Chapter Five

Tirohanga Maori

Maori Health Perspectives

At the opening of the Hui Whakaoranga, a national Maori health conference held on the Hoani Waititi Marae, Auckland, in 1984, the Hon 'Ben Couch, Minister of Maori Affairs in the National Government, dec1ared, " , . there is no such thing as Maori health or Pakeha health; there is only people health'. He went on to ascribe differences in health standards to self-inflicted lifestyle choices, ' ... most people who enjoy good health have earned it. The rules are the same for people of all races; good eating, plenty of sleep and exercise, and moderation in all things', 1 His views were not atypical of the era but they were out of step with Maori thinking in tV,TO respects. First, they ignored Maori experience and the growing body of evidence which linked culture and health; and, second, they disregarded socio-economic status as a significant determinant of good health, quite apart from individual motivation.

Over the succeeding two days the Hui Whakaoranga rejected the notion that cultural factors were irrelevant to health and concluded on quite a different note, recommending that 'health and educational institutions recognise culture as a positive resource' and that 'the feasibility of including Maori spirituality in health education programmes in schools and in tertiary educational institutions be investigated' _2

Illness and Treatment

Prior to 1976, professional and academic interest in Maori perspectives on health and sickness tended to confine discussion to particular clinical syndromes which were unique to Maori and of anthropological as much as medical interest. Makutu and mate Maori, for example, attracted considerable comment from Western-trained psychiatrists, though tended to be reinterpreted as superstitious phenomena and of doubtful diagnostic significance.v' Maori concepts of illness were increasingly reinterpreted by the medical anthropologists in mental and psychic realms, scarcely relevant to the vast majority of

67

68 T'irohanga Maori

Maori Health Perspectives 69

human illnesses and hardly applicable to contemporary times. It was left to Maori writers to point out the continuing relevance of culture to illness and treatment, and to provide some balance for the more esoteric ideas which had appeared in the earlier medical and scientific literature.

The process starred with an examination of medical practice and hospital procedures to determine the significance of culture to Ma~ri patients in everyday situations. Durie concluded that, although Maori were more often than not Westernized, or at least appeared to be, cultural heritage continued to shape ideas, attitudes, and reactions, particularly at times of illness. 'The concepts of tapu and the perception of illness as an infringement against tapu are central to much of the anxiety and depression which surround the Maori patient while in hospital. Family involvement at times of illness is likewise a very traditional and culturally necessary attitude which must be recognised in the management of the whole patient and not just his impaired or-gan." ,

The relationship between tapu and noa, and explanations of illness based on a postulated breach of tapu, continued to have meaning for Maori and therefore had implications for doctors in the management of Maori patients as well as the care of the deceased as long as they were still in hospital custody. Because early retrieval of a relative's body was critical to uphold the mana of the family and the individual, mourning Maori furnilies were grossly offended if the body were not released within twenty-four hours of death. Post-mortem delays, or simple administrative inefficiencies, could add immeasurably to the grief of an already distressed family."

Tipene-Leach, writing about aspects of the doctor-patient relationship, described a number of sensitivities and behaviours relevant to communication during a clinical examination." For instance, immediately asking patients to reveal their names, without any preliminary remarks, could lead some Maori to feel threatened even before the examination had commenced. Similarly, expecting a Maori patient to engage in direct eye-to-eye contact could be interpreted as an invitation to demonstr-ate bad manners since looking an older person in the eye was a sign of haughtiness or disrespect. Various parts of the body were also described as having special significance, though not necessarily at a conscious level. Medical or nursing interventions involving the head, sexual organs, hair, and nail clippings, required a measure of caution and a greater degree of circumspection than was customary in busy hospital wards.

