Episode 31: Ngā Kaitiaki Hauora
Episode 31: Ngā Kaitiaki Hauora
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‘Ngā Kaitiaki Hauora’ translates as ‘guardians of health’. This podcast emerged from a meeting near Auckland organised by the RACP’s Māori Health Committee in November 2017. Members of various medical colleges and institutions came together to share perspectives on the delivery of health care to New Zealand’s population of Māori and Pacific Islander people. This conversation comes in the context of the Wai 262 claim, which is forcing a re-examination of the Crown’s obligations to the Māori population under the Waitangi Treaty of 1840.
On this episode, Reverend Hirini Kaa proposes that all institutions of civil society must be committed to recognising Indigenous sovereignty not just over land, but also the natural environment, the language, and cultural practices. GP Dr Peter Jansen and oncologist Dr George Laking describe the variation in medical care that Māori and Pacific Islander patients receive on a day to day basis, and how this can emerge in part through cultural ‘mismatches’. And public health physician Dr Elana Curtis describes the successes and future targets of streaming Māori and Pacific Islander students into medical school.
Claim CPD credits via MyCPD for listening and using resources related to this episode.
Guests: Dr Peter Jansen FNZCGP FRACMA (Ngāti Raukawa, Mauri Ora Associates, Accident Compensation Corporation); Dr George Laking FRACP (Te Whakatōhea, Auckland City Hospital); Dr Elana Curtis AFPHM (Ngāti Rongomai, Ngāti Pikiao, University of Auckland); Rev Hirini Kaa (Ngāti Porou, Ngati Kahungunu, University of Auckland), Mr Chayce Glass (Tumuaki, University of Otago). Commemoration to Matua Leo Buchanan given by Dr Tuwhakairiora Williams.
Extended Podcast: Further Outtakes from the Hui and Interview Excerpts [RACP]
He Ritenga Whakaaro: Māori Experiences of Health Services [Mauri Ora Associates: Jansen]
Examining the Predictors of Academic Outcomes for Indigenous Māori, Pacific and Rural Students Admitted into Medicine via Two Equity Pathways [BMJ Open: Curtis]
Variation in the Use of Medicines by Ethnicity During 2006/07 in New Zealand [NZMJ: Laking]
Patterns of Privilege: A Total Cohort Analysis of Admission and Academic Outcomes for Māori, Pacific and Non-Māori Non-Pacific Health Professional Students [BMJ Medical Education: Wikaire]
Irihapeti Ramsden: The Public Narrative on Cultural Safety [The First Peoples Child & Family Review]
Cultural Safety and Nursing Education in Aotearoa and Te Waipounamu [Victoria University: Ramsden]
Lung Cancer in New Zealand: Overcoming Barriers [Best Practice Journal]
Ko Aotearoa Tēnei: This Is New Zealand [NZ Ministry of Justice]
Ko Aotearoa Tēnei Synopsis [NZ Ministry of Justice]
About the Waitangi Tribunal–Te Rōpū Whakamana [Te Ara]
RACP Indigenous Health Scholarship Program
Cultural Competency Resources
[MCNZ and RACP]
Dealing with Diversity in the Profession and in Practice
[IMS 2016: Dr Papaarangi Reid]
Guidelines on Māori cultural competencies for providers
Guideline Commentary on Consulting with Māori and their Whānau
Written and produced by Mic Cavazzini. Music courtesy of Jason Shaw (“Autumn Sunset”), Doctor Turtle (“Making a Change”) and Broke For Free (“Feel Good Instrumental”). Image of the Te Whare Tapa Whā health model by Sir Mason Durie, provided courtesy of NZ Ministry of Health: Manatū Hauora. Executive producer Anne Fredrickson.
Editorial feedback for this episode was provided by RACP Fellows Dr Katrina Gibson and Dr George Laking and RACP staff Ms Harriet Wild, Ms Nicola Fowler, and Dr Cristiana Palmieri.
