GPs and the health needs of Maori: a challenge we all must meet
Monday 16 July 2007, 4:19PM
By Dr Pita Sharples, Speech
607 views
As the events of this week unwound, I found myself thinking of a poem written 21 years ago by African American poet, educator, historian, best-selling author, actress, playwright, civil-rights activist, producer and director, the one and only Maya Angelou; and I want to quote from part of that poem now:
You may write me down in history
With your bitter, twisted lies,
You may trod me in the very dirt
But still, like dust, I'll rise.
Just like moons and like suns
With the certainty of tides
Just like hopes springing high
Still I’ll rise
It is my great privilege to be here today, to share with you all, my thoughts about the challenges ahead for general practice and general practitioners, practice nurses, practices managers and indeed all members of the primary health care team.
And as I think of your conference theme, meeting the challenge, Kokiringia te Wero, it is the hope springing high, the resilience and passion of indigenous peoples in their pursuit of wellbeing, that strikes me as the most significant challenge facing Aotearoa.
How do general practitioners respond to the challenge of, say for starters:
Maori facing an 8-9 year lower life expectancy than non-Maori;
Maori experiencing major inequalities across most morbidity indicators – particularly most chronic diseases, infectious diseases and injuries;
The finding of the NZ Health Survey, reported last year in The Lancet, that self-reported experiences of racial discrimination were highest amongst Maori and that any such experience was strongly associated with negative health effects.
But still I’ll rise.
And then of course there’s the obvious workforce issues. Studies in the New Zealand Medical Journal have shown the total average medical student debt at graduation is far greater for Maori than Pakeha, with the average debt for Maori graduates being $81,250.
What we know is that medical student debt has had a dramatic effect on the health workforce. Two thirds of graduates intended to leave New Zealand within three years of graduation, which has had particularly dire consequences for general practice.
I want to tell you why I love the Maya Angelou poem.
I know in some communities, talk of the moon and stars as being health indicators would be viewed with considerable scepticism. There would be talk of having your ‘head in the clouds’; ‘sun-struck’; or perhaps being captured in a sci-fi fantasy.
But for tangata whenua, our whole being is immersed in a relationship with the natural world – our seas, lands, rivers, mountains, flora, fauna are part of who we are.
In such a world view then, the dislocation we have experienced as indigenous peoples through colonisation, and the subsequent removal and alienation from our land, has had a direct impact on our health status.
Now I’m not suggesting meeting the health needs of Maori means that another challenge for GPs is that you become astronomers, geologists and natural scientists, but the point to note is the relevance of both our history and our links to the natural world.
One of our whakatauaki emphasises this;
He tangata i kakahuria ki te rimu moana e kore e ora ki te noho tuawhenua
Literally a person covered with seaweed will not survive dwelling inland. It gives a sense that for a person accustomed to living by the seaside and feasting on kaimoana, they will have difficulty in adjusting to living inland in an entirely different environment.
In much the same way, when I seek spiritual sustenance, the energy to lift my spirits, to enable me to rise above it, I always return to Horehore, the old pa site on the range just to the east of Takapau called Ngahinaki-a-Tarawhata.
In our world views, the connections between past, present and future are seamless.
Our tipuna – those who have travelled the pathways ahead of us – and our whakapapa – the connections we can trace over generations are critical elements of the whole package.
We are who we are. We are who they were.
Our heritage, our history, our cultural beliefs are an integral factor in determining our wellness.
My present stretching out in front of me is a direct result of the tribal experiences recorded in the old Kahungunu manuscripts, Kauae runga kauae raro – the manuscripts of Te Matorohanga and Nepia Pohuhu.
I did not come here to strike fear into the hearts of the GP workforce, to plant the expectation that you must all proceed, with haste, to the nearest Maori Land Court to familiarise yourself with the Minute Books and whakapapa records of your client base.
But I do want to plant the seed that Maori aspirations for improved health and wellbeing are inextricably linked to Maori cultural values. Concepts such as:
Understanding the value we place upon our kaupapa and tikanga, if you like, our rules for living;
Being aware of the connection between our wairua, our spiritual force and the importance of a healthy environment;
Respecting the importance placed upon ancestry, Maori cultural values, and the significance of whanau ora.
So why should any of this concern general practitioners?
I am aware, of course, that despite 17.7% percent of people living in New Zealand being of Maori descent; only approximately 3% of GPs serving this country are Maori.
