Chapter Five
Towards Cultural Safety

There is ongoing debate surrounding the definition of Maori ethnicity. Having referred, in Chapter One, to some of the complexities involved in obtaining data on students who may enter or exit the nursing and midwifery programmes at differing stages of their emotional identity, it is worthwhile elaborating on the concept of Maori used in this work.

Kawa Whakaruruhau: Maori Issues

Definitions of Maori have changed over time. For example, according to the Williams Dictionary (Williams, 1971) the word Maori means normal, usual and ordinary (p. 179). 'Maori’ denoted ordinary citizens as opposed to non-Maori who entered their environment and were considered different and unusual (Buck, 1950). The New Zealand settler government redefined its meaning by using the word Maori for census purposes from 1858 to describe people as "half caste" Maori/European or more based on the notions of race and blood quantum. This was still in practice in the Maori Affairs Act 1953 (Mako, 1998). The Maori Affairs Amendment Act 1974 responded to Maori concerns that many Maori were not eligible to identify as Maori in relation to the Act and the census, even though they were of Maori descent, being Maori had meaning for them, and they emotionally identified as Maori. Concepts of ethnicity became accepted as more relevant and the first major change was made to the census question on race in 1976 (Reid & Robson, 1998). In 1986 the definition based on ethnicity was adopted followed by a question on self-identification in the 1991 census.

For the purposes of this work, Maori are accepted as people who have descent from a Maori and who may or may not claim that descent, or may be located at any position on the identity gamut. The emotional identity spectrum experienced by people of Maori descent is acknowledged and supported. Generally the people of Maori ancestry referred to in this study have self-identified as Maori although that identity may change according to social and emotional pressures which they may experience over their lifetimes. Statistics New Zealand (2001) acknowledges that ethnicity is a dynamic concept and that individuals can belong to more than one ethnic group at a time and can move between ethnic groups over time.
The effects of colonisation and the growing awareness through the 1970s and 1980s of the ongoing and long term impact of the colonisation process on Maori health outcomes were a critical impetus for the development of Cultural Safety. As political awareness and activity among Maori during this time began to increase, gatherings of Maori people working in, education, welfare and justice and health were also meeting together, many for the first time, to discuss those areas of concern in relation to Maori.

The attention of health authorities to the state of Maori health had been reinforced by the participants of a hui held at Hoani Waititi Marae Auckland, in March 1984. Primary Maori concerns had formerly been land, education and welfare. Now the attention turned to health. This well attended gathering of Maori health professionals was the first national hui to be held on Maori health and was a focus for a large number of concerns including the need for research, the requirement that Maori should be involved in Maori health service design and delivery, and the need for government to recognise the growing body of evidence that Maori health and disease issues were different from those of the general population.

Durie (1994) states that there were hui throughout the country in the early part of the decade which accepted a model of health incorporating, taha wairua (spiritual health), taha hinengaro (mental health), taha tinana (physical health) and taha whanau (family health), and that this became widely accepted as the preferred Maori definition of health Hui Whakaoranga also recommended that health and education institutions recognise culture as a positive resource. Spiritual and emotional factors as contributors to health and wellbeing were emphasised at the hui. Although Durie admits that the Whare Tapa Wha model is simple, "even simplistic", it had immediate appeal to Maori and pakeha alike. For example the model was adopted widely by nursing schools and formed the basis for the philosophy of the inaugural curriculum of the Waiariki Polytechnic nursing school at Rotorua which was set up in 1985. A further model appeared during this period which has enjoyed a level of acceptance, Te Wheke (Pere, 1991), which represents the tentacles of an octopus, each concerned with an aspect of health or illness or community and family.

The Treaty of Waitangi

The formal agreement between Maori hapu and the British Crown took the form of a treaty written in both Maori and English which was signed initially at Waitangi in the Bay of Islands in 1840. Later versions were signed at several other sites around the country (Appendices 3a, 3b, 3c).

Although the first article in Maori ultimately accommodated a very loosely worded transfer of sovereignty, the Treaty of Waitangi made significant guarantees of Crown protection of Maori taonga/treasures while guaranteeing that Maori also retained control over Maori resources in article two. In article three the treaty guaranteed Maori the same rights and privileges as British subjects enjoyed in 1840. In common with all treaties this one was written with the future in mind. Although the treaty was declared a simple nullity in 1877, because it had never been incorporated into New Zealand law by a specific Act of Parliament, it was acknowledged as the founding document of New Zealand in 1992 (Durie, 1994).

