In October 2018, the Waitangi Tribunal began the Wai 2575 inquiry into health services and outcomes for Māori.
The resultant report is a stark and disturbing reminder of the inequity of health outcomes for Māori people in Aotearoa.
Māori are twice as likely to die of heart diseases than non-Māori.
Māori are twice as likely to die of a stroke than non-Māori.
Māori are over twice as likely to die of cancer than non-Māori.
These are not cherry-picked statistics, points out Māori health consultant Gabrielle Baker.
“You show me a health indicator and I'll show you an area where there's a Maori Health inequity.”
Ultimately, this is why the life expectancy of Māori is seven years lower than non-Māori.
Gabrielle has made understanding and challenging this alarming trend her life's work, and it all started with a graph.
Having studied law and policy, Gabrielle didn’t know exactly how, but she knew she wanted to dedicate herself to challenging inequity and injustice in Aotearoa. The way to do that became clear when she first saw a graph demonstrating the relationship between deprivation and health outcomes in New Zealand. Firstly, it showed that there are fewer Māori in the rich communities, and more Māori in the poorer communities. As a Māori woman who has lived under the thumb of colonisation, this socio-economic imbalance was not what surprised Gabrielle.
What she found surprising was how the graph goes on to look at life expectancy broken down by ethnicity and where you live. It showed that Non-Māori living in the poorest areas still had a higher life expectancy than Māori living in well-off areas.
“To me, that showed that [Māori health] was not just about inequity, it was very clearly about racism,” Gabrielle says.
So she pursued a master's degree in Public Health and gained more understanding about how socio-economics are not the only factor in why Māori are disproportionately represented in poor health outcomes.
“That was something I had been fed, as much as anyone else - that health differences are economic, and that poorer people are going to experience poorer health outcomes. But it wasn’t just that, there was something else going on.”
That something else is racism, Gabrielle says. This showed her that the most impactful way she could challenge inequity and injustice in our country would be to work towards the reform of a system which led to these race-based health outcomes.
She spent the next ten years working for the Ministry of Health as a lead of Māori health policy. During that time, she got to be part of a progressive new movement inside the department, making moves such as including research into racism and health in Te Kete Hauora (the Ministry's former Māori health business unit).
But Gabrielle also experienced a growing frustration with the bureaucracy of working in a Māori focussed department in a large Government department - where talk and acknowledgement didn’t often translate to action.
“The main reason that I left, is that I got overly frustrated with having lots of good words around Māori health… but what I wasn't seeing was organisations, being prepared to do something different as a result of those policy directions. There was not the action you needed, those documents would sit on a shelf.”
Gabrielle also felt like the New Zealand public wasn’t acknowledging or talking about the dramatic inequity of Māori health.
“I felt really frustrated that there were no conversations happening about Maori Health at all. For around nine years, the kind of media coverage on Maori Health had been really, really minimal. I could probably count on my hands the number of articles that properly looked at Maori Health over those years.”
As a public servant she wasn’t in a position to be a voice for these issues in the way she wanted to see, so she decided to move out of Government and become a consultant. This has allowed her to continue her work on advising and supporting Māori health, while also being able to raise her voice as an advocate of this issue - especially around the ingrained racism of our health system.
Now, Gabrielle works with health planning entities, district health boards, public health organisations and non-profits - using her knowledge to try and deconstruct and rebuild the systems that would lead to disparate outcomes for Māori people.
To do this, Gabrielle needs to make people understand the different forms that racism takes, and how the systemic racism we see in our health system generally doesn’t take the form of the outward bigotry most commonly associated with the term. To do this, Gabrielle has adopted the framework of Amercian academic Camara Jones, called ‘A Gardener's Tale’.
“She tells the story about her and her husband buying a new house,” Gabrielle says. “In the new house there are two planter boxes, one planter box has soil in it already, but the other is empty, so they go and get some new fertile soil and fill up the other one. Then they take a packet of seeds and split them between the two.”
The flowers in the new, fertile soil thrive. But the old soil only produces a few scraggly, scrawny, little flowers, Gabrielle says.
“She tells it as a story of institutional racism. We're products of the environment that we're in - we're a product of the soil that we're in - same seeds, different outcomes.”
Camara extends the metaphor to explore other forms of racism. The first is personally mediated racism, Gabrielle says, where we look at the thriving flowers and say ‘we much prefer these flowers, these were the better flowers all along, just look at them’, and to the scrawny, scraggly things, we say ‘they need to work harder, look across and see how well they other flowers are doing - they need to be doing as well as them.”
“These are our biases coming through - not thinking at all about the environment, just saying we like those ones, we don't like those ones,” Gabrielle says.
This leads to the third tier of internalised racism, Gabrielle says, where the scraggly flowers end up looking across at the thriving blooms and saying, ‘Those are better, and we want to be more like them. I can't understand why we're not more like them’.
“This simple story helps communicate some relatively complicated ideas,” Gabrielle says.
For her work, Gabrielle wants organisations in the health sector to consider this wider view of racism, but more importantly she wants them to consider who the gardener is in all this, and consider their role.
“What's prevented the gardener from fixing the situation? What could they do about the situation?,” Gabrielle says. “Whenever I talk about racism, I'm trying to focus on the Gardener.”
