Culture Matters

Don Brash says, “I can’t think of anything in health which is specifically Maori.” So why treat Maori differently?

Listener: 20 March, 2004.

Keywords: Health; Maori;

Sadly, the proportion of Maori who smoke, and as a consequence suffer the diseases from smoking and die early, is higher than that of Pakeha. Moreover, although there has been some success from the campaign to reduce smoking, it seems to have had little impact on Maori rates. So it makes sense to have a specifically Maori anti-smoking campaign, administered by Maori. One of its successes has been that most marae now ban smoking. No Pakeha-dominated organisation could have achieved such an outcome.

Culture matters in public health, so it makes sense to deliver it via culturally sensitive agencies. As much as their grandparents may be dismayed, we will only successfully tackle teenage smoking when the campaign engages with the young on their terms. Similarly, public health campaigns concerned with alcohol misuse and obesity, which impact differentially on Maori, require an engagement with their cultural dimension, too. Majoritarian public health programmes miss the minorities.

This is not to say any Maori provider will do. Some are probably ineffective, but so are some non-Maori ones. When the government funds a provider, it owes it to the taxpayer and the client population to make sure the money is well spent. But that is a case for carefully choosing Maori (and non-Maori) providers, not for eliminating them.

Sometimes public policy uses “Maori” as a substitute for a cluster of variables, or because it is the most effective targeting variable available. The impressive “Decades of Disparity” research programme, led by Dr Tony Blakely of the Wellington School of Medicine, has shown that not only do Maori have a shorter average life expectancy than non-Maori, but the age level has also stagnated while the rest of us have had increases. The higher Maori morbidity cannot (yet) be explained by known differences, such as age, gender, location and socioeconomic status.

The Ministry of Health therefore gives Primary Healthcare Organisations (in which GPs and other health professionals serve) a financial premium in proportion to the number of registered Maori (and Pacific Islanders). The ministry also varies its payments by the practice’s composition of age, gender, socioeconomic status and High User Health Cards, trying to better target the available funds on the basis of health need. If they did not, PHOs with more of the needy would have heavier workloads for the same amount of public funding. But in each case the categories are only an indicator for underlying health factors that cannot (yet) be identified (or be effectively targeted).

Were there better indicators, the ministry would use them. Its use of Maori is not conferring racial privilege but a pragmatic response to measured differentials in morbidity and mortality. (It insists that PHOs may not charge their patients differently by race.)

Sometimes we treat people differently by social characteristics. Years ago, when low proportions of women were recruited to medical schools, it was argued that a medical profession dominated by males would not be fully sensitive to the needs of half the population, no matter how hard it tried. (Alas, subsequent events – say, over cervical smears – suggested that not all tried hard enough.) Since there were far more students who met the minimum academic standard for a degree in medicine than could be taken on, it made sense to select future doctors to better reflect the overall population, rather than just by highest academic achievement. The gender imbalance has been corrected, but the same principle applies for other groups, such as Maori. (Although I have the greatest compassion for the individuals, I celebrate meeting doctors who are blind or have multiple sclerosis or some other handicap, because I know they enrich their profession’s understandings of their conditions.)

Should one of two people in identical medical situations get preferential access to treatment? Suppose one is richer than the other. Should the rich be treated because they can purchase therapies that the poor cannot? I have agonised over this for decades. My current view is that privately purchased medicine is in the public interest if the rich pay all the costs themselves (so there is no government subsidy) and they don’t crowd out the treatment of others (but entice more resources into the system).

So, how to deal with the following situation? Two patients require an expensive but necessary treatment. But there are only sufficient resources for one of them. Their medical needs are identical, as are the various social characteristics (such as age) and family circumstances. One is Maori and the other is Pakeha. Who should we treat?

The Maori, because of being tangata whenua? Wrong.

The Pakeha, because they are from the dominant culture? Wrong.

Flip a coin? Wrong.

The correct response is for the government to provide more resources, even if that means higher taxes.