A growing body of New Zealand research has found links between racism and health, which show, among other things, that negative health outcomes are not solely reducible to socio-economic status. Racism is also a key determinant of people’s experience of health services. Taken together, these studies provide compelling evidence of racism as a major determinant of negative health outcomes and ethnic inequalities.
A 2006 study (Harris et al) found that racism, both interpersonal and institutional, contributes to Māori health losses and leads to inequalities in health between Māori and Europeans in New Zealand.83 Their findings suggest that the experience of racial discrimination may potentially be a major health risk that contributes significantly to ethnic inequalities.84 Harris et al argue that interventions and policies to address health inequalities must take into account the health effects of racism.
The wider social and economic context does have a role to play in perpetuating disadvantage between ethnic groups. Researchers in the Decades of Disparity (2006) series analysed the ways in which structural reforms combined with global economic downturn significantly disadvantaged Māori and Pacific peoples and worsened health outcomes during the 1980s and 1990s. Māori life expectancy, for example, stagnated in the 1980s and early 1990s, while non-Māori life expectancy showed strong increases. The structural reforms of the 1980s and early 1990s, and in particular the high unemployment rates that peaked in 1991-92 at 25% for Māori compared to 8% for European, almost certainly contributed to the divergence of Māori and non-Māori life expectancy trends in the 1980s and 1990s.85
In December 2009, one of the Decades of Disparity researchers, Professor Tony Blakely, warned that the most recent economic downturn would disproportionately impact Māori and Pacific peoples and could lead to increased suicides. The recession was also likely to slow improvements in Māori and Pacific health.86
Using data from the 2002/03 and 2006/07 New Zealand Health Surveys, a University of Otago and Ministry of Health study published in 2011 found that, controlling for other socio-economic variables, experience of racial discrimination was linked to a range of negative health outcomes and risk factors. Their findings were consistent with international findings on the links between racism and negative health outcomes. Reported experience of racial discrimination was measured in both surveys and covered five items: experience of an ethnically-motivated physical or verbal attack; and unfair treatment because of ethnicity by a health professional, in work, or when gaining housing. Reported experience of racial discrimination increased between 2002/03 (28.1% ever) and 2006/07 (35.0% ever) among Asian peoples but remained largely unchanged for other ethnic groupings (Maori 29.5%, Pacific 23.0%, European 13.5%). Experience of racial discrimination was associated with all negative health measures except excess body fat. The authors concluded that “racial discrimination experienced across a range of settings has the potential to impact on a wide range of health outcomes and risk factors”.87
A further 2012 study using data from the 2006/7 New Zealand Health Survey found that racial discrimination in health care and other domains was associated with lower odds of breast and cervical cancer screening among Māori women. Racial discrimination – both in general and specifically by a health professional – was associated with negative patient experiences for all participants.88
A 2012 University of Auckland study, using data from the Youth2000 survey, researched the relationship between ethnic discrimination and health outcomes among secondary school students in three areas: unfair treatment by the police, unfair treatment by health professionals, and bullying. Pacific, Asian, Māori and other ethnic participants were significantly more likely to report ethnic discrimination by health professionals than New Zealand European participants. The study found that students who reported ethnic discrimination were more likely to report fair/poor self-rated health, have experienced significant depressive symptoms and be cigarette smokers. Again, these findings are consistent with international studies.89
Culturally-specific health provision
Despite a growing body of research that shows that socio-economic deprivation and monocultural approaches are key factors in persistent ethnic disparities in health, public debate on the issue is still sometimes explained using a “deficit theory” approach i.e. placing the blame on the victim by claiming that individual choices or cultural differences results in poor health outcomes. Health researchers Papaarangi Reid and Bridget Robson suggest that New Zealand’s policy focus on universal health provision, i.e. providing the same service to all irrespective of socio-economic status or ethnicity is at fault. Universal health provision:
assumes that everyone has equal access to services and ignores the obstacles faced by ethnic groups (such as Māori and Pacific peoples) in accessing services. The adoption of a universal approach to service provision both legitimates the non-recognition of ethnic disparities and privileges Pākehā. In so doing, it provides evidence of institutional racism. 90
Several examples of culturally-specific health initiatives provide evidence that shifting away from a universal health provision focus has benefits for Māori, Pacific and Asian communities. Researchers Tony Blakely, Don Simmons and Norman Sharpe describe the benefits of health promotion and screening programmes that include tailored components for Māori and Pacific populations:
Pacific health provider development has also progressed in leaps and bounds. Many – if not just about all – major health promotion programmes and screening programmes include tailored components for Māori and Pacific audiences, for example Māori language components of Quit campaigns. The One Heart Many Lives Programme has been a particular success in heart health promotion focused primarily on Māori men.91
Recent health literature outlines the importance of developing and applying culturally appropriate health research and practice frameworks.92 Specifically, this literature highlights the limited ability of Western frameworks and philosophies to understand and effectively address non-Pākehā health concerns, a concern echoed in the Waitangi Tribunal’s Ko Aotearoa Tenei report. Professor Mason Durie’s holistic health model of wellness – Te Whare Tapa Whā – employs a Māori philosophy of health—one that moves beyond physical health as the sole determinant for wellbeing. Te Whare Tapa Whā describes four cornerstones of Māori health: whānau (family health) tinana (physical health) hinengaro (mental health) and wairua (spiritual health). Durie applies Māori conceptual tools to understand and explain Māori experiences. This research illustrates the potential of adopting culturally-specific frameworks and worldviews within existing health systems as a promising approach to addressing health inequities.
Promising initiatives to address structural discrimination including the Whānau Hauora Village initiative are discussed in the case-studies following this systemic discussion.