Elizabeth Rata and Carlos Zubaran
A version of the article reproduced below was first published in 2009 as ‘When Criticism is Silent: Mental health in New Zealand’, chapter 6 in Openshaw, R & Rata, E. (Eds.), The Politics of Conformity. Pearson Publishers.
In 2016, Rata and Zubaran published ‘Ethnic Classification in the New Zealand Health Care System’ in the Journal of Medicine and Philosophy, Issue 41, pages 192- 209.
The version below was adapted in July 2021 from the 2009 chapter in response to the Government’s intention to establish a separate Maori Health Authority.
Authors’ Biographies (July 2021)
Professor Elizabeth Rata is the Director of the Knowledge in Education Research Unit (KERU). She is based in the School of Critical Studies, Faculty of Education, University of Auckland. Her expertise includes investigating the politics of ethnicity in New Zealand internationally with a focus on government policy, primarily though not exclusively, on education policy.
Professor Carlos Zubaran Jr holds a Conjoint Professorial appointment with the School of Medicine at Western Sydney University and is also the Acting Clinical Director of the Drug and Alcohol Program at St John of God Richmond Hospital. He is a Fellow of the Royal Australian and New Zealand College of Psychiatrists and member of the its Faculty of Addiction Psychiatry and was the recipient of the World Psychiatric Association International Fellowship Award (1996) and the US National Institute on Drug Abuse Distinguished International Scientist Award (2009). Professor Zubaran is the co-chair of the Section of Transcultural Psychiatry of the World Psychiatric Association. He has worked as a clinical psychiatrist in the New Zealand health system.
Introduction
Descriptions of Māori mental health made disturbing reading at the time this article was first written in 2009 and continue to do so in 2021. The suffering of individuals, the distress to families, and the loss of healthy active citizens to New Zealand society speak loudly from the bald statistics of government reports (Ministry of Health, 2006). At least since the 1980s and 1990s, the health status of New Zealanders has been characterised by marked disparities between Māori and non-Māori, ‘particularly for schizophrenia and bipolar disorder. The situation is exceptionally serious for male Māori adults under the age of 40, the group most likely to be clients of mental health services’ (MoH, 2006, p. 131). Adding to the human suffering is the growth in anxiety and eating problems along with the more traditional ‘mood, alcohol and drug disorders’ (p. 131).
Mason Durie’s Māori Health Model, Te Whare Tapa Wha was embraced as the solution (Ministry of Health, 2009; Durie, 2006; Chaplow, Chaplow & Maniopoto, 1993; Dyck & Kearns, R., 1995; Cunningham, 2000). Despite an absence of scientific scrutiny (Marie & Haig, 2006), the model has become the orthodox and unchallengeable approach to Māori mental health policy and practice in the New Zealand health system. The model informs not only Māori mental health but underpins the spread of a distinctive ethnicised approach throughout the health sector in professional practice, administration, and the structure of the system itself (He Korowai Oranga, Maori Health Strategy, 2002). In 2021 this distinctive approach has become so uncritically accepted that it is to be formalised in the state’s governance structures. In May 2021 the government announced that a Steering Group, led by Sir Mason Durie will provide advice to the Transition Unit overseeing the establishment of a separate Māori Health Authority.
The Māori Health Authority is based on the belief that ethnically separate health care leads to improved health which, in turn, contributes to greater social equality. However, there is no agreement among scientists that this is, in fact, the case. Indeed, some authors caution that the continued use of imposed ethnic categories actually enforce disadvantages and perpetuate inequality (Ellison et. al., 1997) as classification systems reinforce stereotypes and condone inequalities. Importantly too, ethnic categorisation obscures factual causal relationships (Kaplan & Bennett, 2003). Socio-economic location, sub-cultural factors, racial discrimination, and their complex interplay are more likely candidates contributing to low mental health status:
What the science says
The view that ethnicity significantly influences beliefs held about psychopathology and that Maori and non-Maori express distinct attitudes towards mental health (Ministry of Health, 2001) is not confirmed through formal scientific scrutiny. Indeed, a comparative study conducted to investigate lay perceptions of Maori and non-Maori participants using a major depressive disorder as a paradigm, found that no evidence of different views was observed between the two groups (Marie, Forsyth & Miles, 2004). These findings challenge the claim that Maori and non-Maori individuals have different understanding and familiarity with mental illness (Marie & Miles, 2007).
Government policy encourages health professionals to accommodate elements of the alleged Māori non-Māori distinction into their professional practices (McCreanor & Nairn, 2002). An example of this is the common belief within the New Zealand mental health community that patients from a Māori cultural background develop more side effects to conventional antipsychotic medication in comparison with the general population, particularly movement disorders (Mahmoud, 2008). As a consequence, there is a stigma attached to the use of these neuroleptics in this population. This may negatively influence the attitudes and reactions of Māori patients to their recommended treatment.
