should be established, supported by the Medical Research Council and the Department of Health. (5.7.3)
15 Vision hearing testers are unable to screen all children effectively because of the demands on a relatively small workforce. It is recommended that the ratio of testers to population be re-examined to give a better indication of the numbers of testers necessary for testing all preschool children.
It is further recommended that area health boards commit funds to maintain existing services and to increase them so that the testing of 3 and 4 year olds can be guaranteed.
16 The number of qualified Teachers of the Deaf in Kelston School for the Deaf needs to be increased to ensure equality of service throughout the country. An estimated 39 additional teachers to cover the needs of pupils on the register is recommended.
Chapter 6- Sign flcant Health Research 90
Similarly 7.5 more Advisers on Deaf Children are needed in the northern region to obtain the same child-adviser ratio that the southern region enjoys.
17 Hearing impairment among Mãori people involves agencies from several sectors and it is recommended that an interdepartmental committee be established with representation from the Departments of Health, Education, Social Welfare, Justice, Labour and Statistics, and convened by the Ministry of Mãori Affairs. (5.7.4)
Chapter 1- Overview 91
6.6 He Mate Huango - Mãori Asthma Review
Details
A review of Maori asthma, commissioned by the Minister of Mãori Affairs, Hon. K.T. Wetere, was published in 1991.
Proceedings
Introduction
Asthma is a major health problem in New Zealand and death rates have been the highest in the world since the 1960s.
There has been considerable concern at the excessive number of deaths from asthma in Mãori people and large numbers requiring hospital treatment. Although asthma does not appear to be more common among Maori children than pãkehã, it seems to be more severe.
The team was asked to advise the Minister of Mãori Affairs on: • how many Maori asthma sufferers there were; • what specialist services are available to them; • what obstacles prevent Mãori people from using these services effectively; and, • the consequences of asthma in the Mãori community.
Recommendations
38 recommendations were made. Of importance are the following:
A A major improvement in Maori asthma will only occur through the effective involvement of Maori people in the planning and delivery of asthma care;
B Improved access to health care is vital if Mãori asthma statistics are to improve;
C Eduation about all aspects of asthma and its management is vital for optimal treatment success. Maori people have expressed a strong desire to be involved in all aspects of the education process;
D Information and education material about asthma needs to be available and appropriate if management is to be optimised. Oral and visual materials are favoured by many Mãori people;
E Pãkehã health workers need to be aware of and sensitive to cultural factors which adversely affect Mãori asthma management;
Chapter 6- Significant Health Research 92
F Research is important if the causes of asthma are to be found and existing/new programmes are to be properly evaluated. Maori people have several areas they wish to be specifically researched;
G Tobacco smoke is bad for asthma. The high prevalence of smoking among Mãori must be reduced;
HAn action plan for the management of asthma should be made available to the Maori community and be user friendly.
The key person in the long-term management of asthma is the informed patient.
Chapter 7- The Health Reforms and Mimi 93
CHAPTER SEVEN
THE HEALTH REFORMS AND M,A,ORI
This Chapter discusses the Health Reforms since 1991 and Mãori views.
A number ofpapers have been published and these are summarised.
Chapter 1- Overview 94
7.1 Treaty and the Health Reforms7s
The health reforms, recommending major structural and procedural changes, were developed with minimal Mãon involvement. There was no marae debate, nor any serious consultation with national Mãori organisations.
The state has not given any indication as to whether the Treaty of Waitangi is relevant to health and to the health sector. Mimi on the other hand are adamant that it j576 not only in respect of Article 3 and the promise of protection and citizenship rights, but also through Article 2 and the guarantees of tino ran gatiratanga over "o ratou wenua, o ratou kainga, me o ratou taonga katoa."
Tino ran gatiratanga is taken to mean, at the very least, the recognition of iwi as trustees for their people and the expectation that they will be consulted in the formulation of policies as well as in their implementation. Some would go further claiming tino rangatiratanga as the right to control the health entitlements allocated on behalf of tribal members.
Of particular interest, however, is the full meaning of the word taonga . Mãori language, because it is basic to the maintenance of culture, was described by the Waitangi Tribunal77 as a taonga and therefore warranting a Treaty approach by the Crown (with a policy of active protection).
Is health a taonga? Many would argue that because health, family, the environment, land and culture are inextricably linked, health is indeed a taonga and that if the State policies fail to protect it as guaranteed in Article 2, then a claim against the Crown might be justifiably taken to the Waitangi Tribunal.
It would not be a straight-forward claim and there would clearly be a need to clearly demonstrate that Crown policies, rather than individual actions, had created the situation. Nonetheless the potential for health to be regarded as a taonga has been one of the major arguments in favour of the Treaty of Waitangi being included in proposed health reform legislation. 7.2 A Summary of Mãori Concerns7a
To date, MAori participation in the reform process has been limited.
2 The principle of partnership is relevant to RHAs and iwi.
75Maon, Health and the State, M.H. Dune, Annual Conference of the Public Health Association, 1992. 76The relevance of the Treaty to health is outlined by ME Dune (1989) in "The Treaty of Waitangi and Health Care"; NZ Med.J 102:283-285. 77see Waitangi Tribunal (1986) "Te Reo Report". 78Maori Development, Maori Health and the Health Reforms, M.H. Dune, Hui Hauora a Iwi, TakapuwahiaMarae, April 1992.
Chapter 1- Overview 95
3 There should be a clear agreed upon process for the disposal of all surplus Crown assets.
4 Earlier understandings and arrangements between iwi and health authorities should be reflected in CITE policies.
5 The relationship between funders and providers should be capable of facilitating iwi health development.
6 Health entitlements should acknowledge health risks.
7 Any competitive advantages unique to RHAs should be matched with compensatory provisions for Mäori Health Care Plans.
8 Guarantees beyond three years are needed for effective long term planning.
9 Potential Mãori health providers will need assisted entry into the new system.
10 Prevention and treatment should go hand in hand. The Public Health Commission must develop close and uncomplicated links, with the funders and providers of treatment services.
11 A Mãori Health Authority should be given similar status toRHAs.
7.3 Core Health & Disability Support Services
The following are recommendations from a report of the Ministerial Advisory Committee on Mãori Health on the "Definition of Core Health Services"79.
The Government believes we must defme more explicitly what are to be included in Core Health Services for all New Zealand.
The standing of Mãori and their health problems not only relates to the wider issues such as housing, employment and education, but also to cultural and social alienation, oppression and subsequently limited access. Present day health profile of Mãon demands that the values and norms inherent in Mãori society are reflected in the future initiatives implicit in the health reforms.
Not only must Mãori societal values be reflected in the definition and delivery of core health services but also in the area of representation in the various Advisory Committees that are developed during the health reforms.
"Submission on the Definition of Core Health Services, Te Roopu Maori Takawaenga Tohutohu kite Minits Hauora, January 1992.
Chapter 7- The Health Reforms and Miori 96
Major restructuring of the health services is matched only by new directions and trends in the broad field of Mãori development. Positive initiatives and outcomes will come from aspects of the health reforms for Maori. Some aspects of the reforms were not agreed upon.
Mãori in defining the core must consider the definitions of Core Health Services in the context of the reforms and not in isolation.
7.4 Guiding Principles
MACMH applied the following principles as the basis for the determination of which objectives in the core debate are appropriate for Maori:
Treaty of Waitangi, from which Mãori might reasonably expect that they should enjoy a standard of health as high as other New Zealanders
The Treaty re-affirms the values and norms inherent in Mãori health and well-being, as well as reinforcing the spirit of partnership and all the elements comprised therein.
2 Every person must be entitled to receive quality and appropriate health care that is both equitable and accessible. Maori must know exactly what services they are entitled to so that they may reasonably expect access to basic and essential health care. Access to health care must not be compromised by need rather than inability to pay. Quality health care must be defmed in terms of the effectiveness of any health care intervention (in terms of health status outcomes), efficiency in the distribution of scarce resources and appropriateness vis a vis cultural context. All three must be addressed through an on-going monitoring, evaluative and research process. 3 Active Participation.
4 Appropriate Delivery Systems.
5 Empowerment.
6 Prevention vs Cure.
The MACMH believes that a good system should meet the following objectives:
must be transparent to all users and have clearly defmed responsibilities with accountability
Chapter 1- Overview 97
2 it should be uniform to all, yet flexible enough to allow for special regional needs
3 it should provide value for money (including the quality and type of service provided), the quality of service needs to be explicit and agreeable
4 it must be fair - particularly in terms of access to services (and rationing them as necessary to achieve this)
5 it must deliver equity [a Core should ensure that the disparities in health status that exist between Mãon and non-Mãori are addressed at both a regional and national level]
6 it must deliver an improved standard of care for all New Zealanders.
Chapter 1 - Overview 98
I Chapter 1 - Overview 99
PART II CHAPTER EIGHT
WAHINE M.XORI
This section of the report highlights some significant events for the period 1980-1994 which contribute to the collective published health knowledge and influence ofMdori women.
Chapter 1- Overview 100
8.1 Historical/Politicalao
Mãori women began to organise separately in 1951, when the Maori Women s Welfare League was formed. The political women in the league had been pushing for changes for twenty years by 1970, when a radical new Maori organisation, Ng! Tamatoa, was formed. Women in this organisation were critical of some of the roles traditionally ascribed to Mãori women, and in 1971 Nga Tarnatoa member Hana Jackson became the first women to speak on the Waitangi marae, as part of the Treaty of Waitangi protests which have featured at the marae since the early 1970s.
Two women were actively involved in the first Auckland Welfare League groups - Donna Awatere and Ngahuia Volkerling (Te Awekotuku). However by 1973 these women and other Maori feminists were more involved in Mãori organisations, and worked with Maori men on issues of joint concern, such as language and land. Mãon women were invited to address and run workshops at the first two united Women s Conventions, but their presence generated no political push on the majority of pakehã women.
In 1976 the lapsed Auckland branch of Nga Tamatoa was re-formed, and led by women. They held discussions onMãori women s issues, and wrote Maori women s songs. There were all women groups within Mãon action organisations Whakahou and Te Matakite, and some strong women leading the Polynesian Panthers. Maori women featured in one of the Woman series of programmes made by feminists for New Zealand television.
In 1977 there was an intense focus on Maori land issues, with the occupation of Bastion Point (Takaparawba) and efforts to reclaim Raglan golf course. Maori women took these matters extremely seriously, with Eva Rickard leading the Raglan protest. Maori women ran two kinds of workshops at the 1977 United Women s Convention, one on Maori culture specifically and the other on racism generally.
In 1978 Mãon women gave their distinctive perspectives at the Piha Welfare League congress - a criticism of all strands of the pakehã Welfare League Movement. A separate Maori women s conference was held in Auckland. From this conference a number of Mãori women s consciousness raising and study groups were set up, and met weekly during 1979 to discuss feminist articles and issues. Nearly all of the women in these groups had been involved in Mãori struggles, and already had - or quickly acquired - some knowledge of Marxism.
Consciousness raising groups were also meeting in Wellington and Hamilton.
The signs that Maori women were getting organised as a separate force became evident that year when black women made a strong statement on racism at the 1979 United Women s Convention; the Waitangi Day planning committee was all women; there was a Mãon woman s protest at the Auckland Cenotaph in April over the land wars; and the He Taua incident occurred at Auckland
8OTJp from under, Women and liberation in New Zealand, 1970-1985, Christine Dann, 1985.
Chapter 1- Overview 100
8.1 Historical/PoIiticaI8o
Mãon women began to organise separately in 1951, when the Mãon Women s Welfare League was formed. The political women in the league had been pushing for changes for twenty years by 1970, when a radical new Mãori organisation, Nga Tamatoa, was formed. Women in this organisation were critical of some of the roles traditionally ascribed to Mãori women, and in 1971 Nga Tainatoa member Hana Jackson became the first women to speak on the Waitangi marae, as part of the Treaty of Waitangi protests which have featured at the marae since the early 1970s.
Two women were actively involved in the first Auckland Welfare League groups - Donna Awatere and Ngahuia Volkerling (Te Awekotuku). However by 1973 these women and other Mãori feminists were more involved in Mãori organisations, and worked with Mãon men on issues of joint concern, such as language and land. Mãori women were invited to address and run workshops at the first two united Women s Conventions, but their presence generated no political push on the majority of päkehA women.
In 1976 the lapsed Auckland branch of Ng! Tamatoa was re-formed, and led by women. They held discussions on Mãori women s issues, and wrote Mãori women s songs. There were all women groups within Mãori action organisations Whakahou and Te Matakite, and some strong women leading the Polynesian Panthers. Mãori women featured in one of the Woman series of programmes made by feminists for New Zealand television.
In 1977 there was an intense focus on MAori land issues, with the occupation of Bastion Point (Takaparawha) and efforts to reclaim Raglan golf course. Mãori women took these matters extremely seriously, with Eva Rickard leading the Raglan protest. Mãon women ran two kinds of workshops at the 1977 United Women s Convention, one on Mãon culture specifically and the other on racism generally.
In 1978 Mãori women gave their distinctive perspectives at the Piha Welfare League congress - a criticism of all strands of the pakehã Welfare League Movement. A separate Mãori women s conference was held in Auckland. From this conference a number of Mãon women s consciousness raising and study groups were set up, and met weekly during 1979 to discuss feminist articles and issues. Nearly all of the women in these groups had been involved in Mãori struggles, and already had - or quickly acquired - some knowledge of Marxism.
Consciousness raising groups were also meeting in Wellington and Hamilton.
The signs that Mãori women were getting organised as a separate force became evident that year when black women made a strong statement on racism at the 1979 United Women s Convention; the Waitangi Day planning committee was all women; there was a Mãori woman s protest at the Auckland Cenotaph in April over the land wars; and the He Taua incident occurred at Auckland
80Up from under, Women and liberation in New Zealand, 1970-1985, Christine Dann, 1985.