The gradual introduction of Maori concepts into medical routines was not entirely welcomed, but nor was it dismissed outright. By the mid-1970s there was some tentative recognition that ethnicity and culture had implications for health. Maori views, though not always understood, were often taken on board at face value, even though they could not be rationalized in medical terms. Moreover, discussions of similarities between rohunga and doctor in

the New Zealand MedicalJournal had generated sympathetic interest." Both, it seemed, were experts in history-taking as a prelude to making a diagnosis; both took extensive family histories (tohunga more than doctor); both employed specific treatment methods; and both recommended periods of rehabilitation. By removing Maori concepts from the realms of the supernatural, and emphasizing their continuing importance even when a patient did not profess to subscribe to them, Western-tr-ained health professionals were more able to appreciate their significance and respect them.

Health and Well-being

Having shown the relevance of culture to health and sickness, Maori interest then turned to the wider contexts of health and community. For some years it had been acknowledged that there were many dimensions to health. In its 1947 definition, the W orId Health Organisation concluded that health was greatly influenced by social and cultural factors: 'Health is a state of complete physical, meneal and social wellbeing and not merely the absence of disease or infirmity'." The definition was a reminder to the world that there was more to health than biological dysfunction and that it went well beyond the province of the health sector. Neither was it the exclusive province of the medically trained doctor or nurse, although they had a particular interest in some aspects of it having made spectacular advances in the treatment of physical illnesses, especially infections, from the 19405 onwards. The problem was, or at least "vas perceived as being, that medical interest in physical disease greatly outweighed an interest in the person as a whole within a sociological and ecological environment. A cellular focus no longer seemed adequate for understanding the complexities of health even though it had been a useful step in the past.

During the 1970s Maori were beginning to insist that a narrow focus on micro-organisms or even on physical illness created a distorted frame ... york within which to consider health and to plan for the future. Interest moved towards a view of health that made sense to Maori in Maori terms, and outside hospital. As Maori participation in the health debate escalated, a number of Maori perspectives were advanced. All emphasized the value of traditional belief systems to health, though not necessarily at the expense of Western medical practice, Indeed, seldom did debate move towards an exclusively Maori system. Greater balance was the. goal.

Several views emerged, but one which subsequently gained wide acceptance as 'the Maori health perspective' ... vas a four-sided health construct, later known as whare tapa wha (a four-sided house). 10 Though often described as

70 Tirohanga Maori

Maori Health Perspectives 71

a traditional Maori approach to health, more correctly it was a view of health which accorded with contemporary Maori thinking. Its ready acceptance by Maori was to some extent proof of that. The characteristics of whare tapa wha are shown in Table 12.

of balance between them was also introduced. The model later appeared in the Rapuora report: 'To say that a person is a psychosomatic unity, a personality fonned jointly by physical and mental processes, only partly embraces the Maori concept. A study of Maori health must follow more than two strands. Tinana is the physical element of the individual and hinengaro the mental state, but these do not make up the whole. Wairua, the spirit and whanau the wider family, complete the shimmering depths of the health pounamu, the precious touchstone of Maoridom' .12

The four-part framework was again presented by Durie at a health hui held at the Palmerston North Hospital in December .198213 and further developed for the 10th Young People's Hui·held at the Raukawa marae in May 1983.14 The four dimensions of health were originally portrayed as a set of interacting variables, not dissimilar from a holistic view, nor for that matter from the World Health-Organisation 1947 definition but, unlike them, firmly anchored on a spiritual rather than a somatic base.

Taha wairua is generally felt by Maori to be the most essential requirement for health. It implies a capacity to have faith and to be able to understand the links between the human situation and the environment, Without a spiritual awareness and a mauri (spirit or vitality, sometimes called the life-force) an individual €annot be healthy and is more prone to illness or misfortune. A spiritual dimension encompasses religious beliefs and practises but is not synonymous with regular churchgoing or strong adherence to a particular denomination. Belief in God is one reflection of wairua, but it is also evident in relationships with the environment. Land, lakes, mountains, reefs have a spiritual significance, quite apart from economic or agricultural considerations, and all are regularly commemorated in song, tribal history, and formal oratory. 15 A lack of access to tribal lands or territories is regarded by tribal elders as a sure sign of poor health since the natural environment is considered integral to identity and fundamental to a sense of well-being."