Recent advances in pharmacogenetics suggest that different genetic make-up may interfere in the way drugs are metabolised and consequently reduce effects of medications in humans (Wilffert, Zaal & Brouwers, 2005). Significantly however, these differences do not translate necessarily into categorical distinctions of race or ethnicity (Parra, Amado, Lambertucci, Rocha, Antunes & Pena, 2002). Furthermore, the impact of pharmacogenetics on public health may be more limited than previously expected, since additional factors are critically involved in the mediation of a pharmacological response (Kollek, van Aken, Feuerstein & Schmedders, 2006; Collier, 2003).
Race and Ethnic Identification
The application of an unscientific racial model to clinical practice is set within and reinforced by practices of racial or ethnic categorisation. In at least one New Zealand regional mental health unit, patients with psychiatric disorders and deemed by the admitting nurse or doctor to be Māori – based on self-identification, appearance, or surname – will be treated within the Māori mental health framework. That patient will only be treated under the usual mainstream mental health system reserved for all other patients, including Asians, Pacific peoples, and those of European descent if the patient clearly states a preference for the mainstream option (personal communication).
The fundamental difficulties in using ‘race’ and ‘ethnicity’ as variables in public health surveillance include differences in terminology, data collection procedures, perceptions of group identity, and changing demographics of population subgroups (Barnes, de Leon, Lewis, Bienias, Wilson & Evans, 2008; Harris, Tobias, Jeffreys, Waldegrave, Karlsen, Nazroo, 2006; Bramley, Hebery, Tuxxio, Chassin, 2005; Chandola, 2001). There are significant inconsistencies and systematic biases (Bennet, 1997) leading to ‘statistical ghettos’ (Graham, Jackson, Beaglehole, de Boer, 1989) in major sources of racial and ethnic analysis.
In the United States the concepts of ‘race’ and ‘ethnicity’ are weakly defined and the way by which ‘ethnicity’ or ‘race’ is incorporated into studies or measured among government agencies is inconsistent (Warren, Hahn, Bristow, Yu, 1994; Sheldon, Parker, 1992). In New Zealand, the conceptual confusion of ‘race’ and ‘ethnicity’ has been resolved by a sleight of hand, whereby ‘race’ is placed in opposition to ‘ethnicity’. Statistics New Zealand (2005) defines ‘ethnicity (as) the ethnic group or groups that people identify with or feel they belong to. Ethnicity is given as a measure of cultural affiliation, as opposed to race, ancestry, nationality or citizenship. The use of the term to replace ‘race’ was an attempt in the post-1960s’ period to reject the biological or genetic component attributed to race, and to understand descent-group identity in terms of socially constructed values, beliefs and practices alone. However, ‘ethnicity’ makes no sense if it does not include the concept of group belonging that has a genetic or biological base (Yinger, 1985).
Despite the efforts of one Maori leader, Pita Sharples (Stokes, 2003), to side-line the uncomfortable inclusion of ‘blood’ for a socially constructed notion of ethnicity, saying that ‘culture is not about the amount of blood you have, it is about beliefs, customs and aspirations’ it is the case that to be eligible for the Maori electoral roll and to claim tertiary Māori scholarships for example, a person does need to be descended from a Māori ancestor. Willie Jackson recognises this genetic component in describing ‘whakapapa’ (genealogy) as ‘what determined being Māori, the ability to link genetically to a Māori ancestor’ (Stokes, 2003). Both Whatarangi Winiata and Sidney Mead are very clear that genetic ancestry is the primary criteria for Māori ‘membership’. ‘A person who is 1/1024 requires only nine or ten generations ancestry to be identified with a full Maori. By contrast, a person who does not have one dot of Maori ancestry is unable to do this. Whakapapa is vital in Maori organisational arrangements and, of course, they are central together with whakapapa per se to tikanga Maori’ (1988, cited in Tremewan, 2006, p. 110). ‘If you are born a Maori, then you have to accept the consequences of that biological fact, and the culture that comes with it’ (Mead, 1997, p. 8).
The race/ethnicity conceptual confusion is not confined to ideology and policy. There is a lack of scientific consensus on the nature of ‘race’ and ethnicity. Indeed the concept of race or ethnicity as a biological category is not supported scientifically. The World Health Organisation does not record race or ethnicity in its international health statistics (Hahn & Stroup, 1994). The use of race or ethnicity is considered reductionist by some commentators who describe the labels as a misleading, stereotypical, and racist scheme that exert ideological and political functions (Yankauer, 1987; Caldwell & Popenoe, 1995; Hayes-Bautista, 1980).
