Transcript
MIC CAVAZZINI: Tena koutou and welcome to Pomegranate Health, a podcast about the culture of medicine. I’m Mic Cavazzini for the Royal Australasian College of Physicians. And that karakia, or welcome, was given by Dr Danny De Lore in Rotorua, Aotearoa-New Zealand.
DANNY DE LORE: I'll just introduce myself, Mic, just for the record. Te Reo
I'm paediatrician. I've been involved with the Māori Health Committee of the College of Physicians for, it might be 13 years, something like that.
MIC CAVAZZINI: We were joined paediatric registrar, Dr Ngaire Keenan, who has a research interest in epilepsy.
NGAIRE KEENAN: I have done the majority of my training in Te Whanganui a Tara in the Wellington region, but for training purposes, I have now moved to Adelaide, and I am a paediatric neurology Advanced Trainee over here.
MIC CAVAZZINI: And also Dr Matthew Wheeler.
MATTHEW WHEELER: My name's Matt. I have the honour of chairing the Māori Health Committee with Danny. And I live in Tauranga, where I'm a general physician as my inpatient specialty. I'm a haematologist as an outpatient specialty,.
MIC CAVAZZINI: We’ve covered previously on Pomegranate Health the disparities in health outcomes between Māori people and the Pakeha populations that have migrated to Aotearoa since it was colonised in 1840. In episode 50 we heard about the chronic underservicing of regions outside the major urban centres in New Zealand and in episodes 31 we discussed some of the biases that add to the poorer care received by Māori and Pasifika patients, resulting in shorter consultations fewer tests, referrals and interventions. In episode 94 we talked about how such large discrepancies in care don’t require racism at an individual level, just institutional and structural prejudice that goes unnoticed or ignored.
One of the biggest contributions that could be made to the quality of care for minorities is to have them better represented in the health workforce. New Zealand’s medical schools have been doing their part by increasing the quota for Māori or Pasifika students, and the proportion of Māori doctors has now reached over 5 percent, double where it had been for many years. There’s still way to go, however, before this representation reaches 17 percent as per the proportion of Māori people in the wider population.
And this rapid transition hasn’t come without a backlash. Later in today’s podcast we’ll talk about some of the conflict over preferential intakes at medical school and the reactionary politics that saw the Māori Health Authority, Te Aka Whai Ora, disestablished after just one year of operation. But if we’re going to throw stones, we have to start with our own glass house.
The gains made in the medical workforce as a whole have not yet translated to the RACP membership. In data for 2024 published by the Medical Council of New Zealand, just three and a half percent of general physicians and 4.8 percent of paediatricians identify as Māori. Doctors from Pasifika backgrounds make up a further 1 and 2 percent respectively.
We sometimes take a dig at the sink or swim culture of surgery but, in fact, almost 8 percent of surgeons identify as Māori. I asked doctors Danny De Lore, Ngaire Keenan and Matthew Wheeler to speculate on the culture within the RACP or its training partners that might be turning away potential recruits from to biggest training pathways. For those not familiar with Māori language or Te Reo, hui is the word for a gathering or meeting.
DANNY DE LORE: Yeah, the RACP, the Royal Australian College of Physicians, hasn't been able to capitalize in the way that some of us had hoped on the graduate numbers of Māori, Pasifika and Aboriginal and Torres Strait Island doctors. I think that the experiences that young doctors have and students have within the different medical specialties is a major contributor to the career choices they make.
So, that's things like when you go and you work within a specialty as a student or a junior doctor, young doctor, are these the sort of people that you're working alongside, are they the sort of people that I want to work with for the next 40 years? Do these people share my values? Do they understand me? Are they like me?
It would be good if we had Māori doctors all through medicine and paediatrics, but we don't. So, you know, we're relying on our colleagues to give that experience where people, students and junior doctors, come along and they say, “This department, they seem to value Māori culture and Māori language. This department, they seem to understand some really important issues related to Māori health, and they're prioritizing it”. So, if medical schools are training Māori and Pasifika doctors, but they choosing other specialties instead of our specialty, then it's up to the members to change the experience that those junior doctors and students are having.
