Image: Tina Tiller

ĀteaNovember 4, 2021

How the vaccination rollout failed to deliver for Māori

Ātea editor

Image: Tina Tiller

Māori health experts say they did everything they could to go hard and early on a targeted Covid-19 vaccine programme, but many were passed over or ignored. Liam Rātana reports.

The government has known that it would have to undertake the nation’s largest vaccination rollout in history since Covid-19 became a global pandemic in early 2020. As it had almost a year to plan, many are asking how the government still failed to deliver a timely programme for Māori.

At time of writing, only 72% of eligible Māori have received their first dose of the Pfizer vaccine, and only 53% are fully vaccinated. However, Māori account for 40-50% of recent cases in the delta outbreak.

With spread to areas with high percentages of unvaccinated people, such as Te Tai Tokerau, it’s widely accepted that efforts by the government to ramp up vaccination rates among Māori has come too late.

But it’s not for lack of options.

“We do national programmes but we just don’t seem able to learn from the mistakes that we make in rolling them out,” says former deputy director general of health Teresa Wall, one of four Te Rōpū Whakakaupapa Urutā (National Māori Pandemic Group) co-leaders.

On March 9, 2021, the government announced it was establishing an Immunisation Implementation Advisory Group, which originally comprised five members. The next day, the government unveiled its official plan for delivery of the Pfizer vaccine across Aotearoa. No vaccination targets were set publicly.

“Dr Rawiri Jansen was the rep for Te Rōpū Whakakaupapa Urutā on the government’s Immunisation Implementation Advisory Group,” says Wall’s co-leader, Sue Crengle (Ngāi Tahu). “He resigned because he felt as though his advice wasn’t being listened to.”

Te Rōpū Whakakaupapa Urutā was formed in March 2020 as a response to concerns that Māori were being left out of planning decisions for Covid-19 and treated as an after-thought. In January 2021, Jansen told media his appointment to the Immunisation Implementation Advisory Group meant Māori would be a priority in the vaccine rollout. By April 2021, he had resigned due to cabinet’s refusal to adopt an age adjuster, so Māori could be included in the high-risk elderly group at 50 or 55 rather than 65. Cabinet was also advised to immunise anyone in residential care, including imprisoned, homeless and addicted people. Instead, it stuck with its general rollout, and only Māori and Pasifika people over 70 were vaccinated as part of group two. Group three, restricted to those aged 65 and over, disabled people and their carers and others with severe illness, were vaccinated over June and July 2021.

A handful of Māori health providers instead chose to “interpret” the rollout in their own way, ignoring cabinet guidelines but implementing exactly what experts like Jansen had recommended instead.

Te Puna Ora o Mataatua in Whakatāne categorised the subsection of group two as “kaumātua”, rather than by age, as well as vaccinating the whole household so that they wouldn’t have to come back. In Te Kaha on the east coast, this approach of vaccinating whole whānau early on meant that 80% of Te Whānau-a-Apanui were vaccinated before the delta outbreak began in August. In Northland, the age for group three was brought forward to 50 in order not to waste unused vaccines.

“There are still serious issues around accessibility to the vaccine for Māori,” says Crengle. It is unclear exactly who the government consulted with prior to releasing its vaccine rollout plan. What is clear is that a number of Māori experts and organisations feel as if their recommendations were ignored.

Cabinet minutes from March 31, 2021 show that plans were tabled to vaccinate all of Counties Manukau DHB district, home to the country’s largest Māori and Pasifika population, including those not already included in group two or three. However, an OIA request by The Spinoff revealed that the DPMC received no advice relating to whether the vaccine should or should not be prioritised for all residents of South Auckland.

Wall is critical of the the total population approach taken by the government and its failure to fund targeted initiatives and involve Māori health providers and experts from earlier on in the planning process. “Why did the government lack the courage to say, ‘We want 90% vaccination rates for Māori and Pasifika or whatever groups make up large percentages of different health board populations’? I think that the government has not been terribly courageous and I don’t know why they have not,” she says.

She wonders if their reluctance to announce targets specifically for Māori stems from public backlash in the early 2000s, centred around the then Labour government’s “closing the gaps” policy.

“The idea that we can only have a total population approach has played out over the Covid-19 vaccination programme because people will think that we’re ‘advantaging’ Māori over other groups. The system has to work harder and put more effort into addressing the inequities it has created.”

The government released its Covid-19 Māori Vaccine and Immunisation Plan on March 20, 2021, 10 days after the release of the national plan. It allocated $11 million to support providers in preparing to implement the programme across their communities. An additional $24.5 million was allocated to develop a Covid-19 Māori vaccine support service and $2 million to provide tailored communications to whānau, hapū, iwi and the Māori health sector. The amount of money allocated to the vaccine rollout for Māori has grown over time, with the most recent news being an announcement of $120 million in late October.

