Emergency department entrance at a hospital
Photo: Getty Images, additional design by Tina Tiller

ĀteaJune 18, 2024

When a Māori person goes to hospital, they don’t leave their Māori identity at the door

Emergency department entrance at a hospital
Photo: Getty Images, additional design by Tina Tiller

Nicola Willis said her budget delivered for Māori, because New Zealanders ‘don’t turn up at the emergency room thinking about their ethnic identity’. Research into kaumātua health suggests differently.

When entering a hospital or health clinic, you arrive with the hope that you will go home with improved health and wellbeing. However, while waiting to be seen you might be confronted by negative memories of past experiences. You remember your rongoā being dismissed: “We don’t allow that sort of thing here.” Your reo is not understood, and there is an absence of whakawhanaungatanga. You are unwell, you need help, but there is only one option and that is to turn to a system that was not built or designed for you. Many Māori share this experience when accessing Aotearoa’s healthcare system.

The government’s 2024 budget significantly defunds Māori-targeted initiatives. Te Aka Whai Ora (the Māori Health Authority) was disestablished before it had a chance to implement change. When questioned about the defunding of Māori-centred initiatives, finance minister Nicola Willis said her budget “delivers for Māori” because when a New Zealander turns up to an emergency room or a school, “they don’t turn up thinking about their ethnic identity – they turn up thinking about their need”.

Research into kaumātua health suggests differently. The story of Māori health inequities and discriminatory health policies is not new. The enactment of the Tohunga Suppression Act (1907) marked a beginning of governmental policies and actions that came to affect Māori health, pushing the use of rongoā Māori and traditional Māori healing practices underground. Two decades later, in the wake of the 1918 influenza pandemic, Kiingitanga leader Princess Te Puea Hērangi advocated for a Māori hospital at Tūrangawaewae marae. Her dream was thwarted by health officials who refused a licence for a hospital. Epidemics such as polio and tuberculosis led to Māori being stigmatised as carriers of these diseases.

More recently, during the Covid-19 pandemic, Māori were left out of decision-making processes, leading to ineffective strategies being implemented. For example, the Covid-19 vaccination programme initially prioritised those over 65, failing to take into account the disproportionally younger median age of the Māori population. These are just a few examples of actions that have contributed towards the erosion of Māori health and the growth of inequity. Māori have been forced to integrate into the general health system, a system that has inadequately served Māori.

For the past seven years, the James Henare Research Centre has conducted qualitative research projects in close collaboration with kaumātua and kuia (older Māori) from 14 sites across several rohe (regions), including Tai Tokerau, Tāmaki Makaurau, Waikato and Tauranga. Our participants’ ages ranged from 55 to 90 years, with the majority being in their 70s. Our body of research addresses kaumātua and kuia experiences of Aotearoa’s healthcare system, and their own priorities and aspirations for wellbeing. In the course of our research, kaumātua and kuia have spoken of significant barriers for many older Māori to access health services including a lack of tikanga Māori competency by health professionals, the erosion of a sense of personal rangatiratanga, and failure to take into consideration the unique Māori ways of thinking and being. Many discussed experiencing hospital stays that lacked manaakitanga (hospitality, generosity, kindness), breached tikanga (customary protocols), and were overall detrimental to their hauora.

Image: Bianca Cross

Others spoke of how they felt like they were not being treated with care and respect and this manifested in a variety of forms. We heard stories of kaumātua and kuia being insufficiently informed about their medication, given contradictory and unhelpful advice from health professionals, karakia (prayers) not being available, and being prevented from using rongoā Māori. Some have experienced long delays in receiving medical treatment and the refusal of entitlements such as disability parking permits, shower rails or ACC compensation for medical misadventures. Such interactions diminish their sense of mana and mauri and have led to a reluctance for some to go to a hospital or seek medical treatment unless absolutely necessary, which results in worse outcomes for their health.

