Tirohanga Mäori By Mason Durie

Tirohanga Mäori by Mason Durie  
Extracts from Chapter Five of Mason Durie's book 'Whaiora'
(reproduced with the author's permission)

Tirohanga Mäori
Mäori Health Perspectives
 

At the opening of the Hui Whakaoranga, a national Mäori health conference held on the Hoani Waititi Marae, Auckland, in 1984, the Hon. Ben Couch, Minister of Mäori Affairs in the National Government, declared,

'...there is no such thing as Mäori health or Pakeha health; there is only people health'.

He went on to ascribe differences in health standards to self-inflicted lifestyle choices,

'...most people who enjoy good health have earned it. The rules are the same for people of all races; good eating, plenty of sleep and exercise, and moderation in all things'.¹

His views were not atypical of the era but they were out of step with Mäori thinking in two respects. First, they ignored Mäori experience and the growing body of evidence which linked culture and health; and, second, they disregarded socio-economic status as a significant determinant of good health, quite apart from individual motivation.
Over the succeeding two days the Hui Whakaoranga rejected the notion that cultural factors were irrelevant to health and concluded on quite a different note, recommending that 'health and educational institutions recognise culture as a positive resource' and that 'the feasibility of including Mäori spirituality in health education programmes in schools and in tertiary educational institutions be investigated'.²

Illness And Treatment
Prior to 1976, professional and academic interest in Mäori perspectives on health and sickness tended to confine discussion to particular clinical syndromes which were unique to Maori and of anthropological as much as medical interest. Makutu and mate Mäori, for example, attracted considerable comment from Western-trained psychiatrists, though tended to be reinterpreted as superstitious phenomena and of doubtful diagnostic significance ^3,4.  Mäori concepts of illness were increasingly reinterpreted by the medical anthropologists in mental and psychic realms, scarcely relevant to the vast majority of human illnesses and hardly applicable to contemporary times. It was left to Mäori writers to point out the continuing relevance of culture to illness and treatment, and to provide some balance for the more esoteric ideas which had appeared in the earlier medical and scientific literature. The process started with an examination of medical practice and hospital procedures to determine the significance of culture to Mäori patients in everyday situations. Durie concluded that, although Mäori were more often than not Westernized, or at least appeared to be, cultural heritage continued to shape ideas, attitudes, and reactions, particularly at times of illness. 'The concepts of tapu and the perception of illness as an infringement against tapu are central to much of the anxiety and depression which surround the Mäori patient while in hospital. Family involvement at times of illness is likewise a very traditional and culturally necessary attitude which must be recognised in the management of the whole patient and not just his impaired organ.' ⁵

The relationship between tapu and noa, and explanations of illness based on a postulated breach of tapu, continued to have meaning for Mäori and therefore had implications for doctors in the management of Mäori patients as well as the care of the deceased as long as they were still in hospital custody. Because early retrieval of a relative's body was critical to uphold the mana of the family and the individual, mourning Mäori families were grossly offended if the body were not released within twenty-four hours of death. Post-mortem delays, or simple administrative inefficiencies, could add immeasurably to the grief of an already distressed family.⁶

Tipene-Leach, writing about aspects of the doctor-patient relationship, described a number of sensitivities and behaviours relevant to communication during a clinical examination.⁷ For instance, immediately asking patients to reveal their names, without any preliminary remarks, could lead some Mäori to feel threatened even before the examination had commenced. Similarly, expecting a Mäori patient to engage in direct eye-to-eye contact could be interpreted as an invitation to demonstrate bad manners since looking an older person in the eye was a sign of haughtiness or disrespect. Various parts of the body were also described as having special significance, though not necessarily at a conscious level. Medical or nursing interventions involving the head, sexual organs, hair, and nail clippings, required a measure of caution and a greater degree of circumspection than was customary in busy hospital wards.

The gradual introduction of Mäori concepts into medical routines was not entirely welcomed, but nor was it dismissed outright. By the mid-1970s there was some tentative recognition that ethnicity and culture had implications for health. Mäori views, though not always understood, were often taken on board at face value, even though they could not be rationalized in medical terms. Moreover, discussions of similarities between tohunga and doctor in the New Zealand Medical Journal had generated sympathetic interest.⁸ Both, it seemed, were experts in history-taking as a prelude to making a diagnosis; both took extensive family histories (tohunga more than doctor); both employed specific treatment methods; and both recommended periods of rehabilitation. By removing Mäori concepts from the realms of the supernatural, and emphasizing their continuing importance even when a patient did not profess to subscribe to them, Western trained health professionals were more able to appreciate their significance and respect them.