NGAIRE KEENAN: I completely agree, and I think it's going to take time, and it's going to take generations. Because there's a huge importance on role models within the College. I was lucky enough to know Leo Buchannan, a very prominent paediatrician from the Hutt Valley, and I do remember this one particular hui when I was a med student, and for some reason, the conversation went to how all Māori doctors should be GPs and public health physicians. And Leo stood up and he and he slammed the table and he said, “No, we need more physicians.” And the reality was that he's completely right, we need more physicians, we need more paediatricians, and having a role model like that is more likely to bring more people in who are then going to encourage the next generation to come through as paediatricians and adult physicians.
MIC CAVAZZINI: Public Health does stand above the parapet, with ten percent of the NZ workforce identifying as Māori and 3 percent Pasifika. But back in 2017 Associate Professor Elana Curtis, at the University of Auckland, told me what you just did. How it’s unfair to expect Māori medics to go and fix the problem when they might aspire to be neurologists or plastic surgeons.
And she also said, I'll quote, “Some of these inequities that our students face don’t just dissolve once you get your doctor’s certificate—they're still there. That pipeline is not exactly extending upwards and outwards, and it needs to. So, there's a big challenge here to Colleges about how come the equity argument stops at their point of entry” So my question is, should the Colleges do something like the medical schools in terms of reserved places, affirmative access of a kind at that stage. Or is there a difference? Matt, I think you wanted to say something.
MATTHEW WHEELER: Well, the College currently doesn't have an entry into training requirement, per se. At most it's, “go and talk to your director of physician education, say that you're interested, and then get a job”. The College struggles with the idea that the College is not the employer, and that's why they've been probably working for five to 10 years on entry into training policy.
My view is that even just the having to approach a DPE, who you may not know, to say, “I want to do training”, still is enough of a barrier. Certainly, the Auckland, the Waikato and the Tauranga regions. If you wish to be a med reg, at least, and you're Māori, you're automatically—we're going to find you a place. So, we were tired of waiting for the College to get on board, and so we just, everyone's just gone and done it in the regions that they are. But there's a ton of other regions where some great potential Māori physicians could be coming from that haven't got that, it’s just because we’ve got people in places
I mean, certainly there was a study a number of years ago, and it said that the experience you had at medical school was more likely to determine what And so I've taken the that that as a policy, to try and get any of the Māori medical students put onto my medical team, any of the Māori house surgeons put onto my medical team, such that hopefully that exposure, just by sheer numbers, will make them go, “Hold on, I can do this, and this specialty is here, and we should do that.”
But that that's not necessarily the College doing anything. The College really needs to be spreading all the way back into the first and second year house surgeon years, you know, when they've finished the pipeline at medical school, and be trying to draw them in with either an interest forum or some other something that will bring them into the into the College. And then it's mentoring and supports to make sure they get through training. Because actually, physician and paediatric training is hard. You know, Ngaire is moving, probably, for the third or the fourth time. That's really difficult for some people. And so how do we support that so that more people are willing to do physician and paediatric training.
This year, we've been really fortunate. I mean that the College has listened to us. And we, the first year, have had a lead Fellow and two registrars working part time within the College. And so, one of the things that they're working on is a structured mentoring program for Māori trainees. We now have ethnicity data to know that where and who our Trainees are, should they identify themselves—it's voluntary, and for those who are comfortable and do want to identify there is coming a time where we have mapped out their entire Trainee journey, the touchpoints within which that the College can make it softer and easier to be in touch with you, and then with a plan to have a fully-fledged mentoring program, whether you do or don't have a Māori consultant at your hospital. And so, I think, we're on the way. It's just a manpower problem at the moment.
MIC CAVAZZINI: On January 15, just three weeks after this interview was recorded, the College released a report on the Review of Paediatric Clinical Exams in Australia and Aotearoa. The report findings add some depth to the conversation you’ve heard as they suggest there may have been bias in the structure or delivery of recent examinations which could have disadvantaged groups on a racial basis.
The review was conducted in response to a formal complaint made by the New Zealand Resident Doctors Association in April 2023 around a lack of fairness in the clinical exams. The submission was written on behalf of thirty anonymous complainants, some of whom had already made submissions in the preceding months, and it also referred to the fact that a prior submission about the 2021 exam had gone unaddressed.
