El cuestionario como conjunto

Durie (1996), Smith (1996), Glover (1997) and Hotere (1998) focused on Māori as practitioners and stakeholders. Glover characterised Kaupapa Māori research in a different manner:

[it] can be defined by what it is not (i.e. positivist) [sic] as much by the statements about what it is (i.e. a Māori theory of research/ te wānanga mō te mātauranga rangahau). Two main themes that arise out of the kōrero about Kaupapa Māori health research are that Māori are central to the process and its basis is a Māori world view. (Glover, 1997)

This view of Kaupapa Māori provided an extension of the points outlined by Smith and Durie’s approaches. The explicit exclusion of a philosophical domain

(positivism) was not unexpected in terms of the history of positivist research on Māori. Early research had alienated many Māori and accrued little benefit to Māori in terms outlined by Smith and Cram (Cram, Pihama, Jenkins, & Karehana, 2002; L. T. Smith, 1999). Glover’s view of Kaupapa Māori health research was one that attributed greater value to Māori discourse over an analysis based upon summary values. Glover posited that a positivist approach, common to the physical sciences was inconsistent with Kaupapa Māori health research. The contribution made by medicine, a discipline that has a tradition of science-based positivism, to research

that had accrued benefit to Māori was absent from Glover’s analysis. The absence of Māori practitioners in the development and application of science to things valued by Māori had denied Māori the opportunity to contribute to the understanding of a positivist approach. In this light, positivism may be seen as a non-Māori domain. Determining the roles Māori take and how Māori undertake these roles, their philosophical approach, and how analytical tools may be selected to understand and interpret the data gathered is determined by what tools they bring to research. Pluralism that broadens the scope of these philosophical approaches, including Kaupapa Māori, will go some way to fulfilling Ngata’s wish that Māori in the future should equally well versed in science in all its forms, as well as Māori culture (Cox, 1995).

Scientific Method

Progress in Māori health has been made by better understanding the environment in which Māori live, the factors that determine Māori health, and utilizing the benefits that technology has to offer. In the early 19th and 20th century Māori adopted new technology to their lifestyles with success and commercial enterprise. By the late 20th century and into the new millennium, the benefits of technology became

restricted by the slow growth in technical expertise and its applications to vulnerable populations. This is illustrated in the application of vaccines to prevent

communicable disease. There were two small pox outbreaks, the first in the late 19th century and the second early 20th century. When the mortality rates are compared between Māori and non-Māori, a distinguishing feature is the relatively high

mortality amongst Māori during the second outbreaks when there was a short supply of vaccine (Dow, 1999). Absent from the scientific discussion of the medical and social issues around these outbreaks was a disseminated Maori analysis that could inform the wider debate. There were Maori who were well qualified to discuss these issues and they had some impact.

The same can be said today with the relatively high rates of vaccine preventable disease experienced by Māori (Minister of Health, 2007; Ministry of Health, 2006a). Vaccine is a metaphor for the utility of scientific method in Māori health, the

development and expertise exist outside the domains of many Māori communities, and although there are many Māori skilled in the understanding and use of scientific method in order to maximize the use of technology, there remains lingering

suspicion of scientific method amongst Māori researchers (Glover, 1997; Te Awekotuku, 1991). In contrast to these firmly held beliefs, the value of a scientific understanding of a health issue that is of concern to Māori has been helpful. A detailed examination of the history and epidemiology of hepatitis B in New Zealand since the early 1980s will provide a case study of the impact a Maori

analysis can have on the perception of a health issue at many levels in New Zealand. Professor Eru Pōmare was asked to review the Eastern Bay of Plenty Hepatitis B Programme (Pomare, 1985). Pomare noted that Hepatitis B was endemic in Māori, Pacific Island Peoples and some Asia people in New Zealand (Milne, Allwood, Moyes, Pearce, & Newell, 1987; Tobias, Miller, Clements, & Patel, 1987). Within New Zealand there was a degree of household clustering of hepatitis B markers associated with the HBsAg positive index case (Martin, Moyes, Lucas, & Milne, 1996). Hepatitis B vaccine was first available in 1984 and made available to children of ‘carrier’ mothers in the Eastern Bay of Plenty (EBOP) in April 1985 (Pomare, 1985), and six months later to most of the north island, to all neonates from Northland to Gisborne in 1987 (Patel, personal communication, 1992) and to all children under five in 1988 in a national campaign (Milne, Moyes, Waldon, Pearce, & Krugman, 1990). The schedule for babies born to carrier mothers is a birth dose of hepatitis B immunoglobumin (HBIg) together with a dose of hepatitis B vaccine within 12 hours of birth. The second dose is provided at six weeks, the third at three months and the fourth dose at five months.