In addition the collection of individuals according to continent of origin based on patterns of allelic frequency does not validate the claim of genetically defined races (Haga & Venter, 2003). The conclusion of the Human Genome Project is that the scientific evidence indicates that any two human individuals are about 99. 9 percent the same genetically. The remaining 0.1 percent represents approximately three million differences between each individual’s DNA. Only a small fraction of these differences are responsible for variations in health, behaviour and other human characteristics (Cargill et. al., 1999; Halushka et. al. 1999).
Furthermore, the greater part of phenotypic traits (including pharmacogenetic variability and nongenetic factors) results from a complex interaction between genetic and nongenetic factors (Goldstein, Tate & Sisodiya, 2003; King, Rotter & Motulski, 1992). Humans are much more than a plain sum of genes, simplistic concepts of ‘race’ are ‘bad medicine’ and ‘bad science’ (Patrinos, 2004). This means that racial classifications do not adequately describe the distribution of genetic variation in humans (Tishkoff & Kidd, 2004).
Differences in human skin colour are fallacious indicators of biological differences among populations (Parra, Kittles & Shriver, 2004). ‘Race’, whether imposed or self-identified, is a weak surrogate for genetic and nongenetic factors associated to health status (Royal and Dunston, 2004). Current genetic data reject the notion that purportedly different ‘human races’ genetically constitute distinct human populations. Studies developed during the last decade (prior to 2009) provide evidence that there is no connection between self-identified race or ethnicity and frequency of particular genetic variants (Angier, 2000; Marshall, 1998). The low level of genetic variability and of structuring of the human species is incompatible with the existence of race as a biological entity (Pena, 2005).
The American Medical Association (AMA) admits that the recognition of race and ethnicity as socially defined entities presents significant challenges to public health surveillance and medicine and that the current classification systems have limited usefulness in public health or medicine (Kaplan & Bennet, 2003). Yet, in New Zealand, public health policy and practice remains informed by ideological views that support ethnic or racial categorisation. In the following section we examine and criticise three justifications for the Maori models of health: ethnicised world-views, separate systems in the past, and the use of ethnicity as a social construct.
A ‘world view’ justification
It is claimed that Maori commonly believe that cosmological or spiritual forces may cause illness and psychological distress with ‘health related to unseen and unspoken energies’ (Ministry of Health, 2009). This Maori knowledge or matauranga Maori approach is then contrasted with the Western biomedical model (Durie, 1999). The latter is referred to as representing the views of the white descendants of European settlers, and positioned as an oppositional system to the Maori model of health understanding (Marie et. al., 2004). These purported differences in world and health views are deemed not only irreconcilable but also not amenable to exegesis, since, for the proponents of these ideas, ‘indigenous knowledge cannot be verified by scientific criteria’ (Durie, 2006).
Indeed, there is widespread acceptance, even in universities, of the claim made by an academic at Auckland University of Technology that ‘indigenous people already have their own answers’ (Harvey, 2005, B3). However, the philosopher, Mario Bunge (1998) warns against confusing science and local knowledge. For Bunge the scientific method cannot remain at the local. ‘All sciences . . . seek patterns underneath data, and all of them account for individuals in terms of universals, and employ particulars to guess at and check generalities. Facts and stories can be local; science never is’ (p. 23). That warning was also issued by New Zealand historian, Peter Munz. In his damming review of Linda Smith’s influential book, Decolonising Methodologies Munz refers to its ‘mischief’ in failing to distinguish between the knowledge of local communities which serves as ‘social cement’ and science which serves as the ‘disinterested scrutiny of evidence’. (1999, p 5).
The reduction of universal modern science to localised cultural knowledge serves to protect it from the scrutiny applied to scientific knowledge. It means that ideology presented as science, such as Durie’s Māori mental health model, moves unchallenged into health policy and professional practice.
Earlier we used the example of the belief within the New Zealand mental health community that patients from a Maori cultural background present a higher prevalence of adverse reactions to conventional antipsychotic medication in comparison with the general population, particularly movement disorders (Mahmoud, 2008). Unfortunately the lack of scrutiny means that the consequences of such clinical practice for Maori patients are unknown but may well include the unsubstantiated rejection of an effective class of neuroleptics, and unwarranted abbreviation of the pharmacological arsenal to treat psychosis.
Historical justification
The historical inclusion of racial and ethnic differences (Marie, Forsyth, Miles, 2004) in the development of New Zealand public policy is used to support expanding the dichotomy in the way Durie (2006) proposes for Maori mental health. The Maori Health Strategy, He Korowai Oranga (2002) is committed to ‘fulfilling the special relationship between iwi and the Crown under the treaty of Waitangi’ (p. 2). This political approach is in the interests of tino rangatiratanga, an ethno-nationalist movement which has re-interpreted the Treaty of Waitangi as an agreement between two equal political entities. Accordingly, the claim is made to separate systems of governance under the control of the respective political entities. The current establishment of the Māori Health Authority is the realisation of this agenda in the health sector.
