Dreaming of a Māori hospital

There’s a long-held dream for a Māori hospital, going right back to Princess Te Puea Herangi’s efforts to create one at Tūrangawaewae marae in the 1920s. Her project was stymied by the health authorities of the time.

Yet research today continues to show adverse outcomes for Māori at New Zealand’s public hospitals, with many older Māori, in particular, experiencing hospital stays as detrimental to their wellbeing.

Here, Marama Muru-Lanning and Hilary Lapsley argue that hospitals developed by, and for, Māori are a dream worth pursuing.

 

Three years ago, in April 2021, our team from the James Henare Research Centre met with kaumātua and kuia from Waikato iwi, to listen to their experiences in healthcare and hear their ideas for change. Our meeting coincided with the official announcement of the establishment of the Māori Health Authority, Te Aka Whai Ora.

Two of our kaumātua, Matua Taitimu Maipi and Whaea Ramari Maipi, had been at the announcement in Wellington. They were full of the news, and we rearranged our programme so Matua Taitimu could talk to us about the history of Māori health activism.

He spoke about a number of initiatives, going back to the historic fern collection of King Tāwhiao, the second Māori king, which identified the rongoā (healing) uses of different species. He also spoke of Princess Te Puea Herangi’s mission to improve the health of Waikato Māori, and her efforts to create a small hospital at Tūrangawaewae.

Princess Te Puea was a living presence during the youth of the kaumātua at our meeting. She dedicated her life to safeguarding the Kīngitanga and its people. She followed the Pai Mārire faith, opposed conscription in the First World War, envisioned and built Tūrangawaewae marae and did much to develop an economic base for Waikato Māori.

Following the influenza pandemic of 1918, when a quarter of the population at Mangatāwhiri died, Princess Te Puea organised the historic move of the marae from Te Paina (Mercer) to Ngāruawāhia. There she established makeshift homes for the many orphans and supporters who followed her.

Concerned about future epidemics, she began fundraising for a hospital for Māori, and this led to the erection of the tūpuna whare at Tūrangawaewae, Māhinārangi. Opened in 1929, Māhinārangi was to provide rongoā as well as western medical treatments, in a building that looked reassuringly like a meeting house. In the hospital, tikanga would be observed. It would be open to any Māori, not just those from Waikato.

But after all of Princess Te Puea’s efforts, the application for a licence for Māhinārangi to be used as a private hospital was declined by health authorities. Yet Māori had been refused treatment at Waikato Hospital when it first opened, seeding decades of mistrust in public health services and providing a further argument for a hospital at Tūrangawaewae.

After this devastating disappointment, Māhinārangi was repurposed as a place for Waikato Ariki to host manuwhiri. Te Puea’s disappointment was not the only one, however. During the early 20th century, Dr Māui Pōmare promoted the vision of a network of Māori hospitals. He consulted iwi leaders, and the plans were supported by Dr Peter Buck/Te Rangi Hīroa, Āpirana Ngata and James Carroll. Funds were raised and sites donated, but the additional and necessary government funding, despite promises, never came through.

At our hui in 2021, Matua Taitimu recalled his involvement with the ongoing fight for Māori health services, beginning in the 1970s with the activist group Ngā Tamatoa. He went on to play a central role in initiating a series of hauora claims to the Waitangi Tribunal.

Matua Taitimu reminded us that, through claims to the Waitangi Tribunal, Māori have made three demands:

1. Mana motuhake, or Māori control of Māori initiatives.
2. An apology from the Crown for 200 years of suppression, genocide and racism.
3. A legislative act for Māori control of their health.

With the third demand finally realised in the new Māori Health Authority, Matua Taitimu had hope for the future. However, the new coalition government disestablished it, and it was formally closed on June 30, 2024, just two years after it came into existence.

Yet the need remains. From that first Waikato wānanga, and in our ongoing work on kaumātua health and wellbeing, our research team documented unpleasant experiences for Māori in our public hospitals.

The stories were echoed at research sites in Te Tai Tokerau, Tāmaki Makaurau and Tauranga Moana.

There were common threads in these stories: The lack of manaakitanga shown to our kaumātua, breaches of tikanga, and experiences labelled by participants as racist. Stories about limited access to hospitals and treatment delays, particularly experienced by northern kaumātua living at a distance from services, were also perceived as lacking manaakitanga.

Manaakitanga, or respectful reciprocal relationships, is fundamental to Māori life. It encompasses the culturally appropriate ways of doing things. Not putting effort into manaakitanga, or breaching tikanga in other ways, can diminish mana, cause whakamā, embarrassment or shame, and result in mistrust and reluctance to engage with hospitals.

