A modo de síntesis: Limitaciones y potencialidades

Professor Mason Durie (Durie, 1993a) wrote:

Health policies are not the exclusive province of the health sector; indeed all policies have implications for health in so far as they are able to modify the health status of the population. For Māori the greatest gains are likely to come from healthy socio-economic policies and it will predictably fall to the health sector to make the connections (p. 11).

Publicly funded housing was being sold into private ownership in the early and mid 1990s. The stock of housing for low income families was decreasing and it was feared that the health of low-income families would be affected. Links between poor housing and health were discussed at the Socioeconomic Inequalities and Health Conference (Wellington, 1996). Discussion within the Māori Stream Workshop raised concerns about the high costs of adequate housing and the direct impact this has on the health status of Māori. Consequently, “research into issues related to housing was seen as vitally important to improving Māori health status” (Crampton et al., 1997). Similar links have been stressed with education. Walker (Walker, 1996) identified a strong association between economic status and education, saying “the educational oppression of Māori by the ruling class had a necrotic effect [on Māori] ” (Walker, 1996. p. 164). Walker was sure education policies contributed to the social imbalance of Māori with far-reaching cultural and economic implications and health.

The impact of economic factors on Māori health had not been comprehensively considered in relation to government policy until a cluster of reports was published by two Government agencies. The Ministry of Māori Development, Te Puni Kōkiri, published the report Progress Towards Closing Social and Economic Gaps Between Māori and non-Māori (The Gaps Report) (Te Puni Kokiri Ministry of Māori Development, 1998) and the NHC released the report The Social, Cultural And Economic Determinants Of Health (SCEDH) (National Advisory Committee on Health and Disability, 1998). Both reports shed light on factors associated with health inequalities. SCEDH associated the relative health status of Māori with a number of factors including a genetic disposition, differences in the uptake or effectiveness of health services, and high rates of smoking, socioeconomic status

and other behavioural health risks. The NHC indicated in SCEDH in order to reduce health inequalities, it was important to identify and understand the main factors that protect and promote good health. The NHC called these factors the determinants of health, and the factors shown to have the greatest influence on health were income and poverty, employment and occupation, education, housing, and culture and ethnicity. The NHC added there is increasing interest in the role of what has been termed social cohesion or social connectedness, that is, the degree to which individuals are integrated with, and participate in, a secure social environment (Kawachi & Kennedy, 1997).

The NHC (1998), concerned about health inequalities experienced by Māori quoted Pōmare & de Boer (1988):

…there is general agreement that most of the excess morbidity and mortality is a result of the poorer social and economic status of Māori (p. 41).

According to Woodward “it is important to emphasis that the burden of ill health associated with social disadvantage is onerous” (Woodward, 1997, p. 6). Woodward described socioeconomic status as the hierarchy of social standing that can be demonstrated by individuals in a population (Woodward, 1997). Housing, income, unemployment, and social assistance were also used as social and economic indicators as described by Stephens & Waldergrave (1997). The NHC (1998) acknowledged the contribution they thought social and economic determinants of health made to health inequalities with their recommendations:

Ultimately, the ability of the healthcare sector to deliver effective and high quality services in an equitable way is highly dependent on addressing adequately the social, cultural and economic context in which ill health and disability arise. The National Health Committee considers reducing socioeconomic inequalities in health to be a very high priority (p. 89).

The relationship between ethnicity and health inequalities was less certain until the report, Decade of Disparity (Ajwani et al., 2003) was published by the Ministry of Health:

Most notably, there has been little (if any) decline in Māori and Pacific mortality rates over these two decades [1980-1999] despite a steady decline in non-Māori non-Pacific rates. As a consequence, the gaps in life expectancy between Māori and Pacific and non-Māori non- Pacific ethnic groups increased markedly over the 1980s and 1990s. (p. 45)

…there is some New Zealand evidence for ethnic differences in access to, and quality of, health care. While unlikely to account for all the inequality in survival chances between the ethnic groups demonstrated in this report, such health service explanations could make an important contribution to the observed disparities. (p. 52)

Being Māori was closely associated with poor health and over representation in negative social statistics. The NHC suggested that racism influenced health inequalities. When race and not need determined the response to health need, racism was evident. Recent studies of racism and health in New Zealand have described significant statistical relationships between quality of life, perceived barriers to health services and self reported racism (Harris, Tobias, Jeffreys,

Waldegrave, Karlsen, & Nazroo, 2006). Racism appears to be an important barrier to health services and a contributor to poor health outcomes for Māori.

The NHC identified culture as a fourth category when considering health inequalities, emphasising a strong association between ethnicity and underlying socioeconomic status. The presence of these strong associations in the mind of policy makers may help explain why there was some confusion between being indigenous and poor health. Although being Māori appeared to be strongly associated with being poor or sick, the NHC appeared to be uncertain about the contribution cultural determinants made to health (NHC 1998). The NHC recommended that culture be considered separately from social and economic determinants because culture was not as well understood as social and economic factors (NHC, 1998). The NHC defined culture as “accepted patterns and norms of behaviour within identifiable groups in society” but they did not specify any cultural determinants (NHC, 1998, p. 33). Helman (1994) described the concept of culture as a set of explicit and implicit guidelines people become heir to as members of a particular society or group. The NHC went on to say that Māori experienced an excess burden of morbidity and premature mortality, attributing this to poorer socioeconomic circumstances (1998). The NHC indicated cultural determinants should be considered separately from social determinants because culture is ‘central’ to the health and wellbeing of ethnic groups (1998). Māori have a greater share of the burden of unemployment than their non-Māori peers. Crowded housing, low incomes, and the lowest access to a household telephone are also reflective of the socio-economic disparity experienced in Northland in a Health Funding Authority

(HFA) prepared by Dr Ratana Walker (HFA 1998). Given the association of poor health status and lower social and economic status (NHC 1998), Māori demonstrate consistently lower socioeconomic indicators when compared with non-Māori (NHC, 1998).

Economic development at a tribal level was the goal identified at Hui Taumata (1984). Māori wanted to regain equity and autonomy over their matters, especially iwi development and management, applying tikanga Māori and kawa to provide services for Māori by Māori (Durie, 1998). Māori saw a need to secure traditional assets including natural resources and cultural assets6 under Article II of the Treaty of Waitangi (The Treaty). Maintenance of citizenship rights, including social justice, is guaranteed under Article III of The Treaty.