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6.1 Indigenous Public Health

Indigenous Peoples’ concept of health and survival is both a collective and an individual inter-generational continuum encompassing a holistic perspective incorporating four distinct shared dimensions of life. These dimensions are spiritual, the intellectual, physical and emotional. Linking these four dimensions, health and survival manifests itself in multiple levels where the past; present and future co-exist simultaneously (Committee on Indigenous Health, 1999, p. 3).

Indigenous models of public health generally recognise that health is intimately linked to indigenous world views and development (Durie, 2004). M.

Cunningham (2009, p. 155) in her review for the United Nations, contends customary practices are based on indigenous communities seeking to maintain interior and exterior equilibrium and harmony between community members and the cosmos around them in a combination of practices and knowledge based about the human body, nature and spirituality. In a statement to the United Nations the Osiligi peoples from Kenya (1998), p. 1) explain:

Indigenous people’s health issues and other problems cannot be separated from the critical and related problem of continued dispossession and alienation from their traditional lands and land resources. Indigenous health relates to our spiritual and cultural expression.

The North American “medicine wheel” reflects indigenous holistic, spiritual philosophies and beliefs (Dapice, 2006). There are many variations in medicine wheels (see Figure 10) but they often have distinct coloured quadrants which pertain to the four dimensions of life. Medicine wheels continue to be used for various astronomical, ritual, healing and teaching purposes, including as the basis of individual and community level health interventions (Eaton, 1994; M. King et al., 2009).

Figure 10: Creation Story

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This representation of the medicine wheel, entitled the creation story, was developed by Don Lemieux93 which shows the relationship of the Anishinaabe people with the earth the larger orb and the creator, - black background and the need to live in harmony with other races, - four colours of the medicine wheel, and spirits, - various colours, that exist in this realm. Used with permission.

The relatively strong health status of indigenous peoples prior to European contact, the impact of colonisation and the resulting collapse in indigenous health status brought on by infectious diseases, warfare and urbanisation and land alienation are well documented (see Bird, 2002; M. Cunningham, 2009; Durie, 1994b; Gracey & King, 2009). The legacies of these common experiences across indigenous health, particularly for those, that are a minority population within their own lands, are being increasingly linked by health researchers such as Anderson et al. (2006) and Cohen and Northridge (1999) who offer contemporary examples of life expectancy and quality of life discrepancies between indigenous and non-indigenous peoples.

Around the world, indigenous peoples are at various stages in terms of reclaiming political power and rebuilding infrastructure and capacity to lead their own development (Department of Economic and Social Affairs, 2009). There remain considerable ongoing challenges in terms of revitalising indigenous languages and securing the return of misappropriated lands. Cunningham (2009, p. 181) and King, Smith and Gracey (2009, p. 76) contend that the restoration of indigenous wellbeing is inextricably linked to decolonisation processes, and the enactment of indigenous self determination.

Indigenous responses to health and wellbeing challenges are diverse. The advent of globalisation there is increasing cohesion within the indigenous peoples’ rights movements as demonstrated with the collaboration over the Geneva Declaration on the Health and Survival of Indigenous Peoples (Committee on Indigenous Health, 1999) and more recently the United Nations Declaration on the Rights of Indigenous People. Through the Geneva Declaration indigenous peoples called for increased investment in indigenous health, advocating for indigenous led and controlled services delivered from an indigenous epistemology. Alongside this call are demands for constitutional and legislative reforms by state parties and a commitment to reduce the inequities accompanying globalisation.

Indigenous researchers have raised a number of high-level concerns related to indigenous health planning. Nettleton, Napolitano and Stephens (2007), Te Rōpū Hauora o Eru Pōmare (2002) supported by departments within the United Nations (Department of Economic and Social Affairs, 2009) have all tabled concerns around the lack of robust processes in the collection of ethnicity data pertaining to indigenous peoples rendering the experiences of indigenous people invisible within much state level analysis of morbidity and mortality. This distorts the evidence base upon which health planning is based. Similarly indigenous health

93Don Lemieux is a member the Bad River band of the Lake Superior Chippewa.

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researchers Chino and De Bruyn (2006, p. 596), Reid (2002b) and E. Pōmare (1986, p. 411) question the effectiveness of generic health models and interventions in meeting the needs of indigenous peoples. They call for greater state accountability about effective service delivery to indigenous peoples, and assert their right to monitor the Crown. Considerable intellectual energy has also been invested in isolated holistic indigenous measures of health status to convert mono-cultural bio-medical measures of indigenous wellbeing into more culturally responsive practice (see Durie, 2005, April; Durie et al., 2002; Durie, Fitzgerald, Kingi, McKinley, & Stevenson, 2003).

Māori Public Health

Durie (2001) holds that there are diverse Māori realities and different whānau, hapū and iwi have distinct traditions and approaches to health and indeed Reid (2002b) argues that there is much still to be written about Māori health. Based primarily on the writings of Durie (1994, 1999, 2001, 2004) and Ratima (2001), in this section I contend that there are two distinct manifestations of public health practice - customary and Māori health development. The former predominated in the period prior to colonisation and into the early nineteenth century with an emphasis on the interconnectedness of all things and maintaining balance. The latter is influenced by affirmations of Māori sovereignty, modern traditions of hapū development, and the evolution of western public health traditions.

