Monday, 15 August 2011

What you said: Did it include me?

At the finish of my lecture in Auckland, a Maori woman started by saying: “you are the first white man who ... (I got a bit alarmed at where this was going and did not quite hear the finish, but it was along the lines of) ... spoke to me in a way I could believe in; what you said: did it include me?” She then, in traditional Maori fashion, introduced herself in terms of her background: who her grandparents and parents were. But then she said: I think what you said includes me, but I want to hear from you that it is so.
I was overcome. I struggled with my emotions before an audience of 250 people. I could see people in the audience on the edge of their seats in that anxious combination of riveted fascination, embarrassment and empathy one has when someone publicly looks to be at risk of, shock!, displaying emotions. The chair of the NZMA, Paul Ockelford, told me afterwards that he could see the tears in my eyes – he had tears in his eyes when he told me this – as I was visibly moved. Finally, in a small voice I said: if what I said did not include you then I am doing something terribly wrong. Of course, it includes you. I then quoted the song the Thai children sang (quoted in my BMA speech):
                We are all waves of the same sea
We are all stars of the same sky
It’s time to learn to live as one.
Much of the concern with health inequalities in New Zealand is with Maori/non-Maori differences. Martin Tobias concluded that about half of that difference is socioeconomic in origin. There is a good deal of resentment among Maori academics at both halves: the socioeconomic disadvantage and the long history of discrimination. While the health position of New Zealand Maori compared to non-Maori (pakeha) is a good deal better than that of indigenous Australians compared to non-indigenous, Maori life expectancy trails pakeha by about 9 years.
I was keen to see what is happening at community level and asked to visit a Marae – a Maori community centre. I was taken to see the Kokiri Marae Health and Social Services Centre in Lower Hutt, a down at heel area outside the main city of Wellington. The story we were told was one of Maoris being encouraged off the land into the cities to find work and finding not so much work but marginality and social exclusion – a regretfully familiar tale of gangs of young males getting into trouble, alcohol, physical abuse of women and children.
Kokiri Marae was started by and is run by women. They get a variety of government grants to run services. The one man that we met, and it was he that did the traditional Maori greeting, told us the story of how the Marae was founded by his grandmother.
The story of Grandma and the gangs is the stuff of movies. In short, Grandma was in the Lower Hutt in the same poverty as all the other Maoris but wanted to provide a community centre for the young men who were getting into all sorts of trouble in gangs. Every day with whatever ingredients she could find, Grandma made a tureen of soup, and every day for two months she threw it out. She invited the gang members to come and eat, but it had to be on her terms: shoes off, respect, no violence. No respect, no soup. For two months the standoff between Grandma and the gangs continued. They wouldn’t meet her terms and she threw the soup out at the end of the day. Finally, they took their shoes off and came and ate.
“Hollywood ending?”, I asked. “The gang members all became lawyers and members of parliament?” Not quite. Still a lot of mayhem and family violence, but Grandma’s vision flourished.
Among the programmes of the Kokiri Marae is one called “Whanau Ora”. The CSDH and the English Review highlighted empowerment, dignity, participation in society, (long live the Oxford comma!) and the Amartya Sen concept of freedom to lead a life one has reason to value. I was therefore entranced to read the following description of enhancing whanau capabilities:
·         To become self managing
·         To be living healthy lifestyles
·         To be participating fully in society
·         To be confidently participating in Te Ao Maori
·         To be economically secure and successfully involved in wealth creation
·         To be cohesive, resilient and nurturing.
Terrific. This is putting into practice the kind of principles espoused by the CSDH and Fair society Healthy Lives. Does it work? I am convinced that this is wonderful, I told them, but if I want to be able to communicate this to others round the world, I need to have something more, showing that it is effective. We then had a highly nuanced discussion about both the need for evidence of what works, but of the difficulties of doing the right kind of evaluation and their miserable experience in the past at the hands of researchers.
They painted a realistic picture of continuing processes of exclusion, of family violence and young men getting into trouble. But they have hope and commitment and it gives me more grounds for optimism. Maori life expectancy may be lagging behind, but it IS improving. It has risen to the level of whites 20 years ago. Improvement but a long way to go!

Bubbling Up Down Under

A medical colleague in New Zealand said: fancy the doctors taking a lead on social determinants of health! You have opened another front.
The New Zealand Medical Association has produced an excellent statement of the importance of health equity for New Zealand, building on the findings of Fair Society Healthy Lives. (see here) One of the pleasures of the social movement we have been trying to create is that while on the one hand we rely on analyses of data and synthesis of evidence, on the other, much of the action comes through personal relationships.
The immediate past chair of the NZMA, Peter Foley, had come to the BMA meeting a year ago where I was installed as President. He heard me do my best to bring the BMA with me on the social determinants agenda, and said: we should be doing this in New Zealand. He convinced me to visit and organised several events around it in Auckland and Wellington, organised by the present chair, Paul Ockelford, and Don Simmers. In Wellington, the capital, the Minister of Health opened the symposium. I was told that it was not just his speech writer who had read our English report but the minister had read it himself and referred to it liberally in setting out what they were doing.
A parliamentary breakfast, meetings with parliamentarians from across the political spectrum, and public servants, plus the board of the NZMA helped.  Len Cook, who was head of national statistics in New Zealand and the UK suggested that the UK is good on analysis not so good on implementation; in New Zealand, it is the converse: not so good on analysis but good at getting things done. He related this to scale. There is more intellectual fire power in the UK but it is more difficult to implement things.
The Board of the NZMA then met to consider further action – the feedback was all positive. If the NZMA do lead the charge in New Zealand it will be an important example for other countries to follow.