Whanaungatanga (relationships) is highly important to Māori. With Aotearoa experiencing a doctor shortage, many of our kaumātua and kuia participants lamented the loss of rapport with their regular consistent doctors and their lack of control over who they see and when they can get an appointment. Kaumātua and kuia expressed that they selectively shared their wairua (spirit) and are reluctant to speak openly of their health because of whakamā (embarrassment), and the tapu (sacred) nature of the human body. The implicit biases and systemic inequities in Aotearoa’s current health system impede the nurturing of these relationships, leading to mistrust, and kaumātua and kuia withholding disclosure of their medical ailments and concerns.

Kaumātua and kuia spoke about how health and social providers often did not understand te ao Māori and tikanga Māori, leading to a preference to see Māori health professionals. An awareness of tikanga and te reo Māori was directly linked to quality of care for the participants of our study, all of whom were connected to their marae. When experiencing poor health, kaumātua and kuia described their cultural and spiritual wellbeing as being uplifted when they heard te reo Māori being spoken and tikanga Māori applied. Like other western biomedical-centric models of health, Aotearoa hospitals appear to provide a limited understanding of hauora, while a Māori view of wellbeing encompasses much more than physical health alone. Kaumātua and kuia embrace a holistic approach to health, aligning hinengaro (mental), tinana (physical) and wairua (spiritual dimension) wellbeing. Suggesting that Māori don’t turn up thinking about their ethnicity devalues Māori identity. Ethnicity is intrinsically connected to identity – what they “need” is connected to who they are as Māori.

Kaumātua and kuia expressed extreme frustration at the stubborn inaction to improve Māori health inequities, they want mana motuhake (autonomy) for Māori in health services. Kaumātua and kuia across different rohe reiterated that they wanted a by-Māori-for-Māori approach to health.

Dark skin toned man with hands clasped. Elderly man sitting with a walking stick with his hands clasped in his lap. Model wears light colored long sleeve jumper and dark blue trousers.
Photo: Getty Images

On the day the establishment of Te Aka Whai Ora was announced, the James Henare Research Centre were conducting a research wānanga with Waikato kaumātua and kuia. There was a sense of cautious optimism, with some kaumātua and kuia celebrating this news with waiata and haka. However, four years on, this hope has been dashed and replaced with concern for themselves and their mokopuna. The premature disestablishment of Te Aka Whai Ora prevented the implementation of any meaningful change, leaving the status quo, full of barriers to equitable health for Māori, intact.

Contrary to Willis’s statement, the experiences shared by the kaumātua and kuia we have worked with provides strong evidence that when many Māori walk into the emergency room, GP surgery, or any other health service, they are very well aware of their ethnic identity.

The systemic discrimination against Māori should not come as a surprise to the finance minister – it has been well documented for decades. A 2020 systematic review concluded that “for many Māori, the existing public health system is experienced as hostile and alienating”. The New Zealand Health Survey (NZHS) report (2023) found that Māori, Pacific and Asian adults continue to experience racial discrimination in healthcare, with the proportion of Māori facing racial discrimination increasing from 10.8% in 2011/12 to 13.8% in 2020/21. This is worse for Māori women, who have seen an increase from 9.7% in 2011/12 to 16.8% in 2020/21.

The government’s apparent obsession with outcomes, the wilful ignorance of the well-established and well-evidenced difference between inequality and inequity, and the continuous undermining of Te Tiriti o Waitangi has led the coalition government to homogenise us all as the same, as “New Zealanders”. This is evident in the finance minister’s statement about the budget. The budget might allegedly deliver for “New Zealanders”, but it does not deliver for Māori. It is a racist budget.

Willis makes the promise at the beginning of the statement that this budget delivers for Māori, but follows that promise with words that dismisses the history of Māori experience in our health system documented through decades of evidence-based research. The minister goes on to emphasise that Māori are worst affected, and that the government is committed to focus on the “need”. Māori are now one in five in Aotearoa and experience the worst disparity in our health system. It is disingenuous of the finance minister to make the promise that the budget delivers for Māori given the significant defunding of targeted Māori health initiatives.

The finance minister fundamentally misunderstands the research showing that when Māori go into hospitals (and schools), they receive poorer outcomes. When a Māori person turns up at a hospital, they don’t leave their Māori identity at the door.

James Henare Research Centre researchers Soriya Em, Nicholas Jones, Ahmed Aziz, Keri Mills and Hilary Lapsley contributed to this piece.

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