Within ethno-nationalist politics (see, for example, statements by Whatarangi Winiata in Tremewan, 2006), separate Maori systems are justified in terms of the putative revival of historical tribal structures and organisational systems. The existence of a separate Maori health system in the 19th century contributes to justifying a contemporary distinction in the same way that the historical existence of the Native Schools is used in education to justify kura kaupapa Māori.
However, there is a profound difference between the distinction that existed between Māori and non-Māori health services in the past and the distinction claimed today. The former is attributable to specific material conditions, the latter is the ideology of tino rangatiratanga politics. Graham Butterworth’s (2006) account of the heritage of Māori health care in the hospitals established by Governor Grey during the colonial period shows that the separate treatment of Māori was in response to the situation of Māori at that time.
Disease, poor sanitation, geographical isolation, a limited government infrastructure and government concerns about Māori responses to the rapidly growing settler population saw Grey adopt pragmatic policies. Grey’s hospitals gave ‘free admission to Maori patients, appointed native medical officers to treat Maori in their home areas and even instituted campaigns to vaccinate Maori’ (p. 192). By 1866, there were ‘some 29 appointees (about 20 percent of registered medical practitioners)’. ‘This service was to continue into the 20th century until the advent of social security in July 1939 made hospital services free and lowered the cost for doctor’s services’ (p. 192).
The Department of Health, established in 1900 ‘was given responsibility for Maori health and gradually given the power and resources to become effective’ (p. 193). Butterworth describes the influence of the Maori Councils Act 1900 which ‘set up elected Maori councils and village committees with the responsibility to enforce sanitary bi-laws. Dr Maui Pomare began a ‘vigorous campaign of health reform’ (p. 193). ‘The Maori infant mortality rate, which had dropped progressively from 400+ between 1844 and 1857 to 230 per thousand between 1901 and 1911’ (p.194) was still very high. According to Butterworth, this was the result of endemic contagious disease rather than epidemic disease. (‘The drop continued and in the 1961-1965 period was at 40 per thousand births’ [p. 196]). ‘In 1904 a Native Sanitary Inspectorate, drawn from local Maori leaders, was created to improve the villages. Subsidised doctors were continued and Public Health Nurses were appointed to work in Maori areas’ (p. 196). ‘By the 1930s, a new approach to Maori health provision meant that the whole health system was to be responsible for Maori health not a small inadequately funded group’ (p. 196).
The historical distinction in health care between Māori and non-Māori was not to the disadvantage of Māori. Free Māori health care in the state system may be contrasted with fee-paying public health for many non-Māori – one that was a huge burden for most New Zealanders until the welfare policies of the 1930s’ First Labour Government were introduced. Janet Frame’s character, Grace Gleave, describes the ‘moments of pure happiness when the notice came from the Health Department that medical and hospital attention were to be free, free, and their father had collected all the unpaid hospital and doctors’ bills, brushed the dust from their windows, opened them, smoothed them, read them aloud, shuffled them into a pile, and with a shout of joy, pokered the ring from the stove and thrust them into the fire (2007, p. 155). In similar vein is Ida Frazer’s (2002) reference to the financial hardship experienced by her family in the early 1930s when one of eight siblings spent 6 months in Auckland Hospital suffering from rheumatic fever.
The history of separate Māori and non-Māori health care and its grounding in specific material conditions also explains the continuation of some separate forms of health provision well into the 20th century. For example, the voluntary Plunket Society, dealt mainly with non-Maori mothers and babies because Maori mothers were already catered for. Linda Bryder (2003) refers to ‘the complex relationship between Plunket and Maori’ (p. xv) that resulted from the early inclusion of Māori health care in the public system. ‘The department and Plunket reached an agreement early on that departmental, not Plunket, nurses would deal with Maori infant health. Maori women were entitled to use the Plunket clinics, though few did so’ (p. xv).
Separate health provision for Māori, just as separate education provision with the Native Schools, was the result of the specific material conditions of an historical period. In contrast, the justification for separate Māori provision today, while drawing on the historical precedent, is an ahistorical or, to use W.H. Oliver’s (2001) term, a ‘presentist’ ideology. Māori and settler descendants are promoted as distinctive ethnic or racial groups, a distinctiveness said to continue throughout time, justifying its recognition in separate public services that are also to be ongoing and under the control of ‘revived’ tribal authority.
The re-interpretation of historical processes for contemporary tino rangatiratanga ideology is not confined to health services. Mason Durie’s considerable influence extends from health and education to the historical revisionism of Nga Tai Matatu: Tides of Maori Endurance (2005) where, as Butterworth (2006) demonstrates in his analysis of Durie’s ‘rather slipshod’ (p. 191) use of population and land ownership figures, the unsustainable Sorrenson thesis that ‘land loss equals population decline’ is promoted.