Nationally, the level of hepatitis B infection for Māori is higher than their European peers (Blakely, Bates, Garrett, & Robson, 1998; Nicholson, 1980; Wilson & Baker, 1996). Pomare was asked by the then Minister of Health to review the early community-based vaccinated programmes that had been funded with community subscription in 1984-1986 (Milne, Allwood, Moyes, Pearce, & Lucas, 1985). The immunogenicity of reduced doses of hepatitis B vaccine, realised in 1985 (Moyes & Milne, 1986), was adopted for universal delivery to children under five-years in 1988 (Milne, Hopkirk, & Moyes, 1994; Moyes, Milne, & Waldon, 1990). These programmes would later demonstrate protection lasted for at least five years (Milne et al., 1992).

Since the days of public prescription for hepatitis B vaccine have now passed with the introduction of hepatitis B vaccine to the immunisation schedule, one could

expect small differences in up take of vaccine and a well documented study of the outcome of prevention. Research published in New Zealand suggests that

immunisation rates for children are lower than expected and that the immunisation of babies born to carrier mother babies born to carrier mothers is sub optimal (Moyes, Smith, & Lennon, 2002; Stefanogiannis, 2001).

Moyes and Lennon quoted two small studies, one by Pearce & Taylor (1999) in Auckland and another by a working group in Christchurch suggesting that the timing of the delivery of Hepatitis B Immunoglobumin (HBIg) and hepatitis B vaccine to babies born to carrier mothers is sub optimal. In the Auckland study 83 of 98 babies born to carrier mothers received both HBIg and hepatitis B vaccine in the neonatal period. In the Christchurch study, the numbers of doses of HBIg fell well below that expected from laboratory identification of HBsAg positive mothers. Moyes & Lennon recommendation that the delivery of HBIg be improved with dedicated tracking and service delivery to cover the small but high-risk group of children. Vaccine is offered free to all children under the age of 18 years and to all household contacts of hepatitis B carriers.

The uptake of hepatitis B vaccine and HBIg and the efficacy of hepatitis B vaccine for babies born to carrier mothers is unknown for children vaccinated New Zealand. Given the higher rates of chronic infection in Māori, it seems there has been little change in the reduction of chronic infection that would be expected with a national immunisation programme. Moyes et al (2002) described this to be sub-optimal in terms of the timing of the dose of HBIg, as well as coverage. The delivery of HBIg is an important aspect the efficacy of the neonatal vaccine schedule for babies born to carrier mothers. Sub-otpimal timing would result in higher than expected failure rates and more children would be chronically infected and become ‘carriers’. There has been no systematic notification of chronic infection for some time now. Community-based screening and referral offered by the Hepatitis Foundation and the screening of women presenting at antenatal clinics remain the two systematic options available for the identification of hepatitis B carriers. Acute hepatitis B infections are notified and action to protect contacts where necessary. The remaining pool of infection remains largely occult because of the lack of official notification at a time when prevention and treatment are available and funded from Vote:Health. The prevention of chronic infection is important because this leads to a

much higher risk of liver cancer.

Hepatitis B Related Primary Liver Cancer

Blakely et al (1999) estimated that in New Zealand, 100 deaths per year are attributable to chronic HBV infection, or about 0.3% of all deaths (Blakely, Bates, Baker, & Tobias, 1999). These are predominantly in non-European men between the ages of 30 and 60 years. Most of these men are Māori. Hepatitis B is a vaccine- preventable disease and the vaccine has been used routinely in parts of New Zealand for up to 18 years. The efficacy of hepatitis B vaccine in New Zealand is well described for children whose mothers are not hepatitis B carriers (Milne et al, 1985, Salmond et al 1999). However the same cannot be said for babies born to carrier mothers. The prophylactic role of HBIg is important in improving the efficacy of hepatitis B vaccine. Although the timing of the dose of HBIg is important (Beasley, 1983, Moyes et al, 2002), delivered within 24 hours of birth to prevent perinatal transmission, for some babies born to carrier mothers this is not happening (Moyes & Lennon 2002). This raises the question about the efficacy of the current schedule for babies born to carrier mothers. We would expect that where the vaccine was not effective, 70-79% of babies born to carrier mothers whose mothers are HBeAg positive would become HBsAg positive (carriers). The rate for HBeAg negative mothers is lower.

Long term follow-up of cohorts of vaccinated children demonstrate immunological memory (Milne et al, 1992). No vaccine failures (chronic hepatitis B infection of susceptible children after vaccination) have been reported to date. Medical Officers of Health review the delivery of the neonatal immunisation to babies born to carrier mothers but incomplete records have revealed questions about administration of the programme for those most at risk of chronic infection. The risk of chronic infection is still higher for children born to hepatitis B carrier mothers and therefore to disproportionately more tamariki Māori. Without Pomare’s report, the success of the user pays programme that established free hepatitis B vaccination in New Zealand may not have proceeded and with its success the introduction of hepatitis B vaccine to the immunisation schedule. This would have been a disadvantage to Māori who still have the most to gain from an effective immunisation programme.