MIC CAVAZZINI: Kia ora koutou and welcome to Pomegranate Health. I’m Mic Cavazzini. Before we start today’s show, an invite to any Fellows and trainees to renew our podcast editorial group. We need avid listeners to help us maintain the standard and interest of the podcast. The group meets by email to propose future topics, suggest experts to interview, and provide feedback on audio drafts before each episode is published. It’s not a huge time commitment, and might be a fun way to gain some CPD credits. Please go to the website for more information about the application process which ends mid-January.
Today's episode comes from a marae or meeting hall at Mangere, Aotearoa, just outside of Auckland. This was the site of the RACP hui, which saw members of various health bodies get together to discuss the future of Māori health. It comes in the context of the Waitangi Tribunal, which is re-examining the obligations of government to the Māori population. Even if you’re listening from outside New Zealand, you’ll find this relevant. The landmark Tribunal could be a template for Indigenous relations in Australia and around the world. We'll hear about the gains made in recruiting Māori and Pacific Islander students into medical school, and we’ll examine cultural competency in the doctor-patient relationship. But first, doctors Peter Jansen and George Laking describe the variation in medical care that Māori and Pasifika patients receive on a day-to-day basis.
PETER JANSEN: Tena koe. Ko Peter Jansen tāku ingoa. He uri ahau no Ngāti Raukawa. My name is Peter Jansen. I work as a—well, I have two fellowships. One in general practice, and the other in medical administration. Currently, I work as the clinical lead for treatment injury in the Accident Compensation Corporation.
GEORGE LAKING: Kia ora. Ko George Laking tōku ingoa. My name is George Laking. I work as a medical oncologist at Auckland City Hospital. My role in the College is to chair the Māori Health Committee of the College. On my mother’s side of the family, I am a Whakatōhea person.
MIC CAVAZZINI: Thank you. So, I guess there are many possible markers of health and equity. Perhaps the bluntest is life expectancy at birth. And this is eight or nine years lower for the Māori and Pacific Islander population, compared to non-Māori. We won't talk too much about socioeconomic determinants of health, I hope that most of our audience is familiar with that. What I want to talk about is the things that we can change within the organisations. So Peter, your 2009 report about Māori experiences of health services notes that socioeconomic factors only explain half of the problem.
PETER JANSEN: Yeah, that’s really interesting. A New Zealand government publication has highlighted that we, as Māori, in New Zealand, not only live shorter lives but spend a greater proportion of our shorter lives either sick, or disabled, or injured. And that situation hasn’t changed decades down the track. The drivers of that, a large proportion are within the control of the health care system. So things like inequitable placement of services. Then the next step is once Māori do access services, what kind of intensity of treatment do we get? We get less. We get less prescriptions from general practitioners.
So we know, for example, that general practitioners find it really hard to make a diagnosis of chronic obstructive pulmonary disease. And there's a difference between their ability to diagnose it in Māori versus non-Māori. But having made the diagnosis, for some reason, practitioners give less treatment to Māori. Despite positively making the diagnosis. That kind of makes no sense.
MIC CAVAZZINI: You’ve stolen my thunder—so for new cases of COPD, less than 10 percent of Māori and Pacific patients receive scripts, compared to 78 percent of non-Māori.
PETER JANSEN: That was from the NatMedCa study. That points strongly towards bias. Another part of that study, for example, looked at when there's a referral needed to a secondary care service, we know that Māori get less, despite greater need. Having got through that hurdle and on to the secondary care service, we know once again there are differences. All of that is very troubling, because it ends up with little differences all along the chain, so that you’ve got worse health and worse mortality at the end of it.
GEORGE LAKING: I'm aware of other sources that point in the same direction as well. I was involved with some work from PHARMAC where we related the national data on dispensing of prescriptions. And it emerged there was a shortfall of about one million prescriptions in the course of a year—that if the experience of Māori for access to medicines were the same as that for non-Māori, there would have been one million more prescriptions written.
And then also I’ve been involved in a project about access to lung cancer care, and the time intervals from first presentation to general practitioner through to treatment. Pretty much every step of the way, it was just a little bit longer for Māori people, compared to non-Māori people. Which added up to quite a significant change.
So this problem is pretty well described, and it gets a bit depressing. Because there's a feeling that there's a lot of describing of the problem, but what are we doing?