Social construct justification
In recent decades the use of racial categories tends to rely mainly on its putative salience as a social construct (Krieger, 2003) rather than in appeals to explicit biological difference. In the New Zealand situation the social construction premise is that low Maori mental health status is the result of being Māori; that is, to be Māori today is to experience life as an indigenous but colonised, hence ‘damaged’ individual within a decimated social structure, the tribe. According to Durie (2003) the ‘climate ofmaterial and spiritual oppression’ faced by members of indigenous populations worldwide produces an ‘increased susceptibilityto disease andinjury’ (pp. 510-11).
Ethnic identity is believed to contain and transmit to subsequent generations the historical experiences of the ethnic group in specific material ways, such as location in an inter-generationally disadvantaged group, but also metaphysically through a ‘wairua’ or ‘spirit’ (Herder’s ‘volkgeist’). The claim is that Māori subordinate status was established by colonisation and is maintained in the social and political relationships between subsequent generations descended from colonisers and colonised. These dominant-subordinate relationships are claimed to be built into New Zealand’s social and political structures. As a consequence, the claim continues, individuals, as a result of their Maori ethnicity, inherit and are locked into the inferior and unequal status built into these social and political structures (Bishop & Berryman, 2006). Finally, it is claimed that this ‘structural oppression’ is expressed in a number of ways at both individual and group level; in mental illness, educational underachievement, prison incarceration, and welfare dependency.
Because colonisation is considered to be the root cause of the structural inequality between the two discrete ethnic groups, Māori and non-Māori, the solution is considered to be the decolonisation of social and political structures (Smith, 1997). The political explanation of structural inequality leads to a political solution; establish separate ethnic structures and systems. Political structures are to be changed by establishing separate Maori systems of governance at all levels, from constitutional separateness at the highest level to the separate administration of services, including health, local government, justice, and education at an operational level. The establishment of Maori mental health is one example of this desired shift to ethnic separateness at a structural level. The Durie Principles (Durie, 2003) upon which separate Maori education is currently being founded another. The 2021 Maori Health Authority’s establishment is the apotheosis of this political movement in health.
The wide-spread belief in an on-going colonial imposed oppression is considered to operate at the social and psychological level as well as a socio-political structural level. Tino rangatiratanga ideology attributes a primary and determining ethnic or racial identity to individuals, one linking the individual to the kin-group and to the group’s ancestral experiences. The person is brought to recognise the consequences of those experiences in his or her own life through the process of ‘conscientisation’.
‘Conscientisation’ is taken from the writings of Paulo Friere, works that have been highly influential in New Zealand from the 1970s and is used to support ethnic politics. The recognition of historically imposed and on-going oppression includes an understanding of how the consequences of colonisation are believed to be maintained politically in the structural inequalities of contemporary New Zealand. The awareness also enables the individual to embrace the intergenerational ‘spirit’ of the people which, it is believed, carries the memory of oppression from one generation to the next to cause mental or spiritual illness in succeeding generations.
The hegemonic nature of these ideas even amongst health professionals is most clearly shown in the favourable reception given by psychologists to Tariana Turia’s (2000) speech to the New Zealand Psychological Society Conference. Turia evoked a ‘holocaust suffered by indigenous people including Maori as a result of colonial contact and behaviour’, one that ‘inevitably wounds the soul’, requiring ‘generations of oppression since colonial contact’ ‘to be articulated, acknowledged and understood’. She referred to Professor Mason Durie identification of ‘the onset of colonisation and the subsequent alienation and theft of the land as the beginning of Maori health issues that manifest themselves today’. The outcome is a ‘post-colonial trauma’ ‘passed down from the period of the Land Wars to current generations’.
Having identified the problem as one of on-going colonial oppression, the social psychological solution is to strengthen the essentialised Māori identity through cultural affirmation (Durie and Kingi, 1997). It is claimed that identification with the ancestral ethnic group that has experienced oppression will enable the descendants of the group to first acknowledge, then reject oppressive experiences and to benefit from the revival of pre-colonial, pre-oppressive cultural integrity. This decolonising approach can be seen in the development of Māori cultural programmes in education, prisons, and the probation service as well as Durie’s Maori mental health model.
However, Toon van Meijl’s (2006) research into marae-based courses found that this approach ‘does not support all categories of Maori people who are struggling with their ethnic identity. Rather it creates an unexpected crisis of identity for those Maori who are unable to identify in terms of cultural ideology as they believe they can never meet the orthodox criteria for recognition as genuine Maori’ (p. 930). Van Meijl suggests that ‘the presentation of Maori cultural identity is fundamentally different from the self-representation of alienated young urban Maori people’, ‘leaving the self of some Maori bewildered with their personal yet deviating notions of Maoriness’ (p. 931).
Class or ethnicity?