Spiritually, the hours immediately following death are particularly significant. As the deceased person's spirit hovers tentatively between the visible world and the world of spirits, mourners themselves are able to feel a spiritual presence and to experience a renewed sense of continuity with their own ancestors, their history, and their future. For that reason a rapid retrieval of a deceased relative from hospital becomes a matter of urgency.

Taha hinengaro is about the expression of thoughts and feelings. In Maori nomenclature, thoughts and feelings derive from the same source, located within the individual. The notion that they are vital to health is a wellrecognized concept among Maori. Western authorities have reached similar conclusions though through circuitous routes that have traversed psychological and psychiatric observations, a path that other cultures have not needed in

Table 12:. The wharf tapa wh« model
Taha Taha Taha Taha
Wairua Hinengaro Tinana Whanau
Focus Spiritual Mental Physical Extended
family
Key Aspects The capacity The capaciry to The capacity The capacity
for faith and communicate for physical to belong, to
wider to think, and 'growth and care, and to
communion to feel development share
Themes Health is Mind and body Good physical Individuals
related to are inseparable health is are part of
unseen and necessary for wider social
unspoken optimal systems
energies development vVhare Tapa Mil

Briefly, the whare tapa wha model compared health to the four walls of a house, all four being necessary to ensure strength and symmetry, though each representing a different dimension: taha wairua (the spiritual side), taha hinengaro (thoughts and feelings), taha tinana (the physical side), taha whanau (family). The concept of health as an interaction of wairua, hinengaro, tinana, and whanau was first presented at the Rahui Tane Hostel in Hamilton in August 1982 during a training session for fieldworkers in the Maori Women's W' elfare League research project, Rapuora." During the welcome , kaurnatua Tupana te Hira had emphasized in Maori the importance of wairua as a startingpoint for health. It was a view that many kaurnatua shared and which was frequently heard on marae throughout the country. Later that evening, psychiatrist Henry Bennett spoke about mental illness and mental health, while Dr Jim Hodge of the Medical Research Council described some of the common disorders such as kidney failure which affected Maori disproportionately. Dr Mason Durie, also a psychiatrist, drew these themes together,

I

calling them taha wairua, taha hinengaro, taha tinana, and taha whanau and

leaving League members with a broadly based view of health which seemed to combine the four basic ingredients for good health. Importantly, a notion

72 Tirohanga Maori

Maori Health Perspectives 73

order to finish up at the same point. Maori thinking can be described as holistic. Understanding occurs less by division into smaller and smaller parts, the analytical approach, than by synthesis into wider contextual systems so that any recognition of similarities is based on comparisons at a higher level of organization.

Consistent with this style of thinking, health is viewed as an interrelated phenomenon rather than an intra-personal one. Healthy thinking from a Maori perspective is integrative not analytical; explanations are sought from sear9hing outwards rather than inwards; and poor health is typically regarded as a manifestation of a breakdown in harmony between the individual and the wider environment. There are several words and expressions which bind the individual to the outside world. Whenua, for example, can mean both placenta and the land, rae is either the forehead or a land promontory, iwi refers-equally to a bone (ko-iwi) or to a nation of people, while hapu can denote pregnancy and a section of a large tribe. The word for birth is whanau, the same term used to describe a family, and wairua, spirituality, can also ~e used to refer to an insect, just as kapo can mean blind or a species of eel. WhaRapo is to darken (as in approaching night) and, as well, to grieve, waimate is a hereditary disease but also polluted water, kauae can be the jawbone or a major supporting beam in a building, and rahuhu refers both to the vertebral column and the ridge pole of a meeting-house.

A further distinctive feature of taha hinengaro is its relevance to both thoughts and feelings. While Western thinking distinguishes between the spoken word and emotions (and generally encourages the word more than the feeling), Maori do not draw such a sharp distinction. Communication, especially face-to-face, depends on more than overt messages. Maori may be more impressed by the unspoken signals conveyed through subtle gesture, eye movement, or bland expression, and in some situations regard words as superfluous, even demeaning. Emotional communication can assume an importance which is as meaningful as an exchange of words and valuedjust as much. Condolences, for example, are frequently conveyed with tears; infrequently with words. So, when Maori children who are chided by their teachers for showing what they feel, instead of talking about their feelings, they are not only made [Q feel unworthy (of their feelings) but must also contend with a sense of frustrated expression.