PETER JANSEN: We call that a lot of hui and not much do-y.
GEORGE LAKING: Yeah. It’s apt.
MIC CAVAZZINI: Since we were talking about prescription rates, you did a study in 2013 that showed for the same number of prescriptions, then there are different dispensing rates amongst Māori and non-Māori. People might say it’s a public system, that’s all covered. What are the hidden costs that prescribers might not be aware of—availability, or cost, or whatever?
PETER JANSEN: I'm going to tell you about a study that’s not generally known. This is in the 1990s, and the health funding authority was newly set up. They wanted to understand why young children were not picking up their prescriptions. The theory was young children can't pick up their prescriptions because the cost of the prescription was particularly high. At that time, it was more like about $10 or $15 per prescription item. Which, in dollar terms now, is huge.
So we worked with all the general practitioners in the south of Auckland—this is in the days before computers, so we had triplicate prescriptions. We were able to track the copy kept with the GP, the two copies with the patient—one handed to the pharmacist—and then track whether it was picked up. And yes, Māori families were less likely to pick up prescriptions. Things that made no difference were the number of prescription items, the total cost, the amount of dispensings, the times per day you had to take the medication, the disease, the urgency—none of that made any difference.
The dominant indicator was who was the doctor. Because we had a line showing from lowest to highest pick up rates by doctor, from 97 percent pick—up down to about 83 percent pick—up. And you'd have to say what's the characteristics of the doctor at the 83 percent end versus the 90—something per cent end? Then we unblinded the data. The Māori doctors were all at one end. Which end? The 90—something percent end. These were people working in a community with a lot of Māori and Pacific patients, who were highly valued by their community. And at the other end, those people clearly needed help with communication skills.
A prescription is an exchange between you and your patient. And whether people follow your instructions is all around, when they are leaving the room, do they understand what's going to happen?
MIC CAVAZZINI: Once in the hospital system, Māori are also less likely to receive cardiac revascularization. And across all presentations there’s a greater association with preventable adverse events. Another figure you report in your review was that hospital stays following an acute stroke were twice as long for Māori patients than for non-Māori patients—36 days versus 18 days. But far from reflecting better care of Māori patients, that actually tells you something about other services. There's a narrative there. Do you want to elaborate on that?
PETER JANSEN: Yeah, so part of the problem is that Māori are more likely to have a stroke at a younger age. But our rehabilitation services are set up to receive older patients. So Māori, at a younger age—in their 40s and 50s having a stroke—in an old person’s service, where the service is not set up to meet their needs, there's a misfit. These services are also located in places that are more challenging. That all just goes to what I would call a cultural fit. Do we mesh well together—your expectations and mine? Are we able to get on?
MIC CAVAZZINI: Improving the cultural fit of medical care to some extent requires getting Indigenous doctors into the workforce. Māori currently make up 15 percent of the New Zealand population, but only 3 percent of its doctors. The Vision 2020 strategy at University of Auckland aims to bring this figure up to 10 percent in the next few years. The director of this program is Dr Elana Curtis.
ELANA CURTIS: Kia ora. Ko Elana Curtis tōku ingoa. Nō Te Arawa ahau. My name is Elana Curtis. I am a public health medicine specialist, and my research focus is on Māori health, Indigenous health, and inequities in health care and health outcomes. And I'm a senior lecturer at the University of Auckland.
MIC CAVAZZINI: And the Universities of Auckland and Otago have this year celebrated their biggest ever intake of Māori and Pacific Islander students, into medical school. Tell us how students come in to the scheme.
ELANA CURTIS: Under Vision 2020, we've got three programs. One is Whakapiki Ake, which is a Māori recruitment program. That program works out in the secondary schools—primarily Year 12 and Year 13 students, right down to Year 9, and with whānau and families, trying to get the exposure to students early. Because you need to look at it as a pipeline. They're supported in their choice of subjects that they take. Because really, at the key of this, is that they take sciences, they take maths, they take English, they are doing well. Because they're not getting the right information.