So the chances are that it is highly likely that a Maori patient will be seen by a non-Maori when they visit a GP.
But if the population data doesn’t provide sufficient reason, perhaps the legal compliance requirements might.
As you will all be aware, cultural competence is a legal requirement of health practitioners under the Health Practitioners Competence Assurance Act.
In fact I am told by my colleague Tariana Turia – who was a passionate advocate for cultural competency in her former role as Associate Minister of Health – that cultural competency is given as much weighting in this Act as clinical competence or ethical conduct.
None of this is news to any of you. Indeed, I want to congratulate the Royal New Zealand College of General Practitioners for your initiative in launching your own tailor-made booklet on cultural competence at this hui.
And I want also to recognise the skills of Ngati Raukawa specialist, Dr Peter Jansen who along with Mauri Ora Associates have been demonstrating great leadership in the creation of cultural competence guidelines for your organisation, ACC, the Medical Council and others.
These resources will be a huge help in giving you the means to engage in strong relationships with whanau – leading to the likelihood of improved diagnosis, treatment plans and health outcomes.
But words are not enough on their own.
For Still I Rise.
The vital factor in creating positive relationships between GPs and whanau, hapu and iwi, must be in the matching of passion and will to collectively, collaboratively meet the needs of Maori.
It is somewhat dispiriting to look back, some five years ago, at a paper in the NZ Medical Association Journal reporting the talk of Auckland general practitioners and Maori users of those services.
The study, entitled Tauiwi general practitioners talk about Maori health, emerged from interviews with 25 female and male tauiwi GPs working in Auckland. Some of those findings included:
Maori identity was very often seen by these GPs as deeply problematic;
Most participants assumed that genetic mixing through intermarriage meant that there was no objective standard; (ie the blood quota argument, ‘but how Maori really are you?’
The GPs perceived Maori to have diffuse lines of personal responsibility – they couldn’t be sure who was actually the child’s caregiver;
The GPs perceived that Maori men almost never come to the doctor;
Many participants were clear that Maori thought about health in quite different ways than do Tauiwi, but were able to give only a general outline of what Maori conceptions were.
Although these are, by their very nature, generalised interpretations, the authors of the study described here are a cause of concern in the way in which they shape interactions between a GP and Maori person visiting their services.
A specific concern was the failure of participants to refer to widely available Maori theories of health in describing the state of health.
With findings like that it gives even stronger reason for the Maori Party to endorse absolutely, the initiative this College has taken in releasing guidelines on cultural competence.
What you do from now on will be critical.
How do you attract an indigenous health workforce, and importantly, retain them?
What investment does this College make in capacity building, research and cultural education and resources to ensure health professionals are fully able to meet the needs of Maori.
And importantly, what investment do you all, as individuals make, to keep hope springing high in the hearts and minds of Maori whanau?
There is plenty of research and academic analysis available.
There is the strength of experience available in organisations such as Te ORA – Te Ohu Rata o Aotearoa – the Maori Medical Practitioners Association of Aotearoa.
For those not in the know, Te Ora comprises Maori medical practitioners working as specialists, clinicians, researchers and teachers through-out the country.
And if I could be so humble as to suggest www.maoriparty.com has details of the Maori Party constitution, which is founded in the strength of a series of kaupapa which would be a starting point towards understanding the unique values and principles which drive us forward as tangata whenua. Values and principles that ultimately we see as benefiting all who call Aotearoa home.
The driving force in your 2007 Annual Conference has been about addressing the challenges. It is not just about naming the problem – identifying the issues. Solutions come from looking for the knowledge to expand our skills and enhance our confidence to get things done; to make progress, to rise about it.
We cannot continue to parade our negative health disparities in public; to know of the reality of racism, to feel the outcomes of discrimination and deprivation amongst the indigenous peoples of this land.
Inequalities in health in New Zealand are most pronounced between Maori and Europeans. You have a vital opportunity to do something about this, to understand how racism affects health, and to believe that racial discrimination is an unacceptable breach of human rights that must be addressed as an urgent health priority.
The Maori Party has been so concerned about this crisis in health that we continually write to the Minister, ask questions in the House, go out of our way to meet the key stakeholders such as yourselves, issue media statements, attend hui, and accept any opportunity to become involved in making the difference.
