Theorising the Wider Parameters of Maori Health Introduction
The literature for this research is diverse, encompassmg health reforms, Maori development and social policy. It also includes a rapidly growing body of literature on Maori conceptualisation of health and Maori epistemology and ontology. In particular the application of a Maori epistemology in education called Kaupapa theory is increasingly applied to health along with a more moderate Maori-centred approach. The review of literature in this chapter does not include specific discussion about public sector reforms, health policy, health status and the health reforms. These topics will be included in the following chapters. Rather it focuses more on the research process itself and therefore serves to provide the canvas for the rest of the painting created in this thesis.
This is not an exhaustive literature review because of the scope of the l iterature; however, this Chapter is intended to help theorise the policy chapters that follow. Further l iterature is preseqted in each of the Chapters and Chapter 6 covers more recent literature on socio economic and cultural determinants of health.
The literature covered also includes a growmg body of Maori material emerging particularly through Masters theses on important topics for Maori health. These include: the characteristics of Maori communities and primary health services; medical literature on Maori health status; debates within epidemiology on the place of poverty, socioeconomic status and culture; social science literature around concepts of ethnicity, race and class; and the discourse surrounding the rationale for and effects of social and economic policy changes in Aotearoa New Zealand from the mid-1 980s.
Much of the thinking within the l iterature intersects, reflecting common concerns about the effects of neo-liberal policies on health outcomes, particularly amongst vulnerable
care. There is also an attempt to grapple with the meaning of Hauora Maori. There is some overlap with the World Health Organisation definition of health as a state of complete emotional, physical, mental and social well-being rather than just the absence of disease. However an assumption of the research is that hauora includes broader social and economic principles and is not concerned solely with physical, mental or emotional well-being. This fits with much of the l iterature on socio-economic determinants.
Race, Ethnicity And Culture
The debate around race, ethnicity and culture is as important today in New Zealand as it
was 100 years ago, and is furthermore of importance in discussing health policy because the tendency has been towards increasingly ethnic specific targeted services (Cheyne,.
O Brien, & Belgrave, 1997, p 1 55). While notions of race may be discredited based on
biological and other scientific grounds (Smaje, 1995), it continues to be operationalised as if race continued to be a valid basis for differentiating between groups of people (McKegg, 1 995). Race is described as a "social construction that has a common sense meaning ... [and its] once accepted scientific status is now rejected by the biological services as inappropriate when classifying human groupings" (Spoonley, Macpherson, Pearson & Sedgwick, 1984, p to). Such understandings were I inked to the expansionist
European colonial experience that sought to differentiate peoples according to phenotype. Inherently these definitions sought to highlight the differences between the superiority of one 'race' over another. New Zealand has struggled with these concepts since British colonisation in the nineteenth century. Te Poata-Smith explains.
This shift (from definitions based on biological criteria called race] primarily reflected the influential growth in national l iberation struggles against Western imperialism, together with the international emergence of new social movements in the West from the late 1 960s. These movements
represented a fundamental rejection of old notions of biological determinism in favour of more liberating ideologies (Poata-Smith, 1 997, p.
1 66).
Part of the refutation of such primordial notions of race relates to the scientific realisation that,
The amount of variation within a racial group is considerably greater than the average genetic difference between races. Clearly the genes responsible for the morphological features that allow us to classify individuals into broad racial groupings are atypical and extremely unrepresentative of the true degree of interracial genetic difference (Poata Smith, 1 997, p. 166).
Thus whileMaori have moved away from a relatively meaningless biological definition
(in scientific terms) to a more encompassing definition of ethnicity, many people act as
though these historical notions of race were still valid (McKegg, 1 995). Furthermore there are inherent tensions between the primordial and instrumentalist constructions of ethnicity, which limit our capacity to use both to explain the practice of ethnicity (Smaje, 1 996a, pp 1 -3). Ethnicity can best be described as 'essentially an identity that reflects the cultural experiences and feelings of a particular group (Spoonely, 1993, pp 36-37) . To elaborate,
For an ethnic group to exist, there need to be cultural practices or beliefs that define it as different from other groups in society. [These are listed as] particular kin structures, diet, religious beliefs, rituals, language, dress, economic activities or political affiliation to the group (Spoonley, 1 993, pp 36-37).
