Learning from indigenous people
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7412.0-f (Published 21 August 2003) Cite this as: BMJ 2003;327:0-f
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The recent BMJ on the health of indigenous people was educational,
emphasizing the unique efforts underway in New Zealand to tackle the
inequalities of health of the Maori compared to non- Maori.
However in order to explain the origin of the discrepancies, it is
misguided to picture the idea of the noble savage perfectly in tune with
the environment, thus overly romanticizing the lifestyle prior to
colonization by Europeans.¹
The Maoris are an impressive people, world renowned for their
cultural prowess, their respect for biodiversity and their sophisticated
deployment of skills in negotiating concepts of sovereignty.
Nevertheless, humans by their mere existence are destructive to their
environment. Maori were no exception. Furthermore, in respect to land
rights, systems of land ownership under way at the time of colonization
(circa 18th century) were essentially feudal and sexist in most
civilizations.
The concepts of the Treaty of Waitangi, the quality
improvement approach, “Whare Tapa Wha” Model of Health do
incorporate the needs of Maori; in particular the spiritual element of
healing .² ³ He Korowai Oranga (Maori Health Strategy) with its core, “The
Whanau Ora” (Health and Well being of the family) is an impressive
movement. Other governments have much to learn from it. If fulfilled, it
will probably help achieve higher health standards for Maori, but the
individual rights of confidentiality prior to family involvement, have to
be also clearly defined, and upheld. These progressive methods should also
meet the rigors of audit and research.
In a parallel fashion, other societies are also seeking further
dimensions to health care, such as homeopathy and acupuncture. But can
all these demands from east and west be met satisfactorily in any society,
no matter how well integrated? In embracing Whare Tapa Wha, is there a
danger of encapsulating Maori and their lifestyle in a glass sphere?
Although partnership is a central theme of the Treaty of Waitangi, some of
the strategies may create segregation and prevent Maori from developing
along side other cultures, creating greater interdependence, and limiting
life experiences. After all adaptability and integration are key elements
to survival for any people.
The key may be to strongly encourage more Maori into the health
roles, education and research. Role models such as sports professionals,
especially rugby players may have potentially favorable influences amongst
the young, especially with regards to smoking. Perhaps looking at the
other races that have immigrated to New Zealand such as Asians who also
practise close family relationships may be also of help in addressing
health aspects of Maori.
1. Smith R. Learning from indigenous people. BMJ 2003: 327: 399.
2. McPherson KM, Harwood M, McNaughton HK. amongst the young. BMJ 2003:
327 443-444
3. Ministry of Health. Reducing inequalities of Health, Wellington:
Ministry of Health, 2002
4. The Treaty of Waitangi, www.govt.nz
Competing interests:
None declared
Competing interests: No competing interests
I have a cavil with your editorial. I believe that it is naive to say
that 'indigenous people did not destroy their environment'. In Australia
and New Zealand, at least, the indigenous peoples altered the environments
to the limits of their technology. The use of fire, predation, and the
introduction of new species all had profound effects - including
extinctions.
Nevertheless, they lived in harmony with the environment which they
had created because when they overstepped the limit they died back - or
robbed and destroyed the next clan. We have continued to develop our
technology and our abilities to alter the environment have continued.
(Perhaps such elements as the green movements and demographic trapping, as
per Maurice King, are indications that we have already overstepped the
mark, and should act accordingly to prevent disaster.)
I actually believe that it is vital to think very clearly in this
difficult area because the alternative is counter productive. I fear that,
in Australia, some of those who would help the aborigines are, in fact
their worst enemies - having contributed to the culture of dependency
against which some aboriginal leaders are now campaigning.
Yours sincerely
JRL Forsyth
Competing interests:
I have lived in Australia for 39 years
Competing interests: No competing interests
Dear Sir
You wrote that “the answer to improving the health of indigenous
people may lie less in increasing their access to modern health care and
more in their rediscovering cultural values and ways” (1) . Should this
"re-discovery" include assessment of local (traditional) health care?
Straightforward as it may seem, this was almost completely absent from the
BMJ issue devoted to “health of indigenous people”.
Today assessment of local, traditional health care is possible.
Special clinical methods have been designed and validated (2, 3). Using
these methods fosters collaboration and rational referral practices
between academic and indigenous health services, and promotes efficient
use of
modern medical services (4).
What prevails today, rejecting indigenous medicines without having
assessed them properly, is neither scientific nor rational. Furthermore,
it may result in overlooking health care that could be of definite
benefit. It may also
result in letting dangerous local treatments being used without anyone
being informed of the danger.
Some authors propose to prioritise funding of health interventions
according to proven effectiveness (5). This is inappropriate if
effectiveness has not first been searched for. So a high priority should
be to fund and perform appropriate clinical studies on indigenous health
care.
Bertrand Graz, Antenna, Geneva, Switzerland
Merlin Willcox, Research Initiative on Traditional Antimalarial
Methods (RITAM), Oxford, UK.
References:
1. Smith R: Learning from indigenous people. BMJ 327 (23 August
2003).