We want you to know that we are here to learn from you, as to how we can work together to urgently improve the ways in which the general practitioner community can work with Maori to better respond to the health needs of Maori.
It is a challenge for us all. A challenge we can and must meet.
You may write me down in history
With your bitter, twisted lies,
You may trod me in the very dirt
But still, like dust, I'll rise.
Just like moons and like suns
With the certainty of tides
Just like hopes springing high
Still I’ll rise
It is my great privilege to be here today, to share with you all, my thoughts about the challenges ahead for general practice and general practitioners, practice nurses, practices managers and indeed all members of the primary health care team.
And as I think of your conference theme, meeting the challenge, Kokiringia te Wero, it is the hope springing high, the resilience and passion of indigenous peoples in their pursuit of wellbeing, that strikes me as the most significant challenge facing Aotearoa.
How do general practitioners respond to the challenge of, say for starters:
Maori facing an 8-9 year lower life expectancy than non-Maori;
Maori experiencing major inequalities across most morbidity indicators – particularly most chronic diseases, infectious diseases and injuries;
The finding of the NZ Health Survey, reported last year in The Lancet, that self-reported experiences of racial discrimination were highest amongst Maori and that any such experience was strongly associated with negative health effects.
But still I’ll rise.
And then of course there’s the obvious workforce issues. Studies in the New Zealand Medical Journal have shown the total average medical student debt at graduation is far greater for Maori than Pakeha, with the average debt for Maori graduates being $81,250.
What we know is that medical student debt has had a dramatic effect on the health workforce. Two thirds of graduates intended to leave New Zealand within three years of graduation, which has had particularly dire consequences for general practice.
I want to tell you why I love the Maya Angelou poem.
I know in some communities, talk of the moon and stars as being health indicators would be viewed with considerable scepticism. There would be talk of having your ‘head in the clouds’; ‘sun-struck’; or perhaps being captured in a sci-fi fantasy.
But for tangata whenua, our whole being is immersed in a relationship with the natural world – our seas, lands, rivers, mountains, flora, fauna are part of who we are.
In such a world view then, the dislocation we have experienced as indigenous peoples through colonisation, and the subsequent removal and alienation from our land, has had a direct impact on our health status.
Now I’m not suggesting meeting the health needs of Maori means that another challenge for GPs is that you become astronomers, geologists and natural scientists, but the point to note is the relevance of both our history and our links to the natural world.
One of our whakatauaki emphasises this;
He tangata i kakahuria ki te rimu moana e kore e ora ki te noho tuawhenua
Literally a person covered with seaweed will not survive dwelling inland. It gives a sense that for a person accustomed to living by the seaside and feasting on kaimoana, they will have difficulty in adjusting to living inland in an entirely different environment.
In much the same way, when I seek spiritual sustenance, the energy to lift my spirits, to enable me to rise above it, I always return to Horehore, the old pa site on the range just to the east of Takapau called Ngahinaki-a-Tarawhata.
In our world views, the connections between past, present and future are seamless.
Our tipuna – those who have travelled the pathways ahead of us – and our whakapapa – the connections we can trace over generations are critical elements of the whole package.
We are who we are. We are who they were.
Our heritage, our history, our cultural beliefs are an integral factor in determining our wellness.
My present stretching out in front of me is a direct result of the tribal experiences recorded in the old Kahungunu manuscripts, Kauae runga kauae raro – the manuscripts of Te Matorohanga and Nepia Pohuhu.
I did not come here to strike fear into the hearts of the GP workforce, to plant the expectation that you must all proceed, with haste, to the nearest Maori Land Court to familiarise yourself with the Minute Books and whakapapa records of your client base.
But I do want to plant the seed that Maori aspirations for improved health and wellbeing are inextricably linked to Maori cultural values. Concepts such as:
Understanding the value we place upon our kaupapa and tikanga, if you like, our rules for living;
Being aware of the connection between our wairua, our spiritual force and the importance of a healthy environment;
Respecting the importance placed upon ancestry, Maori cultural values, and the significance of whanau ora.
So why should any of this concern general practitioners?
I am aware, of course, that despite 17.7% percent of people living in New Zealand being of Maori descent; only approximately 3% of GPs serving this country are Maori.
So the chances are that it is highly likely that a Maori patient will be seen by a non-Maori when they visit a GP.
