A view from Aotearoa regarding indigenous health equity—looking back to move forward

Introduction

Māori are the Indigenous people of Aotearoa New Zealand (NZ) comprising approximately 17% of the total NZ population (4.5 million) (1). A British colonial socio-political infrastructure was imposed by force on Māori following the signing of its founding treaty document Te Tiriti o Waitangi in 1840. Te Tiriti o Waitangi is the Māori text of our nation’s agreement that allowed the British Crown to establish government over its settlers in NZ whilst affirming rangatiratanga (sovereignty) of Māori over their own affairs including natural resources (2). Additionally, Māori were granted the same rights as British subjects. The Treaty of Waitangi is the English text that was drafted which differed significantly to Te Tiriti. However, it was the Māori version that was presented and signed by most Rangatira Māori (Māori chiefs) (2,3). Despite promises of a reciprocal partnership, NZ is a colonial state built on systematic breaches of Te Tiriti o Waitangi where mass migration of British settlers from the mid-nineteenth century occurred coupled with civil war instigated by British settlers to assert their independence (4). As a result, British settler society prospered by building an economy powered by illicit acquisitions of resources from Māori, the exploitation of Māori labour and the subjugation and systemic oppression of Māori culture, economy, philosophy and spirituality (5-7). Therefore, Māori have been socio-politically and economically oppressed with current intergenerational ramifications resulting in contemporary inequities across health, education, justice, income and decision-making (8,9).

Like many Indigenous peoples worldwide, Māori experience significant health inequities such as having, on average, the poorest health status of any ethnic group in NZ (10), with a life expectancy at least 7 years shorter than non-Māori (11). Additionally, Māori receive less access to, and poorer care throughout, the entire pipeline of healthcare services from primary health to tertiary level care (12,13). Even after adjusting for socioeconomic deprivation, health inequities still remain for Māori (8). Addressing persistent health inequities for all Indigenous peoples worldwide requires settler states to revisit their deep-rooted historical, cultural, and systemic foundations (14). Political rhetoric that asserts that everyone starts on a ‘level-playing field’ with respect to socioeconomic opportunities, alongside narratives urging Indigenous peoples to take individual responsibility for health inequities, actively ignores the colonial devastation that has excluded Indigenous participation in, and exposure to, the socioeconomic determinants of health (5). Attributing inequity to surface causes like individual health-seeking behaviours, health system access, and social status completely ignores the colonial basis of the NZ economy, the dominant NZ culture, privileging of Pākehā (NZ Europeans) and the imposed legal and political systems (15).

The Waitangi Tribunal was established in 1975, as a permanent commission of inquiry to investigate alleged breaches of the promises made in Te Tiriti o Waitangi. Breaches related to Māori health fall within the remit of the Waitangi Tribunal. In 2019, over 200 claims were presented before the Tribunal as part of the Health Services and Outcomes Inquiry (WAI 2575) outlining the harmful effects of the Crown with respect to its inaction and action, laws, and policies on Māori health (16). The WAI 2575 report argued that the Crown is in breach of Te Tiriti o Waitangi in its failure to deliver equitable health outcomes for Māori (17). Despite the overwhelming evidence, addressing Māori health inequities within the broader NZ socio-political context, is often met with resistance.

Supporting Māori self-determination to take control of health and wellbeing is a right ratified by Te Tiriti o Waitangi. In July 2022, the NZ (then Labour) government launched Te Aka Whai Ora—Māori Health Authority, the first independent statutory entity, to work in partnership with the Ministry of Health and Te Whatu Ora—Health New Zealand (18). Its establishment followed recommendations from the WAI 2575 inquiry and an independent health and disability system review which found the health system had failed to recognise and properly provide Māori self-determination and autonomy over our health (19). The role of Te Aka Whaiora as a Māori-led, independent Crown agency included advocacy for and commissioning of policies and services to improve Māori health and address unacceptable inequities and institutional racism (18). This aligned with evidence that interventions to address Māori health inequities are informed by Māori worldviews and values, grown from within Māori communities and built in partnership with Māori. For instance, Whānau Ora was established in 2010 and has been tasked with delivering culturally-grounded, holistic approaches to improving whānau wellbeing through wrap-around health and social services tailored to whānau and individuals in the context of their whānau (20).

