WHAIORA: MAORI HEALTH DEVELOPMENT by MASON DURIE OXFORD UNIVERSITY PRESS, 1998 (2ND EDITION).
One small measure of the influence of this book on Aotearoa New Zealand can be found inside the title page, which reveals that it was reprinted four times over the four years between the first edition of 1994 and this revised edition.
Whaiora was launched at the Hui Whakapumau of 1994, in a climate where the Maori present were both deeply aware of the opportunities being offered by the 1993 changes to the health system, and concerned about the impacts that years of economic shocks were having on the health of iwi, hapu and whanau. Whaiora could not have been published at a better time.
The many interwoven themes can best be summed up in Durie's own introduction: "Maori health development is essentially about Maori defining their own priorities for health and then weaving a course to realise their collective aspirations" (p.1). The book reminded us that in Te Ao Tawhito (the world before European arrival) an integrated view of health was central to the functioning of Maori society. Whaiora told stories, some known to many and some new or freshly told, of the tupuna who fought for the right to define what Maori health was, and who struggled to realise their visions. It also offered a series of frameworks, captured in the crisp tables that dotted the text, to help the growing body of Maori health workers, researchers and managers.
There are few academic books published in the last decade that have been as useful. This is why the revision has more significance than simply updating a textbook. While much of the original text remains, Chapters Nine, Ten, and Eleven have been substantively rewritten and expanded to capture developments and changes since 1993.
Whaiora opens with Kimiora, the introduction, which sets out the book's themes, as well as its underpinning assumptions. For Durie:
Enough is known about health to justify an integrated approach to cultural, social and economic development and to recognise the futility of designing highly sophisticated treatment procedures while blatantly ignoring educational failure or inadequate housing. (pp1-2)
From the beginning, Durie also makes clear his view that that spirituality is an essential component of health for Maori.
The term "development" is also discussed. This is important to reframe the concept for some readers who may equate "development" with "economic development". To Durie, "development" is not simply a goal, but a way of approaching Maori health, in which Maori have control over the strategies used, manage and deliver their own services taking a preventive and integrated approach, and work in partnership with the State.
What follows is a short but powerful history of Maori health from settlement to the 1980s: Te Ao Tawhito; Nga Tau Hekenga; and Te Hokinga Mai o Te Mauri. Many readers, Maori and non-Maori, have found these chapters the most valuable reading, as they not only describe, but demonstrate, the Maori view that one must look back to look forward. In themselves, they provide a turangawaewae, a place on which to stand.
Te Ao Tawhito looks at pre-European health systems in a fresh light. Tapu and noa, deep concepts which have often been misinterpreted, are seen as underpinnings of a system of "public health" in which spiritual and social health are linked with elements of physical health. Tapu, placing a person or place "off limits" for a period of time, serves to help the community avoid infection, allows space for recovery from birth, illness or loss, and conserves food resources. Noa was not, as often described by missionaries, something lesser, but the complementary and necessary state of "relaxed access".
Chapter Three, Nga Tau Hekenga, is only 12 pages long, but gives an extremely clear and powerful description of the effects of colonisation on Maori society. It is well summed up in its English subtitle, "Depopulation, disease and dispossession". Between 1800 and 1900, the balance between the dimensions of mana atua (the power of the spiritual realm), mana tangata, mana whenua, and mana Maori (Maori control over their own matters, the Maori political dimension) was overturned. While the consequences for population numbers have been well recognised, Durie also gives an equal place to the effects of the loss of mana atua.
Te Hokinga Mai o te Mauri: Recovery and Growth, characterises the twentieth century through three patterns of Maori participation. In the early 20th century, it was rangatira, leaders such as Apirana Ngata, Maui Pomare, the first Maori medical officer in the Department of Health, Peter Buck (Te Rangihiroa), and Te Puea Herangi who led the way. They were as Durie says "healers first", some trained in Pakeha medicine, others with deep practical experience of healing. Durie presents a balanced view of their actions, some of which (such as supporting the 1907 Tohunga Suppression Act) have been negatively characterised by contemporary Maori.