The full report is available online but I’ll do my best to summarise. In general terms, many complainants felt that there was a lack of consistency in the difficulty of the cases candidates were given and that pre-existing relationships between some candidates and their examiners threatened the objectivity of the assessments. They argued that the marking system was not transparent and that feedback was inadequate to support candidate development. And a few of the Trainees noted that the formalised way in which candidates were expected to rush through an examination of the patient without building rapport, and then turn their back on them as they presented to the examiner, felt like a betrayal of the patient-centred approach they had been taught.
In the context of today’s discussion, was the sense from complainants that lack of standardisation in the conduct of the exams amplified unconscious biases towards trainees from ethnic minority groups. One comment that’s emblematic of this was, “the Caucasian viewpoint on issues such as marital discord, family dynamics, end of life care, are seen as the predominant and “right” answer by the Caucasian majority examiners- further disadvantaging candidates who do not share these views.”
Other complaints suggested that the examination panel was over 90 percent Caucasian and that the chance of passing the clinical exam for non-white candidates was less than half what it was for Caucasians. These numbers could not be corroborated by the Expert Advisory Group as the College does not record ethnicity of candidates or examiners. Discussions are ongoing as to whether such data could be collected in a way that respects privacy of participants and similarly whether it’s feasible to employ video or audio recordings during exams to help review future complaints.
The Advisory Group was satisfied that unconscious biases including racism did likely exist in the RACP Paediatric Divisional Examinations and provided 18 recommendations to improve standardisation and transparency. The College has appointed a Taskforce to ensure that these are implemented to all examinations across the College. Among the measures that will be put in place for 2025 are information sessions for candidates about what to expect on and after exam day and the trialling of Trainee Advocates and Quality Assurance Leads.
For examiners, calibration sessions will be enhanced to improve standardisation of scoring and training will be provided about unconscious bias, cultural safety and managing conflicts of interest. Efforts are also being made to broaden the diversity of examiners. Dr Matt Wheeler was not a part of the Expert Advisory Group, but wanted add that the review simply points to mistakes in the process rather than any blame directed at individuals, noting that it’s a voluntary commitment of time that can generate stress. Let’s get back to the interview, and the next words for your Te Reo dictionary. Whanau, is the Māori word for family. A tamaiti is a child and tamariki is the plural.
MIC CAVAZZINI: Talking about culturally safe training environments, we haven't heard any examples, and I don't want to fish for traumatizing examples. But what are culturally unsafe experiences? What are the experiences that might turn an Indigenous Trainee away from a particular workplace that that the rest of us don't even realize might be culturally unsafe.
DANNY DE LORE: I don't feel the need to talk about exact examples of specific racism. I think that that it's almost absence, it's the absence of recognition of culture that's more important to me, where there’s just this presumption that the dominant culture is the default culture. We've all got biases active all the time, and a lot of them are based on race. And you know, when I started to teach, learn about it and teach about it and talk about it, I put time and effort into understanding my own biases, and it's amazing how you didn't notice them before until you deliberately start putting time into it. By definition, we're blind to our unconscious biases, all the time.
NGAIRE KEENAN: I completely agree. I think, I think there's a lot of microaggressions that run throughout the hospital. And I think pinpointing those is a lot harder. And one big thing is just seeing how other people and consultants practice and interact with whanau, I think would be a huge turn off. You know, I'm a strong believer of a whanau-centred approach, and I'm a strong believer of communication and taking the time. And I think it's particularly challenging when people will brush off other people, or they don't listen, or they make assumptions very quickly.
MATTHEW WHEELER: On that, Mic, the idea that you will try and contact, a tamaiti’s parent once, and then if they don't answer the phone, they get pushed to the back of the line, and so they're less likely to get followed up and they're less likely to get seen. Whereas the people who are okay and comfortable with answering numbers that they don't recognize, are more likely to get seen in hospital. They're more likely to ring your scheduler and say, “I haven't got an appointment yet”, and through that, that squeaky wheel, they get seen first. And it's all these small little things that build up to something. And so that's why you need someone at every place.