Kaumātua told us that when they’re in hospital they like someone to sit with them and talk slowly, taking the time to explain things. Instances of kindness and thoughtfulness from Pākehā, as well as Māori staff, were recounted, but they loved to see Māori faces, telling us things like: “I go to the brown face because I feel safe.”

In Tāmaki Makaurau hospitals, we were told, with pride, that there are “clever people like our mokopunas who graduate . . . we have heaps of our mokopunas working in there [the hospital] now.”

So what would be key to the success of a Māori hospital? Our kaumātua in Waikato told us it must operate according to tikanga and that it should serve the specific health needs of Waikato Māori. Further, our group emphasised that it is kaumātua who are the guardians of tikanga, so they should be central to decision-making in any hospital project.

Two sites of hospital care that were highly spoken of by our participants were Hokianga (Rawene) Hospital and the kaupapa ward at Tauranga Hospital.

Hokianga, a small cottage hospital, was founded early in the 20th century and is now run by the Hokianga Health Enterprise Trust, a Māori-owned hauora health provider. Hokianga models culturally appropriate patient care, such as karakia, blessings and comforting patients with te reo, and ensures appropriate protocol around deaths.

At Tauranga, we were told: “The kaupapa ward is different because when we have patients that are really māuiui, they do put you into a separate place so that your whānau can come in and awhi you and do the grieving before.”

One participant said that when they were discharged from a regional public hospital: “I could not wait until they discharged me into Rawene. When I got to Rawene, I was quite content there. Felt like you were important, and they cared about you. The other place seemed like you were in a factory, and you were passed on to the next part.”

At the regional hospital, a nurse had “chucked in the bin” a rongoā preparation his wife had brought in, saying: “We don’t allow that sort of thing here.” Now that Rawene is relaxed about Māori patients using rongoā, he told us: “The old people are frequenting the hospital a lot more than they were before . . . They never went before.”

Hospitals were described as busy places where communication was inadequate: “They don’t understand what I’m saying, where I’m coming from.” “They don’t help you understand.”

Seeing a number of different specialists could be confusing. Staff busyness meant that whānau sometimes had to help with care, such as showering. Pressure on services could also mean waiting for admission. As one said: “I could be dead by then.” Early discharges occurred, too, because “they needed the bed.”

The emotional tenor of interactions in a busy ward could lead participants to feel that “nobody cared.” One who spent “the worst five days of my life” in a busy hospital said: “Nobody smiles.”

Other stories about hospital behaviour included not allowing a patient who wanted to “put her feet on Papatūanuku” to leave the ward. Not allowing a carer to provide food for her father when the whānau had waited for hours in the emergency department. And telling someone who wanted to complain about their treatment that there were no forms in the ward.

Participants felt bad when they were “spoken down to”, when staff treated them as “slow”, or if they “don’t take your word for what’s wrong.”

Mixed-gender wards could be distressing, especially for kuia. One kui felt so strongly about this issue that she now refuses to go to the local hospital after her campaign about mixed wards being culturally unsafe did not lead to changes.

Transport was a major issue for those living in rural areas. Discharges could involve being placed, while still quite ill, on a shuttle bus for a trip of several hours. Whānau caring for kaumātua found it difficult to fit hospital visits around work and obligations to other whānau, let alone transport and accommodation expenses, which could be higher than the reimbursements available.

We were told that a common attitude among older Māori was that “you only go to hospital to die.” Some participants felt that was changing, but that it nevertheless explained the reluctance of some to go to the hospital.

The experiences we heard while conducting our research are documented in other studies, which describe hospital services for Māori as “hostile”, “racist” and “alienating”.

So it’s not surprising that many studies show that Māori, when compared with non-Māori, arrive later at hospitals, present with more serious symptoms, have more avoidable hospitalisations, are more likely to receive suboptimal care, have more preventable adverse events in hospital, more often discharge themselves early, are admitted more frequently after discharge, and have poorer health outcomes after surgery.

Looking specifically at older Māori, research found that, particularly in rural areas, they were significantly more likely to experience “treatment injury and complication hospitalisations” than non-Māori.

Negative events experienced by kaumātua, their whānau and friends, and historical memories of such experiences, diminish trust in hospital care, and we believe have a causal relationship to these documented disparities. They also feed into the wider picture of health and longevity inequities.

Now is the time, we argue, for Māori organisations to develop hospitals to provide Māori, particularly older Māori, with culturally safe care. Moreover, kaumātua must play an authoritative role in the development of Māori hospitals, as they carry the responsibility for tikanga.