So a number of students that come to us saying, “I got told I'd never be able to be a doctor.” The number of students that come to us and say, “I got told I shouldn’t take sciences, I should do something more active with my subject choice.” You know, those really ugly types of stories. They need to be countered by—some of it is exposure to role models. They need science teachers that engage them. We need to see science as being Indigenous, because it is.
The second key thing that we have is a bridging foundation program, which is called the Certificate in Health Sciences. This is a one year program for Māori and Pacific students only. So for those students who have gaps, we review them and work out whether they need a booster year.
And then the third thing is the Māori and Pacific Admissions Scheme [MAPAS]. MAPAS is an admissions and support program, really. It’s at that point we do this comprehensive best starting point interview. It’s less about whether they're going to make a good doctor, and it’s all about will you be successful if you come into the program.
CHAYCE GLASS: I'd never met a Māori doctor in my life. So 18 years, I'd never come across a Māori doctor until Lance O’Sullivan—it was a big thing on the TV at the time. That was the first time I'd ever seen a Māori doctor.
MIC CAVAZZINI: Chayce Glass is in his fourth year of medical school, and attended the RACP hui as the tumuaki of Te Oranga, which represents over 350 Māori and Pasifika medical students.
CHAYCE GLASS: I guess I was kind of pushed by my Reo Māori teacher. I kept doubting myself, saying I couldn’t do it, that I wasn’t clever enough. And she said, “No, we need more of you in there—you’ve got to give it a shot. You can't sit there and rule yourself out that early on.”
MIC CAVAZZINI: People talk about the culture of medicine as being this big old white institution. I mean, did you feel like an outsider in there? Or did you find your place?
CHAYCE GLASS: Initially, when I started medical schooling—I think every medical student gets imposter syndrome. It’s made worse by being a minority in the system. But it really only took me six months of medical education until I felt comfortable with being a medical student. And I started realising very early on that the things I was taught as a child, from my cultural perspective—of love and compassion—actually put me in a more advanced stead than some of my other colleagues who were having to learn that in medicine. I didn’t notice that with our Māori colleagues. We were already taught how to love and care for people, by our ko mātou and our nannies and our grandads. So we had a bit of an advantage. And I thought “Well, if we've got that, then surely we’re not actually imposters in this case.”
MIC CAVAZZINI: Great example. Within the university program, were there a lot of supports and pastoral groups for your group?
CHAYCE GLASS: Yeah, yeah. We had this sort of wraparound care of there was the normal medical school level of pastoral care, but we also had this extra support from Māori-orientated staff and students, and things like that. Sometimes it was just even having someone to go, “Can I have a cup of tea with you?” “Can I sit down and have a chat about what's going on?” We’d practice OSCE examinations. We’d do an anatomy quiz with each other, where we’d actually go to the anatomy museum and write the questions up for each other.
We had more of a whānau-orientated structure, and we’d support one another. It was—particularly moving from the North Island down to the South Island—I lost that direct connection with my family. And we managed to make a new one with each other, as Māori students, to come together and really wrap around and support one another.
MIC CAVAZZINI: Did you ever hear the sentiment that—you know, special treatment?
CHAYCE GLASS: You get that often. I actually kind of feel sorry for people that think that it’s special treatment for us. It’s just fun. At the end of the day, if you want to call it special treatment, then I recommend you find your own whānau so you can have that special treatment. I think that’s the important thing with getting through medicine. Like Dr George Laking said, whānau just isn’t the ones you're related to by blood, it can be the ones you share an association with.
ELANA CURTIS: I think we need to acknowledge the huge amount of stigma that our students experience by coming into medicine under a quota pathway. We know that our students experience stigma and prejudice around that. Not only from their peers, but even from their clinical educators. Which is shocking. But we've had qualitative research which has told us that. In your face accusations of, “You don’t deserve to be here because you might have come in under a quota.” And that is really a reflection of societal racism, which doesn’t understand the need for, and the rights-based arguments for, equity programs such as MAPAS. So there's always a challenge there.
MIC CAVAZZINI: In one of your papers with Erena Wikaire, she writes that “the first year of health study is often an unsafe and daunting experience where students can be culturally isolated…in predominantly white institutions.” The problem is that you never see privilege when you’ve got it. Is the university experience really that white? How is it alienating?