Contact with introduced diseases, war and poverty contributed to a dramatic reduction in the Maori population from 1769 to 1890. The Maori population, although inaccurately measured, was clearly in continuous decline. Mason Durie states that the Maori population had dropped by a third in less than a century and quoted a prophecy from 1884 in 'Whaiora’:

Just as the Norwegian rat has displaced the Maori rat, as introduced plants have displaced Maori plants so the white man will replace the Maori. (1994, p. 32)

Fortunately this prophecy was not fulfilled but the Maori population remained essentially rurally based until post 1945 when the migration to cities accelerated. As most of the non-Maori population was already urban based there was little real contact between Maori and non-Maori until the mid 1970s when Maori began to recover numbers, and make a critical impact on the social climate of New Zealand.

There has been much debate and speculation over the contemporary relevance of the treaty to health care and the application of the words of the treaty as agreed to in 1840. Debate has also been consistent over the meanings and interpretation of the differing texts in Maori and in English. Fiduciary obligations although unwritten are understood to mean that both parties must act in good faith toward each other.

The practice has emerged of extracting and addressing principles of the treaty rather than to attempting to analyse and understand the exact intention of every word in the English and the Maori texts. Although Durie states that extracting principles and applying them to contemporary health situations has its limitations, the practice has acquired popularity in assisting people to translate the treaty guarantees into possibilities for action (Durie, 1989). There are a range of principles which have been developed over time by different organisations but the ones which have acquired the most currency in daily society are the three which were produced by the Royal Commission on Social Policy (1988). They are the principles of partnership, participation and protection. The ideas behind these principles have been variously interpreted according to the organisation which has employed them.
Graphic evidence of the status of the health of Maori people was recorded in a report to the Minister of Maori Affairs called, Progress Towards Closing Social And Economic Gaps between Maori and Non-Maori (Te Puni Kokiri, 2000). Comparison with non-Maori as demonstrated in this report upholds the argument of many Maori that since the Crown took over the management of Maori health and disease status, Maori have been consistently failed by all Crown agencies concerned with health service and delivery to the indigenous people of New Zealand.

Since the Treaty of Waitangi Act 1975 the treaty has grown steadily in the public attention. Pushed largely by Maori urban activism to address the social and economic consequences of legislatively induced poverty (Durie, 1994), the establishment of the Waitangi Tribunal was seen as a significant outlet for Maori frustrations. Publicity given to the succession of cases and the landmark decisions that it made in respect of tribal claims against the Crown, enabled treaty issues to assume an importance which they had not had over the previous 100 years. The treaty became a focus for race relations activity, particularly in respect to property rights. Maori attempts to assert their arguments regarding these matters often caused vituperative comment from all levels of New Zealand society, ranging from radio talkback to the 1975 Court of Appeal decisions on the role and function of the Waitangi Tribunal.

Political issues in relation to the Treaty of Waitangi or health and economic disparity were unexplored in nursing education and evolving approaches to matters relating to the health of the indigenous people were happening from a "biculturalist or multiculturalist" angle in which the primary emphasis is on ethnicity and exotic cultural difference. All exotic or etic, outside groups of people, came to be included in the multicultural paradigm.

In New Zealand the term biculturalism came to represent the relationship between Maori and others, particularly the Crown. This gave rise to a constant argument that other cultures were not being given adequate consideration in any or all contexts in which Maori were contesting for resources or arguing for attention to Maori defined political issues. The impression was given that Maori were activating simply for their own purposes and that other cultures needed patronising and defending. The idea that there were intact groups of people which could be called cultures was considered to be commonsense and normal and was referred to in everyday conversation as though cultures were measurable and easily definable.

Many Maori have identified health as a major issue worthy of a case to be taken before the Waitangi Tribunal. Although such a case has not yet been constructed there is continuous discussion of the possibility of doing so in Maori circles. Maori nurses have been involved in these discussions at an informal level and would certainly be involved in a case against the Crown in respect to Maori health. (Waitangi Tribunal, personal communication, Wellington, 2000). Because the New Zealand public, including most Maori, had so little knowledge of the treaty, its content and its future implications, the response of the public was volatile and usually ad hoc. Loud protest erupted against Maori activism or non-Maori support for Maori activism, on the radio, in the bias of television and newspaper reporting and letters to the Editors. Cartoons which drew on negative Maori stereotypes and other media further enhanced a climate of vitriolic and angry attitudes and behaviour toward Maori attempts to make change.

Terms which applied to the study of issues of Maori health and disease varied at this period but the most commonly employed were: biculturalism, cultural differences, cultural awareness, and cultural sensitivity. None of these terms addressed the political context in which Maori ill health was happening. The political link between the treaty and its guarantees of equity including the possibility of equal health status with other New Zealanders in article three had not been correlated in the teaching of nurses. The discussion of issues of power and Maori representation in the health service lay in the very near future. It was in this climate that I first encountered classes of nursing students.