We've got some really good evidence in Tauranga, we've got a tamariki Māori clinic here, and the scheduler is Māori, and she just has this unique way of contacting parents. And the DNA rates within that clinic is less than 5 percent, dare I say it, it’s probably the lowest DNA rate in the entire country for a paediatric clinic. You know, as much as we're talking about doctors, we need Māori in every position across the entire health system. And so, the old adage that we always use is that “What’s safe for Māori will be safe for everyone”.
The Māori Health Committee actually wrote an editorial in the New Zealand Medical Journal, June 2021. It’s called Letter on an Iceberg, and it was focused around that a urologist stood up in a meeting in Queenstown and was able to say—felt emboldened to say some quite overtly racist statements to a whole meeting of and, you know, and so that's the tip of the iceberg. And it doesn't, it doesn't appreciate what the stuff under the surfaces and the institutional and the organizational racism that's ongoing.
MIC CAVAZZINI: While today’s podcast is focused on the experience of Māori and Pasifika Trainees, the College is also very cognisant of Aboriginal and Torres Strait Islander Trainees. This is a group that’s even more minoritised, with less than 4 percent of the Australian population identifying as Indigenous and only about 0.5 percent of the medical workforce. Representation among medical specialists is less than half of that again.
A critical step in the educational pipeline is at intake into medical school. While Australia has 21 such faculties spread over seven states and territories, Aotearoa-New Zealand has just two, at the University of Otago and the University of Auckland. This can make change easier to implement and these medical schools have certainly been pulling their weight with respect to closing the gap in representation.
Otago has a selection policy called Mirror on Society and Auckland has its Māori and Pasifika Admission Scheme. These programs have been building over a decade such that in 2020, students from these cohorts made up almost a third of about 600 places across both undergraduate and graduate intakes. While this might at first seem disproportionately high, it recognises that it will take a generation or two for that cohort make its way into the workforce and balance the numbers there.
This aggressive campaign has, like most forms of affirmative action, raised the heckles of those who believe it undermines the fabled meritocracy. The back and forth of this debate was reported extensively by journalist Martin van Beynen for the news site Stuff.co.nz. He wrote that once Otago’s Māori and Pasifika admission streams were considered, and also quotas for candidates of rural origin, low SES backgrounds, refugee status or disability, that left just over half of places open for general entry candidates.
This prompted the father of one A+ student who failed to get in to take the University to court, arguing that special admissions schemes were in conflict with the ideals of the Education Act. Other parents brought a complaint to the Office of Human Rights Proceedings, claiming that that their son had been discriminated against. The Otago Medical School got cold feet and was considering scratching three of the 79 places that had been reserved for Māori and Pasifika undergrads.
But after fierce opposition from staff and professional bodies, including the RACP, the Uni awkwardly walked back from this position. I think this story is illustrative because it evoked some really strong arguments about the instrumental, legal and right-based arguments in favour of programs that enhance participation of First Nations people. Dr Matthew Wheeler picks up from here.
MATTHEW WHEELER: I think the Otago policy is really the easiest to articulate, which is called a Mirror for Society. And so that literally says that for the population that you're having for you should be recruiting into medical school. The problem comes is that if you're recruiting for medical school for that population, it's going to take sort of three, four generations to actually meet that because you've got a run in time of when you didn't have these policies. And that's notwithstanding the idea that tamariki Māori may account for, on average, 17 percent across the country. But certainly, if you're looking in Tauranga, they're coming up to 50 percent of the presentations to hospital, and I'm sure that's the same for Danny and Rotorua. And so therefore, if you take that argument of actually we should be recruiting for what we're seeing in the hospital, 50 percent of paediatricians should be Māori in Rotorua. 50 percent of paediatricians should be Māori and in Tauranga. And that's based around the premise that there is a there is a cultural congruence, and there is a trust that is naturally bestowed by seeing someone that you look like and you understand. We know that there's better outcomes associated with that as well.
MIC CAVAZZINI: And I liked the response that the pro-vice-chancellor of Otago’s Health Sciences gave to the press at the time of the legal challenges. Professor Paul Brunton said that even the admission scores, the test score average was itself an arbitrary and unsatisfactory way of selecting medical students as it gave no guarantee that they would be well equipped to serve Aotearoa-New Zealand’s diverse communities. So maybe one of you could say something about…
DANNY DE LORE: I can say, Mic, that as someone who does a lot of a marking and assessing of medical students, and teaching medical students that we certainly have plenty of academically very capable students—they're all academically very capable—but that doesn't necessarily reflect in in effective skills and communication, and empathy and building relationships and understanding big issues that affect people's health. And that could be things like social determinants of health, it could be things like access to care, it could be things like that we teach in the medical school about privilege and racism in the impact of colonisation. Some of those things are very difficult concepts for some even very academically-minded students to grasp and come to terms with.