Several views emerged, but one which subsequently gained wide acceptance as 'the Mäori health perspective' was a four-sided health construct, later known as whare tapa wha (a four-sided house).¹⁰ Though often described as a traditional Maori approach to health, more correctly it was a view of health which accorded with contemporary Mäori thinking. Its ready acceptance by Mäori was to some extent proof of that. The characteristics of whare tapa wha are shown in Table 12.

The Whare Tapa Wha Four-Sided House
 

Table 12: The Whare Tapa Wha Model

	Taha Wairua	Taha Hinengaro	Taha Tinana	Taha Whänau
Focus	spiritual	mental	physical	extended family
Key Aspects	the capacity for faith and wider communion	The capacity to communicate, to think and to feel	The capacity for physical growth and development	The capacity to belong, to care and to share
Themes	Health is related to unseen and unspoken energies	Mind and body are inseparable	Good physical health is necessary for optimal development	Individuals are part of wider social systems

A further distinctive feature of taha hinengaro is its relevance to both thoughts and feelings. While Western thinking distinguishes between the spoken word and emotions (and generally encourages the word more than the feeling), Mäori do nor draw such a sharp distinction. Communication, especially face-to-face, depends on more than overt messages. Mäori may be more impressed by the unspoken signals conveyed through subtle gesture, eye movement, or bland expression, and in some situations regard words as superfluous, even demeaning. Emotional communication can assume an importance which is as meaningful as an exchange of words and valued just as much. Condolences, for example, are frequently conveyed with tears; infrequently with words. So, when Mäori children are chided by their teachers for showing what they feel, instead of talking about their feelings, they are not only made to feel unworthy (of their feelings) but must also contend with a sense of frustrated expression.

The fourth dimension of health, taha whänau, acknowledges the relevance of the extended family to health. There are at least two important considerations. The first is that the family is the prime support system for Mäori, providing care and nuturance, not only in physical terms but culturally and emotionally. Reported rises in the prevalence of family dysfunction including signs of abuse, do not lessen the point but underline its significance.¹⁷ Mäori still maintain that ill health in an individual is a reflection on the family and may well blame a family for allowing a person to become ill or to die, even when there is no direct causal link. The practice of muru is still observed in some areas. When there is evidence that a lack of quality care by the family has contributed to death, neighbours and more distant relatives may seek retribution by removing family property or personal belongings, especially when the deceased is a community leader. Similarly, in cases of child abuse or neglect the extended family may take it upon themselves to remove the boy or girl from parental custody and take over the caring role. Parental rights often tend to be seen as secondary to the interests of the whänau or even the tribe to ensure that future generations are protected.

A second consideration of taha whänau relates to identity and sense of purpose. The much-lauded state of self-sufficiency or self-realisation does not convey a sense of health to Mäori. Quite the reverse, since an insistence on being overly independent suggests a defensive attitude, while a failure to turn to the family when the occasion demands is regarded as immaturity, not strength. Inter-dependence rather than independence is the healthier goal. Sometimes this goal clashes with the European regard for independence in teenagers as 'one of critical developmental tasks of adolescence, ...a fundamental building block of health'.¹⁸

Even in modern times a sense of personal identity derives as much if not more from family characteristics than from occupation or place of residence. Interest in family and tribal background rivals personal qualifications or achievements so that credibility, certainly in Mäori settings, depends on an individual being able to make the links and demonstrate that there is active whänau and tribal support. On that basis, it has become a common occurrence for family members to accompany job-seeking applicants to an interview. Their role is a dual one: to convince the interview panel that their relative is the best person for the job, but also to ensure that the job itself is suitable and not likely to lead to exploitation, unfulfilled expectations, or disrespect. There have been instances when an applicant has been successful but the family, unhappy about the interview, has counselled against accepting the position. Similarly, there are numerous anecdotal accounts of candidates being passed over because of the family's confronting attitude during the interview.

Underlying the whare tapa wha model is the consistent theme of integration. Individual health is built into a wider system, the boundary between personal and family identity being frequently blurred. Similarly the divisions between temporal and spiritual, thoughts and feelings, mental and physical are not as clear-cut as they are have been in Western thinking since the advent of Cartesian dualism. ¹⁹
Mäori interest in redefining health in their own terms and reclaiming a positive role in shaping health services was accelerated when the whare tapa wha model was introduced. It was simple, even simplistic, but that was also its appeal. In addition, it appeared at a time when Mäori were debating the general direction which health services were taking. Widespread concern had focused on three issues.