“As the plan was rolled out, at different stages, Māori health providers have been engaged. Initially it was more around what we thought about what the ministry was doing. Only in the last four or five weeks has that shifted to them wondering about what we could or would do,” says Geoff Milner (Ngāti Porou, Ngāti Kahungunu), chief executive of Ngāti Hine Health Trust.

One group that approached the government early on in the planning process was the Whānau Ora Commissioning Agency. The group is contracted by Te Puni Kōkiri to invest in initiatives and services provided in communities across Te Ika a Māui. With over 81 service provider partners across the North Island, the Whānau Ora Commissioning Agency met with representatives from throughout the motu and drafted a comprehensive proposal detailing how they could help ensure high rates of vaccination among Māori.

“We reviewed nursing capacity, doctor capacity, training requirements and solutions for reaching communities in ways that work for them,” says Awerangi Tamihere (Ngāti Kauwhata, Rangitāne, Ngāti Porou, Rongowhakaata), COO for Whānau Ora Commissioning Agency.

“We worked very hard on a comprehensive proposal and said ‘We can do this but we need to go now’, because we knew it was going to require such a long lead-in time to get to the point of vaccination.

“That proposal was submitted in April and was declined. I’m not sure of the reasons why. I understand that the funding instead went to the district health boards, who would then manage their own solutions around engaging with Māori in their respective areas.

“Rather than take a collective Māori view in terms of a response for our people, [the Ministry of Health] took a funder-centric view and said, ‘We’ll put the money through the current distribution mechanisms of the individual district health boards to do things their own way’. So it was a great opportunity that was missed,” Tamihere says.

Awerangi Tamihere (Photo: Whānau Ora Commissioning Agency)

Tamihere is not alone in her criticism of the government’s decision to provide money to the DHBs to distribute, instead of directly to providers. Others say that the decision added an unnecessary layer of bureaucracy to accessing funds, slowing down the availability of resources at a critical time. They also say the move has led to a fragmented vaccination rollout, with approaches and messaging differing greatly across the country’s 20 district health boards.

“If we go back to March, when the Ministry of Health delegated the allocation of additional resources for Māori through the DHB networks, that’s been abysmal… Money that was allocated in March didn’t hit our bank accounts until September, with multiple strings attached,” says Milner.

“I do believe that if the Ministry of Health had backed an entity like the Whānau Ora Commissioning Agency, there would have been a rapid Māori response for our communities and I’m almost certain the result today would have been different.”

The full effects of the vaccination rollout for Māori are yet to be realised, which is a discomforting thought for many. Even worse for some is the realisation that had the government approved plans such as the one submitted by the Whānau Ora Commissioning Agency in March, vaccination rates among Māori would undoubtedly be a lot higher than they currently are.

“Had Māori and Pacific providers been involved earlier, had there been earlier access to the vaccine for Māori, then we wouldn’t be seeing the inequities in vaccine coverage that we are seeing currently,” Crengle says.

For Tamihere, the figures are clear: “There were 500,000 vaccinations done by September 30 by Whānau Ora partners across the North Island. With the data we’ve analysed, if we were given the funding back in March, we would be sitting at 90% vaccination rates for Māori across the North Island.”

According to Wall, the recent announcements around the new traffic light system and continued shortcomings with the vaccine rollout continue to grow the inequities in the health system. Like others, Wall is concerned that targeted lockdowns in areas with low rates of vaccination will disproportionately affect Māori communities.

“People need to consider that maybe it’s not the fact that Māori are hesitant to get vaccinated but that the system isn’t doing a very good job delivering for Māori.

“We’ve got a bit of discourse in the media at the moment that Māori people are hesitant. We’ve immediately gone to a victim-blaming approach, as opposed to asking whether the system has made it easy for people to get vaccinated,” says Wall.

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(Image: Getty Images/Xoë Hall)

ĀteaNovember 4, 2021

Tīhei mauriora: the history and tikanga of our breath

Te Kuru o te Marama Dewes

Contributing writer

(Image: Getty Images/Xoë Hall)

Māori are among a number of cultures whose understanding of breathing goes beyond the simple act of inhaling and exhaling.

“Tīhei mauriora!” is a common expression in te reo Māori. It acknowledges the breath of life, and is expressed on the pae during whaikōrero or mihimihi. It refers to the Māori creation story when the first human was fashioned from clay in the form of a wahine. The hongi symbolises this first exchange of breath between atua and tangata.