Chapter 1- Overview 101
University. (Engineering students who had failed to respond to polite requests to stop their racially offensive haka party were confronted by Mãon men and women who intervened physically to stop the show.).
In 1980 the first National Black Women s Hui was held - nearly eighty women from five black women s groups met in Otara to discuss common issues of concern. The new feminist magazine Bitches, Witches and Dykes ran a separate section, edited by a Mãori woman, called Black Forum ; and women in the new Mãori political party, Mana Motuhake, formed a separate Mãori women s policy group, Mana Wãhine.
Nineteen-eighty-one was a very busy year for black women activists. In January a black women s health hui was held, and in June a black dykes hui. In the middle of the year the Springbok Tour absorbed tremendous amounts of energy. The tour and the protests surrounding it were recorded in a film directed by a Mãori woman, Merata Mita.
Black women still found time to study (a political economy of Mãori women course was offered in Auckland); to attend the second National Black Women s Hui; to form a new group, the Pacific Peoples Anti-Nuclear Action Committee (PPANAC); and to form regional Maori women s groups. The first regional Maori women s hui was held in Northland that year.
In 1982 Ripeka Evans, who organised the political economy of Mãori women course and edited the Black Forum section of Bitches, Witches and Dykes, went on a controversial women and racism speaking tour; and Donna Awatere s articles on MAori Sovereignty began to be serialised in Broadsheet. These articles were an extremely important summation of the analysis and goals of Mãori radicals. It is significant that the first pAkehA to hear of them (and in some cases to appreciate them) were female radicals. The Broadsheet collective later published them in book form.
Also in 1982 Bastion Point was reoccupied and twelve women were arrested; and in April a black women s health hui was held in Otara.
By the end of the year MAori and Pacific Island women had decided to meet separately, so in 1983 the first National Mãori Women s Hui was held. Radical Mãori women were involved in organising the Hikoi to Waitangi; and the Aotearoa delegation to the Third Nuclear Free and Independent Pacific Conference in Vanuatu consisted of ten Mãori women, two Pacific Island women, and two Mãori men.
The second National Mãori Women s Hui, held near Tauranga in 1984, was attended by 400 women. There was a big effort by older and younger MAori women to listen and learn from each other in their different areas of experience and expertise.
The Maori Women s Welfare League published Rapuora, the results of a survey of Maori women s health it had been conducting over several years, in 1984. The news, as expected, was not good, and Maori women of every political persuasion are concerned to make an impact on the status of Mãon
Chapter 1- Overview 102 women s health. Mãon women had a strong impact at the Mãori Economic Development Summit Conference in 1984; and the new Minister of Women s Affairs accepted the need for a secretariat to deal specifically with MAori women s issues within the ministry. At Victoria University that year there were protests by Mãori women demanding speaking rights on the university marae.
The 1985 Herstory Diary was produced by a Mãori collective and celebrated Mãori women; and Mãori women made a strong showing at the 1985 government-sponsored national conferences on employment and rape. A national collective to set up centres for Mãori women suffering from rape, sexual harassment and other abuse was formed. The women secondary teachers at the PPTA Women s Conference in April called for a hui on Mãon women and education, and the establishment of Mãori women s wananga. Once MI-on women had taken up the questions of feminism, they organised fast. Their experience disproves one of the early generalisations about women s liberation - that it is only relevant to white women. However, this does not mean that all the issues relevant to white feminists are relevant to black feminists or that black feminists should or could be assimilated into white feminist organisations.
The Mãon women s movement has brought new issues to the attention of the Welfare League Movement in New Zealand. Practical issues, such as the appalling state of MAori women s health. Issues of identity, such as land and language, which are particularly vital in a land so recently colonised. PãkehA feminists have been challenged to look beyond their they re as good as us liberalism to see just how different the two cultures in New Zealand are, and how the colonising culture dominates the indigenous culture, causing physical, mental and spiritual ill health among the women (and men) of that culture. Some pãkeha feminists have responded by looking seriously at the issues raised by Mãori feminists, either privately or in discussion/action groups such as Women for Aotearoa; others have been hostile.
As with all political movements, the Mãori women s movement has had its share of fierce political debates. Tribal affiliations and identity have sometimes given rise to contention; lesbians and heterosexuals have had their differences as they have within the white women s movement; and differences between Mãon women, Pacific Island women, and other women of colour have been contentious at times. Not all radical Mãori women are feminists or Women s Liberationists, and among those who are influenced by Marxism there are the inevitable differences of interpretation and application.
The Mãon women s movement is both a criticism and a continuation of women s liberation in New Zealand, and in its focus on the indigenous spiritual values of land and identity it offers a vision of new ways to create and enjoy a just and peaceable society. With the theoretical and practical development of the concept of Mãori sovereignty, Mãon feminists have made a significant new contribution to the political analysis and progress of their own people, and to New Zealand as whole.
Chapter - WihineMiori 103
8.2 The Reasons for Changes,
In a paper published by the Ministry of Women s Affairs, Putea Pounamu, an account is given of the definable periods of Mãori development.
Historically, there are five definable periods. They are:
The Age of Experimentation
This was to last from 1780s to the 1840s. In this period the Maori learnt both the desirability and the negative consequences of the impact of European technology and ideas. They did not, however, withdraw into conservative isolation but vigorously experimented to fmd solutions to the new problems. The adoption of literacy, the acceptance of Christianity and finally the signing, by so many chiefs, of the Treaty of Waitangi must be seen as part of the Maori desire to come to terms with the pãkehã.
The Age of Domination
Prior to Waitangi and even arguably the decade afterwards, Maori people were still masters of their own fate. However, from 1850 onwards this position changed. George Grey started the process by refusing to give Maori custom the force of law or to give the chiefs a place in the machinery of government. Maori numbers declined dramatically. Mãon were excluded from the Parliamentary process when white settlers were given self government in 1854 and the growing numbers of pakehã started to impose their own solutions on Mion people. While this was done easily, the wars of the 1860s showed the Maori determination to resist.
The Era of Reconstruction
This broadly covers the period from the mid 1890s to the 1940s. During this time, leaders of genius such as Princess Te Puea, Mere Rilciriki, Sir James Carroll, Sir Apirana Ngata and Wiremu Ratana emerged with their own solutions for Mãori problems. Carroll and Ngata in particular were masters of the political process and were able to win concessions for Mãoridom from the political system. The initial phase of the wealth estate and the land development programmes that Ngata began was to create a viable rural Maori society. Ngata gave a new economic base to the Maori tribes and the Maori remaining culturally strong and achieved a moderate standard of living.
The Age of Dislocation
The most spectacular feature of the preceding period was the rapid growth in Maori population, which doubled between 1886 - 1945 and
81Ihi Consultants, from Putea Pounainu, Ministry of Women s Affairs, Wellington, 1989.
Chapter 1 - Overview 104
again between 1945 - 1966. This rapid growth meant that the economic base in tribal areas was insufficient to provide a decent standard of living for many people.
The Mãon Women s Welfare League was founded to provide support for women and housing for Mãori families, under the Presidency of Whi.na Cooper and Mira Szasy as first Secretary. The Mãori Health League was formed in Rotorua and Mdori women helped pioneer the District Health Nursing programme. In addition, many hoped, as a result of the rise in Mãori aspirations, to take advantage of the economic and educational opportunities of the urban centres. The government, from the 1960s actively encouraged this process. The end result was a massive re-distribution of the Mãori population, which proved costly, from a Mãori perspective, because it separated the young people from their cultural base in tribal areas. I
Rangatiratanga
This marks the period of resurgence of Mãoridom socially, culturally, economically and politically and the acknowledgement of tribal principles as a positive foundation for future change. It began in with the 1975 Mãon Land March led by Whina Cooper. Since then Mori have been looking for a way of overcoming the cultural dislocations of the preceding period, evidenced by welfare dependancy and recent socio-economic hardships. Mimi women began taking a more active role in politics (Whetu Tirakatene-Sullivan - former Minister of Tourism), land issues (Eva Rickard - successfully won a claim! for the return of Mimi land being used as a golf course in Raglan), litrature (Donna Awatere published her book "Mãori Sovereignty"), media (Ripeka Evans was appointed as special adviser to Television NZ), international events (Georgina Kirby, past president of the MWWL and the Te Mãori Exhibition in the USA.).
Now the creation of iwi authorities offers Mãori women another challenge - to accept decision making responsibility at whanau, hãpu, and iwi levels and foster the future development of social, economic,
educational and cultural services. I
Chapter 8- Wi/line Mimi 105
8.3 Mono Wahine82
Me aro koe ki te ha o Hineahuone Pay heed to the dignity of women
Te mana wahine is the concept which symbolises and defines the status, power and authority of Mãori women. In the context of Maori culture, mana wahine is a reminder of Mãori women s matrilineal descent from Papatuanuku, the Earth Mother. It is the vital source of Maori women s contemporary power and authority. It justifies their status in Maori society and carries the promise that the status will continue for future generations of Mãon women.
The notion of mana wahine has embedded within it a philosophy concerning the sphere of influence, a code of behaviour, and knowledge built up over generations. It is the intellectual property that belongs to Mãori women.
The status of Mãori women was based on traditional mores of iwi. Maori women s roles were clearly defined as different but complimentary to those of men. The status of Mãon women was parallel to the status of Mãon men.
A small number of Maori women were included as rangatira (chiefs) who signed the Treaty of Waitangi. Recognition of Mãori women s status to sign on behalf of the iwi or hãpu depended upon the judgement of the British men who negotiated. At least one female rangatira was refused the right to sign. Consequently, her husband would not sign the Treaty document.
Early interpretation of Maori women s status by missionaries and other new settlers signalled the beginning of displacement of Maori women s comparative position with men within their own society.
Colonisation of New Zealand brought with it patriarchal institutions superimposed with a Christian morality and Victorian values. Over time these severely eroded the cultural, social and political structures of Maori people. Maori economic activities expanded briefly in the period of initial contact with Europeans, but contracted rapidly with the slump in the Victorian market in 1856. A sharp decline in Mãori population from introduced disease as well as loss of tribal land through war heightened Maori disillusionment with pãkehã society.
The colonial experience has led to diminished and undervalued status for Maori women s formal role in relation to marae atea, (the open space in front of the meeting house) and the paepae (men s speaking bench). Circumscribed post- colonial roles initially assigned to Mãori women on the marae in the 19th century are also transferred to other institutions. Membership of tribal trust boards established by statute after World War 2 exemplify the extent to which MAori women have been ostracised form participating at decision-making levels of iwi business.
82Women in NZ
Chapter 8- WIhine MJori 106
In recent decades this has been further complicated by a wariness, rarely expressed openly, about promoting Mãon women in leadership roles in non- Mãori institutions. This is especially true of roles such as chairperson or manager where European selectors may be influenced by the false premise that because men sit on the paepae, they alone have speaking rights in MAori society.
Hinga atu he tetekura, arc mci he tetekura A leader falls, another leader arises
The kakano, or seed of women s leadership is contained within the concept of mana wahine. Each kakano is nurtured by kuia. Their transmission of knowledge and culture is vital to the well-being of whanau, hãpu and iwi. These older women, the pou, the central pillar of Mäori society, are respected and honoured for their wisdom and mana.
Very few Mãori, a mere two percent, are aged 65 years and over. This has placed tremendous pressure on kuia (and koroua) in their leadership roles.
As the Mimi population ages over the next 20 years, it has been estimated that the number of kuia and koroua will increase threefold to around six percent of the total Mãori population. Such an increase will potentially provide a sharing of leadership roles. However, the wisdom and mana of kuia may still be under threat of loss as the ill-effects of identified health problems, especially those due to tobacco use, become fully apparent.
Nevertheless, Mãon women continue to provide strong leadership. Mãori oral tradition testifies to the richness in the variety and depth of women leaders. Modem history records the influential roles of Mãori women leaders such as Te Puea, Makereti Papakura and Amiria Stirling.
One of the most significant features of the past 25 years is the increasing extent to which Mimi women have become visible as leaders at the local, national and international levels. Mãori women leaders, like Dame Whina Cooper (first national president, Mãori Women s Welfare League 1951 and Te Matakite - Land March 1975), and Donna Awatere have made significant contributions to the resurgence of Mãon interest in strengthening the social, cultural i political and economic foundation of iwi.
A large gathering of Mãori - the Hui Taumata - called in 1984 by the Government signalled the modem era of Mãori political activity. More recently, the restructuring of the public sector which began in 1984 has had major implications for Mimi women and their families. Changes in the labour market and new responsibilities placed on communities, particularly through the reform of the health and education sectors and devolution of resources and responsibility from central state agencies, have removed bathers to Mãori social women s participation in institutional management, commerce and service delivery.
During this period of rapid change, Mäori women have sought to maintain and enhance their skills. For example, a small grant programme, Putea Pounamu, managed by Te Ohu Whakatupu (Mãori women s section of the Ministry of
Chapter 8 - Wãhine Mlori 107
Women s Affairs) to foster the development of decision-making skills amongst Mãori women reached more than a thousand women in just over two years.
Mãori women actively sought election to new school boards of trustees, area health boards and local government bodies set up recently. Although only a few were successful in attaining elected positions it is unlikely that these opportunities will be overlooked in future. A small number of ministerial appointments of Mãon women have been made to statutory bodies, and a number of communities have co-opted Mãori women onto school boards of trustees.
MAori women still provide a wide range of voluntary services to iwi through both marae activities and community work via government sponsored initiatives such as Maatua Whangai (extended family parent scheme) and Te Kohanga Reo (pre-school language nests). Mãori women often have major management responsibilities on the marae. This is especially evident on formal cultural and social occasions when large numbers of visitors are cared and catered for.
Mãori women continue to play a leadership role in political action over land matters. The kuia (women elders) of Taranaki, for example, are greatly respected for their major role in bringing the Motunui claim regarding their traditional coastal fishing rights and the pollution of their coastal fisheries before the Waitangi Tribunal. Nganeko Minhinnick, Ngati Te Ata has brought the case of her people concerning their ancestral lands, sacred places and waterways before a number of forums including the United Nations.