ELANA CURTIS: Oh, it’s hugely. Yeah. There's a few issues. One is that when you can't see yourself in something, it’s hard to connect. It’s very othering. So Pākehā students get to see themselves everywhere. They're there in the face of the librarian. They're there in the face of the lecturer. They're there on the page that they're learning about. They're there in the theorists they're given. It’s white, male theorists that they're going to see as the gold standard. All around our students is—to be ‘normal’ is to be Pākehā, is to be white. Then when they do see themselves in the curriculum, we are the problem patient—the fat patient, the obese patient, the smoking patient. The really, really, really, really sick patient.
And so when you do see yourself, you see a really shitty picture of yourself. You only see one version of what it is to be Indigenous, and that’s often unwell. That’s often non-compliant. That’s often the bad version of the patient. So you need counter stories and you need counter stereotypes, essentially. You need to see Indigenous academics, or Indigenous theory, or Indigenous knowledge.
MIC CAVAZZINI: So the institutional problems are more just the modelling that—the seeing of role models, rather than…
ELANA CURTIS: I think the institution is set up for a student who has parents at home that have good money, that can support them. They're able to study. They have transport in and out to the university. They have food on the table. They don’t have too many other expectations on them. They get to study, and they can do really well. But in reality, our students—some of them are trying to work 20 to 30 hours a week as well as study. Some of them are trying to provide money for their families. Not just for them, but for their families. They are doing that as well as trying to study. They’ve got complex lives, and I think the institution doesn’t necessarily operate in a way that understands that.
MIC CAVAZZINI: So in the past, without the support within the university, there were high withdrawal rates of MAPAS medical students. But in your BMJ paper this year, you noted that this has been brought down to a mere 15 percent difference in graduation rates of Māori and non-Māori students. You made the comment that this is really quite incredible, given the disadvantage they start out with.
ELANA CURTIS: I think we need to acknowledge that when you actually compare our students to general entry, there's about a two-point difference in grade point average at point of entry and that’s huge. Which are sort of artificial. The reason there's a two-point gap is because it’s so competitive for general students to get in. It’s not necessarily that you need to have a grade point average at that point. When you look at how different they are at the point of entry, and then actually the fact that we still graduate the majority of these students, I think is a hugely successful outcome.
MIC CAVAZZINI: It’s one thing to get through medical school, but then you’ve got trainee programs and they’ve got selection criteria of their own, and you need to have done extra research and….
ELANA CURTIS: If you're thinking about this as a pipeline, we've got some really solid interventions now at the tertiary pipeline level. 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 around, how come the equity argument stops at their point of entry?
MIC CAVAZZINI: The RACP hui also commemorated the recent passing of Matua Leo Buchanan, the founding Chair of the Māori Health Committee. He was remembered as a playful and brave paediatrician, who reached thousands of disadvantaged children through interventions in the hospital and the community.
Differences in culture and communication style are often a barrier to delivering effective health care. When you add discrepancies in health literacy and education, it’s easy to blame patients for failing to adhere to medication or attend follow up appointments. But Peter Jansen says the onus is on health practitioners to try and bridge the cultural divide in order to give patients more faith in the consultation.
PETER JANSEN: That goes back to what I was saying about this cultural fit idea. I like to treat people like me. That’s just normal human nature. So we've just come from a hui—a meeting—in a meeting house. It’s a very Māori environment. And all the Māori feel extremely comfortable there. We know what's going to happen. We know the protocols involved in carefully meeting each other, then approaching the business of the day, and how to wind up the day. That’s very comfortable for us. On the other hand, when I travel to a foreign country where I don’t know the protocols, and I'm afraid that I'm going to offend, it’s very troubling. I think that kind of explains what's happening in a cross-cultural communication.
But we, the health professional, need to be able to step outside that and go, “You know, I'm the guy holding the knowledge. I'm the guy that can change this situation and deliver really important health messages. How do I do that?” There's a Māori whakataukī about that, which I won't say in Māori, but I’ll give you the sense of it. It’s about people going to a wānanga, a teaching meeting, and it goes like, “The quality of the teaching was so good that when the teacher and the learner came out into the sun, you couldn’t tell one from the other.”