2.Lewith G, Jonas WB, Walach H (eds) : Clinical Research in
Complementary Therapies: Principles, problems and solutions”
Edinburgh,Churchill Livingstone, 2002.
3.Willcox ML: Guidelines for clinical studies on herbal
antimalarials. In: Willcox ML, Bodeker G, Rasoanaivo P (eds). Traditional
Medicinal Plants and Malaria. London: Taylor & Francis (in press).
4. Le Grand A, Sri-Ngernyuang L, Streefland PH: Enhancing appropriate
drug use: The contribution of herbal medicine promotion. Social Science
and Medicine 1993; 36 (8): 1023-1035.
5. Bloomfield A, Logan, R: Quality improvement perspective and
healthcare funding decisions. BMJ 2003; 327: 439-443
Competing interests:
Bertrand Graz performs clinical studies on
traditional health care in Mauritania and Mali
Competing interests: No competing interests
Who "owns" the BMJ? This question has arisen particularly in relation
to our theme issue on the health of indigenous people. Some British
doctors have protested that there was nothing for them in the issue. But
are British doctors the "owners" of the BMJ?
The legal answer to the question is "yes." The BMJ is owned by the
BMA--and so by the 120 000 members, most but not all of them in Britain.
But these doctors have inherited the journal from the much smaller number
who started the journal 160 years ago. The legal owners are "stewards":
they are not expected to cash in on their ownership but rather hand the
journal on to subsequent generations.
But isn't the true ownership broader than the legal owners? Doesn't
the BMJ--one of the four major general journals--belong to the world? I
believe it does. Many of the studies we receive and publish come from
outside Britain. Many reviewers are from outside Britain. We have more
readers outside Britain than inside it. Much of the income for the journal
comes from outside Britain, and none of it comes from BMA members. None of
their subscriptions come to the BMJ. Indeed, money flows the other way,
meaning that their subscriptions would be higher without the BMJ. And
science and health are global activities, and most of the sickness and
premature death in the world is in the developing world.
And isn't there a sense in which patients are owners of the BMJ? The
point of the enterprise is not just to amuse doctors but to improve health
worldwide.
The same goes, I argue, for the other major journals. They belong to
the world, and their legal owners are stewards--as are we, the editors.
Richard Smith
Editor, BMJ
Competing interests:
I'm the editor of the BMJ and accountable for all it contains.
Competing interests: No competing interests
An entire issue of the BMJ on the health of indigenous peoples, with
suicide mentioned only in the article by Young(1), and mentioned but
fleetingly!
Tatz(2) has recently reviewed suicide amongst the indigenous peoples
of Australia, New Zealand and North America. In summary, Australian
Aboriginal suicide rates are two to five times those of non-Aborigines,
Maori youth suicides doubled between 1984 and 1994, and suicide rates
amongst Native American and Canadian Indians are at least ten times higher
than the national rates.
How did it come about that this appalling phenomenon gained almost no
mention in the BMJ theme issue?
(1) Young, TK Review of research on aboriginal populations in Canada;
relevance to their needs. BMJ 2003;327:419-422
(2) Tatz, C Aboriginal suicide is different: a portrait of self-
destruction. Aboriginal Studies Press, Canberra, 2001
Competing interests:
PCA edited the book by Tatz referred to above
Competing interests: No competing interests
European/Pakeha is NOT an infrequently used term in Aotearoa/New Zealand. Consult a variety of formal reports and the reader will discover that ethnicity is presented as European/Pakeha (with a macron above each 'a' to indicate that the pronunciation of these vowels is long)in survey data. New Zealanders who do not identify as Maori (a macron should be above the 'a' here , too), NOR Pacific Island, and are averse to identifying themselves as Pakeha/European select "other" as a category for ethnicity. Some also go on to clarify that they identify simply as "a New Zealander". (Refer to pages 15 & 16 of the NZ Ministry of Health "Taking the Pulse The 1996/97 NZ Health Survey" (1999) which provides (courtesy of Statistics New Zealand)an explanation of the coding conventions for ethnicity.)
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
For a long time I have read and enjoyed your editorials. They have
been relevant, pithy, full of useful information and universal in their
application. Regretfully, this week's contribution does not seem to reach
your usual standard of excellence which has become the norm.
However, the third paragraph is one with which I agree
wholeheartedly; particularly the concept that spiritual oppression can
arise from cultural subjugation. I wonder how much the indigenous people
of England feel their culture is being subjugated by the present socio--
political environment.
Competing interests:
None declared
Competing interests: No competing interests
'Pakeha' is an infrequently used term thesedays to describe
Europeans.However, as the editor had felt apt to use such word,I explored
this matter.An interesting paper on the origins and meaning of 'pakeha'
could be seen by following the URL below.
http://maorinews.com/writings/papers/other/pakeha.htm
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
First you send me a patients’ edition of the BMJ. Now you send an
Aboriginal social worker’s version.
Any chance of a British doctor’s version?
Yours sincerely,
Dr N J Hague
Competing interests:
None declared
Competing interests: No competing interests
Maori Health - Rodney Hide MP
MAORI HEALTH
“Racism is the lowest, most crudely primitive form of collectivism.”