But if the population data doesn’t provide sufficient reason, perhaps the legal compliance requirements might.
As you will all be aware, cultural competence is a legal requirement of health practitioners under the Health Practitioners Competence Assurance Act.
In fact I am told by my colleague Tariana Turia – who was a passionate advocate for cultural competency in her former role as Associate Minister of Health – that cultural competency is given as much weighting in this Act as clinical competence or ethical conduct.
None of this is news to any of you. Indeed, I want to congratulate the Royal New Zealand College of General Practitioners for your initiative in launching your own tailor-made booklet on cultural competence at this hui.
And I want also to recognise the skills of Ngati Raukawa specialist, Dr Peter Jansen who along with Mauri Ora Associates have been demonstrating great leadership in the creation of cultural competence guidelines for your organisation, ACC, the Medical Council and others.
These resources will be a huge help in giving you the means to engage in strong relationships with whanau – leading to the likelihood of improved diagnosis, treatment plans and health outcomes.
But words are not enough on their own.
For Still I Rise.
The vital factor in creating positive relationships between GPs and whanau, hapu and iwi, must be in the matching of passion and will to collectively, collaboratively meet the needs of Maori.
It is somewhat dispiriting to look back, some five years ago, at a paper in the NZ Medical Association Journal reporting the talk of Auckland general practitioners and Maori users of those services.
The study, entitled Tauiwi general practitioners talk about Maori health, emerged from interviews with 25 female and male tauiwi GPs working in Auckland. Some of those findings included:
Maori identity was very often seen by these GPs as deeply problematic;
Most participants assumed that genetic mixing through intermarriage meant that there was no objective standard; (ie the blood quota argument, ‘but how Maori really are you?’
The GPs perceived Maori to have diffuse lines of personal responsibility – they couldn’t be sure who was actually the child’s caregiver;
The GPs perceived that Maori men almost never come to the doctor;
Many participants were clear that Maori thought about health in quite different ways than do Tauiwi, but were able to give only a general outline of what Maori conceptions were.
Although these are, by their very nature, generalised interpretations, the authors of the study described here are a cause of concern in the way in which they shape interactions between a GP and Maori person visiting their services.
A specific concern was the failure of participants to refer to widely available Maori theories of health in describing the state of health.
With findings like that it gives even stronger reason for the Maori Party to endorse absolutely, the initiative this College has taken in releasing guidelines on cultural competence.
What you do from now on will be critical.
How do you attract an indigenous health workforce, and importantly, retain them?
What investment does this College make in capacity building, research and cultural education and resources to ensure health professionals are fully able to meet the needs of Maori.
And importantly, what investment do you all, as individuals make, to keep hope springing high in the hearts and minds of Maori whanau?
There is plenty of research and academic analysis available.
There is the strength of experience available in organisations such as Te ORA – Te Ohu Rata o Aotearoa – the Maori Medical Practitioners Association of Aotearoa.
For those not in the know, Te Ora comprises Maori medical practitioners working as specialists, clinicians, researchers and teachers through-out the country.
And if I could be so humble as to suggest www.maoriparty.com has details of the Maori Party constitution, which is founded in the strength of a series of kaupapa which would be a starting point towards understanding the unique values and principles which drive us forward as tangata whenua. Values and principles that ultimately we see as benefiting all who call Aotearoa home.
The driving force in your 2007 Annual Conference has been about addressing the challenges. It is not just about naming the problem – identifying the issues. Solutions come from looking for the knowledge to expand our skills and enhance our confidence to get things done; to make progress, to rise about it.
We cannot continue to parade our negative health disparities in public; to know of the reality of racism, to feel the outcomes of discrimination and deprivation amongst the indigenous peoples of this land.
Inequalities in health in New Zealand are most pronounced between Maori and Europeans. You have a vital opportunity to do something about this, to understand how racism affects health, and to believe that racial discrimination is an unacceptable breach of human rights that must be addressed as an urgent health priority.
The Maori Party has been so concerned about this crisis in health that we continually write to the Minister, ask questions in the House, go out of our way to meet the key stakeholders such as yourselves, issue media statements, attend hui, and accept any opportunity to become involved in making the difference.
We want you to know that we are here to learn from you, as to how we can work together to urgently improve the ways in which the general practitioner community can work with Maori to better respond to the health needs of Maori.
It is a challenge for us all. A challenge we can and must meet.