So, there's no perfect way to select the people who are going to turn in to be really good doctors. But we know that we can have a more effective health workforce if we make a diverse health workforce. But it also helps us, in our own practice, to have diversity within the workforce, because it means we're bouncing ideas of each other, we're teaching each other, we're helping each other understand different perspectives, different ways of seeing the world.
MIC CAVAZZINI: Yeah, this argument for investing in doctors more who are more likely to have cut through in the communities of greatest need, that's what we call the instrumental argument. But there's also an important legal argument. So, Zoë Bristowe at the Uni of Otago’s Kōhatu Centre articulated this pretty clearly in a radio interview at the time of this controversy. She described how the Dean of the Otago Medical School had told the Medical Admissions Committee, “It's not our job to address 200 years of disadvantage,” to which her response was, "Well, actually, that is our job. That is our commitment under the Treaty." Who wants to tackle this legal—particularly for our listeners outside Aotearoa, how far the obligations of the Waitangi Treaty go.
MATTHEW WHEELER: I mean, in its purest form, the Treaty of Waitangi essentially gives permission for non-Māori to be in New Zealand. What people often people forget is it's not the treaty in isolation, it's all the legal framework that necessarily came around it. And so, five years earlier, there was what's called te Whakaputa or the Declaration of Independence. And so, albeit it wasn't as signed as widely, Māori were declared as an independent nation five years before the Treaty of Waitangi was signed. And so, the Treaty of Waitangi was actually a contract or a treaty between two peoples, allowing Māori to maintain their general rangatiratanga, or their chiefly authority, there right to self govern, but gave away Kawana, or governorship, to the British Crown that was setting up.
Now, going through, a lot of people have said, from the legal argument point of view, that that is, therefore, a Crown to Māori agreement. And certainly within the College of Physicians, we were having this argument when we were making a constitutional change to have the indigenous object put in place at the AGM last year. And one of the arguments that was made was that there is no obligation of the College, being a non-Crown entity to put this in at all. And that's fine, there may not be a necessary obligation, but the College represents a vast majority of Crown-employed doctors who do have an obligation to the Treaty. And University of Otago receives money from the Crown for the education of the people, and so they also have an obligation.
So, it depends on what degrees of obligation you're necessarily talking about. So there's the legal obligation and there's a moral obligation for us to do something. And that's where I think the rural systems, and, you know, we should be choosing people who grow up in places like Patia or Wairoa, who are in the movie like Boy, you know, those are the people who you want to try and get into medical school, people who want to go back to their rural communities, who wants to engage with their own populations, who can do it naturally, and don't necessarily have to be trained to do it.
MIC CAVAZZINI: You mentioned that the college is a non-Crown entity, but it does have Royal in the name.
DANNY DE LORE: If I could just touch on that rights-based argument about pathways. Because I really like thinking about it as a—you develop an indigenous workforce, not because you need Indigenous doctors, Māori doctors, but because Māori people have as much right to be doctors as anybody else, they have as much right to participate in medical school and health system as anybody else. And Māori children should grow up believing that they have the same career opportunities as other children, including opportunity to go to medical school.
So some people think that the Treaty, Te Tiriti o Waitangi is historical, that the grievances are historical. And that we're in a different world now, a modern world, and that you can't hold people in the modern world responsible for what happened in the past. But colonisation is ongoing and continual. The impact of loss of culture, of loss of land, those are continual and someone is still paying for it. So Māori children, Māori people are still paying for that, with respect to how we share the wealth and power in this country, with respect to all of the statistics about who's in institutions, who's got drug and alcohol dependency, income and health outcomes, so someone is still paying for it. So, when you think about it like that, we're all still responsible for correcting that.