The focus on the social construction of ethnic identity in explaining the low status of Māori mental health tends to reduce other factors to secondary status. Te Rau Hinengaro, for example, does recognise that the experience of socio-economic disadvantage in lower household incomes, less education and living in areas of high deprivation ‘contributes to the differences between Māori and non-Māori (particularly for serious disorder, substance disorder and disorders overall)’ (Ministry of Health, 2006, p. 131). However, the Report points out that this ‘does not explain all the disparities between Maori and non-Maori’ (p. 131). It is here in the ‘unexplained disparity’ that one of the claims for separate Maori mental health policy and practice is made. Those who promote the Māori mental health model do so on the premise that the disparity, which can’t be explained by socio-economic factors, is therefore attributable to a fundamental difference between Māori and non-Māori. This position is supported by Hawker, Bakhshi, Ali & Farrington (1999) who found no evidence for a justification for the observed inequalities based only on socio-economic deprivation. However, other studies do not support this finding.
Roy Nash (2001) suggests that the placement of Māori within very broad socio-economic categories is significant. For example, he notes a ‘particularly large difference between the ability scores of Maori and pakeha students from the upper professional category: where pakeha occupations are predominantly secondary school teachers, administrative civil servants and senior business executives with a high proportion of scientists, doctors, dentists and lawyers, Maori occupations tend to be predominantly secondary school teachers, primary school teachers, and executives within Maori organisations. Many of these latter, in particular, have very low educational qualifications’ (p. 27). Nash considers that in discussing the ‘is it class or ethnicity?’ question the ‘issue at stake in this argument is the significance of within class differences in literate resources in both populations’ (p. 29, italics in the original).
Marie, Fergusson, and Boden (2008) were also unable to locate evidence of cultural factors contributing to Maori disadvantage in education. They found instead that educational underachievement amongst Māori is caused by disparities in socio-economic status during childhood with the same factors producing educational disadvantage amongst non-Māori. The attribution of disparities between Māori and non-Māori to specific socio-economic location rather than an unidentified ethnic or cultural factor is supported by Simon Chapple’s influential research.
Chapple (2000) draws attention to the disproportionate sub-cultural disadvantage experienced by those who identity only as Māori, who have no educational qualifications, and who live outside the major urban centres (p. 101). He describes those Māori who are most disadvantaged as ‘sole Maori with low literacy, poor education, and living in geographical concentrations that have socio-economic problems, not the Maori ethnic group as a whole. There are probably also sub-cultural associations with benefit dependence, sole parenthood, early natality, drug and alcohol abuse, physical violence, and illegal cash-cropping’ (p. 115).
The national mental health survey also found that the prevalence of disorders was greatest among those Maori with lowest household income and levels of education (Baxter, Kingi, Tapsell, Durie & McGee, 2006). Sub-cultural associations, particularly involving long-term drug use by those in disadvantaged socio-economic groups, is relevant to understanding the low status of Māori mental health. A study designed to compare the profile of clients attending alcohol and other drug treatment services in New Zealand with data from a 1998 survey revealed that Māori clients were younger, used cannabis more, and were less likely to live in a large city and to attend follow-up appointments (Adamson S, Sellman D, Deering D, Robertson P, de Zwart K., 2006).
Chapple’s research on the ‘is it class or ethnicity?’ question suggests that ‘the policy issue may need to be viewed primarily at a sub-cultural and socio-economic level rather than the coarse ethno-cultural level of Maori/non-Maori binaries’ (2000, p. 115). This approach is supported by research by Sankar et. al (2004) and Collins (2004) who also regard racial or ethnic disparities as deriving primarily from differences in a myriad of factors, including culture, diet, socio-economic status, education, access to health care, discrimination and additional social determinants and criticise the excessive emphasis on genetics as a foremost explanatory element for health disparities.
Bramley, Hebert, Tuxxio and Chassin (2005), and Chandola (2001) favour socio-economic deprivation as the main factor in accounting for explaining different health outcomes according to distinct ethnic groups while Bhopal (2002) argues that analysing ethnic or racial inequalities in health status without a material groundwork on socio-economic factors is naïve. According to Ellison, de Wet, Ijsselmuiden and Richter (1997) the focus should be directed to all socioeconomically disadvantaged individuals.
Significant evidence supports the proposition that socio-economic differentials are likely to be a fundamental explanation for the observed inequalities in health status among minority groups (Nazroo, 2003). However, in understanding the reasons for the low health status experienced by various sub-groups, it is necessary to focus not only on socio-economic status but to examine both the influence of racism and discrimination, and the complex relationship that exists between socio-economic position and experiences of racism and discrimination.
Racism and discrimination
Extensive research evidence indicates that racism does play a major role as a determinant of health (Barnes, de Leon, Lewis, et. al., 2008; Paradies, 2006; Krieger, 2003) with subjective experiences of racism and discrimination, rather than race or ethnic affiliation, related to poor health outcomes (Barnes et. al., 2008; Dominguez, 2008; Peters, 2006). These experiences, rather than ethnicity or race per se, are among the main vectors through which limited access to health care and unfavourable health outcomes affect members of minority groups.