Taha tinana (bodily health) is a more familiar health dimension, though the Maori emphasis is different in that there is the dear separation oftapu and noa. Certain parts of the body, and the head in particular, are regarded as . special (tapu), and bodily functions such as sleeping, eating, drinking, and defecating are imbued with their own significance, reflecting various levels of importance and requiring quite different rituals. Food, for example, is a leveller

which removes any vestige of sacredness or distance (as between people). Because cleaning the body and eating are polar opposites, separation of food from toileting functions is regarded as necessary to maintain good health, a condition severely tested in hospital wards where all functions are frequently

conducted in the same confined space. .

Body image may be regarded differently by Maori. Slender body forms are not necessarily prized more than well-rounded shapes, nor does obesity provoke the same sense of disapproval encountered in society generally. Perhaps because of this, anorexia ncrvosa remains relatively infrequent among Maori girls. By the same token, however, health workers report difficulties in trying to convince Maori patients that they should lose weight. Their efforts might be better spent in appealing to health risks, especially for future generations, rather than to personal vanity.

The fourth dimension of health, taha whanau, acknowledges the relevance of the extended family to health. There are at least two important considerations. The first is that the family is the prime support system for Maori, providing care and nurturance, not only in physical terms but culturally and emotionally. Reported rises in the prevalence of family dysfunction, including .signs of abuse, do not lessen the point but underline its significance. Maori still maintain that ill health in an individual is a reflection on the family and may well blame a family for allowing a person to become ill or to die, even when there is no direct causal link. The practice of mum is still observed in some areas. When there is evidence that a lack of quality care by the family has contributed to death, neighbours and more distant relatives may seek retribution by removing family property or personal belongings, especially when the deceased is a community leader. Similarly, in cases of child abuse or neglect the extended family may take it upon themselves to remove the boy or girl from parental custody and take over the caring role. Parental rights often tend to be seen as secondary to the interests of the whanau or even the tribe to ensure that future generations are prorecred.

A second consideration of taha whanau relates to identity and sense of purpose. The much-lauded state of self-sufficiency or self-realization does not convey a sense of health to Maori. Quite the reverse, since an insistence on being overly independent suggem a defensive attitude, while a failure to turn to the family when the occasion demands is regarded as immaturity, not strength. Interdependence rather than independence is the healthier goal." Sometimes this goal clashes with the European regard for independence in teenagers as 'one of critical developmental tasks of adolescence, ... a fundamental building b 10 ck of health' . 1 B

Even in modern times a sense of personal identity derives as much if not more from family characteristics than from occupation or place of residence.

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Maori Health Perspectives 75

Interest in family and tribal background rivals personal qualifications or achievements so that credibility, certainly in Maori settings, depends on an individual being able to make the links and demonstrate that there is active whanau and tribal support. On that basis, it has become a common occurrence for family members to accompany job-seeking applicants to an interview, Their role is a dual one: to convince the interview panel that their relative is the best person for the job, but also to ensur-e that the job itself is suitable and not likely to lead to exploitation, unfulfilled expectations, or disrespect. There have been instances when an applicant has been successful but the family, unhappy about the interview, has counselled against accepting the position. Similarly, there are numerous anecdotal accounts of candidates being passed over because of the family's confronting attitude during the interview.

Underlying the whare tapa wha model is the consistent theme of integration.

Individual health is built into a wider system, the boundary between personal and family identity being frequently blurred, Similarly the divisions between temporal and spiritual, thoughts and feelings, mental and physical are not as clear-cut as they are have been in Western thinking since the advent of Cartesian dualism. I ~

Maori interest in redefining health in their own terms and reclaiming a positive role in shaping health services "vas accelerated when the whare tapa wha model was introduced. It was simple, even simplistic, but that was also its appeal. In addition, it appeared at a time when Maori were debating the general direction which health services were taking. Widespread concern had focused on three issues.