First, Mäori were not impressed by the overemphasis on physical aspects of health with its biological constructs and increasing preoccupation with cellular phenomena. Nor for that matter were a number of other New Zealanders. At a national conference to consider the role of the doctor, holistic care was emphasized to balance a perception that many doctors had acquired too narrow a focus, their work often lacking ecological and caring dimensions. 'Because the scientific and technical aspects of practice cannot he separated from human concerns and social skills, particular attitudes are required: the readiness to treat people as equals; empathy; willingness to share information two ways; and a recognition that patients have a responsibility for their own health.' ²⁰

Second, many Mäori felt that their relationship with health professionals, and with the health system generally, had become strained. Rightly or wrongly a feeling of alienation had arisen, not necessarily because of poor access or even inadequate care, bur mainly because there was a lack of shared decision-making and limited recognition of Mäori views. The more professionals acted as if they knew best, the less tolerant Mäori became. Surely, they argued, Mäori health belonged to Mäori people. Mäori health perspectives such as whare tapa wha were welcomed because they provided the necessary framework within which a semblance of ownership over health could be entertained.
Third, despite a century and a half of colonization, Mäori remained convinced that good health could not be gauged by simple measures such as weight, blood pressure, or visual acuity. Spiritual and emotional factors, though more difficult to measure, were equally important.

Te Wheke
There were other Mäori health perspectives which gained acceptance in the 1980s. One of these, te wheke (the octopus), was discussed by Pere at the Hui Whakaoranga in 1984. In order to illustrate the main features of health from a Mäori family perspective, she compared health to an octopus.²¹ Each of the eight tentacles of the octopus symbolized a particular dimension of health while the body and head represented the whole family unit. The intertwining of the tentacles indicated the close relationships between each dimension.
Like te whare tapa wha, the model included wairuatanga (spirituality), taha tinana (the physical side), hinengaro (the mind), and whänaungatanga (the extended family, similar to taha whänau). The other dimensions were: mana ake, the uniqueness of the individual and each family and the positive identity based on those unique qualities; mauri, the life-sustaining principle resident in people and objects, including language; ha a Koro ma a Kui ma, literally the breath of life that comes from forebears and an acknowledgment that good health is closely linked to a positive awareness of ancestors and their role in shaping the family; whatumanawa, the open and healthy expression of emotion, necessary for healthy human development; and waiora, total well-being for the individual and the family, represented in the model by the eyes of the octopus.

Nga Pou Mana
In 1988 the Royal Commission on Social Policy described another set of values and beliefs - four supports, nga pou mana - as pre-requisites for health and wellbeing. ²² As with the other models a set of interacting variables was proposed, the combination leading to individual and group well-being manifest by the retention of mana, cultural integrity a sound economic base, and a sense of confidence and continuity. This model, unlike the other two, placed greater stress on the external environment and the significance of oral tradition as a stabilizing influence. Though prepared primarily to examine foundations for social policies and social well-being, nonetheless it has relevance for health and has similarities with Durie's three 'institutions of health' - land, language, and family. ²³
The four supports - family (whänaungatanga), cultural heritage (taonga tuku iho), the physical environment (te ao turoa), and an indisputable land base (turangawaewae ) -brought together social, cultural, and economic dimensions in a way which could be readily appreciated by Mäori and which demonstrated the links between the three. Particular reference to the environment (te ao turoa) was perhaps influenced by the Waitangi Tribunal's landmark decisions in respect of claims made by tribes against the Crown and on the basis of pollution of tribal waterways. ²⁴  These claims had all recognized the significance of a clean environment for good health and drew attention to the overlap between physical and cultural pollution. Quite apart from the effects of effluent on seafood and the consequent risks of hepatitis or other alimentary diseases, Mäori claimants also described a type of pollution which debased spiritual and cultural values. Disposal of human waste, treated or not, onto potential food sites or into wahi tapu (historical sites declared tapu) offended Mäori just as the depletion of traditional foods through pollution created embarrassment when families were unable re meet customary hospitality obligations when visitors arrived.

Turangawaewae is a pou mana with cultural, social and economic significance. Not only does it refer to land rights and access to an economic base, it also includes the marae, an institution, perhaps like no other, where Mäori custom and tradition, including language, have priority. A measure of Mäori identity, and indirectly a health measure, is the level of access, as of right, which an individual has to a marae. Since the marae is the epitome of a collective identity and one of the few remaining opportunities for social relationships to be strengthened in a manner which is mutually supportive, it enables Mäori to redress some of the imbalance between individual and group pursuits inevitably created by life in suburbia.