And that’s the kind of thing we need to be thinking about in our consultations with people who are Māori, or not from our background. That our interaction is so good that you're completely satisfied they know exactly what to do next, when they're leaving the room.
GEORGE LAKING: Interesting also that—if we unpack a little bit further the notion of
Patient-centred care. In the Māori world, it’s whanau-centred care, so family-centred care. Here’s a term that I heard a few days ago, that to my Western ears sounds very strange indeed: “whānau with cancer”. Well hang on a minute, cancer is for one person. Or for one organ, even. How does a family have cancer? Well, of course, if we can reflect on our own experience, we realise yes, this affliction spreads outwards, and the family suffers and is in pain. Who do they turn to? They turn to the medical profession. And although our paycheque may be related to the services that we provide to the nominal patient, I would love our profession to recast its sense of obligation in terms of an obligation to whānau.
PETER JANSEN: George, I've got a follow up question for you. You're an oncologist. What does it mean if a Māori patient with cancer doesn’t come with their whānau?
GEORGE LAKING: Well, it means I worry. When we think about what people need to exist and to get through difficult things, the number one thing in fact is the whānau. So to see a person on their own, that creates some worry.
PETER JANSEN: George is quite right. A person with a significant diagnosis like cancer, alone, gives you some cause to think—to pause for thought. What does this mean? Not asking the question would be troubling, to me. If George’s answer had been well, it is what it is, that would be a concern.
MIC CAVAZZINI: There was a document, sort of a Māori culture 101. “Some physicians might be daunted by encountering the whole whānau coming.” What tips would you give?
GEORGE LAKING: I think the first thing to acknowledge is that, for me as a doctor, that is an honour for me, that this large number of people has assembled in my clinic. And then of course, consider if I ignore or do not take into account the whānau member, the family person who’s come there to support, that person is going to feel diminished. And they won't just carry that on their own. That will spread across to all the other people in that group, and now we all share that pain, which is fully iatrogenic.
PETER JANSEN: Firstly, as George is pointing out, this is your place. You're welcoming these people into your place, and that’s a simple protocol thing. You welcome those people in. Acknowledge them all. You'd want introductions. You'd also want to negotiate some kind of communication protocol and what’s the expectations of the family about who can receive information, who can come back? And let them lay it out, in their terms.
Let me tell an anecdote on this. So you won't be aware Mic, but I did have a head and neck cancer about 15 years ago. I'm going to talk about Professor Randall Morton. I went to see him and he examined every part of me, and the head and neck. He gave some explanation. He turned to his computer and started to type in his computer. My wife said, “Professor Morton, why don’t you just get a knife and cut this cancer out?” I observed him turn around, wheel his chair over directly in front of my wife, speak to her directly, and say, “Because people do worse.” And he sat back, and he waited while she digested the information.
She had another question. He gave her a clear response. He waited. She had another question. He repeated this procedure. My whole family gathered that evening to discuss this terrible affliction that had beset their brother, son, father, et cetera. And in the midst of this, one of the people piped up and said, “Why don’t they just get a knife and cut that thing out?” And my wife was able to answer all of those questions. Absolutely superior communication skills by Professor Morton. Such that the whole family was now at ease. They were able to understand what's the problem, what's going to happen next, where’s our role? They understood everything. And it was all smooth sailing from there.
ELANA CURTIS: Cultural competency plays into the notion that you just have to understand the culture of the other person. “Oh well, if you learn more about Māori language, or Indigenous language, or you know about the culture”—then somehow you're going to be a safe health practitioner. There's a notion that you can get competent in someone’s culture. You know, you go off and do your little course, you reach a bar and then you're done. You’re—‘tick.’
I think that’s nice, to think that you can get there, and we like to pass things, and that’s it. But actually, it’s a lifelong learning process. You could have the best Te Reo Māori, you could know tikanga Māori, you could know what to do on a marae, but you could still have a bias, and you could still have a stereotype, and therefore you could still provide treatment which is not meeting gold standard and is not high quality, and therefore will not produce equitable health outcomes.
