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The way ahead for Maori and PI health - Turia

Hon. Tariana Turia
17 August 2001 Speech Notes

Mid-winter dialogue, Christchurch Medical School, "The way ahead for Maori and Pacific Island health"


A couple of weeks ago I was being driven in a Crown car, (a "VIP car"), along a rural road in Northland with the Hon Mark Gosche, the Minister of Pacific Island Affairs, Transport and Housing.

We were going to a World Leaders Building and nail driving ceremony sponsored by an international Christian organisation who were assisting in the construction of houses.

And we got lost!

This experience really made me think, after all, I am a rural person, quite familiar with what preparation is needed to find places in isolated rural areas and the potential hazards of country roads.

We got lost because the person who gave us the directions and who drew the map was not a local and did not know the area. No matter how good our drivers were or how powerful the car, and influential its passengers, we still got lost. We did not realise that the map was draw by non-local people. We didn't communicate directly with the local people to check out the arrangements.

There are clear parallels for me with the topic that we are addressing today. If those who draw the maps, build the roads and drive the vehicles in which we Maori and Pacific peoples travel, are not of us, and if we are not represented around the table where the maps are drawn, our needs will never be met.

What we learnt when we finally reached our destination, was that the visiting expert had not asked the locals about how we should get to where we were going. So here we were, two Ministers of State, in Crown cars with our advisors and very experienced drivers getting lost, because we relied on a person without local knowledge and expertise.

Maori and Pacific peoples may be recognised as "very important people" ("priority populations") and even be offered a VIP car but unless Maori and Pacific people are sitting at the table when the destination is decided, the maps are drawn, unless they have their own vehicles and drivers, we are not likely to get to where we want to go.

Who sits around the table and who should be at the table is one of the issues I wish to address today. The other issue I want to address relates to the obstacles on the road that are faced by Maori and Pacific groups.

I have used this analogy of sitting around the table on previous occasions, the most recent being the Bill regarding representation on the Bay of Plenty Regional Council.

I want to consider who originally sat around the health table to design the original system upon which the current system has been based. I also want us to consider who currently sits around the table, who may in the future sit around the table, and indeed, who should sit around the table to ensure we achieve a more inclusive, participatory and healthy democracy. We must go past the rhetoric of social and economic inclusion, demonstrate how it can happen, and then make it happen.

What I will say is those who originally sat around the table, designed the system with their interests in mind.

Those original designers could not help but create something which was of them, and for them. The design, the method of design, the processes followed and the culture, reflected those who participated around the table.

This has remained constant in succeeding generations. There has been however here in Aotearoa the exercising by Maori of their rights under the Treaty of Waitangi and in this process, some adaptation of the system.

The next phenomenon has been the increasing cultural diversity of New Zealand society particularly the increase during the sixties of the numbers of our Polynesian kin from other parts of the Pacific.

What has become apparent is that diversity, exhibited by the physical, spiritual and cultural differences was never accounted for in the original design of the system. It is fair to say that the accommodation of difference was never part of the original design brief as here in Aotearoa the intention of the early colonial designers was to assimilate Maori and make us more like them.

That this never happened, has created difficulties for Maori in terms of accessing health resources. Maori and other Pacific people are often excluded. If they are at the table, they are often being asked to comment on maps that are already drawn, where the landmarks are unfamiliar and where important roads and destinations are not featured.

To begin to address this the Labour Alliance government committed itself to producing a New Zealand Health Strategy that would provide the framework for what we intend to achieve in health. The Strategy sets our goals to ensure effective use of health resources, to reduce the health disparities that exist between populations and involve all communities in the decision-making processes to work towards their needs being met.

We know that groups who are excluded, who are kept on the margins and who never get to “sit around the table”, who do not participate in making the decisions which affect them are, to all intents and purposes invisible.

The only apparent option for them to gain recognition is to emulate the original designers. What we then get are a number of organisations which copy western structures and designs but which I put to you may not necessarily serve the people they purport to represent, very well. I have met such groups who openly state their “success” (if you can call it that) is because they comply well with the demands of the system. But they have told me they feel they are not serving the people as well as they could if theyhad the power to participate in the design of their own system.

It appears to me that what they have adapted to and taken on board are the same designs of omission to which they were previously subjected. Times are changing and this is reflected in the governments response to these outdated design faults and practices.

'Acknowledging the special relationship between Maori and the Crown under the Treaty of Waitangi' is identified as one of seven underlying principles that the government sees as fundamental in the New Zealand Health Strategy. Within that, 'Maori development in health' is identified as one of ten strategic goals aimed at helping sharpen the focus toward action based solutions and outcomes.

He Korowai Oranga – the Maori health strategy – was born out of the pre-election commitment to improving whanau, hapu, iwi and Maori development. It is supported by the commitments laid down in the New Zealand Health Strategy. The action plan for the implementation that accompanies He Korowai Oranga demonstrates the commitment of this government. This is due for release later this year.