The idea of an Indigenous hospital is not without precedent. There are examples from other countries — the 170-bed Alaskan Native American hospital at Anchorage being the most often cited. That hospital, and its associated health clinics, developed the innovative Nuka System of Care for the 70,000 Native population of the district.

The Cherokee Indian Hospital in South Carolina, serving a smaller population of 12,000 Cherokee Indians, is another example. It is a 20-bed hospital with associated specialist clinics and a hospice, developed with finance from the tribe’s own resources, breaking away from the Indian Health Service. Both these hospitals embed tribal values into their patient-centred systems of care.

The Queen’s Medical Center in Honolulu offers a different model. It is a city hospital with 575 acute care beds and a comprehensive range of specialties, open to patients of all ethnicities. A non-profit, founded in 1859 by Queen Emma and King Kamehameha IV, it is now the backbone of the Queen’s Health System, which runs several smaller hospitals and delivers “comprehensive health care services and programs to Native Hawaiians and all people of Hawai‘i”. Indigenous frameworks of healthcare are recognised in its programmes.

In Asian countries where colonisation never occurred, or where independence put Indigenous people in charge again, many fine hospitals provide services equivalent in most respects to those in western countries. These may incorporate treatments seen as “alternative” in the west, with acupuncture in Chinese hospitals a well-known example.

In Aotearoa, hauora is embedded in a system of primary care for Māori, underfunded though it is, and we have mentioned two hospital settings, albeit small, that provide kaupapa Māori services. There is also the historic Te Puia Springs hospital, a Ngāti Porou hauora.

A mixture of iwi, private and public health funding could provide for the development of new state-of-the-art hospitals.

After the disestablishment of Te Aka Whai Ora, the current government promised to devolve that health funding to iwi. It should be held to its promise.

The private hospital system in this country is expanding, meaning that there is investor capacity and expertise available. It’s worth noting that some iwi already provide health insurance for kaumātua, and at least one provides cover for all members, which is another way of making a private hospital model affordable.

Imagination is required. Simply looking to overseas models of financing Indigenous hospitals may not be sufficient, as our history and policies are very different in Aotearoa New Zealand.

A key feature of current hauora services for Māori is that they are available to non-Māori as well. That policy could be necessary for successful Māori hospital development, and a service emphasising manaakitanga and tikanga Māori could well be attractive to non-Māori patients.

Scope, as well as funding, requires much thought. A hospital can be a small facility, these days usually no fewer than 60 beds. It could offer specialised care for mate wareware, surgical specialties, maternity or end of life, to name several possibilities.

However, visions for a large general hospital should not be dismissed out of hand. This should be a serious consideration in Waikato, with pressures on Middlemore and Waikato hospitals, the populations of Auckland expanding southwards and Hamilton northwards, as well as the prospect of a new medical school at the University of Waikato.

In the north, smaller general hospitals, guided by tikanga Māori, could be repurposed and enlarged to provide a wider range of services. Staffing, of course, would be a major issue, but we would expect that a Māori hospital could be staffed by suitably trained professionals of any ethnicity.

Serious thinking about Indigenous hospitals in this country is underway. Shortly before the nationwide hui for Māori in January 2024, Rahui Papa, a spokesperson for the late Kīngi Tuheitia, called for a Māori hospital, referencing Princess Te Puea:

“In her view, and the argument still stands strong today, that if Māori can see themselves in the medical system, then they will engage a little bit better.”

As Princess Te Puea herself famously said: “Mehemea, ka moemoea ahau, ko ahau anake. Mehemea, ka moemoea tatou, ka taea e tatou. If I dream, I dream alone. If we dream together, we shall achieve.”

 

This opinion piece is dedicated to Dr Ngapare Kaihina Hopa who inspired us to advocate for Māori aged care facilities and Māori hospitals. It is with great sadness that she passed away at the conclusion of the writing of this article.

This is an edited version of a full-length article that first appeared in the New Zealand Medical Journal.

Marama Muru-Lanning is an associate professor of anthropology and the co-director of the James Henare Research Centre at the University of Auckland. She chairs the Waikato-Tainui Endowed College for Research and Development. As a social anthropologist, she focuses on the cultural specificity of tangata whenua and their unique sense of place and belonging in Aotearoa. Marama is from Tūrangawaewae marae in Ngāruawahia, a potent living memorial to the many Waikato people taken by the influenza pandemic of 1918. She has whakapapa that connects her to Waikato (Ngāti Puhiawe), Ngāti Maniapoto and Ngāti Whātua.

Dr Hilary Lapsley is an honorary academic at the James Henare Centre, University of Auckland Waipapa Taumata Rau.