Issue 3 • 2021

Māori Health Equity: Building Cultural Safety into Clinical Practice

In March, an article was published detailing racist remarks made by a Christchurch urologist at the Annual Scientific Meeting held in Queenstown, Aotearoa New Zealand in November 2020. A member of the national Māori cancer group Hei Āhuru Mōwai, and the sole Māori delegate in attendance laid a complaint with the Urological Society of Australia and New Zealand. The urologist apologised to the complainant and the Māori community for his remarks. What followed is described by the urologist as a “huge journey” of learning and confronting his personal biases.

His journey would not have started without the free cultural labour provided – or rather, necessitated – by Hei Āhuru Mōwai in highlighting the problematic comments. But by zooming in on a privileged individual, instead of placing racism within the Aotearoa New Zealand health system at the forefront, the narrative was re-centred: a non-Māori practitioner was given the platform and agency to determine what should happen next, at the expense of Māori.
Once again, Māori doctors were left to challenge the blatantly racist, public-facing attitudes towards Māori, and then be expected to teach non-Māori how to be anti-racist.
Dr Cheri Hotu, Deputy Chair of the Māori Health Committee (MHC), led the development of an open letter from the Committee to call for change from within the medical profession. The MHC chose to submit their letter to the New Zealand Medical Journal (NZMJ), a widely read and respected publication in the Aotearoa New Zealand health sector. This enabled the MHC to write deliberately and directly to medical practitioners, calling for a pro-equity, anti-racist and Te Tiriti-centred health system and workforce.
The MHC has had previous success in using Open Letters as a strategy when advocating as a collective. In 2020, the Committee’s letter criticising Otago University’s decision to cap the number of Māori students entering their medical program gained significant attention from the media, academics and colleagues in the health sector.
The letter to the NZMJ uses the metaphor of an iceberg, to describe how single incidents of racism are highlighted at the expense of the “hidden substructure of power and culture that form and reinforce” systems. Focusing on the actions of individuals like the urologist serve only to chip away at the tip of the iceberg, failing to address the deeper systemic, structural, societal and institutional determinants which establish the conditions that condone racism. To actualise ingrained respect for Tangata Whenua and reaffirm Te Tiriti o Waitangi, an upheaval of the health sector is required. The iceberg must be melted.
The letter calls for all who comprise the health sector to take responsibility as governing institutions duty-bound to create the best health outcomes for Māori. This is especially significant as Māori die, on average, seven years younger than non-Māori. Building cultural safety into clinical practice will guide the way the health sector challenges prevailing sub-structures of power, bias and privilege that comprise the base of the iceberg.
“Many of the existing systems and structures within the health sector in Aotearoa are based on a colonial ideology of superiority and privilege of western knowledge and approach. Over many years, this has served to differentiate access to healthcare for different groups, leading to inequitable health outcomes where Māori are perpetually disadvantaged.” – Dr Cheri Hotu, Deputy Chair of the Māori Health Committee.
In Aotearoa New Zealand, Te Tiriti o Waitangi is a critical foundation of the health sector. Between the letter’s initial drafting and its publication in June 2021, the government announced a significant program of health sector reforms. Key to these reforms is the establishment of a Māori Health Authority with full commissioning and funding remit. As a provider of medical training, the College has a responsibility to adhere to the principles of Te Tiriti and is accountable to the standards set by the regulator, the Medical Council of New Zealand. Te Manatu Hauora, the Ministry of Health, as the funder of District Health Boards, which are the major employers and training settings for College trainees and Fellows, also work to a clear Te Tiriti o Waitangi framework. Dr Hotu sees an opportunity for the College to challenge and decolonise the existing systems and structures in the Aotearoa health sector. “The RACP has an important role to play in advancing justice and equity for Māori with regard to health outcomes by supporting the deconstruction and decolonisation of these existing systems and structures, and by advocating for their reconstruction in which Indigenous perspective, influence, self-governance and self-determination are embedded into the organisational framework.”
In 2019 Te Kaunihera Rata o Aotearoa, the Medical Council of New Zealand, refreshed its standards for medical practitioners on cultural safety, as well as publishing a peer standard, He Ara Hauora Māori, A Pathway to Māori Health Equity, saying: “When considering the needs of your patients’ cultural safety requires you to reflect on, take ownership of, and consider in your practice … challenging the cultural bias of individual colleagues or systemic bias within health care services, which may contribute to poor health outcomes for patients of different cultures.”
Confronting your own personal biases, privilege and power can be uncomfortable for some. But why is it uncomfortable? Is it the realisation that – whether intentional or not – you are complicit in the systemic contempt towards Māori? Perhaps there is anxiety around challenging the existing structures you have worked within for many years, or maybe melting the iceberg simply seems like a mammoth task? Whatever the case, it is only through sitting with this discomfort that medical professionals can begin truly reflecting on and understanding how these prejudices reinforce the iceberg’s base. To start, we encourage you to read some of the RACP’s own current documents in this area: the Indigenous child health in Australia and Aotearoa New Zealand statement and the Indigenous Strategic Framework 2018-2028. We also encourage you to go beyond this. Learn from and listen to Māori voices to ensure your reflections are inclusive, culturally competent, and safe. Since publishing the letter, Dr Hotu has welcomed the outpour of support from RACP Fellows and trainees, saying that “Our community of RACP Fellows and trainees have responded to our open letter with overwhelming support, advocating for the dismantling of the existing systems and structures within the healthcare sector that uphold institutional racism and inequitable health outcomes, and providing resolute support to shift to a new paradigm where robust anti-racist and pro-equity policy and cultural safety measures are incorporated into health organisations and services.” The persistent and partnered work non-Māori do now towards positive change is needed. It must accumulate and accelerate. The end goal is for the health sector and medical professionals to do their part in instating pro-equity and anti-racism policies that will see better treatment and outcomes for Māori interacting with and working within the health system. Once we begin to do this, the iceberg will begin to melt.
© 2021 The Royal Australasian College of Physicians