The growing leadership of women characterised the period from the 1930s to the present. Maori women showed a capacity to "work between two worlds", to effectively liaise between a largely rural and conservative Maori society and the expanding domains of a health world captured by health professionals and powerful health institutions" (p.46). Whaiora provides a fascinating description of the origins and role of the Women's Health League, the first large-scale Maori women's health organisation, as well as the better known Maori Women's Welfare League.
This period also saw an increase in the number of Maori entering those health professions. Durie reminds us of the importance of the Maori district and public health nurses, among them my whanaunga Martha Te Punga, who were "knowledgeable in tikanga Maori and well respected in nursing circles." This section may sometimes feel a little like a catalogue of names, but it provides a rare opportunity to see the achievements of these people and their whanau in the context of their times.
The 1975 Hikoi against the alienation of Maori land is represented as beginning a new period of mana Maori. Durie provides case studies of three Maori health initiatives -- Waiora; the Rapuora research project on Maori women's health; and Tipu Ora, a well-child and whanau support programme that is still running. Nga Ringa Whakahaere o te Iwi Maori brought together Maori healers and marked the "public re-emergence of Maori healers". Durie sets this in the context not only of mana Maori, but of the loss of faith by Maori and others in Western models of medicine.
The book then takes a major shift in perspective, to outline Maori ways of conceiving of health, the application of the Treaty of Waitangi to health, and the relationship of health and biculturalism. On first reading, I found this shift in tone from the historical to the theoretical slightly disconcerting, but readers interested in any aspect of social policy should find this essential reading.
Tirohanga Maori discusses and contrasts the different models of Maori health developed and promoted over the last two decades. As Durie has been the main developer of the Whare Tapa Wha model, he gives it particular attention, but also discusses other perspectives, focusing on the many commonalties and the way in which they fit into Maori views of the world as a whole.
Durie compares the different ways in which the Treaty has been analysed. He goes on to compare Treaty-based approaches with the development of the concept of biculturalism, setting it in the context of changes in official government policy. It is a pity that Whaiora went to print before it was able to include discussion on the impact of the Waitangi Tribunal report on the claim of Te Whanau o Waipareira, which has extended thinking around the Treaty directly into the realm of social policy and delivery of services. Durie has since expanded on the models of social policy outlined here in Te Mana, Te Kawanatanga: the politics of Maori self-determination, which in many ways should be read in conjunction with Whaiora.
Most of the new material can be found in the three final chapters - one on the background to, and results of, the 1991 health reforms, and two which contrast government objectives for Maori health with priorities as Maori see them. As noted above, while Maori had mixed feelings about the health reforms, many iwi, hapu and non-tribal groups worked hard to seize the positive opportunities the reforms offered.
Much of this section describes key events and initiatives, which represents another shift in style. I would have liked the revised Whaiora to include more about the exponential increase in "by-Maori-for-Maori" providers since 1993, the challenges faced, and what Durie considers the lessons to be applied in the future. It would also have been interesting to have more analysis of the impact of new structures, particularly joint ventures between iwi and the Crown, and Maori health purchasing organisations.
The final chapter returns to Maori perspectives, offering Durie the chance to strongly state his own conclusions. While pointing out that, as measured by mortality and morbidity Maori are healthier today than ever, he maintains that "there is now a great need to aim for standards of health which transcend physical dimensions and encompass those aspects which have been relatively neglected: wairua, hinengaro and whanau."
Despite my reservations on the shifts in tone between different chapters, Whaiora persuasively develops and reinforces the links between events, people and ideas. Durie clearly shows that from first contact with Europeans to the present day, Maori have maintained the same broad aims -- autonomy, self-determination, keeping the old while learning from the new.
It is perhaps the major accomplishment of Whaiora that, without denying or minimising the problems that Maori face in achieving our aspirations for health, it leaves the reader feeling affirmed, and positive about what has been and can be achieved.
In doing so, it continues in the tradition of Maori leaders such as Apirana Ngata, who in 1899 wrote to his friend Peter Buck, later the first Director of Maori Hygiene for the Department of Health:
I hope you are acquiring knowledge of Maori life among my people -- don't pick holes in them, we have done that time and again, but seek rather for the good qualities such as may be perpetuated for the good of the race.
Keriata Stuart Ministry of Health