The Mãori Women s Welfare League, a voluntary organisation, established in 1951 to improve the social well-being of Mãori, has identified and developed a number of Mãori women leaders. Significantly, these women have become prominent leaders in a variety of fields, such as Mãori land rights, the Treaty of Waitangi, business development, the initiation of new social services, health, the arts, sport and human rights.
E kore cc i ngaro te kakano i ruia mcii Rangiatea I will never be lost for I am the seed that was sown at Rangiatea
In the past, responsibility for the transmission of cultural values and traditions was shared between men and women in the whanau. Each passed on traditional, gender-specific skills and knowledge. More and more this general function has been devolved upon women. That Mãon language and culture have survived at all, and are in the process of revitalisation despite conflicting pressures, is a direct result of the role of Mãori women especially in the kohanga reo movement.
The strengthening of whanau, hãpu and iwi is seen by Mãon women as integral to ridding Mãon. This policy, together with the heightened awareness by New Zealanders of the Treaty of Waitangi as a constitutional and political document, has raised the debate of the place and role of Mãori people in this society to an unprecedented level. The political and economic relationships of
Chapter 8- WihineMaori 108
Mãori people with the Crown have become matters for wide public scrutiny with major implications for the improved status of Maori women.
Ko tepae tawhiti whaia ida tata; ko tepae tata whakamaua ida tina Seek out the distant horizon and cherish those you attain
Major policy changes over the last 20 years have been made in a political climate in which the implications of racist policies and past practices for the survival of the race have been particularly stark. Until recently, social indicators have focused policy thinking on remedial rather than long term solutions for the well-being of Mãori.
Health
Mortality and morbidity statistics show that as a group Maori women face the highest health risks in New Zealand, and, in some instances, in the world. For example, Maori women have the highest mortality from lung cancer amongst women in the world, and a lung cancer death rate 3.6 times higher than non- Mäori women in 1986.
The direct cost of hospitalisation of Mãori from smoking in 1988 was over $7 million. In the same year $72,000 was allocated to programmes designed to discourage Mãon smoking. It should be noted that at the same time Maori people contributed $111 million in tax on tobacco products. MAon women s access to health services is limited by a complex range of financial, social, and other barriers. For instance, the fact that the health service provider is from another culture may limit access for women. Yet based on relative risks of premature mortality and morbidity, Maori women should be going to doctors far more frequently than the evidence suggests they do. Recently, these concerns have been addressed by Mãori women s health groups around the country. Many local health centres have been established to provide primary health care services including hearing testing, cervical cancer smears, asthma programmes, and vaccination programmes.
Employment
Changes in the labour market such as business closure or downsizing are likely to be felt swiftly and heavily by Mãori women. Between March 1986 and March 1.990 the unemployment rates for Mãori increased from 8.5 percent to 20.6 percent. The corresponding increase for non-Mãori was from three percent to 6.5 percent. Unemployment has had significant secondary health consequences especially in terms of mental health, alcohol abuse and violence. Mãori women have borne the brunt of this physically, emotionally, spiritually, as well as financially.
Evidence of governmental recognition of the need to accelerate Maori participation in paid work can be found, for instance, in the State Sector Act 1988 which is potentially a strong legal instrument for Mãori women. It requires that each employer governed by the Act have:
Chapter 8- Wahine Miori 109
(b) an equal employment opportunities programme; and
(c) the impartial selection of suitably qualified persons for appointment; and
(d) recognition of- (1) The aims and aspirations of the Mãori people, and (ii) The employment requirements of the Mäori people; and (iii) The need for greater involvement of the Mdori people in the Education service; and.. Women as a large group of public servants, have become increasingly confident and vocal. Mãori women have increased in numbers mainly at lower levels of the public service. They have moved to higher levels in the public service than ever before but remain generally under-represented in senior management. The State Sector Act also provides for a Senior Executive Service of senior public servants across the public service. There are currently approximately 150 public servants in this group at the moment. Of these, twenty are women: one in this group is a Mimi women.
Over the past two decades, Mãori women have entered the labour force in steadily increasing numbers. Statistics indicate that they continue to work throughout the peak of their child-bearing years. They tend to take full-time rather than part-time jobs.
In the late 1980s however, the numbers of Mãori in employment dropped by 41,440 while the numbers of Mãori actively seeking work increased by only 7,500. Some 34,000 seem to have dropped out of the paid labour market. At the same time the total Mãori working age population (those over 15 years) decreased by 21,000 from 173,700 to 152,700 while the working age population for non-Mãori increased. The question arises whether amongst other things, the depression-in the labour market has caused the migration of Mãon people to find paid work overseas, especially in Australia.
In 1986 only 3.1 percent of the Mãori female workforce were self-employed or employers of others (compared to 9.5 percent of the total female workforce and 7.2 percent of the Mâori male workforce). Clearly there is potential for increased participation by Mãori women in the commercial and business sector.
Many are now seeking to establish business enterprises to support themselves and their families, provide work for their families and return some kind of security and cohesiveness to their communities. Networking with other Mãori businesswomen, mentoring and the establishment of a fund for a Mãori Women s Bank are recent examples of Mãori women s initiatives to help support their increasing participation in business.
Chapter - WIhuseMiori 110
Fertility
The availability of effective contraception has given women in general an opportunity to gain a measure of control over their fertility. The extraordinarily large drop in Maori fertility (from a rate of 6.2 to 2.3 per woman) since 1962 would seem to indicate that Mãori women have taken advantage of this facility. However, a closer look at Mãori family planning statistics suggests that other factors are also significant in determining Maori fertility patterns.
First, Mãon women are over-represented among the clients of abortion services. Second, pregnancies among Maori women under 20 years of age appear to be unplanned. Third, Mãori women bear more children than non- MAori women and in a much shorter time frame than was common in the past.
Mãori fertility patterns suggest that contraceptive and family planning information is failing to reach young Maori women. It appears that contraceptives are being used, not as a means of planning and managing family formation, but as a means of bringing about the cessation of child bearing.
Education
Statistics point to the improvement in the rate of school qualifications attained by Maori girls over the last twenty years. Nevertheless Maori girls still lag behind the educational attainment of other New Zealand girls.
Over a third (39 percent) of all MAori girls leave school with no formal qualifications. More than half will have left before School Certificate exams, and those who do pass will average a Cl grade: 31 -44 percent.
The challenge to improve Mãori educational attainment is implicit in the findings of the Waitangi Tribunal on Te Reo Mãori in 1986: Judged by the system s own standards Mãori children are not successfully taught, and for this reason alone.., the education system is being operated in breach of the Treaty. It seems that the incentives for education agencies are too weak to address the failings of the system in the education of Maori girls. Maori people have responded to these signals in the first instance by establishing Te Kohanga Reo and then more recently through the development of kura kaupapa Maori. Te Wananga o Raukawa was the first modern iwi tertiary institution to be established and others are proposed. However other education agencies have yet to provide high quality education for Maori children.
Mãori women were consulted extensively in the formulation of Maatua Whangai, Tu Tangata, and Kohanga Reo programmes. They also participated on a voluntary basis in their implementation. Indeed, were it not for the unpaid effort of the women none of these programmes would have got off the ground. All are based around the concept of whanau. Chapter 8-WihineMiori 111
8.4 Whala TO Iti Kahuran9183
Recommendations:
It is a basic principle that when identity is restored to a person, to a people, that negative conditions are arrested and health and self-esteem is restored, and the quality of life will promote peace and confidence to the nation". Our recommendation, based on this principle, are as follows:
That Papatuanuku is nurtured and preserved, and that her resources are maintained and distributed equitably among her descendants. To continue in the direction that this country is heading is to invite the wrath of Papatuanuku.
2 That Mãori women s autonomy is restored throughout society in Aotearoa and that she is granted resources to assist this process (for example, rewriting her own story, and thereby resurrecting her own mana and tapu).
3 That Mãon women be given access to participate in the management of resources of the country (for example land and fish), and the opportunity to develop their own corporate (whanau) structures to ensure the welfare of all.
4 That decision-making processes with respect to the economic and social development of Aotearoa persues a partnership, under the Treaty of Waitangi, that promotes whanau, hãpu and iwi decision-making processes, and takes account of the fact that information gathered and analysed, as part of national decision-making processes, is at present carried out in a predominantly monocultural framework.
In conclusion, we return to the proverb provided at the beginning of this paper:
Whaia te iti kahurangi Kite tonu koe, me he maunga teitei
Seek ye the treasures of your heart. If you should bow your head, Let it be to a lofty mountain.
In reclaiming Mãori women s autonomy we seek to reunite with Papatuanuku and her resources. To assist this process, we claim, in economic terms, fiscal
83Whaia Te Iti Kahurangi - Maori Women Reclaiming Autonomy, Vapi Kupenga, Rina Rata, Tuki Nepe & Alison Robins, November 1988. Prognosis for the Socio-Economic Future of Maoridom, Submission to the Royal Commission on Social Policy, Marsden, Rev M, 1987.
Chapter 8- WI/line Mori 112 protection to quantify the quality of life for whanau, thereby ensuring te mana me te tapu o te wahine.
"He putiputi kei i a ia ano tona kakara" "A flower that exudes her own fragrance"
Chapter 8- WJhineMiori 113
8.5 Mâori women and social policr
18 01 r-101UVIIII
The final submission from the Director-General of Health states that:
"We recognise that New Zealand will succeed in the achievement of "Health for All by the Year 2000" only if the particular health needs of the Mãori people are met..."
In their submission to the Royal Commission, Mãori women deplored the low health status of Mãori as a whole and Mãon women in particular. They identified the broad range of changes that are required if the low health status of Maori is to be improved. These include:
easier access to health facilities in rural areas;
health programmes and clinics to be set up on marae;
clinics to incorporate Mãori tradition and custom;
• encouragement of a closer liaison between community and medical services; • positive action to encourage Mãori people to enter the health areas;
delivery of health services through tribal authorities;
representation of Maori authorities on Area Health Boards;
• elimination of culturally inadequate, and at times offensive practices such as the burning of the whenua after childbirth;
further research into the causes of Mãon health problems;
• education aimed at young Maori women regarding health hazards such as smoking and aimed at raising contraceptive awareness.
Maori women also identified the paramount importance to their health and status in terms of their spiritual links to the land.
Statistics highlighted by Dr Em Pomare in a paper to the Medical Research Council Jubilee Symposium in 1987 emphasised both the low health status and the lack of access to appropriate services experienced by Mãori.
A study of Maori health by Neil Pearce and Allan Smith in 1984 estimated that only 20% of excess Maori mortality could be ascribed to socio-economic
85Maori Women and Social Policy, The Royal Commission on Social Policy.
Chapter 1- Overview 114 factors. The dramatic differences between Mãori and non-Maori in mortality rates from some diseases, they suggested, could be explained by lack of equitable access to appropriate health services. This is not news to Maori women who in recognising the appalling short comings in the health services and distribution of resources, have challenged existing systems and developed their own alternatives.
Maori women have fought long and hard for Mãori health care. In the early 1900s Princess Ic Puea of the Waikato tribes sought to build a hospital in her tribal area so her people, almost destroyed by the settler introduced diseases of small pox, could remain near their whanau. The public health authorities blocked this idea even then.
To foster an interest in health maters has been a principle aim of the Mãon Women s Welfare League since its inception in 1951. The leagues major health survey -Rapuora, Health and Mann Women - provides a unique source of information for current and future policy makers. It also demonstrates the value of having Maori women control, plan, carry out and analyse substantial research projects within their communities. Practical outcomes from the study include the establishment of Whare Rapuora, that is Maori health centres for clinical, social and health activities; preventative programmes such as "smash the ash" (an anti-smoking campaign), and a campaign for the inoculation of Mãori communities against Hepatitis B.
Innovative health initiatives are developing on some marae, such as Waahi in Marae Huntly. Here Maori community health workers operate in partnership with Hospital and Area Health Boards, have close links with the Department of Health and promote preventative health care and the holistic aspects of Mãori health. They cater for the person as a whole rather than parts of her or him (such as ears, throat, feet specialists).
There has also been an upsurge in the number of organisations bringing a Mãori perspective to particular aspects of the health services. These include:
the Maori Nurses Association which has been instrumental in promoting and encouraging Maori women and men to enter the nursing profession by assisting in the establishment of a preparatory training course. It has also acted as a major channel through which Maori nurses support and promote Maori initiatives and actions within the health services;
Te Waiora o Aotearoa Trust which aims to educate and enhance the well-being of Mãori people through the medium of video and the encouragement through Trust funding of Mãon sporting, cultural and holistic health oriented activities;
Te Puea, Michael King, p 72-73, 1977.
Chapter - WãhineMdori 115
Te Kakano o te Whanau Trust, a national network of Mãori women s groups working in the area of sexual abuse and violence with whanau members.
Activities by organisations such as these draw attention to the limitations of many existing services, the inadequacy of the information on which they are based, and the possibility of alternatives in decision making processes and in the provision of services.
The final submission of the Department of Health continues by saying:
"Devolution of responsibility for health care for the Mãori people is an issue which requires resolution within the wider move to create a network of area health boards. We are all aware that the health of the Mimi people lags behind that of the non-Mãori population in many respects. There is a need for formal recognition of the principles of the Treaty of Waitangi, and for the identification of ways to foster biculturalism and partnership between Mãori and non-Mãori. It is hoped that options for the respective roles of central government, area health boards, iwi authorities and Mãori people themselves will be identified in discussions with those most concerned with this issue"87.
The Health Department, Hospital Boards and other medical institutions are beginning to respond to the pressure created by the facts of Mãori ill-health. Mäori women have already done much to bring about improvement in the health of their people but they stress that there is still much to be done. The need for comrehensive action is urgent. The involvement of Mãori women in any future discussions such as the implications of the Gibbs report Unshackling the Hospitals , and the composition and administration of Area Health Boards, is vital to any future planning in the area of health.