Ethnicity or race as a blanket category is insufficient to explain ethnic or racial inequalities in terms of access to health care (Alegria, Canino, Rios, Vera, Calderon, Rusch & Ortega, 2002). Personal experiences of racism, harassment and discrimination are associated with multiple indicators of poorer physical and mental health status (Nazroo, 2003). Socially inflicted trauma and internalised oppression are considered among the leading pathways through which racism can harm health (Krieger, 2003). Discrimination is multidimensional and produces negative emotional states such as anxiety and depression, which in turn alter biological processes or patterns of behaviour (James, 2003).
However, as with the influence of socio-economic location, disagreement exists among researchers concerning both the extent of the direct influence of racism, and also with how the interplay between these experiences of racism and socio-economic status act to affect health status. A number of studies have identified the association between self-reported experiences of racial discrimination and poor physical and mental health outcomes for a range of ethnic groups in various countries. (Karlsen & Nazroo, 2002, 2004; Williams, Neighbors & Jackson, 2003). Correlations have also been found between self-reported experience of discrimination and unfavourable health outcome in New Zealand (Harris, Tobias, Jeffreys, Waldegrave, Karlsen, Nazroo, 2006). The latter found that self-reported experiences of discrimination are strongly associated with poor health for all ethnic groups, independent of the effect of socio-economic position. However, other studies have found it likely that racism is experienced more frequently by individuals in marginalised socio-economic groups rather than people in the middle and upper-middle class as well as which sub-groups experience persisting obstacles at the level of health care provision (Adamson, Ben-Shlomo, Chaturvedi & Donovan, 2003).
The type of discrimination associated with higher mental health needs is also relevant to understanding which sub-groups in the population are most affected. One study conducted in multiple New Zealand regional hospitals revealed that volunteers who self-identified as Māori or Pacific had reported more psychotic phenomena compared to a group consisting of ‘all other’. The differences between ethnic groups also varied according to socio-economic deprivation level (Trauer, Eagar & Mellsop, 2006). In addition, discrimination is not confined to the Māori – non-Māori binary. In the work setting, Asians reported the highest prevalence of discrimination (Harris et. al., 2006). Other immigrants, including non-English Europeans of white appearance, may be particularly vulnerable to racial discrimination due to limited proficiency in the native language, illegal visa status, and different cultural and religious backgrounds.
Another study (Harris et.al., 2006) of the personal experiences of racial discrimination, for example, ethnically-motivated physical or verbal attacks and different types of unfair treatment that affected different minority groups in New Zealand, including Asians, Pacific peoples and Maori, found that Maori reported the highest prevalence of ‘ever’ experiencing any of the forms of racial discrimination (34 percent). This was followed by similar levels among Asian (28 percent) and Pacific peoples (25 percent). However, this finding requires further investigation. Both the method of classification and the fact of skin colour are implicated in any analysis of discrimination towards Maori. In the matter of classification, descendants from intermarriage between Maori and ‘white’ parents who select the two corresponding census categories will be classified as Maori only. This is the case even if the person does not present physical attributes to suggest a Maori categorical affiliation.
Socio-economic class appears to be implicated in links between discrimination and skin colour. A Māori person with ‘white’ physical appearance is more likely to identify as both Maori and non-Maori. This group tends to be ‘socially and economically much better off than all other Maori’ (Callister, 2008, p.21) and therefore less exposed to the full spectrum of racism and discrimination experienced by individuals who record Maori-only ethnicity in official surveys. The latter group may include those who ‘look more Maori’, and ‘if discrimination is common in New Zealand, the Maori-only (or Pacific peoples) group would be more likely to suffer discrimination from police, landlords and healthcare providers’ (p, 21).
Skin colour is certainly implicated in the cultural politics of the professional class. According to a Maori involved in tribal development with reference to Maori in senior positions in the public sector, ‘fair-skinned Maoris are one of the stealthiest, most potent weapons for pushing the Maori cause in the public and private sectors’ (Himona, cited in Rice, 1989, p.1).
A legacy of incongruent health care data
A series of studies have highlighted inconsistencies and discrepancies in the way that race, and more recently ethnicity, have been defined in New Zealand for the purpose of health care, monitoring and policy making (Smart et. al, 2002; Thomas, 2001; Blakely, Robson, Woodward, 2002). The definition of race and ethnicity has been specifically criticised in the context of ischemic heart disease (Priest & Jackson, 1994), diabetes (Swan, Lillis & Simmons, 2006), breast cancer (Curtis, Wright & Wall, 2005) and paediatric community care (Bramley & Latimer, 2007). The authors of the latter publication concluded that the poor quality of data based on ethnicity was ‘an ongoing issue’ in the New Zealand health sector (p. 46). In fact, continuous investigation over more than two decades in New Zealand has consistently documented erroneous information in hospital records and highlighted significant inaccuracy of ethnicity data (Swan et. al., 2006). In addition, the validity of Maori mortality statistics has been challenged due to discrepancies in ethnic classification (Graham et.al., 1989).