So cultural safety plays into the notion that you don’t need to know everything about their culture, per se, of the patient. You need to know about your own self. And actually be competent in your own cultural biases, because it’s your culture that’s actually causing the problem, not theirs. When you're not Indigenous, you often take your own culture for granted. You often take your own assumptions as being normal. And you're not really seeing that there is even an alternative worldview paradigm. So it’s hard to see there's anything different going on, that you need to be doing for patients of different ethnic backgrounds.
So, it would be great if you could do it in different languages, et cetera. But it’s not that. It’s actually about getting the patients what they need, which is actually medical care for the right condition, at the right time, in a way that’s going to produce outcomes.
MIC CAVAZZINI: The power dynamic between doctor and patient is writ large in the relationship between government and the Māori population. The Treaty of Waitangi was signed in 1840 between the British colonisers and the Māori tribes or iwi. But in 1991, a legal challenge was brought against the Crown, maintaining that it had been broken its side of the deal.
HIRINI KAA: Wai 262 was a claim by a number of iwi to the Waitangi Tribinal where they claimed breaches of the treaty.
MIC CAVAZZINI: Rev Hirini Kaa is from Ngāti Porou and Ngāti Kahungunu, two of the iwi which raised the Wai 262 claim. He is an academic at the University of Auckland Faculty of Arts and a minister in the Anglican Church. Reverend Ka explained the obligations of the Crown to protect Māori cultural treasures or tāonga, and how these duties extend to all civic institutions, including the health system.
HIRINI KAA: Yeah, so part of the report and part of the initial concerns were around biological species and how these were being used. But it quickly involved into a discussion around knowledge. For example, there was kūmara seedlings, and some were taken to Japan by a scientist. And then the scientist started testing the genetics of these plants. So questions arose around who has the rights to them? Kūmara being not just a staple plant for Māori, but also having a lot of spiritual value.
So in some ways, it wasn’t just around the plant. It was around Māori identity. Because in our understanding that everything in our world is connected, what happens to us—these aren’t just some plants. These are our identity that’s being altered here. So it kind of shows in the title of the report, which is—it’s got two titles. One is ‘Ko Aotearoa Tēnei’. The other one is ‘This is New Zealand’. They kind of mean the same thing. But at the same time, they don’t. Because one is saying this is a Māori land, the other one is saying this is a Pākehā land. Together, they're saying this is both.
MIC CAVAZZINI: The Ko Aotearoa Tēnei describes the Crown as kaitiaki of Māori culture. What does this term imply?
HIRINI KAA: Kaitiaki is a protector, a maintainer. It’s having a role in terms of nurturing these values. So kaitiaki is those who have a responsibility for the protection of these taonga, in all their forms whether it’s language, or species, or even telephone frequencies, which is about the transmission and the protection and the survival of the language.
MIC CAVAZZINI: And even Māori traditions of health, rongoā are considered a form of tāonga, which were previously actively suppressed by the Crown, isn’t that right?
HIRINI KAA: Yeah. Of course, one of the challenges of colonisation was the imposition of a particular worldview, and the eradication of another. And health went with that. So Māori understandings around health and healing being holistic, being whanau-centred, being determined by things beyond the biological. All of which now is being re-understood, of course. Tohunga were the repositories of traditional knowledge, and that included healing.
And the Tohunga Suppression Act was the eradication of Māori healing practices—at least driving them underground, and also saying that Māori knowledge was not valid. It was another example, alongside education, alongside the economy, where Māori were told, “Your way of viewing the world is not valid; our way will be the only way here in New Zealand.”
MIC CAVAZZINI: So this role of kaitiaki, of gatekeepers, therefore extends to all instruments of the Crown, doesn’t it? To schools, the justice system—and dare I say it, the Royal Colleges.
HIRINI KAA: So the mandate of the Waitangi Tribunal was to outline breaches by the Crown of the treaty. But in some ways, the implications are much broader than that. It’s pointed at all aspects of New Zealand society, and that includes the various institutions that make up civil society in New Zealand. So certainly the Royal Colleges of health—the various Royal Colleges—have the responsibilities of upholding these tāonga of Māori. And Wai 262 then challenges the fabric of New Zealand society. Its institutions, its ways of thinking about itself, the various signs and symbols that can make up a culture, in terms of who we are, and how we relate to one another, and how we protect these tāonga of Māori.