Directions (recommendations):
That legislation be brought in by Government to amend the Area Health Boards Act 1983 so that the following can be included:
(a) Re-writing of the Act to recognise the Treaty of Waitangi, its spirit and principles as related to the health of Mãon.
(b) That in true partnership, the Area Health Boards Act include membership to equal 50% Mãon representation as elected by the iwi, not through the present voting (democratic) system where Mãon people can always be outvoted on numbers alone.
"Final Submission to the Royal Commission on Social Policy, Department of Health.
Chapter 8- Wr7huze Mimi 116
(c) That direct allocation of Vote:Health resources and funding be based on people s needs in which a target area would be Mãori health.
2 That a Mori Health Authority/Commission be set up in place of the existing Mãori Health Standing Committee (under the New Zealand Board of Health) with direct allocation of Vote:Health resources and funding. This Authority/Commission to work in close liaison with:
- Central Government - Minister of Health - Health Department, Head Office - Area Health Boards - Tribal/Iwi Authorities.
I
Chapter 9- The Health Status ofMäóri Women 117
CHAPTER NINE
THE HEALTH STATUS OF MAORI WOMEN.
This section gives a description of the factors thought to influence Mdori women s health staus.
A brief summary of health status indicators for Mãori women is also given.
Chapter 9- The Health Status ofMãori Women 118
9.1 Achieving A Better Health Future For Mâori Womenu
3 It has long been recognised that the health status of Mãori people compares most unlavourably with that of the non-Mãori majority. However, only recently has it been acknowledged that the underlying structural causes of this inequality are economic and political and related to the failure of the implementation of the principles of the Treaty of Waitangi. The double disadvantage of suffering from diseases of poverty and affluence appears to be a triple disadvantage in the case of Mãon women with their lesser access to employment, income, education, and associated life chances.
4 Four basic groups of factors may be considered to impact upon the health status of Mimi women and therefore to explain existing inequalities. These are:
• biological • life style/behavioural • environmental/structural • health and medical services.
There is little evidence that biological factors are important in explaining inequalities.
Behavioural factors, while important and mutable, are to a large extent determined by materialist/structuralist factors such as the social, economic and political environment including access to work, housing and education.
Health and medical services are relatively unimportant in their influence upon health status, especially mortality, and hence in explaining inequalities.
5 Economic factors impacting upon health status include:
• income • unemployment • education, and • housing.
In all these factors, Mãori women are particularly disadvantaged with respect to access. From the evidence available this can be expected to have an important impact on their health status and general well being.
88Ecnic and Organisational Factors In Achieving A Better Health Future For Maori Women, Laurence Malcolm et aL, Paper prepared for the Ministry of Women s Affairs, June 1991.
Chapter 9- The Health Status ofMiori Women 119
6 There are serious inequalities in the availability of health services in New Zealand. This evidence is suggestive that this especially limits access to Mãori women. These inequalities are geographic, for example the contrasting availability of general practitioner services between central and south Auckland. They are also allocational, for example, the emphasis upon pharmaceuticals, rather than education and support services, and are strongly influenced by the status of provider groups and pharmaceutical companies. Despite this there are no structures in place, at either the national or area health board level, to address these inequalities or to establish an accountability framework in order to achieve desired health and health service goals.
1 P TrnTI
A workshop on primary health care in an area health board context in March 1988, organised by the Board of Health, recognised the WHO concept of health as being89:
• a philosophy concerned with social justice, equity, self-responsibility and a broad concept of health
• a strategy in which services are accessible, relevant to the needs of the population, functionally integrated, based on community participation, etc
• a level of care to which the population has first contact when it has health care problems
• a set of activities including health education, maternal and child health care, immunisation, basic treatment of health problems, provision of essential drugs, etc
The workshop took the view that all primary health care activities should be delivered through area health boards... A model of this process-proposed that
• primary health care is the foundation service for the area health board
• that from a Mãori health service perspective funding be channelled to iwi authorities not only primary but secondary care funding through referral from primary to secondary care services
that this should be based upon the principles of the Treaty of Waitangi and the philosophy of primary health care should be the driving force behind all the boards activities.
8911nn .ary Health Care in an Area Health Board Context, New Zealand Board of Health, Department of Health, March 1988.
Chapter 9- The Health Status ofMr7ori Women 120
9.2 National Perspective of Mâori Women s Health9°
This section highlights the leading causes of death and hospitalisation of Maori females in comparison to non-Mãori females for the total New Zealand population. Leading Causes of Death
Table 1 shows
major causes of deaths in New Zealand for 81 percent of all deaths
• death rates per 100,000 population directly age standardised to the New Zealand total population
Table 1: Major causes of death in the New Zealand population, all ages by Mdori female and non-Maori female, 1990.
Cause of Death Mãori Female non-Mãori Female neoplasms 252.9 173.4 ischaemic heart disease 236.7 147.3 cerebrovascular disease 100.0 76.3 cord 85.8 25.4 lung cancer 69.5 22.6 other heart disease 52.4 29.7 breast cancer 31.8 36.4 large bowel cancer 25.6 27.7 injury and poisoning 28.5 31.6 pneumonia and influenza 23.6 28.1
all causes 1040.5 631.2
A Brief Summary
• death rates are higher for MAon than non-Mãori for all age groups except females aged 15-24 years • death rates increase with age (except for the youngest age group) • the smallest proportionate difference between Maori and non-Maori occurs in the 65 and over age group - particularly since there are many more non-Mãori in this age group than there are Mãori • ischaemic heart disease and other forms of heart disease total 289.1 per 100,000 people or 27.8% of the total causes of Maori female death.
90Maori Womens Health Statistics 1986-1991, Hineringa Trust, A report for Population Health Services, 1993.
Chapter 9- The Health Status ofMäori Women 121
Table 2 shows:
age-specific rates per 100,000 for age groups, and age standardised rates per 100,000 for all ages (standardised to NZ total population) between the ages of 15 -24 the mortality rate of Mãori women is at its lowest, almost on par with the non-Maori rate for all causes of death and at all ages, the Mãori female rate of mortality per 100,000 of the entire NZ population is higher than the non-Maori rate
Table 2: Death from all causes in New Zealand by Mdori females and non- Maori females and age, 1990.
Age Group Mãori Female non-Mãori Female
0-14 117.3 68.4 15-24 54.7 57.5 25-44 164.8 94.8 45-64 1370.6 578.5 65+ 5955.8 4884.2 All ages 1040.5 631.2
Leading Causes of Hospitalisation
The major causes of hospitalisation in Table 3 accounts for 63% of public hospital separations in 1991. Separations are discharges, deaths or transfers.
The all-cause rate of hospitalisation in New Zealand is 41% higher for Maori females than for non-Maori females.
Other differences in the all-cause rate of hospitalisation in New Zealand for Maori females and for non-Mãon females is detailed in the following table:
Table 3: Leading Causes of Hospitalisation of Mdori females with percentage differences in comparison with non-Mãori.
Causes % Higher Causes % Lower Pregnancy and childbirth 31 Genital organ disease 8 Injury and poisoning 17 Ischaemic heart disease 1 Neoplasms 19 Perinatal conditions 22 Symptoms/Ill defined 26 Arthropathies 2 conds. cord 187 Other heart disease 176
Table 4 shows hospitalisations for all causes for Maori females in comparison with non-Mãori females by age in 1991. These are age-specific rates per 100,000 for age groups, and age standardised rates per 100,000 for all ages, standardised to New Zealand total population.
Chapter 9- The Health Status ofMdori Women 122
Table 4. Hospitalisations for all causes for Mdori females in comparison with non-Mdori females by age in 1991.
Age Mãori non-Mãori differences % of Mãori Females (M) Females (M) - (nM) Female (nM) hospitalisatio n against Total Mãori Female 0-14 11929.6 14029.9 -2100.3 9.7 15-24 29399.5 16925.1 +12474.4 23.8 25-44 27041.7 20398.8 +6642.9 21.9 45-64 20130.0 11370.8 +8759.2 16.3 65+ 34899.2 26558.9 +8340.3 28.3 Total 123400.0 89283.5 +34116.5 100.0
Priority Ranking Diseases and Conditions
Key conditions affecting Mãori women are:
• heart disease: chronic rheumatic, hypertensive and other forms of heart disease • cancers: lung and cervical cancer • respiratory diseases: asthma, chronic obstructive respiratory disease (cord), pneumonia, and acute respiratory infections (infants) • diabetes • sudden infant death syndrome (infants) • mental health conditions: total admissions to psychiatric hospitals and institutions licensed under the Alcohol and Drug Addiction Act, schizophrenic psychoses, and alcohol and drug dependence and abuse.
Mimi females have higher overall rates of death and hospitalisation relative to non-Mãori females. Ischaemic heart disease, chronic rheumatic heart disease, lung cancer, cervical cancer, chronic obstructive respiratory disease and asthma were listed as the most important health status areas in which to effect reductions in incidence.
Finally, Mãon females tend to have children at a younger age than non-Mãori females and this is reflected in the higher rates of childbirth and pregnancy complications.
91Source: Maori Health Statistics in the Auckland Region, Triggs & Coulson, Department of Health, Wellington, 1992.
Chapter 10- Mod Women s Perspectives on the Treaty of Waitangi 123
CHAPTER TEN
MXORI WOMEN S PERSPECTIVES ON THE TREATY OF WAITANGI
This Chapter briefly presents a Mãori Women perspective on the Treaty of Waitangi. Chapter 10- MIon Women s Perspectives on the Treaty of Waitangi 124
10.1 Mäori Women s Perspectives on the Treaty of Waitangi2
Much has been written on the Treaty, but a perusal of the extensive writings available reveals that the status, existence and rights of Mãori women guaranteed under the Treaty of Waitangi have never been addressed or actively protected through legislation since 1840.
It is not generally known that at least five Mãori women signed the Treaty of Waitangi, they were:
Ana Hamu, the widow of Te Koki, original patron of the Paihia Mission.
2 Te Rau o te Rangi (Kahe) of Te Whare Kauri and Ngati Toa, at Port Nicolson. This same Te Rau Rangi swam from Kapiti Island to the mainland with her baby strapped on her shoulders to warn her people of invaders from Kapiti.
3 Rangi Toperoa - an Ariki of Ngati Raukawa and Ngati Toa, at Kapiti. A Chieftainess and one of Te Rauparaha s military strategists.
4 Rere 0 Maid, a woman of rank at Wanganui.
5 Ereonora, a high born wife of Nopera, Chief of Te Rarawa - at Kaitaia93.
It is significant that Mãon women were party to the covenant which established the New Zealand nation and the hopes of our tupuna for the future. This has been a major revelation to modern Mãori women as an indication of our status and mana and the attitude of our tribes towards women in pre-European times.
What is startling, though affirming of the mana of Ma-on women, is the information revealing that more women of high rank and standing could and should have been signatories if they had been-allowed by Government agents, such as Major Thomas Bunbury, to sign the Treaty.
"Bunbury, however, refused to allow the signing of the daughter of Te Pehi the celebrated Ngati Toa chief.... The woman was naturally angered by the insult. Her husband ... would not sign as a consequence94.
This is a dramatic illustration of the imported cultural values and attitudes imposed by representatives of the English Settler Government.
92Mi Women and Social Policy, Royal Commission on Social Policy. 93The Treaty of Waitangi, Claudia Orange, p 90,91; 1987. 94The Treaty of Waitangi, Claudia Orange, 1987. Chapter 10- Mãori Women s Perspectives on the Treaty of Waitangi 125
The Treaty of Waitangi is seen by Mãon women as a covenant which sought to establish partnership and a code for co-existence between Mãori tangata whenua and the settler Government. Both partners stood to gain as partners in a new enterprise.
To Maori women it is seen as an affirmation of their mana wahine as equal participants within this partnership - "Ici nga tangata katoa o Nu Tirani" (Article 2) ("to all the people of New Zealand").
Maori women have fought for the mana of the Treaty of Waitangi.. . .The principles of partnership and equality enshrined in the Treaty must, in reality, be applied to Mãon women in all spheres of the economic, social and spiritual development of Mãon people.
In the 1930s, Princess Te Puea Herangi wrote in a song about the Treaty -
"Te Tiriti o Waitangi, e tu moke m gi ra, i waho i te moana e..."
She likened the Treaty to a lonely lost soul, adrift at sea. Maori women assert that this analogy has been held by many for too long.
Mãori women require Government to fully accept and openly inform the nation that the Treaty of Waitangi must be entrenched as the constitutional basis, the supreme law for the country s present and future actions.
2 The Government must recognise the need for initial and ongoing negotiation with a Central/National runanga authentically representative of Maori views and opinions. It must establish this by seeking the views of Maori people as to its form, membership and accountability and its terms of reference for the implementation of partnership at all levels of social, administrative and economic activity.
3 The Mãori contingent of this Official Runanga must be at least 50% Maori women, proportionate to the number of Mãori women in the Mãori population and in keeping with Tikanga Mãori. It must be fully resourced and staffed with the same membership ratio in mind. This principle of representation must extend to all areas of decision-making.
4 Government must develop and implement a contract of compliance requiring that any agency or organisation entering into a contract with Government to receive funding for the delivery of services should be required to have 50% Maori, 50% non-Mãori membership, and that Chapter 10- Miori Women s Perspectives on the Treaty of Waitangi 126
men and women should be equally represented in each group.
5 A need exists for an independent Commission - such as a Waitangi Commission which would have an initiating, developmental and monitoring role with regard to the implementation of the Treaty. The Waitangi Tribunal would be an arm of this Commission s operations.
6 Government should rigorously enforce its policy of 1986 where departments were to report on the implications of the Treaty of Waitangi with regard to any new or impending legislation. These reports in the future should be referred to the Commission before proposed legislation is available for public submissions.