MIC CAVAZZINI: This argument over preferential admissions to medical school took place in 2020, but it was a taster of what was to come on a much bigger scale. That year also saw a landslide win in the general election for the Labour Government led by Jacinda Ardern.
With this mandate, the government overhauled the bureaucratic structures overseeing Health, creating three agencies independent of the Ministry. Health New Zealand was established to replace the 20 District Health Boards that had existed previously. The Public Health Agency took the place of the Health Promotion Agency and picked up responsibilities for regulation and disease surveillance.
And finally, Te Aka Whai Ora, or the Māori Health Authority. The authority was allocated almost $300 million New Zealand dollars for four years of operation, still just 2.3% of the Health Budget. There were high hopes that with deeper involvement from the Māori community, health services would be more engaging and more effective.
The three agencies started operating in July 2022, but by this time the economy was flagging and post-pandemic inflation was biting hard. Much of the electorate was demanding that the government focus on jobs and cost of living rather than so-called identity politics.
Capitalising on this sentiment, the opposition National Party promised to abolish Te Aka Whai Ora should the public endorse them in the October 2023 election. The Nationals’ Health spokesperson, Shane Reti, claimed that an independent Māori Health authority created “a two-tiered funding system based on race." Sure enough, on the 27th of November, the Nationals took the reigns of government in coalition with the populist New Zealand First party and the right-libertarian ACT New Zealand.
The new government received entreaties from dozens of health advocacy groups and hundreds of doctors to spare the axe on Te Aka Whai Ora. In a public statement the RACP’s President for Aotearoa-New Zealand, Dr Stephen Inns described Te Aka Whai Ora as an opportunity to champion the equity, partnership and cultural safety enshrined in Te Tiriti o Waitangi, the Treaty, signed in 1840 between Māori iwi, or tribes, and the British Crown.
Claims were filed in a court known as the Waitangi Tribunal, stating that the Government's plans constituted a breach of the Treaty, but it was all to no avail. The Disestablishment of Māori Health Authority Amendment Bill was passed as one of the new government’s first pieces of legislation. While thin on details, Shane Reti assured parliament a single health system would be more efficient, more accountable, and did not preclude consultation with Iwi Partnership Boards and Hauora Māori Advisory Committees.
The legislation went into effect in July, but just four months there was an even greater ruction when the government’s junior coalition partner, ACT New Zealand, started making noise about their own election promise. They want to wind back all Māori-specific legislation or governance at a national level which they say only breed resentment among the broader population.
In their view, the Treaty of Waitangi promised “the same rights and duties for all New Zealanders” and granted the Parliament of New Zealand full power to make laws and govern over the country. The problem is that in the Te Reo version of the Treaty signed by Māori chiefs the word “sovereignty” was replaced with “kāwanatanga” which simply means “governance.” They felt that while they were ceding government of the country, they would maintain the right to manage Māori affairs.
Another article of the English-version Treaty guaranteed Māori “undisturbed possession of their lands, forests, fisheries and other properties.” But the Teo Reo version could more accurately be translated, as “chieftainship, over their lands, villages and all treasured things,” taonga katoa, which many take to include cultural treasures not just tangible ones. The modern day impasse came to a head in November when a dozen of MPs brought Parliament to a standstill with a spellbinding haka that made international news. That was followed by a nine-day hikoi or protest march numbering 40,000 people.
After all the tumult of the past year, I asked Danny De Lore and Ngaire Keenan how they saw the future for policy relating to Māori Health. Matt Wheeler had to duck to another meeting for this final part of our conversation, but I’ll link to a submission he made to the justice select committee on the controversial Treaty Principles Bill and also a broader discussion of this for the BHN podcast.
DANNY DE LORE: The Waitangi Tribunal here produced a really comprehensive report in 2019 called Hauora about primary care delivery in this country and whether or not it's met its obligations under Te Tiriti o Waitangi—it said that how we're going to achieve the best health outcomes for Māori people, is Māori people, designing, delivering health care, making decisions about health priorities, where resources go, and being the face of the health care system. And that's what Te Aka Whai Ora did. It gave control to Māori interests, Māori expertise within health system, and it recognized that we're not all the same, we haven't all become assimilated into one culture, and that we shouldn't, that we should embrace our diversity, that we should protect Māori culture as it set out in Te Tiriti. And because we're not all the same, the healthcare system can't deliver the same care to everybody. It has to be flexible and nimble and have expertise in different places that can cater for different health needs. That's what Te Aka Whai Ora did.
