For the last four decades, cultural competency has been promoted as the answer to Māori inequities in health. But, despite many moves to insert Māori culture into health, Māori health statistics are no better — and in most cases, they’re worse, as Dr Elana Curtis writes.
I was born in the middle of the Māori cultural renaissance that occurred within many metropolitan suburbs across Aotearoa New Zealand in the 1970s.
Raised in West Auckland, I grew up with a professional Māori father working within urban Maori educational settings but still connected to his Te Arawa iwi roots about three hours away — and fully supported by my white Australian mother.
I understood the importance of culture from a very early age. In fact, as a young Māori girl immersed in many Māori cultural settings, I felt sorry for Pākehā who didn’t seem to understand why a karakia was being said, or how to conduct themselves on a marae.
With this backdrop, I decided, at 10, that I would become a Māori doctor. Not for altruistic reasons, but more because I wanted to make a political statement that “Māori could do anything”.
My naive 10-year-old mind already understood that Māori were at the bottom of the heap and, quite frankly, I wanted to piss off Pākehā.
Jump forward 40 years, and I’m a doctor and public health medicine specialist with Māori and Indigenous health expertise. And I find myself in the unenviable position of still valuing my culture, but being fully aware that my culture is not the cause of, and therefore not the solution to, contemporary Māori health inequities.
So what is the cause? And the solution?
Unfortunately, it’s impossible to divorce the historical (and contemporary) colonial context that has led to the inappropriate assumptions of European superiority and English sovereignty and control.
The process of colonisation systematically appropriated Māori land, which resulted in both fiscal and spiritual loss for Māori, and created an environment of Pākehā socioeconomic privilege and Māori disadvantage. So we’ve had a dual economy where Pākehā prospered and where Māori have been subjugated, culturally and politically, all across New Zealand.
In summary, colonisation created an environment that’s designed to ensure Pākehā power and control at the expense of Māori indigenous rights and good health.
Being powerless, being marginalised, and being poor all equate to a person being less likely to enjoy good health and more likely to die prematurely. And so it continues.
It’s understandable that, as New Zealand began to recognise its failure to honour the Treaty of Waitangi and allow Māori cultural expression, an investment in Māori culture should be supported.
Suddenly, pōwhiri and mihi whakatau were in. Meetings would be started with karakia, and buildings and organisations were given Māori names. Concepts of tapu and noa spread across hospital floors and corridors. Enlightened Pākehā knew not to sit on tables and would avoid touching a Māori child’s head.
Health services responded by employing Māori kaiāwhina or support workers to provide the cultural requirements of Māori who found themselves in hospital. Māori managers were employed to manage the Māori kaiāwhina and Māori “health” teams popped up everywhere. Biculturalism became the new black.
Things were looking up. Finally Māori health — well, at least Māori culture — was being taken relatively seriously.
Yet, here we are, 40 years later, and Māori are still dying before their time — and, by almost every health measure you can consider, are still worse off than Pākehā, with some inequities getting worse.
The investment in Māori culture within health hasn’t fixed the problem.
Really, we shouldn’t be surprised. The one-dimensional approach to a complex web of causes always needed a much more sophisticated response — and it still does.
In fact, the national and international evidence is clear that ethnic inequities are inextricably linked to issues associated with racism and privilege.
We need to get our heads around how racism and privilege operate in society, and how they operate within our health care institutions.
We need to understand that Pākehā culture, assumptions, stereotyping and bias against Māori are likely to be part of the problem. And that they need to be addressed.
As Aboriginal academic Chelsea Bond tweeted:
The solution 2 racism is NOT cultural awareness. The solution is a critical race consciousness which has nothing 2 to do with my culture.
Cultural safety — rather than cultural competence — provides a mechanism to begin the important work of critical consciousness where healthcare professionals and their organisations examine themselves as being part of the problem.
In other words, they examine and foreground their own culture, rather than the culture of the “exotic other”.
First spearheaded by Dr Irihapeti Ramsden within nursing and midwifery in New Zealand in the 1980s, cultural safety explicitly acknowledges and re-aligns “power”.
After all, the power to order necessary investigations in a timely manner lies with the healthcare professional making the right assessment, and the healthcare organisation funding the right mix of services that can respond to Māori health need appropriately.
Although it might be nice for the Māori patient, none of this requires a karakia or a mihi whakatau. It just requires access to best practice, evidence-based care. Let’s start there.
Maybe then we’ll see Māori health inequities eliminated. Maybe then my little 10-year-old self might stop wanting to piss off Pākehā and can go back to the business of dreaming a different reality where Māori are thriving in healthy, happy lives, free of racism and discrimination.
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