Despite nearly two decades of work dedicated to the delivery of Whānau Ora solutions relevant to whānau health, the current coalition government of NZ has swiftly disestablished Te Aka Whai Ora citing that after 2 years in transition and 1 year in operation, little tangible outcomes have been produced. In response, the Waitangi Tribunal in attempted to open an urgent inquiry (WAI 3307) over the Crown’s intention to disestablish Te Aka Whai Ora and shortly after this announcement the NZ government passed the Pae Ora (Disestablishment of the Māori Health Authority) Amendment Bill under urgency prohibiting Māori agency and self-determination in challenging this decision in the political arena (21). This review outlines the evolution of Māori health in the NZ context and presents a model encapsulating how we as Māori clinicians and academics seek to research from, and develop solutions towards, health equity for Māori.

A rights-based approach to health

When developing solutions to address Māori health inequities, it is prudent do so using a rights-based approach where Māori health inequities have arisen at their most basic cause as a consequence of consistent breaches to Māori rights reaffirmed by Te Tiriti (22). A rights-based approach to health is multidimensional and supports Māori concepts of health extending beyond physical interpretations. Indigenous worldviews often hold holistic perspectives of health that combines physical, intellectual, social, emotional, and spiritual dimensions which extends to natural environment (23). A rights-based approach ensures that the ultimate goal of health policy, strategy and programme delivery advance the realisation of the right to health and other health-related human rights as affirmed by national and international human rights legislation. In conjunction with Te Tiriti o Waitangi, the rights of Māori are also recognised in various domestic laws and international human rights standards that apply to Māori as the Indigenous people of NZ (24). The right to health for Māori in NZ has been recognised through ratification of core human rights treaties, including conventions about racism and the rights of women, children, and persons with disabilities (24). The Human Rights Act in particular, prohibits direct or indirect discrimination in relation to health status or health services, or in relation to key determinants of health such as employment, housing, and education (25).

Research

One of the most poignant assessments of Western research on Indigenous peoples is that by Smith [1999], where she states:

“The word itself, ‘research’, is probably one of the dirtiest words in the Indigenous world’s vocabulary. When mentioned in many Indigenous contexts, it stirs up silence, it conjures up bad memories, it raises a smile that is knowing and distrustful.” (26)

Western research on Indigenous peoples has been an extractive and violent process whereby assessments have been made on Indigenous peoples, places or knowledge systems without Indigenous collaboration or even their full informed consent (26). Indigenous research methodologies can serve as direct rebuttals to Western or mainstream research and as an act of Indigenous self-determination to tell our own stories in our own authentic way (26). Indigenous methodologies seek to directly serve and connect with Indigenous communities through sharing research knowledge with those communities to uphold their agency over their own stories and to ensure a reciprocal process is established and maintained (26,27). More contemporarily, Indigenous knowledge sharing in this way is also motivated by the colonial experiences of exclusivity where Indigenous peoples have been excluded from access to knowledge and have had their knowledge systems relegated to myth and legend and thereby erased (28). In this way, research can act as a site of resistance by equipping Indigenous peoples with the skills needed to critique the ‘myth-education’ of colonisation.

There are many examples of Indigenous Māori led research that has directly informed health policy and service delivery in NZ. Professor Sir Mason Durie is one of our most esteemed Māori health researchers whose work spans over 30 years and continues to inform public health policy and shape the practice of healthcare professionals interacting with Māori (29-32). With the conceptualisation of Kaupapa Māori research methodology in 1997 by Professor Graham H. Smith, a significant growth in Māori-led health research has been observed (33). Through research, Māori are now able to provide evidenced theoretical statements to inform health policy and realise practical solutions to existing health inequities.