MIC CAVAZZINI: Tell us why you are optimistic about this process, through the way the identity of the Anglican Church has changed.
HIRINI KAA: The Anglican Church was part of the formation of the colonial state, was part of the oppression of Māori, was part of the process of Māori culture being suppressed, eradicated where possible. It’s all a very unfortunate history. And of course, Anglican Church then reflects the power structures and the power imbalances of New Zealand very clearly.
But Māori consistently retained, as much as we could, a sense of agency in this process. We retained our knowledge. So in the midst of making the Book of Common Prayer central to our worship, there was also a Book of Common Prayer translated into Te Reo Māori, with Māori ideas and concepts embedded in it. We had experts in our Reo, in our tikanga, almost nurtured and protected within this most English of institutions. But there are lots of examples of people, of places, of spaces that were both very Māori and very Anglican, without needing to destroy or disempower one another.
That included, by the 1920s, in my tribe Ngāti Porou, we built a church, this baptismal font in it. So when children are baptised into this font, they're not just brought into that Christian community. They're brought into our iwi world as well. The two things are happening simultaneously. And we see absolutely no paradox, because we reconciled that ourselves about 100 years ago. And so if it could happen there, it could happen anywhere. Including in the health profession.
ELANA CURTIS: We always have to maintain not only a needs-based argument to focus on Māori health, but a rights-based argument, which is reflected in the Treaty of Waitangi. We need to be clear around that. They have a right to this pathway. And—“Here’s your right, your Indigenous right, to dream, to become a doctor in your own country. Therefore what do we need do to help you in terms of academically where you should start?”
MIC CAVAZZINI: So increasing Māori and Pacific representation in medical school is always framed in the context of addressing the needs of these rural and underprivileged communities, from a health system level. But is it even fair—is it a burden to put this expectation on those students? I mean, some of them might just aspire to be inner-city plastic surgeons rather than solving all of the problems.
ELANA CURTIS: Yeah, yeah. I think there are very pervasive and romantic notions about what Indigenous doctors should be. I think we need to challenge those. We shouldn’t be boxing an Indigenous doctor’s future potential about what they can be, in that somehow working in the community or being a general practitioner is what Indigenous doctors need to do. No way. That’s too simplistic, and it’s too narrow, and it’s just too boring, actually. We need Indigenous doctors everywhere. We need the plastic surgeons. We need the brain surgeons. We need everything. I'd love to go and see a specialist who’s Indigenous, who’s working at Auckland City Hospital.
And we’re so excited actually, because—well sadly, one of our staff members whose father actually just passed away this week—and his experience with his father on the ward was that the house officer was MAPAS, the student was MAPAS, the registrar somewhere else was MAPAS. He was getting specialist support from our MAPAS colleagues. That is just so heartening, to know that now we’re seeing the outcome of our students everywhere. We always must remember that we have the potential to dream, as Indigenous peoples.
MIC CAVAZZINI: That was Elana Curtis, ending this episode of Pomegranate Health. Thanks also to Hirini Kaa, Peter Jansen, George Laking and Chayce Glass for contributing to this episode of Pomegranate Health. The views expressed are their own, and may not represent those of the Royal Australasian College of Physicians. There is lots more material from these interviews and the hui itself at our website, racp.edu.au/pomcast.
At the website you’ll also find articles mentioned in the story and many other interesting resources. For example, Mauri Ora, directed by Peter Jansen, provides cultural competency training specifically for health services. And the RACP Indigenous Health Scholarship Program, which funds several places through speciality training.
Aboriginal and Torres Strait Islander doctors are much sought after. First Australians make up 2.7 percent of the Australian population, but only 0.9 percent of the health workforce. It should be remembered that this podcast was produced on the land of the Gadigal people, only a stone’s throw from the cove they called Warrang, where the story of Australasia’s Indigenous people began to change not all that long ago.
I’m Mic Cavazzini. Thanks for listening.