Taking the pulse of Māori public health

Māori have been over-represented in drug, alcohol and smoking statistics in comparison to Pākehā seemingly since records began. The situation is rooted deep within New Zealand’s colonial history. Are things improving for Māori? What approaches are working, and what else needs to be done to address inequities? Matt Calman talks with four figures from the sector about the state of the Māori nation in terms of treatment and harm reduction.

Tuari Potiki, like scores of New Zealanders, grew up in a family that liked to drink alcohol. He was drinking regularly with his mates by the time he left school. By age 28, he was in court-ordered residential treatment in Hanmer Springs for intravenous drug use. He was in and out of residential drug and alcohol facilities over the next five years. His treatment included counselling and methadone. It was five months after leaving his last residential placement in late 1989 that he became drug free, and he has maintained sobriety ever since.

When asked about his struggle with drug use, he smiles and says wryly, “I didn’t really struggle. I just let it happen. When I was a junkie, I used to think naively that all I had to do was stop putting needles in my arm, and it would be okay, but there was a bit more to it than that.”

Potiki has seen treatment from both sides. After successfully giving up, he studied for a couple of years and then began helping others as a drug and alcohol counsellor in Christchurch. In the early 1990s, there weren’t many other Māori alcohol and drug counsellors. There were a handful of Māori treatment centres, but the overwhelming majority were mainstream. There were a couple of “old Māori women who were full on into it” who enticed Potiki to the job.

“It was sort of the beginnings of the Māori alcohol and drug sector really, so it was quite pioneering in some ways,” Potiki says. “They were on the lookout for people to move into this kind of work. I got the bug.”

Potiki, who is of Ngāi Tahu, Ngāti Māmoe and Waitaha descent, has worked in various parts of the sector – at the coalface, in the office and in the boardroom. For years, he counselled Māori in prison. For seven years, he worked at the Alcohol Advisory Council of New Zealand (his role involved engaging communities to take action around alcohol). For the last three years, he has been Director of Māori Development at Otago University. He currently chairs the New Zealand Drug Foundation Board.

How are Māori served today in terms of treatment options compared to when he started counselling in the early 90s?

“I think it’s changed a lot,” Potiki muses. “There are a lot more specific Māori alcohol and drug services around the country, and many of them are attached to iwi or Māori health organisations.”

While the vast majority of treatment centres remain mainstream, some Māori programmes were flourishing, such as Te Utuhina Manaakitanga Trust in Rotorua and Ngāti Toa’s Rangataua Mauriora youth programme in Porirua. Ngāi Tahu is one iwi that has begun providing some health support for its members, Potiki says.

“The whole Māori world has changed, and Ngāi Tahu is a good example. Fifteen years ago, it was all new, and they were just getting into their settlement. Now that they’ve got a few runs on the board, they’re moving into the health sector as well. However, Ngāi Tahu has been reluctant to put tribal money – which has taken 175 years to get – into things that should actually be being provided by the government through our taxes.”

While access to Māori services has improved, the vast majority of Māori still go to mainstream treatment centres, Potiki says. Some parts of the country have more options because of stronger Māori population, such as in Auckland, but the options are far more limited in other regions. “It still depends on where you go. If you went to the Dunedin CADS service, I don’t think there’d be any brown faces in there.”

Potiki says there has been significant improvement in academic qualifications for clinicians since he studied. Today, there are postgraduate certificates and diplomas in drug and alcohol treatment, and there is now a professional addiction practitioners’ body, DAPAANZ. While there is still a dearth of Māori clinicians, inclusion of tikanga Māori in current courses means Pākehā graduates will at least have some grasp of Māori culture when dealing with Māori clients.

“Initially, there wasn’t really a profession as such. It was sort of treated a bit like a poor relation of mental health. It’s become much more professional.”

Auckland-based Papa Nahi, General Manager of Hāpai Te Hauora Māori Public Health, agrees that services are still mainly clustered where Māori populations are. She says there remains a lack of investment in increasing the numbers of Māori in the treatment sector.

“If we don’t have that [commitment], then it’s difficult to try and get any progress,” says Nahi, who is of Ngāpuhi- Nui-Tonu descent.

Hāpai Te Hauora is a national Māori public health organisation funded by the Ministry of Health. Jointly owned by three Māori public health providers, these organisations then undertake much of the organisations health promotions work, including for drugs and alcohol. Its focus is very much on harm reduction rather than treatment.

You can concentrate on the person and their treatment, but there is a political and societal context to this as well, which to me is about human rights.

Tuari Potiki

Nahi says getting out to where Māori are is key, and she is seeing some exciting community-based results. She cites smokefree-promotion YouTube videos by local waka ama clubs and the Otahuhu Mangere Youth Group’s stand against liquor stores opening near their community’s schools as examples of people taking action on an issue to improve health and inspire others.

“We’re bombarded with statistics that are not pretty however. When you’ve got a story of young people getting together and taking a stand on an issue to do with alcohol and drugs, it’s really inspiring, and that motivates all Māori to take action,” Nahi says. “I really believe that strengthbased approaches are the way to go.”

By “strength-based”, Nahi means framing things in a way that empowers people, allowing them to “have a sense of their own mana” and helping them consider action they can take in order to move forward. It’s about buy-in and ownership.

Raukura Hauora O Tainui, one of Hāpai Te Hauora’s owners/ sub-contractors, has been working with sports clubs and community groups around the drug and alcohol kaupapa. In response, the Redhill Rocketz Softball Club in Counties Manukau made banners and went smokefree, and some of the members had gone without alcohol, Nahi says.