Māori Customary Approaches

Māori have long traditions in public health grounded in collective whānau lifestyles and intimate spiritual and practical connections with the natural environment. The application of tikanga minimised disease and injury. Codes of behaviour governed by tapu, noa and rāhui (restrictions) were used to ensure survival, by protecting water supplies, food sources and the safety of whānau (Durie, 1994b; Ratima & Ratima, 2003). In the absence of written laws, the conferment of tapu was a powerful public sanction to limit personal and community activities. Durie (1994b, p. 10) explains:

The balance between tapu and noa was a dynamic one, moving to accommodate seasonal, human and physical needs within a value system that was sufficiently holistic to accommodate health interests.

Pā (village) sites were selected based on consideration of drainage, dampness and military advantage while the use of pātaka [raised food storage] kept food rodent free.

Recognising the importance of water for survival, Durie (1994b, p. 13) notes, Māori developed different classifications94 of water, which helped prevent water-borne disease. A range of traditional healing practices were also developed, from

94 These types include waiora (rainwater), waipuna (hillside spring), waimāori (running streams), waikino (stagnant pools), waimate (downstream sites) and waitai (saltwater).

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ritenga (customs) and karakia (incantations and rituals), rongoā (physical remedies), mirimiri (massage), wai (use of water to heal) and surgical interventions (Ahuriri-Driscoll et al., 2009; Durie, 1994b). Early Pākehā commentators were unanimous in their praise of the Māori health system (Reid, 2002b, p. 52). Captain Cooks’ chief science officer, Banks (as cited in A.

Salmond, 1991, p. 279) recorded at the time: “such health drawn from so sound principles must make physicians almost useless”. Reid (2002b, p. 61) cites the example of the development of a recipe that transforms highly toxic karaka berries into a safe food source as evidence Māori conducted some forms of ‘clinical trials’. The writings of Māori health pioneer Hon. Te Rangi Hiroa95 (1950) outlined elaborate indigenous systems, overlapped with contemporary western ideas of infection control and disease prevention. Demographer, Pool (1991) asserts that for hundreds of year’s tikanga based systems proved effective public health measures.

By the beginning of the twentieth century, Māori wellbeing was compromised through the profound health impacts of colonisation. Kunitz (1994), from his examination of the impact of Europeans on several Polynesian peoples, noted that the alienation of land by making Māori poor also made them susceptible to diseases that flourish under conditions of poverty, overcrowding, and malnutrition. Land alienation disrupted social networks that provided practical and emotional support. These circumstances presented complex challenges to both customary Māori and generic health systems.

At the turn of the twentieth century, within the newly formed Department of Health and through Māori leaders like Hon. Maui Pōmare, an innovative ecological approach to health was embraced. M. Pōmare championed using Māori community leaders as sanitary inspectors, influencing positively on rebuilding and strengthening Māori health infrastructure (Lange, 1999). Customary codes of tapu and noa were however being replaced96 with health regulations and statutes of the new settler government. Critically, M. Pōmare also linked poor health with socio-economic adversity and advocated for a political commitment to health at the highest level. He championed targeted and cultural relevant programs and emphasised the need to develop a skilled health workforce. Durie (1999) argues this approach still holds relevance within Māori public health a century later.

Māori Health Development

The starting points for Māori health promotion are Māori responsive frameworks, with Māori needs, preferences, and aspirations at the centre

(Ratima, 2001, p. 228).

95 Te Rangi Hiroa is also known as Sir Peter Buck.

96 Tapu was retained as a means of environmental management of wāhi tapu (burial grounds) and at the marae.

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Contemporary Māori public health contains elements that are uniquely based on mātauranga Māori but also draws on the traditions of Māori development and generic public health (Pōmare, 1986). In keeping with a kaupapa Māori approach, E. Pōmare (1986, p. 410) asserts, the observation of Māori protocols and engagement with kaumātua and kuia for support, guidance and sanction is common across much Māori public health practice. This tradition is frequently delivered by Māori practitioners from Māori organisations and is assumed inseparable from wider Māori social, economic, political and cultural realities.

Reid (2002b, p. 59) suggests a contemporary turning point in Māori health came with the consolidated political push for pro-active Māori development in the 1970s and 1980s. At a key national Māori health hui, Hui Whakaoranga (Department of Health, 1984, March), Reid maintains, Māori commentators noted the inadequacies of western concepts of health and advocated for greater recognition of culture as an integral part of wellbeing. This increased awareness led to the development of a series of influential Māori health models most notably, Te Whare Tapa Whā97 (Durie, 1994b) and Te Wheke98 (Pere, 1991), which emphasised the importance of culture, the interconnectedness of emotional and physical health and the importance of whānau and spirituality.

