Health & Society Social Determinants of Māori Health Disparity

Sociological Consideration of the Roots of Māori Health Disparity

The sociopolitical history of New Zealand is a paradigm of gross inequity in health observed between indigenous and non-indigenous people within colonialist nations. The indubitable contrast in health outcomes between Māori (the indigenous population) and Pākehā (Europeans) can be attributed to confounding factors such as the repercussions of forced assimilation, the confiscation of land and resources, political disenfranchisement, cultural homogenisation, and the social exclusion of the indigenous population.  This paper uses the sociological lens to explicate the relationship between the disparity in health experienced by the Māori population in New Zealand, and its historical, cultural, and structural roots.

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Although Māori life expectancy has consistently increased since the 1950s, data suggests a persistent and increasing gap between Māoris and non-Māoris (Loschmann & Pearce, 2006). For example, not only do Māori infants die more frequently from SIDS and low birth weight, Māori women also have significantly higher rates of breast, cervical, and lung cancer compared to the non-Māori population (Medical Council of New Zealand, 2006). A recent nationwide study on pancreatitis and post-pancreatitis diabetes mellitus found that the incidence of acute pancreatitis among Māori people was the highest in the world, and that the likelihood to develop these diseases is two to three times higher in Māori and Pacific people compared to New Zealand Europeans of the same age and sex (Sayali et al., 2017). According to a 2013 report, the Māori population experiences a seven year decrease in life expectancy than non-Māori. Similarly, there is an associated higher prevalence of disadvantage in socioeconomic status and most morbidity and mortality factors.  These include major chronic disease, infectious disease, injury, and poor mental health (New Zealand Ministry of Health, 2013). Importantly, Māori people are not to blame for these health outcomes. Rather, they stem from inadequacy of the New Zealand government to facilitate for the needs of the Māori community.

Unfortunately, the health burdens experienced by indigenous people is a commonality of Western colonised countries such as the United States, Canada, and Australia, and is an enduring legacy of injustice imposed on the peoples who had called these lands home. Long before the arrival of Europeans, Māori society already had established medicinal practices and beliefs. Although the biomedical basis of disease was poorly understood by anyone in this time, practices that protected tapu (identifying something as being sacred, or forbidden) also were protective against the spread of disease. Tapu ensured sanitation associated with childbirth and death and prevented contamination of water and food by turuma (designated areas for human waste). Because spirituality was regarded to be synonymous with health, medicinal customs were performed by tohunga, the religious figureheads (Lange, 2018). Although historians are uncertain of the size of the Māori population prior to European infiltration, it was estimated to have been roughly 100,000 upon James Cooks arrival in 1769. Unfortunately, the beginning of the nineteenth century marked a significant decline. An early British colonist, James Busby, recognised the deteriorating health of the native people. In 1837, he wrote a report to Britain that noted the “miserable condition of the natives” resulting from the “total European impact,” and reasoned that further colonisation without any preliminary action “promised to leave the country destitute of a single aboriginal inhabitant.” The Crown’s resolution to the dilemma of deteriorating Māori health, among other motives, was to seek sovereignty. In 1840, the Treaty of Waitangi was signed by Māori chiefs, permitting British rule, colonisation, and governance. In exchange, the treaty explicitly guaranteed “royal protection,” equal citizenship rights of Māori, while still maintaining Māori dominion over their resources and an element of shared authority (Joseph, 2012). This treaty is regarded as New Zealand’s founding document; it both legitimised European presence and formalised the relationship between Māori and the Crown. Unfortunately, this relationship was not successful in protecting Māori rights and wellbeing. At this time, Māori population was estimated to be roughly 80,000, compared to a British population of 2000. However, by the 1890s, the mass colonisation that ensued had devastatingly halved the population to 40,000. This drop was primarily attributed to the influx of new diseases that accompanied the influx of settlers.  Because of a lack of immunity, infectious diseases like mumps, measles, whooping cough, bronchitis, and tuberculosis killed nearly 120,000 Māori annually.  Other culprits included the introduction of musket warfare and the loss of ancestral land. The loss of their lands manifested in the forms of malnutrition via loss of food sources, the loss of economical assets, and a disruption of social systems and cultural practices. As a result, many Māori people were displaced and overcrowded in unhygienic living environments that further facilitated the spread of disease (Pool, 2019). Assimilation was enforced in the forms of legislation that banned the use of te reo Māori (the native language), colonist schools that prohibited expression of Māori culture, and Christian conversion agendas determined to replace existing spiritual beliefs. Māori people that resisted conformation suffered legal consequences, social chastisement, imprisonment, physical harm, and sometimes death (Anderson, et al, 2006).  In 1918, the infamous influenza wreaked havoc throughout the country, but Māori faced the brute of the disease, with a death rate five times that of Pākehā. Māori were ashamedly blamed for their own misfortune, and a widespread call for sanitary reforms berated Māori customs.  The introduction of efforts to “improve” Māori health manifested in “educating” Māori and often attempts to halt traditional practices. For example, in the early twentieth century, Māori mothers were instructed to boil breast milk or altogether discontinue breast feeding to avoid tuberculosis, and the devastating effect of typhoid fever on the Māori population was attributed to a lack of desire for hygiene and better homes (Cram, 2019). Throughout history, Pākehā health officials continually shifted the blame onto Māori for their own poor health outcomes rather than taking responsibility. Ultimately, the opinion of many Europeans was that the Māori population was a “dying race” (Bryder 2001:3).  Only in recent history has the Crown acknowledged responsibility for Māori health and acted to reconcile injustices.