MIC CAVAZZINI: There's a really good article in the New Zealand Medical Journal from Heather Came and colleagues that really analyses, down to the wording of Te Tiriti. And one quote from that is how the disestablishment Act that was passed in into law at the start of this year; “In defiance of the WAI 2575” –so these are the Waitangi Tribunal rulings— “In defiance of the WAI 2575 rulings, there are no mechanisms remaining by which independent Māori aspirations, as embodied in Te Tiriti, might be recognised, or realised. The various advisory groups and boards that persist through the Pae Ora Act are without significant decision-making power and are hampered by the provisions that limit Crown resourcing of their roles.”
DANNY DE LORE: That’s what I was trying to say.
MIC CAVAZZINI: [laughs] Yeah, so that sounds like pretty significant hobbling of the ability to provide Māori-focused health. Ngaire, have you been following this in much detail?
NGAIRE KEENAN: I have actually, I actually watched the disestablishment on the train over here in Australia. It was heartbreaking. Because I think the thing Te Aka Whai Ora, did was, they really got into the community, and they had people around Aotearoa and around the country. And it wasn't just this ministry sitting in Wellington that nobody really knows about. They really worked hard to try and get into the different iwi and have representation. And it was all very much in early stages. And I think it's disappointing that that this has happened.
MIC CAVAZZINI: Again, another quote from that paper is that, “A decision as big as the disestablishment of Te Aka Whai Ora required significant discussion with whānau, hapū, iwi and Māori health leaders. A political campaign trail is not respectful engagement with Māori or civil society.” And in May, four Māori health providers bought a complaint to the High Court making many of these arguments and adding that the urgent disestablishment of Te Aka Whai Ora didn’t follow due process, there was no working group or consultation. It breached not just the Treaty of Waitangi but also New Zealand’s Bill of Rights. Danny, do you know if there are any updates on that High Court challenge?
DANNY DE LORE: I’m not aware that there's been any progress there? I mean Te Aka Whai Ora, is not going to come back, not in the form that it was but the kaupapa, or the way of thinking about this, hasn't changed. And institutions come and go, governments come and go. That will always be the focus for Māori people is te tino rangatiratanga, where Māori have control over our future.
MIC CAVAZZINI: There is a mirroring across the across the Tasman. So, we had a similar, similarly heated debate in Australia last year around the Indigenous voice to Parliament, which was proposed as a to the Australian population in a referendum. It would have simply been an advisory body on policies and legislation that would affect Aboriginal and Torres Strait Islander people. So, it wasn't even as well as concrete a body, I think, as Te Aka Whai Ora. But that was rejected by the Australian voting population. And the arguments made against the Voice by conservatives were very much the same as those you heard in Aotearoa. Peter Dutton told Parliament that the Voice would “re-racialise our nation,”—suggesting that we live in a racial Utopia at the moment—“the proposal will permanently divide us by race. It will have an Orwellian effect where all Australians are equal, but some Australians are more equal than others." These kinds of arguments, they have a ring of common sense to voters that aren't particularly engaged in social justice. How would you respond to them, and how would you appeal to those kinds of voters for why something like Te Aka Whai Ora or the Voice isn't just symbolic, it has real consequences.
DANNY DE LORE: I don't know how to appeal to voters. I couldn't be a politician. I don’t understand voters.
MIC CAVAZZINI: Stick with paediatrics.
DANNY DE LORE: But you know, my argument would be that a lot of those claims are based on this assumption that there is a level playing field, that there's equal opportunity now. And people who put forward that viewpoint, that we're living in an equal opportunity world with a level playing field, they're usually the ones who are doing very well from the systems that they're benefiting from. And you know, privileged people don't know that they're privileged. They don't feel the tail wind that's behind them.
The second thing I'd say is that it's very easy to put forward democracy as a solution to every problem. But the definition of democracy is minorities always lose. You know, that is the tyranny of the majority. If you put decision to everybody, majority is always going to come out on top. Minorities always come out second best. And we have to find other ways to overcome that. Even the strongest proponents of democracy understand that it has weaknesses, and that's the greatest weakness, and we've got to find ways around that.