The interface between indigenous knowledge/science and Western science

Indigenous peoples have survived millennia, living in synchronicity with our environment because of highly developed philosophies, methodologies and scientific exploration. Contemporary relevance of Indigenous knowledge and culture is reaffirmed in the United Nations Draft on the Declaration on the Rights of Indigenous Peoples (UNDRIP) which was initially presented to the United Nation in 1993, and supported by NZ in 2010 (34). The tensions that exist between science and Indigenous knowledge are related to contests of validity and superiority (35). Mistrust among Indigenous communities towards Western science has arisen as a result of the way Indigenous peoples have been (mis)characterised by scientists as inferior and through the illegitimate claiming of Indigenous knowledge (26,35). Equally, Western science has often been intolerant of Indigenous knowledge by reinterpreting it to fit within its scientific logic or ignoring it altogether (35). Indigenous knowledge and science often involves the interpretation of spiritual phenomena and views the natural environment as more than a ‘scientifically observable construct’ (35). Therefore, work at the interface, cannot be done without clear acknowledgement of the validity of both knowledge systems, and clear guidelines around benefit-sharing. However, as evidenced research at the interface seeks to use both Western science and Indigenous knowledge and science to create new knowledge that can be developed into pragmatic solutions for the benefit of Indigenous peoples (35). Measuring the efficacy of new health interventions mostly involves observing changes in health indicators such as life expectancy, mortality, morbidity, disease incidence/prevalence and, at times, quality of life indicators. Whilst most of these indicators are generally applied in measuring health outcomes for all, specific Indigenous indicators of health as determined by Indigenous peoples should also be measured such as community connection, natural resource accessibility, and cultural connectivity and practice (35,36). Figure 1 presents an adaptation of ‘the interface’ with the addition of social justice as an integral lever into realising health equity for Indigenous peoples (35). The interface is grounded in the four core principles of mutual respect, shared benefits, human dignity and discovery (35). Social justice is an added lever of change that feeds into the interface as health equity is a social justice goal that seeks to pursue the highest possible standard of health and healthcare for all people with particular attention paid to those of greater risk of poor health (37). A genuine sharing of power, which will be most necessary by non-Indigenous settler states and organisations, is the only way Indigenous rights to self-determination can be upheld (38). We present examples below from NZ outlining some key ways that mātauranga Māori (Māori knowledge) and Western science have operated at the interface creating Kaupapa Māori models of healthcare and healthcare delivery.

Figure 1 The interface between indigenous knowledge, science and social justice as adapted from the original ‘interface’ model by Durie (35).

In 2007, Mercier posed the question: ‘How can Māori achieve tino rangatiratanga at the interface if the extent of Māori knowledge is not appreciated?’ (39). Whilst research and education at the interface could bring out the best of both worlds, as it stands, Indigenous peoples do not hold absolute sovereignty and self-determination over the own lives. Evidence of this is clear in the ways in which legislation, such as the Pae Ora Amendment Act in NZ, can be swiftly imposed and the right of Māori to challenge this taken away without hesitation (21). Therefore, researching at the interface requires that Indigenous peoples have the absolute authority to utilise either Western science or Indigenous knowledge (or both) at their discretion in order to achieve social justice for our people. In this way, the risk of Indigenous knowledge and science being usurped or claimed by non-Indigenous researchers can be mitigated as Indigenous peoples, tribes and communities lead, guard, and refine research at the interface.

Responsive to indigenous ways

The Māori response to coronavirus disease 2019 (COVID-19)

The NZ government-led national COVID-19 elimination strategy in 2020 was considered one of the most successful strategies in the Organization for Economic Co-operation and Development (OECD) (40). Key to our national success in supporting whānau (families) and communities and in mitigating the effects of COVID-19 was the collective, tikanga (customary) centred and holistic approaches employed by Māori. When COVID-19 first emerged, many predicted that Māori would suffer disproportionately higher rates of morbidity and mortality if uncontrolled community transmission ensued. Looking back, the mortality rate for Māori following the 1918 influenza pandemic was seven times higher when compared to Europeans (41). Additionally, disease rates for Māori during the 2009 H1N1 influenza pandemic were twice as high as European/Other New Zealanders and mortality rates were three times higher (42). Alongside these fears, concomitant fears surrounding the socioeconomic impact of COVID-19 on top of already accumulated inequities and structural racism linked to colonisation and neoliberalism for Māori would exponentially worsen (43). With this knowledge, hapū, iwi (tribal group) and health providers were prepared to respond.