Currently the most widely used Māori public health framework is Te Pae Mahutonga (Durie, 1999). Developed by Durie, it builds on the contributions of Pōmare (see Cody, 1953) and the Ottawa Charter (World Health Organization, 1986, November). Using an indigenous icon (see Figure 11), the model represents the key elements of health and the key capacities needed to strengthen them.

Durie (2004, p. 16) describes it as a “…schema to identify the parameters of practice, and to signpost strategic directions to be pursued by states, the health and education sectors, and indigenous peoples themselves”. He emphasises the need for deeper discussions to occur around Māori health, as part of wider debate about culture, the environment, constitutional arrangements, socio-economic realities and indigenous leadership.

97 Te Whare Tapa Whā articulates an ideal concept of health emphasising the balance between wairua, hinengaro (mental and emotional aspects), whānau and tinana (physical realm).

98 Te Wheke is holistic in nature and inclusive of elements of Te Whare Tapa Whā also raises notions of diversity, vitality, and continuity between the past and present.

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Figure 11: Te Pae Mahutonga

Adapted from “Te Pae Mahutonga: A model for Māori health promotion” by M.H Durie, 1999, Health Promotion Forum Newsletter, p.2-5.

Ratima (2001, p. 239) argues Māori public health is characterised by being both committed to emancipatory goals and being ideologically motivated. She suggests its core values focus on strengthening Māori identity, collective autonomy, social justice and equity. She isolated six principles (see Table 8) which exemplify Māori public health. She concludes her study (2001, p. 234) by defining Māori public health as “...the process of enabling Māori to increase control over the determinants of health and strengthening their identity as Māori and thereby improve their health and position in society”.

Table 8: Principles of Māori Public Health Principle Description

Holism Recognises the interconnections of the past, present and future.

Emphasises importance of intergenerational connections.

Continuity between spiritual and material realms.

Self-determination Māori right to control their own future in all domains and at all levels.

Formal accountability to Māori communities.

Māori initiation, ownership, management and delivery.

Cultural Integrity Interventions that affirm and strengthen Māori identity and reinforce Māori cultural values and practices.

Developing a culturally competent workforce.

Diversity Mindful of diverse and dynamic Māori realities.

Sustainability Durability of solutions not quick-fix solutions.

Welfare of future generations not compromised by the interests of the current generation.

Quality Meet high technical and cultural standards.

Credible in Māori terms and meet Māori expectations.

Systematic collection of accurate and relevant information for planning and evaluation.

Note. Adapted from Kia urūru mai a hauora: Being healthy, being Maori: Conceptualising Maori health promotion, (doctoral dissertation) by M. Ratima, 2001, Wellington, New Zealand: Otago University. Reprinted with permission.

Ratima (2001) and Durie (1994b, 2004) concur that Māori public health is strongly linked to whānau, hapū and iwi development. Ratima argues the links are

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present in the shared purpose, value-base, processes, principles and strategies utilised across both disciplines. The drive of both is to achieve Māori potential.

The point of difference, asserts Ratima, is the breadth of their focus. Durie (1994b, p. 1) emphasises the importance of Māori control and agency across both disciplines, i.e. defining one’s own priorities and then weaving a collective pathway to achieve those aspirations. Puketapu (2000, pp. 126-127) reinforces that Māori development is the prerogative of Māori and “…there is no compelling reason for Māori to depend exclusively on the Treaty partnership as the basis for Māori development planning, policy and programmes”.

The emergence of Māori providers within the public health system from the 1990s has been central to Māori health development. Rather than focus exclusively on health, providers often deal holistically with social, economic and cultural areas of life, sourcing funding from various Crown agents and through entrepreneurial activity. Cram and Pipi (2001, p. 25) in their study of Māori providers success recognised consistency, trustworthiness and accountability as key success factors.

Provider credibility was achieved through ongoing engagement with communities, a strong cultural base and the commitment of skilled staff to the kaupapa (purpose) of the organisation. One of the participants in their study (2001, p. 28) explains:

It’s about serving the people. The critical failure is about not losing sight of why you’re there. The only thing that makes you strong is the number of people that stands behind you, the number of people that you’ve served well. If you lose sight of that, you’re just an individual, waiting to be plucked off.

There is a plethora of emerging evidence to demonstrate the effectiveness of Māori public health interventions engaging Māori whānau. One of the most prominent successes has been the national aukati kaipaipa tobacco cessation programme, delivered by Māori providers. It has achieved some of the highest quit rates in the world (Dowden & Taite, 2001). Māori health researcher, Henwood’s (2007, p. 7) review of the five Te Tai Tokerau based korikori a iwi exercise and nutrition programs found alongside anticipated attributable health outcomes, “…spin-offs were identified in education, community and whānau/hapū wellbeing and development, and longer-term economic development and tourism opportunities”. Tipene-Leach, Abel, Haretuku and Everard (2000) have linked the development of a national Māori Sudden Infant Death Syndrome (SIDS) programme to improved awareness levels of SIDS within Māori communities, enhanced research and evidence base and reduced SIDS rates.

In summary, Māori public health is about Māori control and interventions developed with whānau and hapū that are relevant and embedded within Māori cultural, political, spiritual, economic and social realities.

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