First, Maori were not impressed by the overemphasis on physical aspects of health with its biological constructs and increasing preoccupation with cellular phenomena. Nor for that matter were a number of other New Zealanders. At a national conference to consider the role of the doctor, holistic care was emphasized to balance a perception that many doctors had acquired too narrow a focus, their work often lacking ecological and caring dimensions, 'Because the scientific and technical aspects of practice cannot be separated from human concerns and social skills, particular attitudes are required: the readiness to treat people as equals; empathy; willingness to share information t\VO ways; and a recognition that patients have a responsibility tor their own health.F?

Second, many Maori felt that their relationship with health professionals, and with the health system generally, had become strained, Rightly or wrongly a feeling of alienation had arisen, not necessarily because of poor access Of even inadequate care, but mainly because there was a lack of shared decisionmaking and limited recognition of Maori views, The more professionals acted as if they knew best, the less tolerant Maori became. Surely, they argued, Maori

health belonged to Maori people, Maori health perspectives such as whare . tapa wha were welcomed because they provided the necessary framework within which a semblance of ownership over health could be entertained.

Third, despite a century and a half of colonization, Maori remained convinced that good health could not be gauged by simple measures such as weight, blood pressure, or visual acuity. Spiritual and emotional factors, though more difficult to measure, were equally important.

Te f-Vheke

There were other Maori health perspectives which gained acceptance in the 19805, One of these, te wheke (the octopus), was discussed by Pere at the Hui Whakaorang;l in 1984, In order to illustrate the main features of health from a Maori family perspective, she compared health to an octopus." Each of the eight tentacles of the octopus symbolized a particular dimension of health while the body and head represented the whole family unit. The intertwining of the tentacles indicated the close relationships between each dimension.

Like te whare tapa wha, the model included wairuatanga (spirituality), taha tinana (the physical side), hinengaro (the mind), and whanaungatanga (the extended family, similar to taha whanau). The other dimensions were: mana ake, the uniqueness of the individual and each ramily and the positive identity based on those unique qualities: mauri, the life-sustaining principle resident in people and objects, including language; ha a Koro rna a Kui rna, literally the breath of life that comes from forebears and an acknowledgment that good health is closely linked to a positive awareness of ancestors and their role in shaping the family; whatumanawa, the open and healthytxpression of emotion, necessary for he;llthy human development; and waiora, total well-being for the individual and the family, represented in the model by the eyes of the octopus.

j'\Tga Pou Mana

In 1988 the Royal Commission on Social Policy described another set of values and beliefs-four supports, nga pou mana-as pre-requisites for health and well-being.f As with the other models a set of interacting variables was proposed, the combination leading to individual and group well-being manifest by the retention of mana, cultural integrity, a sound economic base, and a sense of confidence and continuity, This model, unlike the other two, placed greater stress on the external environment and the significance of oral tradition

76 Tirohanga Maori

Whare Tapa Wha

Table 13: Maori health perspectives-three models

Maori Health Perspectives 77

as a stabilizing influence. Though prepared primarily to examine foundations for social policies and social well-being, nonetheless it has relevance for health and has similarities with Durie's three 'institutions of'health'<s-land, language, and family."

The four supports+-family (whanaungatanga), cultural heritage (taonga tuku iho), the physical environment (te ao turoa), and an indisputable land base (turangawaewae )~brought together social, cultural, and economic dimensions in a way which could be readily appreciated by Maori and which demonstrated the links between the three. Par!:icular reference to the environment (te ao turoa) was perhaps influenced by the Waitangi Tribunal's landmark decisions in respect of claims made by tribes against the Crown and on the basis of pollution of tribal waterways." These claims had all recognized the significance of a dean environment for good health and drew attention to the overlap between physical and cultural pollution. Quite apan from the effects of effluent on seafood and the consequent risks of hepatitis or other alimentary diseases, Maori claimants also described a type of pollution which debased spiritual and cultural values. Disposal of human waste, treated or not, onto potential food sites or into wahi tapu (historical sites declared tapu) offended Maori just as the depletion of traditional foods through pollution created embarrassment when families were unable to meet customary hospitality obligations when visitors arrived.