Ethnicity is therefore an intimate reflection of culture and is complex and dynamic in nature, and often self-defined. Ethnicity is not merely an expression of personal preference but rather an inherently political choice ' that tellsMaori much about individuals' and groups' values and orientations towards the issues related to cultural politics' (Bell, 1 996, pp 145-146).
Te Poata (1997) goes on t6 explain that,
The fact that real phenotypical difference has social 'effects' only when some social significance is attributed to that difference. Such approaches emphasise not the biological superiority of some 'races' to others, but the 'cultural ' differences between 'ethnic' groups. Such 'cultural ' or 'ethnic' explanations for M ·ori inequality tend to assume that identities are
primordial, that they originate in the unknowable past, and that they are relatively unchanging. In this way, '''Ethnicity'' or "culture" is conceived as a fate from which those it embraces cannot escape. Although acknowledged as a product of (usually caricatured) history, it is no longer amenable to further change by human action: it has become effectively part of nature (Poata-Smith, 1997, p. 167).
A new racism has emerged (Spoonley, 1993) with rhetoric of cultural difference with its underlying belief that this form of racism is natural behaviour for human society.
Such arguments about the permanence of particular forms of human behaviour are extremely spurious. Indeed, a substantial amount of anthropological and cross-cultural evidence confirms, first, that what is considered 'natural' behaviour for human beings changes radically throughout history and, second, that individuals and/or collectivities 'manipulate' their ethnic identities to fit different social situations (Poata Smith, 1 997, p. 1 67).
Ulhanau, lIapu, /wi
Whanau, hapu and iwi are considered the basis of Maori society, forming the social structures that encompass Maori social activity. The erosion of these social arrangements linked by common whakapapa, is thought to have greatly contributed to the erosion of Maori tikanga and society. These extended family structures are considered to be anathema to western industrial society's valuing of the individual. This has repercussions for Maori health as Penney explains.
The western medical approach, being individualistic had little or no concern for the significance of whanau / hapt.4 issues as they impacted on an individuals health. Whanaungatanga which has been identified as essential to health and well-being of Moori was largely disregarded by the health services . . . The extended family is the group who support the individual through a crisis and families receive sustenance when they feel that they have an important contribution to make to the community they live in. However, the health care systems' disregard of whanaungatanga to health, further set up cultural conflict for M40ri - creating barriers to the
usual expression and demonstration of cultural practices (Penney, 1 996, p 23) .
While the erosion of both social structures and practices are an experience in common with all other colonised indigenous peoples, there is some dispute about the exact nature of these social arrangements in traditional Maori society. This discussion has become important because of the political support for iwi as the preferred channel for Maori development arising from government policy changes in the late 1 980s and 1 990s.
Iwi, hafJ\A and whanau are often used together (so much so in this claim that Mr Boag, the Waitangi Tribunal 's expert witness, described the expression as a 'mantra') in a way that suggests a hierarchy of descent groups, from a broad-based numerically strong iwi or tribe, made up of a number of hap<A federated together, with the hapu. in turn, comprising a number of smaller but even closer-knit whanau or extended family groups. The conception that all these groups function in much the same way, but are found at different levels of the organisational hierarchy, (that hapv are sub-divisions of iwi, and whanau are sub-divisions of hapJ) may be a Eurocentric view of M ·ori society, where power is seen to reside at the top with its exercise delegated to the people below. The M 'ori reality prior to European contact appears to have been quite different. It was the whanau and hap\" that were the effective and autonomous units of M,::iori social and political organisation. This provided a person 's primary source of security and identity, because members lived and acted together as a community. Rangatira signed the Treaty on behalf of hapt.., not 'iwi' (Waitangi Tribunal, 1 998, p 1 7).