Disappointingly, despite the plethora of evidence and knowledge of Māori mortality through previous pandemics, Māori leadership and decision-making was not always sought or respected by government, mainstream health officials and non-Māori (44). In fact, there was unanimous opposition from Māori health and Iwi leaders to the COVID-19 protection framework given the Government’s failure to both design the COVID-19 response jointly with Māori and through not engaging with Māori to “the fullest extent practicable” (45). In response, Māori clinicians and practitioners formed a national Māori pandemic group—Te Rōpū Whakakaupapa Urutā—to protect Māori communities throughout the government mandated COVID-19 strategy. Māori also distributed leadership and localised self-determination and care which included instituting pandemic co-ordination hubs on marae (Māori meeting sites), setting up roadblocks into vulnerable Māori communities, local and mobile COVID-19 testing and vaccination clinics, whānau and kaumātua (respected elders) welfare checks and data connectivity through the provision of culturally relevant messaging and online educational content (46-48). Local hapū (Māori subtribes) also took control of COVID-19 testing and distributing COVID-19 vaccinations (when they finally arrived), as well as other household essentials including kai (food), blankets, home school packs and masks. In one area on the remote East Coast of the North Island in a placed named Te Kaha, local iwi Te Whānau-a-Apanui collaborated with local Māori health providers to achieve an 80% vaccination rate in their region (46). The actual impact of COVID-19 on Māori health inequities is yet to be fully assessed. A large study has been funded by the Health Research Council of NZ to document the impact of COVID-19 pandemic management on Māori health inequities at both a nation-wide and regional level (49). Utilising Kaupapa Māori positioning this research will undertake a quantitative analysis of national data sets ‘pre’ and ‘through’ COVID-19 to examine categories of access to healthcare, quality of healthcare and health outcomes. Whilst we await the findings of this large-scale project, what is known is that the success of the internationally praised COVID-19 response in NZ was underpinned by Māori-led responses (50).

Re-designing models of healthcare

Taking charge after stroke

Research has been useful in developing strategies to improve stroke outcomes for Māori. We showed that despite similar levels of activity and independence at hospital discharge, Māori and Pacific peoples were more dependent, disabled and dissatisfied at 12 months following a stroke compared to NZ Europeans (51). Our hypothesis was that the complex interplay of cultural beliefs and attitudes towards stroke, stroke recovery and the role of the family in the care of a disabled patient were significant factors. Therefore, after conducting comprehensive qualitative work with Māori and Pacific stroke patients, we developed two novel approaches that sought to engage and involve Māori and Pacific stroke patients and their whānau (families) in self-directed rehabilitation strategies. These were: (I) a DVD (digital versatile/video disc) of four inspirational stories by Māori and Pacific stroke patients; (II) a ‘Take Charge Session’ which incorporated a structured risk factor and activities of daily living assessment. Using a randomized, controlled parallel group 2×2 trial design, we compared stroke outcomes between Māori and Pacific patients who received one, both or neither of these two interventions (52). A simple intervention aimed at promoting self-directed rehabilitation strategies in the patient and their whānau and provided between 6 and 12 weeks after stroke, led to a clinically significant improvement in health-related quality of life, reduced dependence and an improvement in the strain experienced by carers (52).

In congruence with the key principles of Indigenous research described earlier, this research collaborated with Māori and Pacific stroke patients and their whānau with an intentional focus on the wellbeing of the collective. The interventions co-designed with both groups sought to empower, support interdependence, and support both stroke patients and their whānau in thriving after having a stroke. As a result of this trial, further adaptation and testing of these interventions have since occurred showcasing that what is good for Māori is good for all New Zealanders where non-Māori and non-Pacific peoples in NZ also showed significant approvement with this approach to collective wellbeing at 12 months following a stroke (53).

Discussion

Health interventions built from Indigenous worldviews are becoming more familiar worldwide. In NZ, Te Tiriti o Waitangi reaffirms Māori sovereignty and self-determination over our own health and wellbeing. Despite the general acknowledgement of the need for Māori solutions in health, we continuously face opposition at all stages which limits the widespread use of Māori-led, refined and controlled health solutions. Western knowledge systems and science are still privileged over mātauranga Māori (Māori knowledge), as often Māori solutions do not fit the criteria of the Western knowledge system to be considered robust and rigorous evidence (54). A mutual respect between Indigenous knowledge and science must exist in the development of pragmatic solutions to Māori health. However, in order for that relationship to thrive, social justice must be simultaneously upheld and sought for Māori. Researching at the interface forms the standpoint by which we as Māori clinicians, academics and dedicated Māori community members unite to develop Māori health solutions.