“We've all got different roles and times when we're the gardener, usually it's the government, but anyone who's making decisions in the health sector has a gardening role. When I work with people I'm encouraging them to think about what's your role as the gardener and how they can you do things differently. And if you're not the gardener, how can you advocate with the gardener?”
In most cases, Gabrielle says, the gardener is going to be Government. Having worked at the Ministry of Health for ten years, Gabrielle knows from experience that these departments can act with urgency when they want to. She points to the rise in need for elective surgeries, such as hip and knee surgery, as an example of this. She saw first hand the Government rally to meet this challenge, with extra funding relatively quickly allocated and a whole framework established to make sure targets are being met. In instances of meeting challenges like these, people were invested, Gabrielle says. When targets weren’t met, it would result in uncomfortable phone calls between board chairs, government officials, or Ministers.
In her time as a public servant, there was data and discussion discussing Māori health inequity with a similar urgency as this need for elective surgeries. However, she never saw Māori health inequity addressed with this level of urgency, attention, or resources.
They often have the data, Gabrielle says, but aren’t paying it the attention they need to be when making decisions. An example of this was presented by the National Hauora Coalition to the Māori affairs committee just last week.
In a statement, Clinical Director at the National Hauora Coalition Dr Rawiri McKree Jansen outlined the urgency need to address this inequity in our health system.
“There are inequities almost all health indicators, and in particular for cancer. These show that we need significant, Māori-led, changes,” Rawiri says.
“Too often, government policies and programmes turn out to be anti-equity. And we as health professionals and whānau have to work hard to even get to an equity-neutral position. Basically, we are handed a bag of lemons and left to make lemonade”
As just one stirring example of this, Rawiri presented how overlooked Māori health outcomes were in bowel cancer screening.
“To be eligible for the screening programme, currently being rolled out across the country, people need to be 60 years or older. But 45% of Māori bowel cancer occurs under 60, compared with only 21% of bowel cancer in non-Māori. There have been repeated calls for changes to this age range that will support health equity, and what we need now is immediate change.”
Gabrielle points to this as an example of just how layered the racism of the health system is. Not only is it ignoring the fact that this age range is completely underrepresenting Māori people, but if you drill down further you have to ask why Māori people are over represented in bowel cancer to begin with. Every health indicator has these layers, Gabrielle says - why Māori are overrepresented, why they aren’t being diagnosed and treated, and then how there resultant over-representation in data is still overlooked.
We reached out to The Ministry of Health regarding how they intend to address the inequity of this health indicator. We received a statement from Stephanie Chapman, the National Bowel Screening programme director, saying ‘The policy direction for lowering the age range on the National Bowel Screening Programme for Māori and Pacific Peoples directly aligns with the New Zealand Cancer Action Plan 2019 – 2029 goal of New Zealanders experiencing equitable cancer outcomes and further states that achieving equitable outcomes in the bowel screening programme is a priority. The Ministry is currently progressing the full roll out of the screening programme.’
We were unclear about if this ‘policy direction’ meant that the programme would be lowering the screening age for Māori people, or any other action to directly address this inequity. We reached out for clarification and were told, ‘No final decisions have been made, but it's important to note that our priority remains ensuring the full rollout of the screen programme throughout the country.”
The Ministry of Health released a report last year investigating this inequity in Māori bowel cancer outcomes. The report says the advisory group did not recommend lowering the screening age for Māori.
This is an example of a clear health inequity for Māori people, and a failure by the Government to address it, Gabrielle says.
“That's one of the definitions of institutional racism; inaction in the face of need.”
“It weighs on me big time, and it frustrates me. We've all got a different concept of time, and of urgency - for me this is truly urgent. I can put my bureaucratic hat on and say, let's think about things in six month increments - but I still want to be moving in each one of those six month increments, versus. ‘It’s a version of priority which says we don't want to upset anything, and we don't want to disrupt anything that's working well’. That’s a very conservative point of view, and I think you can only be that conservative if this doesn't impact on you.
“It's complete privilege. These are not conceptual people to me, these are not conceptual numbers. These are real people, and this is a real system that's causing harm to people because of its racism, and because of its lack of focus on achieving equity.”
As to whether this is being actively recognised and addressed within Government, John Whaanga, deputy director-general of Māori Health at the Ministry of Health, responded to these issues of racism and inequity, saying:
“We know there is still a considerable way to go towards both addressing inequities in health and improving wellbeing for all New Zealanders. Achieving health equity and eliminating discrimination for all New Zealanders is a priority for this Government and for the Ministry of Health.
“It’s unacceptable that current inequities in Māori health still exist which is why I took on the role of the Deputy Director-General of Māori Health at the Ministry.
“The very fact the Māori Health directorate has been reformed indicates how seriously we are about achieving equities in the health sector, and we are in constant communication with our partners in the sector to achieve the ultimate aim of improving access and achieving those equities in health.
“Two areas of immediate priority for me as Deputy Director-General of Māori Health, are enabling new initiatives through the Māori Health innovation fund – Te Ao Auahatanga Hauora Māori and boosting the Māori health workforce. Both areas received extra funding in the recent Budget 19.
“Promoting Māori Health innovation and boosting the Māori Health workforce are two ways to achieve equities and eliminate discrimination. The Ministry is also currently working on a Māori Health Action Plan for the next 5 years. One of the objectives for the development of the Māori health action plan is to address racism and discrimination in all its forms.”
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