7 Government must include the wording of Section 9 of the State Owned Enterprises Act 1987 "Nothing in this Act shall permit the Crown to act in a manner that is inconsistent with the principles of the Treaty of Waitangi" in all future legislation, or a similar statement recognising the mana of the Treaty. This should take effect immediately.
8 Government must acknowledge the call of Mãori women for recognition of their children as nga taonga katoa entitled to protection under the Treaty of Waitangi. The 1985 amendment to the Treaty of Waitangi Act 1975 increases the scope and authority of the Waitangi Tribunal, with regard to any act, policy or procedure administered by instruments of the Crown. Thus all legislation and departmental procedures relating to the welfare of children and families should be redrafted with regard to the rights of the whanau, the rights of the individual child and the implications of the Treaty in mind. Chapter 11 -Mion Women: Smoking and Housing 127
CHAPTER ELEVEN
MXORI : W,OMEN AND SMOKING
MA.ORI WOMEN AND HOUSING
This Chapter presents the findings and recommendations of several reports which have been produced on Mdori Women and Smoking.
This Chapter also presents the findings of a report produced on Mãori Women and Housing.
Chapter 11- Miori Women: Smoking and Housing 128
MAORI WOMEN AND SMOKING
11.1 Kid Manawanufrs
CONCLUSION
The results of this study provide a profile of Mãori women and smoking.
Mãori women start smoking at a very young age between 12 and 16 years. The mean age was 14.8 years.
Inform 2, everyone did it.
Cigarettes, either tailor-made or roll your own were the preferred tobacco product. One particular brand of cigarettes is smoked by almost one third of Mãon women smokers. The producers of this brand have marketed their product well.
I smoke these ones because they re cheap. They re the only ones I can afford.
Almost 60% of the smokers described themselves as being a "medium smoker" and said that they consumed at least half a packet of cigarettes per day. Most of the women who regarded themselves as being a "heavy smoker" consumed one or more packets of cigarettes per day.
The first cigarette starts the day.
Peer pressure and the fact that "everyone else is doing it" is the main reason why Mãori women take up smoking. "Being cool" and wanting to "be in the in-crowd" are the incentives that lead Mãori women to take up smoking.
Everyone else on the school bus smoked and I wasn t going to be the odd one out.
There was an overwhelming association of smoking with the consumption of alcohol. Going to the pub, to parties and social functions where alcohol was consumed were the occasions that Mimi women tended to smoke more.
When I m having afew drinks I ll smoke a lot more. I ll go through a whole packet in a night.
95Kia Manawanui, Ng! Wâhine Mãori me te Kai Paipa, John Broughton & Mark Lawrence, University of Otago, 1993.
Chapter 11- Mimi Women: Smoking and Housing 129
Almost three-quarters of the smokers had attempted unsuccessfully to quit smoking at some stage in their lives. The reasons for wanting to quit smoking was because of the detrimental effect that smoking has on health and for the costs incurred in buying cigarettes.
IfI gave up smoking it will save me a lot of money.
It could buy my babies some bread or milk, food I haven t got.
For the women who had quit, stress was the main reason for the resumption of smoking. Realising the fact that smoking had become a habit they "couldn t help" was also significant.
I can t last longer than a day without a smoke. Ifeel I can t go without it. It s a habit. I need it.
The women admitted that the main reason why they continued to smoke was that they had become addicted.
It s never lasted very long being off the smokes. It s an addiction that I haven t dealt with.
Those women who were non-smokers had never taken it up because smoking was something that they "just didn t like".
It was something that I always found revolting.
Ex-smokers, people who had quit completely, did so mainly for health reasons.
I was always coughing, coughing, coughing. Then I knew what I had to do.
As women get older, fewer and fewer quit smoking. Most women who quit smoking did so in their twenties. Over the age of 45, very few Mimi women quit smoking.
Well I never drank beer. I never gambled. When you re stressed out and haven t got any money you can t go out for a social life-e. So what do you do? Have a smoke.
This is a very significant statement as it illustrates quite plainly the position of many Mimi women in contemporary New Zealand society and the context within which smoking becomes a necessary and important part of their lives.
Once smoking becomes an addiction it is very difficult to overcome. Having a positive mental attitude to the process of quitting smoking was the main factor that made it easy to quit smoking. "Giving up smoking was the easy part, staying that way was the hard part" was a common sentiment.
Chapter 11- MJort Women: Smoking and Housing 130
After the third fry at giving up it wasn t so bad, it was more willpower than anything else.
Over 90% of the women believed that smoking was harmful to health. Cancer and lung cancer in particular were recognised as being the main harmful effects that smoking had on health. The effect that smoking had on body functions and performance were also recognised as being important.
However only two women associated the harmful effect of smoking with Sudden Infant Death Syndrome (Cot Death). The messages as far as this health problem is concerned has not got through to Mãon women. Health promotion campaigns associating Sudden Infant Death Syndrome with smoking do not appear to have been effective within the Mãori community.
In summary, Mãori women start smoking at a young age because "everyone else is doing it". Once taken up, smoking became a habit and an addiction. Smoking by Mãori women is so prevalent that it has become a "cultural norm". Young children growing up surrounded by smokers learn that it is an acceptable part of social activity and the cycle is continued.
Ijust followed the whanau, they all smoked
In order to break the cycle, prevention programmes must be aimed at young people so that they do not start in the first place. Smoking must be seen as being "uncool". As the addiction stage of the smoking process is the most difficult one to deal with, cessation programmes must have a community or population based approach. There is very little use in getting one member of a household to quit smoking. The whole household must move together.
I started smoking again because of all the smokes in the house. Everyone smoked so they were just there.
Prevention and health promotion programmes about smoking must be aimed specifically at Mãori people to be effective. This means they must be culturally appropriate and acceptable.
I prayed to God to help me as I knew I couldn t do it on my own. Praying made it happen. But it was much more than that, it was tikanga Mdori, you know, the wairua. Now I have the strength to say NO.
The first step is to identify exactly what health messages need to be addressed. For example:
• Smoking uptake by young people. • Smoking as a social ritual.
Chapter 11- Miori Women: Smoking and Housing 131
• The actual expense of smoking. • Underlying lifestyle factors that maintain smoking. • The association of smoking and Sudden Infant Death Syndrome (Cot Death)
The next step is to identify exactly who delivers these health messages to the Mãori community. The answer is obvious. It has to be us. The only way to effectively address the question of Mãori people and smoking is to put tino rangatiratanga into action:
OfMJori People. By Miori People. For Mdori People.
Underlying the comments and attitudes of the Maori women in this study to smoking was a very strong political statement. In fact what they were saying could be seen as a reflection of the position of many Mãon people in New Zealand society today:
What has smoking done for our people? I ll tell you all right. The destruction of our people as a whole, that s what. Smoking is a drug that controls people and their lifestyle. It can be the worst of the worst of enemies. It just runs you to the ground Our Mdori people are so active and I think it s a sign of showing how active we are, or we aren t. Because smoking slows you down.
The most oppressed people are smokers and Mãori women are the most oppressed people in Aotearoa. There s no way out for us as far as smoking is concerned until Mdori women have some power. I don t see it happening. Everything is against Mãori women which causes stress and that causes them to smoke.
Our people are so oppressed, socially, economically and especially culturally that it s so easy to just reach up and grab a smoke. The thing to overcome smoking for us as a people is that it has to go right back to giving us back our rights as a people. We decide and control what s best for us. Only then can these things be addressed. It has to be the whole iwi, whatever that s made up of to make the decisions and to be in control. Not just the hapu, the whanau, the individual person, but the whole iwi.
Chapter 11- Mlori Women: Smoking and Housing 132
11.2 Te Taonga Ma! Tawhitfr6
Nga whetu kapokapo Navigation points
Tobacco kills Mimi. It causes death and disease and limits our development socially, culturally, politically and economically. Yet despite this threat to our health and social development, tobacco-use continues to feature prominently in our lives.
The aim of Te-Taonga-mai-Tawhiti has been to show how and why tobacco is such a threat. In summary:
History
• Tobacco is an introduced drug now known to be extremely poisonous. • Since its arrival in Aotearoa, smoking tobacco has become popular amongst us. • At the start, Mãori women took up smoking tobacco at the same rate as Mimi men. • When the health risks associated with tobacco-use became well established in 1948, the high prevalence of smoking among Mãori was well known. • Until 1984, no specific attempts were made to ensure we had access to information and intervention programmes. The level of financial support for these programmes has been disproportionately low compared with the need.
Death and disease
• Tobacco-use is the current major health crisis for Mãori. The disproportionate rate of Mori suffering from tobacco-related disorders is obvious in Mãori health statistics. • It s not only smokers who are at ask. Our tobacco smoke kills and injures non-smokers around us: family, friends and colleagues. Our tamariki are particularly vulnerable. • Smoking around children is deadly for them as well as us. It restricts their development and prepares them to become the next generation of smokers. • Tobacco contains many cancer-causing agents. Mãori people have disproportionately high rates of many cancers. • Tobacco also contains nicotine, which has been found to be as addictive and dependence-producing as hard drugs. The feeling of relief, enjoyment and satisfaction that a smoker feels after a cigarette, reflects the temporary relief from nicotine withdrawal
96Te-Taonga-Mai-Tawhiti, Te Rahori Trust, Paparangi Reid & Robert Pouwhare, 1991.
Chapter 11- Mimi Women: Smoking and Housing 133
symptoms. Nicotine addiction makes it difficult for many smokers to quit. Tobacco kills nearly 600 Mãon people prematurely every year.
The money
Tobacco takes hundreds of millions of dollars out of the Mãori economy.
• Tobacco multinationals profit by billions of dollars by marketing this poisonous drug, throughout the world. Their first target was men, their second was women and teenagers, and they currently have in their sights, tangata whenua throughout the Third World. • Governments are compromised because so many voters are smokers and tobacco companies contribute to political parties. Our government takes over $111 million each year in tobacco taxes from Mãori smokers, far exceeding the resultant hospital costs by Mãori of $8.5 million per year. They have a strong, incentive to keep us smoking. • Tobacco companies sell cigarettes which kill people but support sports and lifestyle events to gain a healthy, youthful and sexy image. The reality is that smoking, tobacco is deadly, dirty and ugly.
13 tT Li) I1F.i IM iii f }Ns1
He wahine, he whenua ka ngaro te tãngata
This whakatauki indicates how our ancients valued women. Land and women were two essentials for which they were prepared to die. Today, Mãori women are still the hub of our whanau, hãpu and iwi.
A critical issue for all Mãori is that of tobacco-use among, Mãori women. Although we re the main movers and shakers in most Mãon health initiatives, Mãori women are also the major victims of tobacco- use. Breaking, the cycle of tobacco-use amongst us will require much support by, and for, Mãori women.
Smoking has become endemic amongst us. There is some evidence that as many as 75% of young Mimi women smoke. It has almost become a cultural norm.
Research indicates several factors which maintain this status quo: • We have a longer history of tobacco-use than other women. This means it may be more deeply entrenched in our society. • We have more parents, siblings and friends who smoke. We are therefore more likely to start and continue smoking tobacco. Its also harder for us to be disapproving when our children want to start.
Chapter 11- MIon Women: Smoking and Housing 134
Women smoke for different reasons than men. We are more likely to smoke in response to stress. Men are more likely to enjoy a cigarette as part of relaxing. Women use tobacco to cope with anger and frustration, with depression and conflicting demands, with conflicts in body image, and often to claim some time for ourselves. Women have been the focus of tobacco advertising and promotion, which works at a subconscious level, emphasising images of independence, slimness, social and sexual success, freshness, health and fitness. Women have been slower to quit tobacco-use than men. Until very recently, most campaigns to quit have been designed by pãkeha men.
Smoking is related to our social position in society. In New Zealand, it is associated with disadvantage of all kinds: gender, race, social, economic, and education. Smoking amongst Mãori women is also a reflection of the sexist and racist society in which we live. Future directions
Our ability to move forward and develop depends on our ability to recognise and evaluate those things which are holding us back. Tobacco use has dramatically affected Mãori cultural, social and economic development. If left unchecked, tobacco will continue to limit Mãori development and colonise our future potential.
While recognising the forces working against us, we must believe that this is one issue where we can take control of our lives, both at the individual and collective levels.
To break the cycle we must: • decrease the numbers of us who start smoking • increase the numbers who are quitting.
Decreasing uptake
Our tamariki are starting to smoke at a really young age. Many start before the age of 10 years. They are vulnerable to the pressures of tobacco advertising. Tobacco companies spent $11 million in 1988 promoting their products and brand names in Aotearoa. As older smokers die or quit, new recruits are needed. Tobacco advertising and promotion prepares 50 New Zealand children to start smoking each year.
To decrease uptake we must give strong clear messages to our rangatahi: • that tobacco-use is not traditional • that advertisements lie. Tobacco is not cool, sexy and healthy. It s dirty, dependence-producing and deadly
Chapter 11- Mimi Women: Smoking and Housing 135
that tobacco is part of the politics of poverty and oppression. We pay the price while others-governments and tobacco multinationals-reap the rewards.
Increasing quitting
Quitting depends on three main factors: • our self-confidence that we can do it • overcoming our dependence on cigarettes • coping with the stress in our lives.
The key to quitting is motivation. We have to psyche ourselves up, and have confidence in both our objective and ability. The vast majority of us will quit by ourselves, while some will need the support of special programmes and groups. Most will take several attempts before quitting, for life. If the worst happens, and we start smoking, again, we mustn t freak out. We just need to build up the motivation and confidence to try again. The support of friends and family will be invaluable.
To decrease our dependence, we need to understand when and where we smoke. Some may find substituting a low tar brand useful, and others may prefer a gradual reduction programme, but most people find cold turkey the best way. Decreasing the stress in our lives is difficult because so much is external, outside our control. Family and friends will need to support us during our quit period.
There is however, one thing that we can all do NOW, without too much difficulty, which will both help lower uptake and increase quitting:
DON T SMOKE AROUND OUR TAMARIKI.