The World Health Organisation ([WHO], 2005), has defined healthy as “the state of complete physical, mental and social wellbeing, not merely the absence of disease of infirmity.” According to this definition, implementation of health care to the Māori population is dependent on an understanding of their unique cultural practices and ideologies. Without this foundation, Māori health is misunderstood, and ineffective. Ample research displaying that mis-diagnosis and non-compliance are far more common among clinicians and patients from different cultures supports this ideal (Durie, 2011). Today, four interrelated elements are central to the Māori definition of health: taha wairua (spiritual health), taha hinengaro (emotional/mental health), taha tinana (physical health), and taha whānau (family health (Durie, 1997)). Each is an important component of Māori wellbeing, and this holistic interpretation of health warrants a more dynamic adjustment to a strictly clinical approach to health care. The Māori belief system places significant value in their tūpuna (ancestors) and whakapapa (genealogy) that provide a connection of past, present, and future.  Importantly, Māori are spiritually connected to the land, as it represents Māori’s genealogical connection to Papatūānuku, the Earth Mother and Rangi-nui, the Sky Father. Therefore, the health of the environment is central to Māori identity and connection to iwi (tribes), hapū (subtribes), and whānau (family groups). Deterioration of environment can have implications on mana (a dynamic element, often translated as authority, prestige, and self-esteem), and can have direct effects on wellbeing and sense of belonging (Stevenson, 2001). Interestingly, mana is not attained from individual successes, but rather is bestowed by the gods, and represents good health. Awareness of tapu and other beliefs and traditions involving death, karakia (prayer), societal roles, interpersonal relationships and community, kinship, the use of te reo, and differences in communication allows health practitioners important insight into the comprehensive Māori worldview (Medical Council of New Zealand, 2006). In recent years, enhanced cultural awareness in the social climate of New Zealand has resulted in an increased accommodation to Māori values in the health care setting. In 1999, the national Health Funding Authority finally prioritised Māori health within New Zealand’s health care scheme, and in 2013 the National Science Challenges (NSCs) initiative, created by the New Zealand government, proposed a goal to reduce health inequities for Māori and other communities by 25% by 2025. An objective was to implement health care in a way that more effectively integrated Māori ideals (Oetzel et al., 2018). [1]

Despite initiatives to improve Māori health, institutional and societal structure are still to blame for the gap in health between European and Māori New Zealanders. A New Zealand health survey reported that the Māori population experiences disproportionately high levels of racial discrimination, self-reporting the highest prevalence of experiencing racism compared to Asian and Pacific peoples, and a 10 times higher likelihood than the European population (Harris et al., 2006). This statistic is particularly concerning, as mental health problems, poor physical functioning, and high-risk behaviours such as smoking and substance abuse have been linked with racism associated stress and trauma. The country’s highly racialist stratification of socioeconomic status and privilege only exacerbates the issue, leading to diminished access to factors that contribute to a healthy lifestyle. In 2013, Māori had lower socioeconomic advantages across all criteria measured: 1) they were more likely to have a personal income of less than 10,000 dollars, 2) they were more likely to need income support, 3) they were more likely to live in a crowded household, 4) they were less likely to have completed school, 5) they were more likely to be unemployed,  6) they were less likely to have access to telecommunication, and 7) they were less likely to have access to a motor vehicle (New Zealand Ministry of Health, 2018). Additionally, 23.5% of Māori lived in the most deprived neighbourhoods, determined by a small-area-based index based on 9 socioeconomic variables, compared to 6.8% of European/other New Zealanders (Atkinson et al., 2014). The resulting association between income and chronic diseases such as diabetes, coronary artery disease, osteoporosis, and cancer is observed in the higher rates of chronic conditions within the Māori population.  33% of Māori adults were current smokers according to the 2017/2018 health update, and Māori and Pacific adults and children were more than twice as likely to not collect prescriptions because of cost, compared to non- Māori and non-Pacific adults and children (after adjusting for age and gender). According to the New Zealand Ministry of Health’s most recent update, almost half of Māori are obese, with a BMI over 30, compared to 29% of non-Māori. In parallel, 7% of Māori have diabetes, opposed to 5% of non-Māori. Additionally, the same report found that Māori have almost twice the health burden measured in disability adjusted life years compared to the rest of the population (New Zealand Ministry of Health, 2019). Furthermore, the structural racial privilege and unequal distribution of wealth in New Zealand has subsequently presented the Māori population with far more hurdles to health and well-being than European New Zealanders. The discouragement resulting from this inequality facilitates an inherent distrust of institutions among Māori people that must be amended.

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In conclusion, the health gap experienced by the Māori largely results from differential access to resources and rights, which itself is a repercussion of historical injustice and the failure of the Crown to act in Māori best interest.  As previously discussed, the equal rights and protection bestowed by the Treaty of Waitangi include responsibility on behalf of the New Zealand government that guarantees Māori “at least the same level of health as non-Māori (Medical Council of NZ, 2006).”  The relevance of the treaty should be considered in economic and social policies and in the adaption of public services to foster Māori ideals and culture. Adoption of a holistic health model that emphasises broad cultural implications of community is vital.  To be reflective of the Māori worldview, this model should also accentuate the health of the environment and encompass the entirety of the individual, including spiritual and mental well-being. Additionally, the political and economic disadvantages should be addressed in legislation aimed to abolish institutional racism and provide equal opportunity and access to resources for all New Zealand citizens. Public efforts should be encouraged to combat implicit bias and interpersonal racism that directly minimizes the Māori experience. Furthermore, the historical, cultural, and structural social determinants of health must be reconciled to manifest a better outlook for Māori health and wellbeing.  

Reference List

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[1] The implementation of Māori terms was meaningful in the depiction of the ‘culture’ element of the sociological imagination, and was discussed with essay coordinator Marg Simmons on 24 May, 2019.