There is considerable historical evidence of an increased homogenisation of iwi, suiting a government requirement for clarity in their dealings with Maori (Ballara, 1 998). This left little room for the dynamic and pluralistic nature of iwi and hapu to be maintained. Western society demanded an identifiable entity that could be held legally accountable. As indicated previously, the notion of whanau, hapu and iwi as a fixed social structure belies the changing nature of Maori society.
The tendency of eighteenth-century halM to organise themselves in communities often derived from the way they used their land and resources. There is. a certain vagueness about hapi..\ in the evidence of many nineteenth-century Native Land Court witnesses; this is often because they were being asked to put labels on a nebulous reality-the ownership in hapu terms of a specific and limited stretch of land ... scattered, independent colonies of descendants over a wide extent of country, interspersed with groups of descendants over a wide extent of country, interspersed with groups from other iwi and/or major hapu:, were more common than otherwise (BaHara, 1 998, p 194).
In Auckland and Northland there are major iwi groupings who are identified as having mana whenua. These claims were legitimised through a series of government agency decisions that gave preference to these iwi in service delivery contracts during the 1990s. A challenge to this de facto and actual pol icy was the basis of a challenge by Te Whanau o Waipareira who lodged a claim with the Waitangi Tribunal. These iwi claims are l inked to the application of the 1 840s rule (Kiro, 1 997), which states that those hapu / iwi who had use of lands at 1840, are the legitimate owners of that land. This is to a large extent a Pakeha convenience that has been rigidly applied to settle Maori disputes. Some of these pre-date the Treaty of Waitangi. Given the prominence of iwi in the strategies pursued in health purchasing, it is worth considering some of the historical evidence and current pol itical debate around the claims of iwi and other Maori organisations.
Most of this historical evidence stems from the eighteenth and nineteenth centuries, although whakapapa recounted by whanau and hapu, goes back to 10 -the Maori supreme
being. Belich (1 996) identifies four kin zones in Northland by the nineteenth century. Nga Puhi were quite cohesive genealogically and had up to 1 50 hapVl but by the early nineteenth century they fel l into three competing and co operating hap V groups: western, or Hokianga, and northern and southern Bay of Islands. South of Nga Puhi, and linked to their western section, were Ngati Whatua. They are said to have come from the Far North, and their carving styles share more features with Aupouri than with Nga Puhi,
but they also had some links with Tainui. Perhaps as late as the eighteenth century, Ngati Whatua displaced the previous inhabitants of southern Northland and the Auckland isthmus, including the Kawerau and Waiohua peoples ... Ngati Whatua absorbed these groups as much by intermarriage as violence, and possibly acquired their own tribal identity in the process. They were a powerful tribe at the end of the eighteenth century, a match for Nga Puhi; though they shared modern-day Auckland with another tribe from further south: Ngati Paoa (Belich, 1 996, p 92).
Belich observes that Ngati Whatua and the northern tribes also had 'associations outside the region, especially with Corommandel and, through it, with the East Coast' (Belich, 1996, p 92) . Like the Nga Puhi federation in the North, Tainui spread - from Kawhia in the south to encompass Waikato, Ngati Raukawa (further south), and Ngati Paoa of Hauraki, along with their allied tribes. Again, the overlaps between tribes highlighted links between Tainui to Arawa in the south, Auckland in the north and Corommandel in the west (Belich, 1 996, pp 92-93).
Thus the picture of tribal identity is complicated by a number of factors, including historical alliances, and contemporary Treaty settlements. Durie explains.
Nor should it be presumed that Moori are homogenous, even though they share many physical and cultural characteristics. Tribal identities and tribal management of resources remain vital for an understanding of contemporary MC'iiori society: Some tribes, iwi, claim nation status for their tribe, insisting that attempts to describe M{\ori as if they were a s.ingle group are forced. Others are able to recognise the role and relevance of tribes but ascribe equal validity to a collective M/iori identity or a single M:>ori nation. It should be pointed out that not all M(Jori have active links with any tribe, even though they may be able to demonstrate tribal descent and even have shared interests in Me:ori land. As urbanisation has escalated, issues relating to MZ;ori who are alienated from tribes have assumed greater importance, especially in urban New Zealand, and they have been further highlighted by the search for a formula for the
distribution of assets such as those derived from M(;ori fishing quota (Durie, 1 998b, p 5).