MIC CAVAZZINI: And to end on an even more touchy question. It does need to be noted that the New Zealand Minister for Health, who presented the Disestablishment Act, Shane Reti, is himself, Māori, as is the more fringe MP who's created a ruckus in the last few months of New Zealand politics. And similarly, the campaign against the Voice in Australia was led by an Aboriginal woman, Nationals Senator Jacinta Nampijinpa Price. There's a lot of nasty things said about these politicians from the Left. I try to take them at their word rather than impugn their motives but, you know, these are people from minoritised groups who feel that the road to representation should be within the mainstream model, not within a sort of affirmative action model like we've described. And, I guess, they allow white Australians and white New Zealanders permission to oppose these affirmative action models without feeling like they're being racist. How would you understand the motives of these politicians and how would you gently resist the free pass that they give to voters who might be sceptical of initiatives like the Voice and Te Aka Whai Ora.
DANNY DE LORE: I think that viewpoint, sees the world as much happier and harmonious and easier if we all just become one culture. And if you assimilate minority cultures into the majority culture, everything becomes easier and happier and more harmonious. But if you assimilate Māori culture—if you continue to assimilate Māori culture into the majority culture, and you take away the language and the culture and the traditions and the values and beliefs of that culture, that oppression. You know, that's destruction of a culture. That sort of assimilation isn't a way to achieve harmony, it's a way to destroy histories and legacies that are not just valuable for those minorities, but that diversity and that different ways of seeing the world and understanding the world that's good for everybody. So that's a form of oppression to me, and we have to resist it.
MIC CAVAZZINI: And Jacinta Price and Shane Reti might well say, “Well, if I can do it, anyone can, Māori or Aboriginal or otherwise.” But maybe not all Māori and Aboriginal and Torres Strait Islander people might be prepared to make the same compromises that they have.
DANNY DE LORE: Or, you know, the way that some of those people might define success, is not the way that other people—you know, Māori. People just want to be Māori. They don't want to take over the world. They don't want to be a politician, necessarily or whatever. They just want to be Māori. They want to live and celebrate and pass on all of that culture and history and everything that was passed on to them, they want it to survive. And that success for Māori people is the Māori cultures thriving.
MIC CAVAZZINI: Ngaire, any final thoughts?
NGAIRE KEENAN: It's a very difficult topic, and I think, like, I always go back to the community. Like, yes there are politicians around, but I think when you take a step back and you look at what Aotearoa is, and who is in Aotearoa, and I think the hikoi is a good example of the fact that, although there are politicians who have these opinions, it's not the opinion of many people in Aotearoa and we need to remember that. Because in the end of the day, we're trying to make the country better and we need to remember who is in the country, and what our country is, and needs. And the reality is, not everybody starts in the same place. When people realize that, bringing one group of people up is not going to bring another down. It just helps everybody be on a level playing field.
MIC CAVAZZINI: Many thanks to Ngaire Keenan, Matt Wheeler and Danny De Lore for sharing their thoughts on this difficult topic. Rather than being disheartened by this conversation, I find myself inspired by their generosity of spirit in bringing all of us on board. Since 2021, the Royal Australian College of Physicians has enshrined within its organisational values the intention to indigenise and decolonise our ways of working. At the web page elearning.racp.edu.au there are expert interviews and presentations on building a training environment that allows Indigenous Trainees to thrive, and there’s also an eLearning course and reading list on culturally-safe practice more broadly.
The term, cultural safety, was actually coined by Māori nurse Irihapeti Ramsden about 20 years ago, and I’ll include her writing among the other references at our webpage. Just go to racp.edu.au/podcast and click on the episode link. If you like what you’ve heard, you can listen to all 126 episodes of Pomegranate Health right from your mobile phone. It’s best to install Apple Podcasts, Spotify, Castbox or any equivalent podcasting app, but late adopters can sign up to an email alert list from our website. This podcast was produced on the lands of the Gadigal clans of the Yura nation. I pay respect to their elders past, present and emerging. Mic Cavazzini toku ingoa. Whakawhetai ki a koe mo te aro me te whakarongo.