Turangawaewae is a pou mana with cultural, social, and economic Significance. Not only does it refer to land rights and access to an economic base, it also includes the marae, an institution, perhaps like no other, where Maori customs and tradition, including language, have priority. A measure of Maori identity, and indirectly a health measure, is the level of access, as of right, which an individual has to a marae. Since the marae is the epitome of a collective identity and one of the few remaining opportunities for social relationships to be strengthened in a manner which is mutually supportive, it enables Maori to redress some of the imbalance between individual and group pursuits inevitably created by life in suburbia.

Taonga tuku iho, cultural heritages upon which intellectual and philosophical traditions are based, are also valued by Maori because they suggest a continuity with past wisdom and consolidate a Maori identity. Increasing recognition oflanguage as a taonga (treasure), important for cultural and health reasons, has resulted in extensive revitalization strategies locally and nationally. After considering a claim brought by Nga Kaiwhakapumau i te Reo (the Wellington Maori Language Board), the Waitangi Tribunal described language as a taonga, categorizing it along with physical resources such as land?" The Tribunal report made it very clear that there was a Treaty ofWaitangi obligation on the Crown to ensure that Maori language was strengthened before it

Components

Wairua Hinengaro Tinana Whanau

Features

Spirituality Mental health Physical Family

Symbolism

A strong house

Supporting structures

Te Wheke

Wairuatanga Hinengaro Tinana Whanaungatanga Mana ake

Mauri

Hi a koro rna a kui rna Whatumanawa

Spirituality Mental he'alth Physical Family Uniqueness Vitality

Cultural heritage Emotions

The octopus

Nga POll Mana

Whanaungatanga Taonga tuku iho Te ao turoa Turanga waewae

Family

Cultural heritage Environment Land base

was lost altogether, and the point was made on several occasions that without language any sense of pride or cultural integrity is seriously undermined.

Cultural heritage, as a basis for well-being if not health, also concerns the ownership of intellectual and cultural property. Cultural erosion has come about not only because of assimilation but also because history, traditions, art forms, healing methods, and poetry have often been appropriated by others and in the process Maori have been denied a guardian or custodial role, or have lost access to their own material altogether.

The Draft Declaration on the Rights ofIndigenous Peoples recognizes both the Significance of intellectual property to indigenous peoples as well as indigenous forms of health care" based on traditions passed down over the generations.P Article 22 of the Draft Declaration states that 'Indigenous peoples have the right to their traditional medicines and health practices, including the right to the protection of vital medicinal plants, animals and materials'. Article 27 is more specific: 'Indigenous peoples have the right to special measures to protect, as intellectual property, their sciences, technologies and cultural manifestations, including genetic resources, seeds, medicines, knowledge of the properties of fauna and flora, oral traditions, literatures, designs and visual performing arts'.

Table 13 summarizes the main features of the three perspectives.

78 Tirohanga Maori

Maori Health Perspectives 79

Gaining Perspective

Other Maori health perspectives were advocated on various occasions. Te Roopu Awhina 0 Tokanui, a group of Maori health professionals at a psychiatric hospital, became active in promoting Maori health, particularly mental health, and were instrumental in establishing a Maori unit, Whaiora, within Tokanui Hospital. At the Australian Congress of Mental Health Nurses held at Adelaide in 1986, they presented a nine-part framework to guide psychiatric nursing: taha wairua (spirituality), taha whanau (family), taha hinengaro (wellbeing), taha tinana (physiology), taha whenua (environment), taha tikanga (compliance), Maoritanga (old world), Pakchatanga (new world), taha tangata (sell) Y