This means our children will be in an environment where tobacco is not normal and accepted, but recognised as dangerous and expensive. It also provides a supportive environment for those who wish to quit. J4i rru i-iioi 41
Our ancestors were great navigators, who regularly traversed the greatest expanse of water in the world, Te Moananui-a-Kiwa.
Without doubt, our tupuna were confronted by huge obstacles during these long voyages, around which they had to navigate.
To help them survive these extraordinary feats, they used their extensive knowledge of the stars. These stars, nga whetu kapokapo, were their navigation points, their information base.
Chapter 11- Miori Women: Smoking and Housing 136
In our journey through life, we also meet many obstacles. As the 21st century approaches, tobacco presents itself as a major obstacle for Mãori survival. Using the information we now have, we too must navigate our way into a secure future.
E te iwi, kua hora te kaupapa. Kare i tua atu i te korero, kei ia tatau tonu to tatau oranga. Kotahi tonu te korero-ko tenei kai te hikareti, he paihana e patu aria ia tatau Ida mate! Kia mataara e te iwi, Ida mataara! Kaua e tuku ma tenei kai-kino a tauiwi tatau e patu.
Kia kaha! Kia manawanui! Kiaukitewahipai Ki te wahi ora Kia ora koutou katoa!
Chapter 11- MIon Women: Smoking and Housing 137
11.3 Mâori Women and Smokin997
Smoking is closely associated with economic stress.
Mdori people are the lowest wage earners in New Zealand and added to the economic stresses of unemployment, poverty for many families has become a way of life.
Sixty-three percent of Mãori women smoke, compared to 31% of non-Mãori women.
Smoking has become the accepted norm among younger Mãon women. In Ritchie s 1985 study of teenage smoking, the Mãori smokers started smoking at an earlier age than non-Mãori smokers, more of them intended to smoke in the future, more of them came from families where other family members smoked, and their parents were less likely to disapprove of their smoking.
The authors of Hauora were concerned about the high smoking rates of Mãori women for its implications in terms of the Mãori family and social structure as Mimi women have such an important role, not only in parenting and nurturing but also in the leadership role they play in the Mãori community.
The high rate of smoking amongst Mãori (men as well as women) is an issue not only of health but of equity between Mdori and other races. Failure to act rapidly on this issue would mean that New Zealand s commitment to Maori health could not be taken seriously.
In their recommendations the authors suggest that it will be particularly important to promote culturally appropriate messages - for instance, smoking and alcohol should be discouraged as they have never been part of traditional Mãori cultural activities.
Ritchie states:
• . It is difficult to see how the rates ofMäori women smoking will change until two things happen: a major change in socio-economic status and a redistribution ofpower will be needed ill our society and then, perhaps, a change in the cultural attitudes and practices that support smoking may follow."
Yet the cost of smoking to the Mãori community is such that it will be difficult to begin to rebuild iwi strength until smoking is addressed.
97Policy Discussion Paper 2: Women & Smoking, Ministry of Women s Affairs, Wellington, May 1990.
Chapter 11- Miori Women: Smoking and Housing 138
MAORI WOMEN AND HOUSING
11.4 For the Sake of Decent SheIter8
The Mãori Women s Housing Research was commissioned and undertaken in a policy environment that is now under significant review. The Government has instigated major reform of the welfare state which has involved targeting three of the areas that this research has focussed upon - housing, Mãori Affairs, and social welfare.
This has meant that while the research has, of necessity, dealt with the known environment, it has not ignored the current reform and has made some tentative recommendations that try to capture the direction of the policy debate. Housing provision, in particular, is being considered in terms of an accommodation supplement. While the report does not discuss this instrument, it does try to provide for the implications that might follow an accommodation supplement approach. It is testament to the validity and veracity of the research that these new directions can still measured against the research findings.
The long-standing housing experiences of Mãon women, as recorded in this report, provide a timely and useful contribution to the comprehensive social policy development occurring now. The voices of these women sound both a provocative and cautionary note for the debate, and for policymakers. We need to find enduring solutions based on an informed understanding of the problems, and we need to do this with those reliant on the State, and not for them.
These are the recommendations which are derived from this report and which, in effect, summarise it. It is recommended to the Minister of Housing, the Minister of Social Welfare and Women s Affairs and the Minister of Mãon Affairs that you: -
note that Mãon women and Mãon communities have participated in and made an enormous contribution to this report;
ii note that the report is based on extensive qualitative research into the housing experiences of Mãon women and their families throughout New Zealand;
iii note the important role that Mãon women maintain within their whanau, hãpu and iwi;
"For The Sake of Decent Shelter, Mãori Women s Housing Research Project, 1991.
Chapter 11- MJors Women: Smoking and Housing 139
iv note the appalling housing circumstance and experiences of Mãori women and their families and the barriers that prevent them from securing decent shelter;
v note that the main barriers to adequate shelter for Mãori women are discrimination, lack of information, institutional intimidation, substandard housing, insufficient or inappropriate supply, affordability and overcrowding;
vi note that the proposed accommodation supplement, provided it is set at an adequate level, will meet only the barrier of affordability;
vii note that decades of ad hoc research into Mãori housing circumstance has been unsuccessful in achieving practical results; and,
viii agree that successive Governments have not adequately addressed the issue of Mãori housing and that the State therefore bears responsibility for the present situation, ix note that Mãori women and their families, along with the State, have borne the brunt of inadequate housing policies and their subsequent failure, and that Mãori women are not comfortable with the high levels of social and economic dependency,
x agree that there is an economic and social advantage for the State in strategically targeting MAori housing need and thus alleviating Mimi dependency;
xi agree that an interdepartmental committee be established to formulate specific housing goals and objectives, performance measures and monitoring systems which target Mãori housing and especially Mãori women s housing;
xii agree that the interdepartmental committee should
consist of representatives from
Housing Corporation of New Zealand Iwi Transition Agency Manatu Mãori Ministry of Women s Affairs Department of Social Welfare Department of Statistics;
xiii agree that the interdepartmental committee be responsible for creating a client profile which uses ethnicity as a cogent variable thus creating a Mãori housing database,
xiv agree that the extent and type of housing need should be assessed;
Chapter 11- Mimi Women: Smoking and Housing 140
xv agree to monitor and assess the impact of an accommodation. supplement on Mãori families and Mãori housing;
xvi agree that an integrated housing policy function must be retained following the Governments reviews of Mimi Affairs, Housing, and Social Welfare;
xvii note that the social organisation of Mãori people in terms of whanau, hãpu and iwi offers an alternative base for policy formulation:
xviii agree that there is urgency in formulating new and innovative policies based on the concept of collectivity which utilises and complements the social organisation of Mãori people;
xix agree that a major policy direction that should be pursued is that of alternative forms of tenure;
xx note the discrimination and intimidation Mãori women have experienced both past and present, in seeking shelter,
xxi note that the current systems for seeking redress to deal with issues of discrimination remain distant from Mãon women and thus are unable to effectively deal with such issues;
xxii note that Mãori women have minimal experience with and knowledge of the private sector, and that the private sector has not actively sought Mãori women as clients,
xxiii agree that as a result, the public sector has a disproportionate representation of Mãori women clients and applicants who may become particularly vulnerable in an accommodation supplement regime,
xxiv note that the housing needs of i-ural Mãori women and their families have suffered long term neglect and that there is an urgent need to address issues of short supply, existing substandard housing, and inflated transport and building costs;
xxv agree to the establishment of a project to formulate policies that specifically address the housing needs of rural communities;
xxvi note the cultural obligation of reciprocity inherent in this report in that Mãori women and their families have participated in good faith and a belief that positive change will occur;
xxvii agree that the findings in this report are valid and accurately represent the experiences of Mãori women;
Chapter 11- Miori Women: Smoking and Housing 141
xxviii agree that the recommendations of the Maori Women s Housing Research Project Report "...for the sake of decent shelter..." be implemented forthwith.
Recommendations to Departments:
Housing Corporation of New Zealand
ii note the ethnicity data currently collected by the Corporation does not accurately record or reflect the client base or waiting lists and serves no purpose in assisting the development of policy;
iii agree to the mandatory recording of ethnicity of clients and waiting list applicants;
v note the poor quality and conditions of state tenancies that are currently being offered to Mãori women and their families;
vii note that the allocation of tenancies is seen by Maori women as being discriminatory and results in a concentration of Mãori and Pacific Island people in older state rental areas;
ix note the dissatisfaction and frustration of Maori women with the present pointing system which has resulted from insufficient public information about the purpose and allocation of points;
x note that an information gap exists between the Corporation and Mãon women and Mãori communities in terms of policy and service delivery and that the present channels of communication are not reaching Mãori women and communities;
xi agree to budge the information gap and utilise appropriate channels of communication to deal effectively and efficiently with Maori women and communities;
xii note that while the Corporation senior management has participated in bicultural awareness training courses, this training has not filtered down through the organisation to frontline staff,
xiv agree that bicultural awareness and communication training needs of all staff be given priority;
lwi Transition Agency
note that housing is not mentioned at all in Ka Awatea, the Report to the Minister of Mãori Affairs;
ii agree that this omission is serious given the circumstance of Maori housing and that the fmdings of this report clearly identify
Chapter 11- Mãori Women: Smoking and Housing 142
Mã ori housing as a crucial issue in the development of whanau, hãpu and iwi;
note that there is growing concern amongst MAori communities about the future of the housing portfolio currently administered by ITA;
iv note that this concern is a result of lack of information within Mãori communities and is particularly unsettling for elderly tenants in kaumatua housing;
v note that an information gap exists between the Agency and Mãori women and Mãori communities in terms of policy changes;
vi note the dissatisfaction and frustration of Mãori people with housing funding and administration:
vii agree that MAori people will be consulted with and in formed of any decisions about the future of the housing portfolio;
Department of Social Welfare
note that the ethnicity data currently collected by the department does not accurately record or reflect the client base and serves no purpose in assisting the development of policy:
ii note that the statistics relating to the accommodation benefit currently administered by the department are unable to provide an ethnic client profile;
iii agree to the mandatory recording of ethnicity of clients and applicants,
iv note the increasing need for advocates to accompany Mãori women into the department in order to receive proper service delivery;
v note the dissatisfaction and frustration Mãori women experience with service delivery from untrained and ill-informed staff
vi note that as a result volatile situations can and do occur which could be avoided,
vii agree that communication training and bicultural awareness inherent in the departments policy statement Puao-te-ata-tu should be implemented immediately for frontline staff,
viii note that an information gap exists between the department and Mãori women and MAori communities in terms of policy and
Chapter 11- Mäori Women: Smoking and Housing 143
service delivery and that the present channels of communication are not reaching Mãori women and communities;
Manatu Mãori
note that housing is not mentioned at all in Ka Awatea, the Report to the Minister of Mãon Affairs;
agree that this omission is serious given the circumstance of Mimi housing and that the findings of this report clearly identify Mãon housing as a crucial issue in the development of whanau, hãpu and iwi;
iii agree that policy development for the future of Mãon housing is a priority for the Ministry;
v agree that the Ministry should maintain good communication channels with Mãori people and Mãori communities;
vi agree to report back to the Consultative Group by 31 December 1991 on action taken on matters arising in the research.
Ministry of Women s Affairs
note that Te Ohu Whakatupu is one of few agencies that actively protects, promotes and anticipates the needs of Mãori women through policy development; Chapter 11 -Miori Women: Smoking and Housing 144
Chapter 12- MJon Women and Health Services 145
CHAPTER TWELVE
MXORI WOMEN AND HEALTH SERVICES
This Chapter presents some qualitative findings on Mãori Women and Health Services.
Chapter 12- Muon Women and Health Services 146
12.1 Mâori Women s Health Services: Case Studies9 Details/Kaupapa
In a report commissioned by the Population Helth Services Section of the Ministry of Health a number of findings on Mãori Women s Health Services are described. Proceedings
Summary of Findings
These are the main service areas being provided by Mãori Women s health service provider groups:
Service areas
Addictions
Drug, Alcohol and Solvent Abuse
Screening
• Basic screening for high blood pressure, cervical smear testing, breast cancer, instruction in self examination for breast cancer. • Hearing and vision • Diabetes, screening and management
Research
• Research into Rangatahi health • Mental Health Research
Mental health
Long term Mãori Mental Health Services
Health Service Development
Establishing Health Clinics.
Women s Support Services
Mdori Women s Refuge
Sexual and Reproductive Health
Sexual Heath for Women
99MZwfi Women s Health Service, Hinennga Trust, 1993. Chapter 12- MJon Women and Health Services 147
Education for the prevention of sexually transmitted diseases and AIDS
Preventing and Treating Abuse
• Sexual Abuse • ChildAbuse • Social, psychiatric and family planning services • Family violence and abuse
Training
Training Asthma Educators
Facilitating Support Services
• Budgeting services • Rangatahi Health Information • Transportation • Plunket Car Seat Hire • Accessibility of networks, liaise, communication • Access resources • Massage
Education and promotion
• Asthma education • Smokefree education • Diabetes
Maternity and related services
• full or part maternity care • antenatal classes • post-natal support • general medical care (particularly for maternity related services) • Parenting and Baby care • Family relationships
Other Health Services
• Dental Care • Nutrition
Service Promotion
These are the main methods used to promote their services
networking and liaising
Chapter 12- Mimi Women and Health Services 148
word of mouth cross-pollination from other programmes don t go out to promote themselves
Service Improvement
Methods and means to improve the services being provided identified by the providers were
• better budgets, including amounts and tiineframes • other resources, besides money • time frame for contracts too short, often 3-6 months, makes long term planning a farce • someone else determines the priorities and the services are not what people really want
Conclusions
Many of the providers think that the reforms represent great opportunities for Mãori in spite of the negativity about what s going on. They believe that there will be improvements in the next two to five years. Why? because of the heath reforms and the changes within the health systems will create opportunities for those who are already in place.