-- Ayn Rand
The National Programme’s Mana News last Monday morning interviewed
the Director of Otago University’s Eru Pomare Maori Health Research
Centre, Dr Paparangi Reid.
Here is what she had to say:
“The WHO [World Health Organisation] is very interested in New
Zealand because there has been this big increase in our life expectancy --
6 or 7 or 8 years. But the issue is all that increase in life expectancy
has been appropriated by Pakeha -- none of it has come to us. Well, I
think that is very, very greedy. I think that is a breach of …, well, we
don’t even need to go to the Treaty or Indigenous Rights, I think it is
just plainly very greedy. And not equitable.”
“What we have to recognise now is that there has been a
misappropriation of our resource, which is ours as of right, a citizenship
right in this country. And it has been stolen. We don’t need to talk about
foreshore and seabed. We need to talk about health being stolen. ‘Years
life’ being stolen. Not because of smoking, nah, nah, nah. No! Because
people get a fast track through the queue. And they ain’t brown people.
And so the privileging -- we have first of all to label it as ‘there is an
inequity’, ‘pakeha people being privileged’ and ‘they are misappropriating
resources that belong to te katoa [everyone], not to them’.”
Dr Paparangi Reid went on to declare that Maori die young from the
stress of not being looked after properly. As the show’s host Dale Husband
explained:
“Paparangi says it is not just a matter of Maori can’t secure their
rightful place in the queue, for example, for cardiac bypass operations,
but of being subjected to health-damaging stress by not having a job, the
income, the housing, the education, and so on, to avoid ill health.”
The solution according to Dr Paparangi Reid? Put Maori first:
“All the evidence that Helen Clark needed to defend ‘Closing the
Gaps’ is now available, some of it was available then, and obviously we do
need to go into a situation where we have to put Maori first in our design
of our education system, in our design of our health system, dare I say
the justice system?”
Over the last fifty years, New Zealanders’ life expectancy has
improved by six years. According to Dr Paparangi Reid, that increase has
been appropriated by non-Maori at the expense of Maori.
Maori make up about 15 per cent of the population. For Dr Reid’s
claim to be correct, non-Maori life expectancy must have increased by at
least 7 years while Maori life expectancy must have stayed the same or
deteriorated. According to Dr Reid’s thesis, the gap between non-Maori and
Maori life expectancy must have widened.
In fact, it has narrowed: from 16 years to 8 years. Maori life
expectancy over the last 50 years has improved and has done so at a much
faster rate than non-Maori. The Statistics Department declares: “A Mäori
boy born in 1996 can expect to live 67 years, 13 years longer than his
counterpart born in 1951. A Mäori girl born in 1996 can expect to live to
age 72, up 16 years on her 1951 counterpart.”
A 1999 Ministry of Health report quotes a United Nations study that
describes the such improvement in Maori life expectancy as “spectacular”.
It’s especially spectacular when compared to pre-European times. The
Oxford History of New Zealand records:
“People in pre-European New Zealand were likely to die relatively
young. An average adult age at death of thirty years has been suggested,
although this differed from one community to another. At the burial ground
of Wairau Bar in Marlborough, in use between the twelfth and fourteenth
centuries, the average adult age at death was twenty-eight, whereas the
that of the people in Palliser Bay in the same period was thirty-eight”.
Note that this is adult age of death. It ignores infant mortality.
Maori life expectancy pre-European must have been very much lower than
thirty.
But Dr Paparangi Reid is not interested in facts. She is interested
in claims of racial injustice. Her interest is of one race ripping off
another even to the extent of stealing another people’s life expectancy to
their own advantage. As if such a thing were possible. I would have
thought that a medical doctor and researcher would appreciate that of all
things life expectancy is not a fixed resource that we can divvy up
amongst the various races.
But Dr Reid is so embroiled in the language and technique of racial
claim that she applies it even to the length of our lives. One race has
stolen years from another. It doesn’t matter that it’s not possible. It
doesn’t matter that the facts say otherwise.
It’s all non-Maori people’s fault. And the racist analysis leads
inevitably to a racist conclusion: put Maori first!
Such nonsense divorced from all facts percolates around and has
political and practical consequence. In August Hon Tariana Turia had a
piece published in the British Medical Journal titled “Tribal Health
Policy in New Zealand”.
She explains, “Conventional Western medicine has been unable to close
the disparities in mortality and health revealed in official statistics”.
She goes on to justify our government’s “for Maori by Maori” health policy
based on precisely Dr Paparangi Reid’s type of analysis.
When asked in Parliament whether she accepted Dr Paparangi Reid’s
thesis that Pakeha have “stolen” Maori life expectancy, Hon Tariana Turia
replied, “I think we need to listen carefully to the arguments that have
been put forward by knowledged experts like Dr Paparangi Reid … and I am
certainly not prepared to ignore such expertise”.
The problem is this: politics can ignore reality. So too it seems can
health research. But a person’s health can’t. The reality of disease and
ill-health is what kills us.
We can ignore facts if we choose to. But that doesn’t change them.
Competing interests:
None declared
Competing interests: No competing interests