All Maori health perspectives had similar themes. Essentially they. sought to widen understandings of health, to translate health into terms which were cultural1y significant, and to balance physical and biological approaches with cultural and sociological views. The Department of Health agreed that, 'Maori people in general believe that their current health status is ultimately linked to their historical, social, cultural, economic, political and environmental circumstances. In order to achieve any improvement in health status, health initiatives must incorporate a holistic definition and approach and be part of a developmental strategy to improve the overall status and wellbeing of a Maori community, tribal or family group. In doing so Maori people would like to define health for themselves; identify their own specific health concerns; . . . take responsibility for their own health; be involved in their own health care'. ~B

The appearance of the Maori health perspectives in the cady part of the 1 980s was not altogether surprising, given the strong moves towards positive Maori development and a rejection of assimilationist ideals. In education, housing, social welfare, and political representation Maori were intent on injecting a genuine Maori point of view as a prelude to reclaiming some degree of ownership and autonomy over social as well as economic arenas. Health was no exception.

But the perspectives also reflected a more general re-examination of New Zealand's health goals and its health services. Maori often articulated issues which had worried a wide cross-section of New Zealanders but \ .. zhich had not otherwise been able to find expression. The S-Factor for example was a concept used to encompass spirit. spirituality, or even 'something which represents that which defies being placed into the categories of ethics, psychology, medicine, and sociology'." It was seen to be similar to taha wairua, but more relevant to Western than Maori culture, and it was introduced to balance a preoccupation with measurable and quantifiable health outcomes.

Once Maori began to talk about spirituality, thoughts, feelings, and family in connection with health, others followed.

However, not everyone was impressed by the Maori health perspectives.

To sceptics, they were based on romantic visions of the past, devoid ofpractical application, and likely to discourage Maori patients from seeking appropriate health care. At a time when scientific and technological advances were enabling organ transplants and new hopes for the disabled, Maori, it seemed, were longing for the quiet life and a return to a world now recognizable only in the history books. Further, because whare tapa wha extended the focus for health well beyond the individual, a sense of futility often developed among health workers. How could a diabetic regain health if the land injustices of the past century were ignored? By taking the debate to the widest possible levels, health programmes ran the risk of being so general and indistinguishable from welfare programmes that they would have no significant impact. Worse, if cultural factors were so important, sometimes it seemed pointless to treat a diabetic unless steps were also taken to provide parallel cultural enrichment; and health workers sometimes felt that they should take the initiative.

Far from improving treatment opportunities, it was argued that the new perspectives would displace clinical priorities and resources with sociological, economic, or political agendas. A further issue concerned the difficulty in measuring concepts as diffuse as taha wairua, While measurements of physical illness and subsequent medical interventions lacked accuracy, they were improving and at least there was some agreement about the desirable indicators. Not so in mental health (taha hinengaro) and even less so in spiritual matters . Was taha wairua of any practical value ifit could not be measured? The critics felt not.

Generally, however, Maori health perspectives were consistent with new orientations and global trends: general systems theory, family psychotherapy, the community health movement, health promotion, primary health care, and calls for de-rnedicalization of the human life cycle. New Zealand was moving in the same direction and, in recommending a national health policy in 1988, the New Zealand Board of Health advocated five principles: holism, empowerment, social and cultural determination, equity of access and devolution, and equitable and effective resource use.3D The Board had borrowed extensively from Maori views and writings.

By 1990, Maori views on health had made a significant impact on New Zealand health services generally, but more importantly they had given Maori people the necessary confidence, based on their own understandings of health, to challenge the system and reclaim a more active participatory role in society and within the health sector.

80 Tirohanga Maori

Maori Health Perspectives 81

Endnotes

23 M. H. Durie, (1985), 'Maori Health Institutions', Community IVIental Health ill New Zealand 2 (1) 63-9.

24 W. I-I. Oliver, (1991), Claims to the Waitangi Tribfllwl, Department of Justice I Daphne Brasell Associates, Wellington. The major claims were brought by Te Atiawa (the Motunui claim), Ngati Pikiao (Kairuna River) , Ngaci Te Ata (Manukau Harbour), and Ngati Kahu (Mangonui Inlet).