When you look at the in-vogue trends, or how government is lobbied by groups and people who have their own agenda, you have to be aware that these trends have a limited life cycle. There is some initial shock- value but then its out in the open - people become more familiar with the problem.
An example of this was Sexual Abuse. Ten years ago it hit New Zealand society like a bomb. It was no longer a hidden issue, cases where brought to the notice of social workers and counsellors and people where taken to court for abuse. Money was available, in seeming abundance, to fund the various national groups and counselling in this area became a big business - other agencies where brought on board and funding was often available within their systems - such as DSW, ACC and others. In reality, how many of health groups are up with the recent political changes? How can we influence the changes to happen in 2 to 5 years, for Mori women? The Public Heath Commission has one goal for women in general, nothing is there for Mãori women - except Cervical Screening Programmes, even then that needs to be looked at again.
Many think that Mãori women s health needs to be much better then what it is - many of the health programmes being offered are just band- aiding and don t actually fix the cause of problem.
Chapter 12- Mimi Women and Health Services 149
Improvements to the System
If women are not well and healthy, then the whanau, hãpu and iwi can be affected, in fact this has expanded and gotten out of hand, really! I ve always been involved as a counsellor and social worker for Mãori women and people - heath is new, looking at Mãori heath - it didn t take me long to realise that if you don t have good heath - then you don t have nothing! What s the use of having a lovely home and a good education and all those other things if you don t have good heath.
• Make Maori women s heath as a priority - when we look at the heath of our women, we look at the whole whanau - their partners and tamariki.
Update health care to look at women s health care.
Get rid of the existing kaupapa and policies for contracting between the Wellington Area Heath Board and iwi Authorities based in the Wellington region - look at other MAori Pan Tribal Groups who are providing heath services to Maori.
Money to employ Mãori people to work these programmes. Funding and access to services that will provide resources within their services - that isn t monitory - they give the resources as in peoples time and skills, providing equipment and materials when necessary.
All the other health initiatives we offer, such as immunisation, blood pressure monitoring, ante natal care, parenting skills, diabetes management all those kind of things we have to find the funding for them - because the need among our people is so great.
There are times when money is not the only asset - MAori need to be aware of that - if they stopped providing these other resources we would be finished - our programmes would cease to exist.
Many systems within government agencies have been set up for iwi development not necessarily for Pan Tribal or Maori development - both are providing for Maori development as well as iwi - it just depends on the group s kaupapa of iwi. Within these places they need to re-focus on some of their policies that have been in systems that have since been restructured - under the different governments they need to be up with the play - we are still being governed by policies of Iwi Authorities and a Runanga Iwi Bill that didn t happen - are no longer equitable and feasible for us.
Chapter 12- Mimi Women and Health Services 150
Employ Mãori People to train our people to work in the area of health - Cervical Cancer, Breast Cancer, Smoking, Blood Pressures, Diabetes to train them to be mobile.
Payments for health programmes need to be paid on time, in conjunction with the contracts - most times these are paid 3 to 6 months late, this puts a lot of pressure on our lwi.
More Mãori Health Workers on these programmes
Programmes are not long enough for us to see any constructive changes in our peoples attitudes and behaviour patterns - a change needs to occur in the development and long term planning strategies for Mãori health. This should not restrict planning to short term, gap-filling methods only
Select health programmes that are appropriate to our communities needs - not because its the only thing available.
Restructure a lot of services to cater for the young population, whereas before we had a mixture of age groups that we worked amongst.
Cost effective budgets that will give us better access to resources to enable us to provide quality services - quite often our budgets are shoe string and doesn t allow us to be creative or diverse in what we can do and how we can offer alternatives to our people.
There is a mass exodus of young Mãori whanau moving from Porirua and Wellington Cities to the Kapiti Coast, in particular Paraparaumu, because it is much cheaper to live there. Our health programmes and contracts need to be in line with the development of these whanau - many are single supporting mothers and their children, only a few are single supporting men.
The economy for many Mãori whanau is going to put many of our women and their whanau at risk especially their health - depression amongst certain communities is slowly being revealed, we just don t have skilled Mimi people to help these women and their whanau.
iwi contracts could be something of the past once these new health structures are clearly defmed and functioning
Provision of services in rural areas
Autonomy to decide what our heath priorities are without being told what others think is appropriate to our needs.
Chapter 1- Overview 151
CHEs, RHAs and PHC should publish a statement of intent enable MAori organisations to negotiate possible contracting opportunities.
Many of the services believe that there is an overall need to empower our women and our people. While many may know what s good for our women and people that doesn t mean they re going to come along. Marae based training programmes and health programmes is a means of getting Mãori people along to the health services. If the funding was available many of the initiatives felt that they would never take the health initiatives away from the marae or training away from the marae - they would strengthen them financially.
Chapter 12- MIori Women and Health Services 152
12.2 Screening for Mãoroo
Detalls/Kaupapo
A consensus hui for Screening Mãori was held in Wellington in 1992. The hui discussed screening programmes both generically and specifically. Relevant findings are prsented below. Proceedings
Requirements for an effective screening programme:
1 The condition should be an important health problem.
2 There should be an accepted treatment for patients with recognised disease.
3 Facilities for diagnosis and treatment should be available.
4 There should be a recognisable latent or early symptomatic stage.
5 There should be a suitable test or examination.
6 The test should be acceptable to the population. 7 The natural history of the disease should be adequately understood.
8 There should be an agreed policy on who to treat as patients.
9 The cost of case-finding (including diagnosis and treatment of patients diagnosed) should be economically balanced in relation to possible expenditure on medical care as a whole.
10 Case-finding should be a continuing process and not a once and for all project.
1oO}ji Whakamarama: A Consensus Hui for Screening for Macrn, Wellington, 1992.
Chapter 12- Miori Women and Health Services 153
12.3 Cervical Screeningioi
The report Women s use of health services in New Zealand 02 reported that cervical cancer registrations during the period 1980-1987 were consistently higher for Mãori women than non-Mãori women. The report noted that preventative services were being implemented to decrease this rate.
A National Research Bureau survey in 1990 found that Mãori women were twice as likely not to have had a cervical smear in the last three years than pãkehã women.
In the report Cervical Screening, MIori women and our whanau, the Mãori Cytology Working group made the following recommendations:
1.0 The immediate appointment of a National Mãori Co- ordinator to oversee the development and establishment of a Mãori National Cytology Register.
2.0 That the Mãori Cytology Working Group be given the responsibility for the advertising, selection, short-listing and appointment of a National Mãori Co-ordinator.
3.0 Appointment of an interim National Kaitiaki Group, comprising the current membership of the Health Research Council s Mimi Committee.
4.0 Selection and appointment of two additional members to the interim National Kaitiaki Group.
Additional members are to be selected from the currently established Mãori Cytology Register Working Group.
5.0 Funding of a National Mãori (Computer) Register for the collection and collation of Mãori cervical screening data and information.
At the Hui Whakamarama: Consensus Hui for Screening for Mori, background papers on Cervical Screening and Breast Screening 103 made the following recommendations:
Ai st L.)UsIi Le]iKD) stsNfl( IsT1 I)
(a) Increasing the uptake of cervical screening by Mãori women by finding ways to encourage unscreened women to have a smear.
101Hui Whakamarama A Consensus Hui for Screening for Maori, Wellington, 1992. 102Women s use of health services in New Zealand, Department of Health, Penny Brader, Justine McFarlane, Judy Paulin & Tere Scotney, 1992. 103Background Papers on Cervical Screening and Mammography, Charlotte Paul & Ann Richardson,
Chapter 12 - Miori Women and Health Services 154
(b) Improving cervical cytology registers for recall, follow-up of women with abnormalities, and quality control.
(c) Improving access for Mãori women to acceptable primary care for cervical screening and for the investigation of gynaecological symptoms.
(a) Cervical screening services which are culturally appropriate for Mãori should be purchased, according to the 1991 Recommendations 04.
(b) Regional managers of cervical screening should continue to be employed to work with local communities to find ways to encourage unscreened women to be screened.
(c) Regional managers should also be employed to work with local communities to find ways to encourage unscreened women to be screened.
(d) National co-ordination and evaluation of cervical screening is required.
104Government policy for national cervical screening, National Cervical Screening Unit, Department of Health, 1991.
Chapter 12- Miori Women and Health Services 155
12.4 Mammographos
!t Ii9 t.iti s . c.& ismi-
Consulting with the local community.
2 Providing information for Mãori women.
3 Identifying and inviting eligible women.
4 Providing an acceptable, effective and efficient service.
In Waikato there are Mãori health educators who go to marae and explain about the pilot programme and invite eligible women.
In Otago-Southland all women are invited by mailed invitations (with the help of general practitioners where possible). Mimi women from Owaka organised the official opening ceremony and powhiri for the Otago-Southland mobile unit. The mobile unit will travel to marae throughout Otago and Southland.
EIs9 I I. ILITTI N 14 b1711(sI.1I ({ tI.) d T fl
Wait for results from the pilot programmes.
Stop subsidising screening mammograms for women under 50.
105HUi Whakamarama: A Consensus Hui for Screening for Maori, Wellington, 1992.
Chapter 12 -Miori Women and Health Services 156
12.5 The Needs of Mâori Women in Maternity Servicesioo
Details/Kaupapa
As there was some concern within the Auckland Area Health Board that the maternity services were not fully utilised by Mãori women, a research project was set up to identify the needs of Mãori women who use the maternity services and then make appropriate recommendations. Two approaches were taken in the research methodology: te taha kihokiho (quantitative) including face to face interviews with questionnaires and taha wairua (qualitative) involving in depth interviews or korero with kuia.
A report was produced. Proceedings
Recommendations:
Redirection of the services to accommodate appropriate Maternity Services for Mori women.
• . .it is necessary that Home Care Services, for example Antenatal classes, Home Promotion and Protection skills be developed to provide culturally appropriate care to Mãori women by Mãori women. It is essential to note that some Mãori women are well experienced in child birth and care from a Mãon perspective that is quite different from the recognised styles of western qualifications.
2 Initiation of appropriate Marae-based Health programmes for example, Parenting Education, Home promotion, Antenatal Services because expressed needs of Mãori people are being met. It is important that Mãori people be involved in the establishment and decision making processes for Mãori people.
3 In relation to the result about the position of the delivery [that is that while some 25% of deliveries are either kneeling or sitting these may not in fact be the traditional practices], Hospitals need to provide alternative facilities in a more traditional manner. It is recommended that Delivery Suite services make available mattresses and/or bean bags placed on the floor to facilitate more traditional styles of delivery such as sitting and kneeling.
106WhJr tn ii, Management Training Programme, Auckland Area Health Board, Sam Rolleston, November 1991.
Chapter 12- Mimi Women and Health Servkes 157
4 More consumer based research for Mãori people by Maori people. In the past, methodology, particularly for Mãori research, has tended to be from secondary, rigidly structured statistics like the census.
5 More than half the respondents resided in South Auckland. This supports the recommendation that more services need to be established in that region.
Chapter 12- MJors Women and Health Services 158
12.6 Parenting Programmesiol
The first part of this report gives an overview of tax payer funded parent support programmes in New Zealand. The second part explores in detail some of the unique features of a number of programmes using a list of "critical factors. These factors were deemed to be critical to ensuring that a parenting programme met Mãori needs and arose out of discussions with a research monitoring group and a hui workshop.
Chapter Three displays the overview of tax payer funded parent support programmes. Parent education and support can be offered at various stages in the life cycle and as a consequence through a number of agencies.
Part Two of Chapter Three, looks in more detail at the relevance of the parenting programmes and support currently being offered to Mãori. And in particular at the m modifications that have been undertaken to met Mãon needs.
The delivery of parenting programmes, particularly those that involve Mãori families, was by and large the domain of community groups. In many cases these programmes were a direct response to the fact that traditional supports (eg Plunket, Ante natal classes, Kindergartens, etc.) have not been well utilised by Mimi communities. This approach has advantages. It ensures that programmes respond to local needs with local people.
But there is also a case to be made that some coordination will bring efficiencies to what is an extremely fragmented market. At the community level parenting programmes often regard their work in an holistic light. Further up the chain at government level the departmental approach to parenting is dictated by its "fit within the specific output framework. There is little coordination between government departments and as a consequence some duplication of service takes place. A large number of community groups, while all trying to achieve a similar outcome, are having to plot a course between departments to obtain resources.
Case Studies
Chapter Four outlines the unique features of a number of parenting programmes. The programmes selected covered the spectrum of
107Parenting Programmes, L Middleton, D Fuli et aL, Department of Health, Wellington, 1993.
Chapter 12- Mimi Women and Health Services 159
approaches taken to providing parent education and in particular explored how the needs of Maori parents were being met.
Three policy models were developed:
Kaupapa Mãori Model
Defined as;
The provision of a service specifically tailored to Mãori needs. This included the programmes run by Te Parekereke and M.U.M.A.
What did the case studies tell us about this policy model?
The strong focus on strengthening the whanau (family) distinguished the programmes in the Kaupapa Maori Model of policy development. This tackled the key policy issue of ensuring a culturally appropriate service was offered. The programmes in tills model were clear about their accountability back to the whanau and the need to promote their programme among their own informal networks. However as the roles of the service provider were redefined away from the demands of the bureaucratic structure the amount of personal commitment and dedication required to run these programmes was high.
Blended Model
Defined as;
a blending of both a established approach to providing services and the provision of a culturally appropriate services, often based on addressing the community needs. This included the programmes run by Early Childhood Development Unit, Te Awataha Marae.
What did the case studies tell us about this policy model?
In the case studies the concept of whanau was incorporated into the provision of an early childhood service and the provision of a child health service. Within that overarching structure the Mãori providers gave a distinct flavour to what they did. In this model a balance needed to be struck between the established agency s focus and the development of whanau concepts. The case studies revealed how the current focus of measuring outcomes may create difficulties for these programmes as objectives like the acquisition of self esteem are hard to measure.