Taonga tuku iho, cultural heritages upon which intellectual and philosophical traditions are based, are also valued by Mäori because they suggest a continuity with past wisdom and consolidate a Mäori identity. Increasing recognition of language as a taonga (treasure), important for cultural and health reasons, has resulted in extensive revitalization strategies locally and nationally. After considering a claim brought by Nga Kaiwhakapumau i Te Reo (the Wellington Mäori Language Board), the Waitangi Tribunal described language as a taonga, categorizing it along with physical resources such as land.' ²⁵ The Tribunal report made it very clear that there was a Treaty of Waitangi obligation on the Crown to ensure that Mäori language was strengthened before it was lost altogether, and the point was made on several occasions that without language any sense of pride or cultural integrity is seriously undermined.

Cultural heritage, as a basis for well-being if not health, also concerns the ownership of intellectual and cultural property. Cultural erosion has come about not only because of assimilation but also because history, traditions, art forms, healing methods. and poetry have often been appropriated by others and in the process Mäori have been denied a guardian or custodial role, or have lost access to their own material altogether.

The Draft Declaration on the Rights of Indigenous Peoples recognizes that the significance of intellectual property to indigenous peoples as well as indigenous forms of health care, based on traditions passed down over the generations.²⁶ Article 22 of the Draft Declaration states that 'Indigenous peoples have the right to their traditional medicines and health practices, including the right to the protection of vital medicinal plants, animals and materials'. Article 27 is more specific: 'Indigenous peoples have the right to special measures to protect, as intellectual property, their sciences, technologies and cultural manifestations, including genetic resources, seeds, medicines, knowledge of the properties of fauna and flora, oral traditions, literatures, designs and visual performing arts'. Table 13 summarizes the main features of the three perspectives:

Table 13: Mäori Health Perspectives - Three Models

	Whare Tapa Wha	Te Wheke	Nga Pou Mana
Components	Wairua Hinengaro Tinana Whänau	Wairuatanga Hinengaro Tinana Whänaungatanga Mana ake Mauri Ha a koro ma a kui ma Whatumanawa	Whänaungatanga Taonga tuku iho Te ao turoa Turangawaewae
Features	Spirituality Mentalxhealth Physical Family	Spirituality Mental health Physical Family Uniqueness Vitality Cultural heritage Emotions	Family Cultural Heritage Environment Land base
Symbolism	A Strong House	The Octopus	Supporting Structures

However, not everyone was impressed by the Mäori health perspectives. To sceptics, they were based on romantic visions of the past, devoid of practical application and likely to discourage Mäori patients from seeking appropriate health care, in a time when science and technological advances were enabling organ transplants and new hopes for the disabled,  Mäori, it seemed, were longing for the quiet life and a return to a world now recognizable only in the history books. Further, because whare tapa wha extended the focus for health well beyond the individual, a sense of futility often developed among health workers. How could a diabetic regain health if the land injustices of the past century were ignored? By taking the debate to the widest possible levels, health programmes ran the risk of being so general and indistinguishable from welfare programmes that they would have no significant impact. Worse, if cultural factors were so important, sometimes it seemed pointless to treat a diabetic unless steps were also taken to provide parallel cultural enrichment; and health workers sometimes felt that they should take the initiative.

Far from improving treatment opportunities, it was argued that the new perspectives would displace clinical priorities and resources with sociological, economic, or political agendas. A further issue concerned the difficulty in measuring concepts as diffuse as taha wairua. While measurements of physical illness and subsequent medical interventions lacked accuracy, they were improving and at least there was some agreement about the desirable indicators. Not so in mental health (taha hinengaro) and even less so in spiritual matters. Was taha wairua of any practical value if it could not be measured? The critics felt not.

Generally, however, Mäori health perspectives were consistent with new orientations and global trends: general systems theory, family psychotherapy, the community health movement, health promotion, primary health care, and calls for de-medicalization of the human life cycle. New Zealand was moving in the same direction and, in recommending a national health policy in 1988, the New Zealand Board of Health advocated five principles: holism, empowerment, social and cultural determination, equity of access and devolution, and equitable and effective resource use. ³⁰ The Board had borrowed extensively from Mäori views and writings.

By 1990, Mäori views on health had made a significant impact on New Zealand health services generally, but more importantly they had given Mäori people the necessary confidence, based on their own understandings of health, to challenge the system and reclaim a more active participatory role in society and within the health sector.

Link to Endnotes and References page