25 Waitangi Tribunal, (1986), Te Reo Maori Report, Department of Justice, Wellington.

26 Working Group on Indigenous Populations, (1993), Drcift Declaration on the Rights of Indigenous Peoples: Report on the Eleventh Session oj the United Nations Working Group Oil Indigenous Populations, United Nations, Geneva.

27 Te Roopu Awhina 0 Tokanui, (1987), 'Cultural Perspectives in Psychiatric Nursing: A Maori Viewpoint', Nursing Praxis in New Zealand 2 (3): 3-11.

28 P. Ngata and L. Dyall, (1984), 'Health: A Maori View', Health 36: 2.

29 C. Benland, (1988), 'The S-factor: T aha Wairua', in The Apn'l Report, op cit., pp.450-68.

30 New Zealand Board of Health, (1988), Priorities for the New Zealand Health Services, New Zealand Board of Health, \Vellington, p. 6.

Komiti Whakahaere, (1984), Hui vVhakaoranga: Maori Health Planning Workshop, Department of Health, Wellington.

2 Ibid.

3 G. Blake-Palmer, (1954), 'Tohungaism and Makuru', journal oj the Polynesian Society, 63 (2): 147-63.

4 L. K. Gluckman, (1976), Tangiu-ai: A l\I[edica[Hislory of 19th Century New Zealand WhitcouUs, Christchurch, pp. 232-60.

5 The psychoananalyse Carl [ ung used the term 'collective unconscious' to describe the continuing influence of cultural belief even when they were beyond conscious appreciation.

6 M. H. Durie, (1977), 'Maori Attitudes to Sickness, Doctors and Hospitals', New Zealand Medicaljournal86: 483-5.

7 D. Tipene-Leach, (1978), 'Maoris: Their Feelings About the Medical Profession', Community Forum, Auckland.

8 Dune, (1977), op cit

9 Vlorld Health Organisation, (1947). 'Constitution of the World Health Organisation', Chronicles if the World Health O(;;anisation 1: 12.

10 M. H. Durie, (1985), 'A Maori Perspective Of Health',Joumal of Social Sciences and Medicine 20 (5): 483-6.

11 E. Murchie, (1984), Rapuora: Health and Maori ~f/omen, Maori Women's Welfare League, Wellington, p. 112.

12 Ibid., p. 81.

13 The 1982 H ui Ora was arranged by a Maori health interest group, made up mainly of Maori professional staff from the Palrncrston North Hospital. It was attended by representatives of major Maori organizations in the area. The keynote speakers were Drs David Yates, Paratene Ngata, and Mason Durie.

14 W. Winiar«, (1984), 'The Raukawa Tribal Planning Experience and Health', in Hui ~:Vhakaoral1g: op cit.

15 D. S. Sinclair, (1975), 'Land: Maori Views and European Response', in M. King (ed.), Te Ao Hurihuri, Hicks Smith, Wellington.

16 M. H. Durie, (1979), 'Land and Mental Health', unpublished paper presented at the the RANZCP Conference, Queestown.

17 M. H. Durie, (1987), 'Implications of Policy and Management Decisions on Maori Health: Contemporary Issues and Responses', Intemational journal if Health Planf1ing

altd Afanagement 2, Special: 201-13, t

18 C. Maskill, (1991), A Health Projile of New Zealand Adolescent5, Discussion Paper 14, Health Research Services, Department of Health, Wellington.

19 M. H. Durie, (1986), "Te Taha Hinengaro: An Integrated Approach to Mental Health', Commuf1ity Menta! Health in New Zealand 1 (1): 4-11.

20 C. J Heath (ed.), (1985), Summary Report-s-National Conference on the Role if the Doctor in New Zealand: Implications jor Medical Education, University of Otago Medical School, Dunedin, p. 8.

21 R. R. Pere, (1984), "Te Oranga 0 te Whanau: The Health of the Family', in Hui Whaleaorang«, op cit.

22 M. Henare, (1988), 'Nga Tikanga me nga Ritenga 0 tc Ao Maori: Standards and Foundations of Maori Society', in The Apnl Report, III, part 1, Royal Commission on Social Policy, Wellington, pr. 24-232.