Incremental Model
Defmed as;
an attempt by a established services to incorporate new elements in an already long established approach to providing some type of strong
Chapter 12 - Mäori Women and Health Services 160
policy directive about how things are done is left in place. Examples in this study included Pakuranga Children s Health Camp and the Poutama course.
What did the case studies tell us about this policy model?
The advantage of the incremental model is that it provides a solid base for parenting programmes with the opportunistic use of resources to change the margins of the service. In general the approaches in this model were confined to the margins and the concern was that the providers had little autonomy to pursue the features they believed would have the most impact in attracting Mãori parents.
Fu i , il iiF I I In general the approaches to providing parent support for Mãori parents in the Incremental model are confined to the margins and the concern is that the providers have little autonomy to pursue the features they believe will have the most impact m attracting Mãori parents. While the Kaupapa Mãon model providers have considerable autonomy to pursue the features they believe will have the most impact in attracting Mãori parents the demands made on these groups to secure adequate resources, train deliverers and motivate those involved are high. The Blended model offers a resource base already in place alongside some autonomy for providers to design features to met Mãori needs.
Critical Factors
The report considered each critical factor in the light of the information gathered from the case studies (Chapter Four) and the overview of parent education (Chapter Three)
The critical factors list is a starting point in developing guidelines to those who are considering how best to design a parenting programme to met Mãon needs. The list represents the insights of those who contributed to the project and is not necessarily an exhaustive list.
1. Mãori families should be targeted While the case studies contained examples of programmes which arose from a need to target Mãori exclusively, the majority of programmes sprung from a background of providing support to all parents. Those original goals where then modified in order to recognise the specific needs of the individual parents. It was at this point that Mon families were likely to be targeted.
This blended approach meant the resulting programmes were able to work with a resource base already in place. As a result providers were then adequately funded and were likely to have a range of skills. When Mãori families were targeted
Chapter 12- Mimi Women and Health Services 161
exclusively the providers had to resource the programmes by plotting a course between the range of government agencies connected with parent education and support.
2 Programmes should be culturally appropriate
The case studies demonstrated the myriad paths open to the providers of parenting programmes to promote the strengthening of the whanau. The strengthening of the whanau is the route most often proposed as a way of recognising distinct Mãori needs.
To implement cultural appropriateness;
first and foremost the providers must be Mãori,
secondly the programmes must promote whanau development throughout all levels of the programmes, and
thirdly the content, context and control of programmes need to include the providers, the whanau as well as incorporating the presence of kuia and kaumatua to link the young parents with the past, present and future. This ensures that the concepts involved in Mimi parenting are transmitted and instilled for future mokopuna.
3. Parenting Programmes should deal with a wide range of topics and do not just confine themselves to child development.
Because parenting programmes in New Zealand have rarely arisen exclusively to address parenting" the concept that parenting programmes should encompass a range of topics is well established. The providers in the case studies promoted topics other than parenting to attract parents to the programme.
Many of the case studies stressed that what they provided moved beyond simple parenting skills and embraced a holistic approach to the participant. This approach was not always easy to measure when funders require indicators of effectiveness . A holistic approach did not fit easily into an outcome framework.
4. Programmes should provide the , opportunity for shared learning and promote networks amongst parents
This concept was fully embedded in the majority of the case studies. A significant feature of across all the case studies was the widespread use of informal networks to encourage potential clients to attend. Once parents did attend the programmes regularly involved the wider whanau and encouraged group discussion.
5. The programme participants must be showing a high level of commitment.
Chapter 12- Mion Women and Health Services 162
The first part of the report revealed how a number of orgamsation had to modify their approaches to successfully attract and retain Mãori families. All the case studies said that their drop out rates were low. A number of the providers stressed that by encouraging whanau development amongst the participants this in turn promoted a whanau concept within the course. Once a course was established strenuous efforts would be made by all involved to ensure that everyone turned up every week.
6 Health messages should be delivered
It was often difficult to disentangle the more medically oriented health component of the programmes from the holistic approach the case study programmes were taking. The scope for increasing access to health services and ensuring that accurate medical health information was passed onto parents was untapped by some of the case studies. It was clear that better use could have been made of health educational resource material.
7. The Deliverers should, ideally be Mãori, and demonstrate the following;
Knowledge of tikanga
Knowledge/experience of the backgrounds of the participants
Should have the ability to facilitate discussion and act as a resource/support person rather than an "expert" with a "top down" approach. The delivers and facilitators of the programmes have a pivotal part to play in ensuring that a parenting programme is culturally appropriate. The providers also have to pass on messages about parenting in a manner that avoids suggesting that they are experts in some form and does not alienate or disenchant those they are working with. Further if parenting programmes are offering parents a wide range of topics then the providers need to have an understanding of these topics.
The key to a parenting programme for MAori is to strike the right balance between giving the provider the autonomy to design a programme and providing the resource and skill base for them to tap into. The Blended models in the case studies are attempts to do exactly that. To develop a service in parallel with an existing service for parents. Because of the complexity of the role providers undertake they need to have the ability to respond immediately to those they work with. More that incremental changes are required to a service to allow this type of responsive service to operate.
Chapter 13- Sign flcant Mimi Women s Hui 163
CHAPTER THIRTEEN
SIGNIFICANT MALORI WOMEN S Hui
This Chapter presents the findings and recommendations of a number of sign ifi cant Maori women s hui which have been convened by the Ministry of Women s Affairs.
Chapter 13- Sign jflcant MJori Women s Hui 164
13.1 Runanga Kula
In 1987 and again in 1991, the Ministry of Women s Affairs hosted two national hui for kuia.
Known as Runanga Kuia (Council of Mori Women Elders) the hui provided a forum for kuia to come together as a support network.
Issues, concerns and recommendations relating to Hauora Mãon are given below:
Runanga Kula: 1987108
Te Ohu Whakatupu has given priority to the need to develop support networks of kuia through Aotearoa in recognition of the particular role and status the kuia have in the Mãori community. To meet this need, .Te Ohu Whakatupu decided to bring together kuia representatives of the many iwi of Aotearoa to a runanga held at Takapuwahia Marae, 18 -20 March, 1987.
The hui was highly successful. It was the first ever national gathering of MAori women elders from throughout New Zealand.
During the hui many subjects were addressed. Twenty-five recommendations were made. A summary of those recommendations is given below:
Recommendation 7
"That this runanga kuia affirm our support of Te Kohanga Reo, which incorporates not only te reo, but nga tikanga me te wairua which has been passed on to the iwi by our tipuna. We must be persistent in our efforts to impress upon the Minister of Women s Affairs and her colleague the Minister of Education, that our schools become bi-lingual. For those children who have missed kohanga and its attendant teachings, it may mean that Matua Whangai will have a role to play".
Recommendation 14 "That housing be identified as a priority need for Mãori women who are increasingly assuming the role of head of the household and mainstay of the home and family."
Recommendation 16
"That Mãori housing on papakainga be made more accessible to those who seek it."
Recommendation 19
108Runanga Kuia, Takapuwahia Maxae, Porirua, March 1987, Ministry of Women s Affairs, 1988.
Chapter 13- Sign flcant Mimi Women s Hui 165
"That eligibility be extended so that Mãori housing needs can be properly attended to. (Home and family continue to be crucial in the development of the Mãori child)."
Recommendation 20
"We recommend that the teaching of parenting skills from a Mãori perspective be included in the curriculum of our schools."
Recommendation 21
"That there be a Mãori Women s Training Centre which will enable Mãori women and girls in the community to learn the skills of parenting, or communication and counselling based on kaupapa Mãon. This could be done in association with existing institutions such as the Community College and Technical Institute."
Recommendation 22
"We note with concern the effects of alcohol consumption on the family and commend the Alcohol Liquor Advisory Council (ALAC) on its educational campaign "Kua Makona" in attempting to reach the mass of our people with its message of moderation."
Runanga Kula: 199110
A second Runanga Kuia was held in March 1991, again at Takapuwahia Marae. The purpose of this second ever national gathering of Mãori women elders was to:
• maintain and strengthen links with kuia throughout Aotearoa and through them to other Mãori women in their respective whanau, hãpu and iwi;
• identify and discuss social, economic, cultural and political issues that affect Mãori women and their iwi ... particularly in relation to. .social welfare, education, health, Mãori land and Mãori women in business;
• report on the work of Te Ohu Whakatupu since the 1987 Runanga Kuia Hui;
• acknowledge and utilise the wisdom and knowledge of the kuia.
109Runanga Kuia, Takapüwahia Marae, Ministry of Women s Affairs, 1991.
Chapter 13- Significant Mjori Women s Hui 166
As in 1987, the overall theme of the 1991 hui was; "Mana Wahine: Mana Mãori".
r. iTi ZTi :m
Health
The presentation [by Te Ohu Whakatupu staff] on Health focussed on potential policy changes arising from the review of Health Services by the Health Services Taskforce which was established to identify and investigate options for defining the roles of Government, the private sector, and individuals in the funding, provision and regulation of health services. (Economic and Social Initiative Statements to the House of Representatives, December 1990). The kuia expressed the following concerns regarding potential changes: in the event that an insurance-based system is introduced the kuia were concerned that access and affordability issues will arise for Maori in relation to their ability/inability to purchase health insurance through the market; the likelihood that insurance agencies will regard Maori people as high risk applicants due to their generally poor health status; and, queried the extent to which an insurance-based health system would reflect the Government s responsibility to improve the health status of Mãori people.
The kuia also acknowledged the problem of the reluctance of many Mäon women to consult a doctor due to factors such as:
• cultural differences • cost • communication problems. r r z: ri &i AIs)IstINU1 i i ri
r n ,•
In acknowledging the poor health status of Mãori women the Minister said: "The issue of smoking is a huge dilemma for me as a Minister and, I believe, for you as Mãoripeople. We know that many ofyour women 40 and over are dying prematurely from tobacco related illnesses. But the frightening thing that I have learned since becoming Minister of Women s Affairs is that the fastest growing group of smokers are young Mdori women between the ages of 14 and 18".
Chapter 13- Significant Miori Women s Hui 167
In recognising that answers to the issue of Mãori women s poor health status are not easy, the Minister was of the view that "they are educational and economic".
The Minister recognised the need for appropriate service delivery to Mãon and, as an example, cited services provided by Mãori plunket nurses.
Chapter 13- Significant Mãori Women s Hui 168
13.2 Putea Pounamuilo
Te Ohu Whakatupu, Ministry of Women s Affairs, was given the task of discovering the specific needs of Maori women and recommending policy and programmes to meet new and changing demands. A national hui Runanga Kuia, in March 1987, provided te aho tapu, the first line of weaving, the sacred line, the foundation work for Te Ohu Whakatupu.
In an interim report dated 1989, progress on the project was reported.
Putea Pounamu is a special information and education grants programme developed by Te Ohu Whakatupu in direct response to the development of iwi authorities. The role of Putea Pounamu is to encourage participation at a decision making level in the whanau, hãpu and iwi by identifying existing and new needs and providing support services to meet these needs and identify new opportunities for Maori women. Putea Pounamu is a four year project. It began in 1987 and is planned for completion in 1991.
110Putea Pounamu, Ministry of Women s Affairs, Wellington, 1989
Chapter 13- Significant Mimi Women s Hui 169
13.3 The Prevention of Early Death"
A hui for Mãori women, hosted by Te Ohu Whakatupu, Ministry of Women s Affairs, was held at Te Whetu o te Rangi Marae in Tauranga in March 1990.
Keynote addresses were given from a number of Maori women, including Dr Paparangi Reid, Rahera Ohia (Manatu Mãori) and
Workshops were also held and the following themes summarised:
rr rn : tEL1
Issues: Unemployment, drugs, alcohol, solvents, legislation, oppression,land, social, economic conditions, racism, violence, wairua, colonisation .
resources need to come directly to Maori community/initiatives collectives
• need Maori trainers to teach Mãori trainees • need more Mãori psychiatric nurses in hospitals/community • work from the grass roots - community level • accountability - process • consultation - Maori people are constantly being asked for advice, but it is often not reflected in the outcomes • differences between urban and rural areas - how are policies decided • empowerment of Maori through dissemination of information • independent Maori development • incorporation of Maori perspectives in medical and nursing training • increased Mãori representation on advisory committees • guidelines for iwi, on how to go about nominating people and developing skills for advisory bodies • built in incentives for Maori health initiatives, who are providing health services, eg, every Maori woman who has a smear, $10 goes to iwi development (health promotion)
I
Parenting skills:
• lack of response to tautoko kohanga • whanau participation in decisions and solutions • accountability to hapu • no one talks about incest - must have empathy, wairua, tikanga • community resource - wairua, tikanga
111The Prevention of Early Death, Ministry of Women s Affairs, Wellington, 1990. Chapter 13- Sign jficantMiori Women s Hui 170
whanau whare set up in urban areas - kuia, koro, whanaunga, funding
Support for kura kaupapa Mãori
Must know our past to understand present - where we want to go in the future
Teach Maori children their own history, that they are not taught in schools
We need to get out of the systems of abuse, alcohol, drugs, smoking etc
Mãori people should look towards autonomy
We need to feel good about ourselves as Mãori
The work and personal development of one person will lead to change for the whole whanau, hãpu, iwi
Need to work with our own - not as the ambulance at the bottom of the cliff - build them up
Needto design our ownsystems as pakehã systems alienate us
Maori people must be consulted:
• tikanga Mãon has been bastardised - need to talk it, live it • our kuia and kaumatua are experts • pro-Maori - (not radical) • tuturu Maori but how far (tapu, makutu?) and to whose definition • Maori need to be recognised as sovereign tribal Mãori
Fi u i!4ti
95% of violence occurs in the home: • no one talks about it • get it out in the open • whanau need to work through the problem together • resources, such as kits developed specifically for Maori • powerlessness on victim s part • alcohol, drugs, solvents - prostitution • marketing self-abuse • mental health
What can we do about it?
• make available listeners, eg - friend, family, "safe houses", women s support group • education