Settler states acknowledging their colonial history as violent and dispossessive, and that colonisation is ongoing, is mandatory if Indigenous health inequities are to be eradicated. In NZ, Mikaere [2011] presents three strategies commonly used by settler descendants (Pākeha) to deal with these uncomfortable truths (38). These include the omission of significant chunks of history as and when suits, the denial and distortion of the truth insisting that colonisation was overwhelmingly positive for Māori, and assuming the mantle of victimhood by asserting that initiatives designed to assist Māori are unjustifiable offences (38). Therefore, despite Te Tiriti o Waitangi, various domestic laws and international human rights standards, opposition to developing Māori solutions to health are never-ending.

With this knowledge, it may seem bizarre to present a framework that seeks to broker partnerships between science, which is largely controlled by non-Māori in NZ, and mātauranga Māori which has been subject to oppression and subjugation by way of colonial scientific discovery (26). However, in the last 20 years a spectacular revitalisation of Māori language and culture has occurred stimulating a strong demand by Māori for increased autonomy and genuine partnership with regulatory bodies in NZ. Whilst there is still a long way to go, the Māori health workforce is growing with nearly 30% of all medical students accepted in 2022 identifying as Māori (55). The emergence of Māori experts in all sectors, Māori community (hapū) experts, and Māori researchers in conjunction with the rising Māori economy now valued at $68.7 billion, mean that solutions incorporating Māori knowledge and scientific practice are in high demand (56).

Conclusions

In summary, operating at the interface between science and Indigenous knowledge is not a new conception but is more relevant in the current climate as we continue to seek absolute authority and sovereignty over our own lives through the development of Indigenous-led health solutions. In order to work at the interface, Indigenous peoples require tino rangatiratanga whereby Indigenous science and knowledge holds the authority at this intersection to utilise (or not) Western science if desired. As the WAI 2575 inquiry has outlined in NZ, the primary health system has failed Māori and Māori solutions are needed for health equity to be achieved (10). From this report, the NZ health system was disrupted with the establishment of Te Aka Whai Ora, signalling that Western science can be challenged to be responsive to mātauranga Māori to support Māori health and well-being.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Mellissa Withers) for the series “Equity in Health: Findings from the APRU Global Health Conference 2023” published in Journal of Public Health and Emergency. The article has undergone external peer review.

Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-40/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-24-40/coif). The series “Equity in Health: Findings from the APRU Global Health Conference 2023” was commissioned by the editorial office without any funding or sponsorship. J.L.R. receives salary from the University of Auckland as a senior research fellow, and reported grants from Health Research Council of New Zealand, The Royal Australasian College of Surgeons (RACS), and Kate Edger Charitable Trust for research not related to this manuscript. J.L.R. reported support from Maurice and Phyllis Paykel Trust for conference attendance to the RACS Annual Scientific Congress (unrelated to this manuscript). J.L.R. also serves as Member of the RACS Indigenous Health Committee (unpaid governance work). J.T. receives salary from Te Korowai Hauora o Hauraki as a general practitioner, and reported grants from Health Research Council of New Zealand for health delivery activation grant, a seeding grant for research regarding long COVID in Indigenous peoples. J.T. also serves as Chair of Te Akoranga a Maui (Māori General Practitioners of the Royal New Zealand College of General Practitioners), which is not related to this manuscript specifically but a leadership role as an Indigenous clinician. A.A. receives salary from the University of Auckland as a senior lecturer, and reported grants from Health Research Council for research unrelated to this manuscript. M.H. receives salary from the University of Auckland as Deputy Dean of the Faculty of Medical and Health Sciences, and reported grants from Health Research Council of New Zealand for research related to some of the material in this manuscript. M.H. also received support from The University of Auckland to attend the APRU Conference in 2023. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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