Data from the coronary heart disease register for almost a decade indicate that, when ethnicity, as recorded during hospital admission, was compared with self-defined ethnicity, the number of those classified as Maori increased almost 12 percent while only 0.5 percent of those classified as ‘other’ considered themselves to be Maori (Priest & Jackson, 1994). Discrepancies specific to each classification group have been identified. The misclassification of ethnic identity was found ‘particularly problematic’ in the group labelled as the ‘other’ ethnic group (Swan et. al., 2006).
Bias can arise when comparing health standards in Māori and non-Māori populations. In a study that reviewed 98 research reports comparing Māori and non-Māori samples from 1980 to 1996, only 19 percent of the articles reported any information about the criteria used for categorising ethnicity and only less that 3 percent mentioned how people of dual or multiple ethnicity were categorised. This led to the conclusion that much of the New Zealand research comparing Māori and non-Māori samples is biased and that most articles in that period did not meet minimum expected standards for reporting procedures for categorising ethnicity (Thomas, 2001). Even in a well developed study using linked census and mortality cohort datasets, changes in definition of ethnicity have been recognised as a possible source of bias in the study (Blakely, Fawcett, Hunt & Wilson, 2006).
Additional evidence comparing ethnic differences in mental health and health style choices among New Zealand ‘Europeans’, Pacific Islanders, and Māori indicated that the latter population group was more likely to be concerned about abuse and anger control (Goodyear-Smith, Arroll, Coupe & Buetow, 2005). The authors acknowledged that the priority system of coding ethnicity ‘gives special priority to Maori’, a faulty system which ‘loses detail and makes assumptions’ (p. 6). Furthermore, people classified within the group of ‘unknown ethnicities’ belong in fact to a variety of ethnic groups and their inclusion in the group of ‘others’ is also inappropriate (Bramley & Latimer, 2007). The use of the term ‘non-Māori’ to those who are not Māori was described as ‘extreme’ example of inaccurate labeling of human populations (Reinken, Salmond & de Lacy, 1983). Although some researchers have recommended methodological ‘adjustments’ for classification and measurement for public health surveillance purposes in New Zealand (Blakely et. al., 2002), the persisting bias and methodological obstacles for that are likely to persist.
Conclusion
While advocates for Durie’s Māori mental health model do accept that social-economic factors contribute to the low status of Maori mental health, they do so from the premise of a Māori non-Māori binary and in the interests of tino rangatiratanga politics. Whether that ethnic distinction is given a biological basis or is regarded as a socially constructed distinction (which does in fact contain a biological or genetic component), the very use of ethnicity or race as a valid category for public policy and professional practice is poor science.
The hegemonic power of ethno-nationalism forecloses the possibility of discussion about whether in fact a separate Maori mental health system is in the best interests of patients specifically, and improving health status more generally. It is assumed, without reliable scientific evidence, that the separate Māori Health Authority currently being established will address Māori patients’ health needs. The intrusion of ethnic politics into health policy on such a scale has compromised science in a number of ways. Along with the elevation of ideology to ‘science’, fallacious assumptions spur research enterprises on ‘ethnic drugs’, i.e. BiDil, and ethnic estimation research, which ‘are poised to exert a cascading effect—reinscribing taxonomies of race across a broad range of scientific practices and fields’ (Duster, 2005). Within the New Zealand health system, professionals, despite being educated in the critical tradition of scientific thought, uncritically practise a non-scientific racial ideology.
The ideological and methodological issues we have discussed do not lessen the suffering and distress experienced by Māori mental health patients. Our concern is not to ignore this suffering nor to divert attention from the need to reduce social disparities between groups in the interests of social justice and human rights. Rather we have identified how the belief, that equality for Māori is achieved through separate and different policies and practices such as the Maori model in mental health, operates at a hegemonic level ensuring an uncritical conformity to racially separate policies and practices.
We conclude with the caution that rights-driven social policies and health care initiatives, despite the best intentions, have the potential to be detrimental (Hunter, 2002; 2006) and share the caution expressed by Ellison et. al., (1997) and Kaplan & Bennett (2003) among others, that the continued use of imposed categories may actually enforce disadvantages and perpetuate inequality. Such an outcome is the very opposite of the intentions of those New Zealanders whose commitment to separate Māori initiatives is driven by universalist liberal ideals of justice and equality.
To ensure that mental health patients receive the best care we suggest that New Zealand health policy and practice address itself to the issue of which specific sub-groups experience discrimination, in all its damaging forms including racism, as well as the complex links between such experiences and low socio-economic status and marginalised life-styles.
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