From time immemorial, we’ve been aware of our breath.

There are many kupu for “breath” and its related functions. In his book Tikanga Māori: Living by Māori values, Tā Hirini Moko Mead defines “hau” as vitality of human life and vital essence of land, while he translates “hauora” as health, spirit of life and vigour. These explanations depict a Māori worldview that is intrinsically connected to the natural world. They connect us to the environment and weave our beliefs around hauora back to that very first breath.

“Hā” is another term associated with breath and breathing, but can also be used to mean essence, tasting and intonation.

Hone Harawira performs the hongi with fellow MP Parekura Horomia, Waitangi Day 2007. (Photo: Phil Walter/Getty Images)

Tei Nohotima (Ngāi Tūhoe), a revered expert and source of Māori knowledge, uses the kupu Māori “hēhē” for breath and breathing. In his younger years Nohotima was exposed to elders who were versed in traditional esoteric Māori lore. Referencing the kōrero of one of his teachers, Anaru Kupenga, Nohotima says Māori breathing techniques and beliefs are “how we receive and instill the breath of life”. He also refers to the late Dame Kāterina Te Heikōkō Mataira, a traditional knowledge-holder who taught him that “through breathing, we are giving light and energy into the atmosphere”. He also recounts how Dame Kāterina would describe goosebumps as the receptors and transmitters of energy.

Our mōteatea and pātere, two different forms of traditional Māori chants, are examples of cultural breathing techniques that have been practised and sustained over the generations, Nohotima says. Some chants are lengthy and require a unique type of fitness to recite while keeping in time with the fast-paced rhythm. He talks about how karakia demands knowledge and experience of nose breathing and engaging the diaphragm. These breathing techniques are widely practised by the many kapa around the country when training for and performing haka. Students of these cultural practices are often taught to breathe through their nose in order to maintain a steady flow, to sustain the tempo, to maximise the use of air and ensure that the words are being delivered correctly without disruption.

This mātauranga can also be applied in our daily life to improve our health by becoming more conscious and aware of how we breathe.

We often don’t think about breathing until it’s a health issue, or our significant other pulls us up about our wheezing when we’re out for a hīkoi, or when we’re called out for snoring during noho at the marae. It’s easy to fall out of sync with these natural bodily functions especially in the fast paced, tech-heavy modern society we’re living in. But new information is emerging about the benefits of focusing on our breath to improve our health.

Try taking a deep breath. If you inhaled through the nose, from your stomach or diaphragm, you’re on the right track.

Now, try breathing in for four seconds and exhaling through your nose for at least eight seconds, then repeat. This is the basis of the Buteyko Method, which recommends engaging in mindful breathing practice for four minutes, four times a day, every day.

Originating in the 1950s from Russian physician Konstantin Buteyko, the breathing exercise programme is based on the belief that hyperventilation, or over-breathing, is the primary cause of a number of disorders such as asthma, high blood pressure, sleep apnoea and panic disorders. Artist Nikau Hindin (Ngāi Tūpoto) learnt the Buteyko Method 15 years ago after suffering from sports asthma. She says she would hyperventilate and suffer from panicked breathing after pushing herself too hard.

“I didn’t have an asthma attack again. I’ve been a nose-breather ever since. It changed my life,” Hindin says.

Hindin says the key to improving the function of our hā is learning to breathe in and out through our noses, rather than through our mouths. She says it is a common misconception that CO2 is purely a waste product, but our bodies actually need it to “bump” the oxygen off the red blood cells, and push it into the cell tissue – our muscles – so we can create energy.

“Breathe through your puku,” she says. “A lot of us breathe quite high up in our chest, so it’s really important to use and exercise our diaphragm, because it’s a muscle, along with our intercostal muscles.”

The book, Breath: The new science of a lost art by James Nestor, published in 2020, has brought the discussion about nose-breathing into the mainstream. Nestor travelled the world looking at different breathing techniques from cultures across the world, including Pranayama, Sudarshan Kriya and Tummo. The premise of the book is that many of us have forgotten how to breathe properly.

Using the mātauranga of kapa haka, karakia, mōteatea and te reo, we can relearn what our elders knew innately. Connecting it with contemporary knowledge and understanding about the breath from other cultures gives us an even bigger picture of its importance.

Tei Nohotima says we acknowledge the exchange of light and energy with our taiao every time we say “kia ora”, or engage in hongi. The uncertainty shrouding us at the moment can be suffocating, but in the moments when the taumaha weighs heavily on our chest, constricting our airflow, we can use these examples to help us breathe through it.