What He Korowai Oranga attempts and what is needed in the view of many from Aotearoa and the Pacific is the expansion of the criteria for participation. Only then can the processes and designs lead to better health. Only then can this society claim to be inclusive and provide equal opportunity for all of its citizens.

To do this we need to ensure that group representation and participation in all future planning and development occurs. It is for this reason that mana whenua throughout the country are seeking to build strong and positive relationships with their DHBs.

The health status of whanau, hapu, iwi and our Pacific cousins will determine the speed at which they are able to develop. District Health Boards have been given responsibility to facilitate the improvement of Maori and Pacific health. They also have the responsibility to respond in a proactive way.

Too often I believe Maori are seen as the "other" whose sole contribution is to offer a cultural perspective. This limits the contribution that Maori and Pacific people are wanting to make to improve the responsiveness of the health sector and increase our health status. The "otherness" of Maori and Pacific peoples which is narrowly based is a restriction which inhibits legitimate participation in the health sector.

Included in that is their participation in the health workforce. Workforce development is an area in which Maori and Pacific people have identified as critical to sustaining and improving health gains. Our desire to hold the skills within our communities to ensure that we can maintain our health and advance our own development should not be underestimated.

Workforce development includes but is not limited to Maori and Pacific people maintaining a well-trained and highly skilled workforce.

Obstacles on the road
If we are to seriously address Maori and Pacific peoples health, we must be brave enough to address the barriers which inhibit the achievement of good health for these two groups.

I wish to address some of those barriers in my speech to you today.

Disparities in health outcomes cannot be explained away, by socioeconomic differences alone. The way the health system operates does impacts negatively on Maori and our relatives of the Pacific in large numbers.

It is necessary for all of us to identify the behaviours, processes and procedures both formal and informal which act as barriers against the equal access and treatment of Maori and Pacific peoples. It is to recognise and understand the subtle aspects of organisational culture which constructs the barriers and breeds bias.

Until we acknowledge the existence of the barriers we will not progress as a society and the health of those discriminated against will not improve.

Bias in all its forms needs to be addressed. We are still a society in denial and the denial reminds me of one of the stages identified by Elizabeth Kubler-Ross in her landmark book, "On Death and Dying". In that book, Dr Kubler-Ross confronted a previously "taboo" topic, created a depth of understanding about the process of dying that has benefitted generations of health professionals and patients. There needs to be the same courage in discussing a taboo topic of our era, bias in the health services.

As you all know Kubler-Ross identified five stages of grief. They include:

1. Denial and Isolation
2. Anger
3. Guilt and Bargaining
4. Depression
5. Acceptance and hope

Often there is depression along the way but if the grief process is supported, a healthy outcome can occur with both acceptance and hope as part of that outcome.

We need to acknowledge that buildings themselves are not the agents of bias. It is the people and the processes, often supported by an internalised negative view of themselves from the patients, where they have have been socialised into believing, that what they get, is what they deserve and yet all of us here, in this conference, know we would not accept, nor would we say we deserved, what is given to disadvantaged groups. So, how have these people come to believe that what is not good enough for us, is good enough for them.

In raising the issue of bias and its impact on health outcomes, I know the grief reaction is inevitable. We as a society feel grief that our vision of 'equality for all' is not the reality for many.

It is a challenge to recognise our own personal and emotional responses to being confronted with this problem and to move on in a healthy way. To get past the denial ("but everyone gets the same treatment"), the anger, the guilt, the bargaining ("we'll put one Maori on our Board, we'll have a health plan for a disadvantaged minorities") and move into a phase of acceptance and hope.

The hope lies in practical and inclusive solutions, in recognising local knowledge and expertise, in sharing the design phase and meeting as partners around the table. It is in this way that we can remove a major barrier on the "road ahead" for Maori and Pacific health.

Exclusion is not confined to Maori and Pacific peoples. There are many groups who face barriers –those with disability, the aged, and those with low incomes.

Under the commercial model of health supported by previous governments, clinicians were often excluded from sitting around the table.

As we redesign the health sector, it is important to ensure that clinicians who are in everyday contact with service delivery have a voice. There are groups who are often omitted as the result of the design. Such groups include rural doctors and other rural health professionals.

All of us here have a responsibility to ensure wide and diverse participation and in the context of this hui, participation by mana whenua and our Pacific relatives.

We must ensure that any health map includes us Maori and Pacific people. We will be testing a democratic system with the elections to the DHBs which should tell us whether we are wanted around the table. That will be a test for our society. Representation at the table is the only way forward. It will be a sign of a maturing nation which will demonstrate it celebrates cultural diversity.

I started this korero with a reference to drawing maps and sitting around tables. I want to end therefore by quoting Afro American writer James Baldwin who once said "Though it is sometimes very difficult to imagine our nation totally free of racism and sexism, my intellect, my heart and my experience tell me that it is actually possible. For that day when neither exists we must all struggle".

Thank you for offering me the opportunity to enter into dialogue with you. I know all of you will welcome the opportunity to sit around a table where the richness of diversity will lead to the creation of health equity and equality.

Na reira, tena koutou katoa.


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