In particular, the claim by Te Whanau 0 Waipareira warrants discussion because of its significance in challenging government and Maori tribal views about the morality of channeling all Maori development through iwi agencies. These debates have become intensely political and have concentrated Maori attention over the past decade. Obviously such a discussion requires close attention to the Treaty of Waitangi which provides the constitutional framework for the discussion about relations between the Crown and Maori.
The Waitangi Tribunal report on Te Whanau 0 Waipareira's claim that ' the Crown's actions were 'significantly prejudicing Te Whanau 0 Waipareira's ability to implement the delivery of necessary Social Services Programmes to the West Auckland Community" (Waitangi Tribunal, 1 998, Appendix n, p 255). The claim specifically concerned the allegation that the Community Funding Agency (CFA)2, had adopted a somewhat narrow definition of iwi and their Treaty obligations such that it prohibited the exercise of rangatiratanga by Maori organisations like Waipareira who are capable of exercising this rangatiratanga (Waitangi Tribunal, 1998). This claim is important because it lays responsibility on the Crown for a more expansive interpretation of the Treaty that includes recognising those Maori groups capable of contributing to Maori development. An evaluation of Puao-te-Ata-tu3 suggests that strengthening Maori networks through the devolution of power and resources can encompass Maori organisations outside of that considered ' iwi' . The Waitangi Tribunal suggests a particular irony in Waipareira's claim against the CFA.
2 The CFA is an arm of the Department of Social Welfare and is responsible for funding community organisations, 'al locating resources and support to community groups and organisations working in the area of social services del ivery ' . (DSW document quoted in Waitangi Tribunal Report, 1998, p 81)
3 Puao-te-Ata-tu i s the report o f the Ministerial advisory committee that reviewed the Department o f Social
Welfare in 1986. It focused on the exprience of Moori in the serives and highlighted the need for a bicultural approach by strengthening traditional Mt70ri structures.
At a time when the Government is beset with problems over who represents tribes, for the purpose of settling claims, Waipareira is one of the few districts where representation for a very large community has been resolved, but its status for the purposes of Treaty obligations is unrecongised. And while the Government has difficulties in determining an appropriate Mi:;ori face to deal with for negotiations, here the roles are reversed. Waipareira has settled coordination problems but is prejudiced by a lack of coordination amongst the many Crown agencies. The Crown has many faces, but Waipareira cannot find a single Crown face to deal comprehensively with its concerns (Waitangi Tribunal, 1 998, p 227).
The significance of this report for this research is that it supports the view that there are 'many Maori faces' capable of delivering appropriate services to Maori, and that these
faces deserve support by the Crown. In this respect, it supports Durie's contention of
diverse Maori realities (Durie, 1995) and suggests that adherence to a dogmatic iwi
centric stance in respect of Maori social service delivery is ultimately acting against the
spirit of the Treaty of Waitangi. Te Mana Miiori
Some of the arguments developed in this research suggest that Maori need to feel part of
what is happening in our society in order to stay well. Alienation and feelings of worthlessness have serious costs for the whole of society and are an entirely predictable outcome of not seeing yourself as participating in society. For Maori the balance
between material well being and spiritual well-being is essential. These ideas are best expressed through Maori concepts of mana, wehi and ihi. However, these terms remain
cloaked in mystery. The terms mana, wehi and ihi relate to the authority, standing,
essence of a person and their status in Maori society. Tapu refers to sacredness and aroha
to affiliation, love and attachment.
The Williams Dictionary of the Maori Language ( 1 975) is regarded as an authoritative translation of Maori, however, Maori terms are not easily translated and with mUltiple
prestige, power" and a "psychic force". Wehi is defined as, "be afraid" and "terrible". Whakawehi means to "terrify" or alternatively, to "safeguard or protect". Wehiwehi