Another of the three owners/ subcontractors, Te Whānau O Waipareira, based in West Auckland, offers an eightweek- long alcohol and drug-counselling programme. Many of its clients are referred to Waipareira’s four-strong team of counsellors by the probation service.

Waipareira AOD Addictions Counsellor Louise Graham says many of the clients come feeling whakamā (ashamed) and have been forced to attend by the criminal justice system, and some don’t want to be there. Others want to be good parents and role models but lack the skills to do it. If clients require drug and alcohol treatment, they are referred to an appropriate treatment facility. The values that underpin the organisation are key to the success of the counselling programme. They include upholding respect, dignity, equity, fairness and a commitment to value all Māori

Graham, a Cook Islands Māori, came to Waipareira seven years ago inspired by her own upbringing in alcohol and an extended whānau that “dabbled in drugs”. She says some of her clients don’t grasp the impact their substance use has had on their families and others.

“We work with the client’s own resources to find an outcome that is individual and meaningful for them,” Graham says. “We identify and enrich the facets of their life that encourage resilience in the face of outside pressures and distractions.”

Graham says one technique that is working well is narrative therapy, which encourages clients to talk about their own story in order to “separate the addiction from the person”.

Another successful technique is interactive drawing therapy, where the clients express their inner thoughts and feelings by putting them to paper.

“It’s very successful, if they aren’t able to describe what’s really going on for them. It helps them get it out. The picture finally tells the story of what’s happening in their lives.”

Is it important to tailor programmes for Māori? And what does a Māori approach look like compared to a mainstream approach?

Potiki describes the fundamental difference is that the mainstream approach will tend to focus solely on a client’s addiction. He likens it to how the frayed ends of a rope represent different parts of a person: the physical wellbeing, mental wellbeing, whānau and culture.

“When you go to a non-Māori service, you hang those ones up, and you just take [the addiction] in, and that’s what they deal with. All of those other bits are there too, but it’s as if they don’t connect. If you want the rope to get strong, however, they have to.”

While there is no one model that encapsulates the Māori approach, it is generally much more about inclusion and being part of the greater whole.

“Us versus I. [It’s about] connecting to whakapapa, connecting to your sense of belonging, identity, all of those things that come with connecting.”

Some will just want to get off whatever they are using and have little interest in the cultural side of things.

“If you need to detox, you need to detox. Some might say you can do it in the bush with rongoā (traditional Māori medicine). Maybe, but if you’re a chronic alcoholic, you can die from just giving it up straight away without a proper medical detox.”

Potiki says, when he counselled Māori in prison, he would see them as Ngāpuhi or Te Arawa or whatever their tribal affiliation was rather than prisoners, rapists, murderers or robbers. It is about seeing them as Māori and also seeing the person sitting there, he says. “It’s hard to explain, but if you can see that, then it helps them to see that too.”

Starting and finishing the sessions with karakia and waiata was an important part of “how we did everything”, aside from it being the obvious example of what Māori do differently to others.

It works the same way in the community. If someone comes to a session, they symbolically bring their whānau, their hapü and their iwi with them, Potiki explains. Making that connection with them is usually a positive.

“They don’t feel alone. They feel connected to something. If they’re going to give up the identity of being an alcoholic or a drug addict, it leaves a hole that needs to be replaced with something. Often for Māori, that’s where the journey begins. They get into te reo and they go to wānanga (university), and they do all sorts of things.”

But it is important that approaches don’t put Māori in one stereotypical box of “this is what Māori do or that’s what Māori look like”, Potiki says. For example, while many Māori believe wairua (spirit) is an intrinsic concept to being Māori, it is less important to others.

“In my view, there are as many different ways to be Māori than there are Māori. It has to be individualised. It has to be meaningful to the person, otherwise it’s just religion in drag.”

Graham says Waipareira offers a holistic wrap-around service and can refer clients to other arms of the organisation, including to the marae-based tikanga Māori programmes. It incorporates the Māori view that taking alcohol and drugs harms a person’s wairua (spirit). The clients are told the counselling is based on the kaupapa Māori model and asked if they’re happy to continue. Most are.

“The majority of them actually want to tap back into their culture, into their roots,” Graham says.

Nahi says tailoring programmes to have Māori at the centre has to be a “core component of everything we do” if we’re serious about restoring equality and addressing health outcomes for Māori. She would also like to see Pākehā build more dialogue with Māori and listen to what Māori want.

“Drug abuse isn’t tikanga Māori. It’s been brought here. Back in the day, Māori have responded by saying ‘Look, this isn’t right. We want to do something about this.’ We’re just continuing that on today.”

Massey University Research Centre for Māori Health and Development Associate Professor Marewa Glover is more familiar than most with the desperately unfavourable Māori health statistics when compared to Pākehā. Glover, of Ngāpuhi descent, has been a leading researcher in tobacco control for more than two decades, has helped design smoking-cessation programmes and is an expert on smoking prevalence among Māori.

What is clear to Glover is that measures such as smokefree legislation, increasing tobacco taxes, grim warnings, gruesome images of smoking-related diseases on packaging and treatment approaches have reduced smoking rates, but things have now hit a brick wall. There is still a large group of Māori who have not been able to quit and another group within that who have never even tried to quit.

For Glover, it’s personal. She took up smoking at 13. Her sister also started in her teens. They grew up exposed to the smoking of their parents “in the house, car, everywhere”. By her early 20s, Glover had developed chronic bronchitis and needed a year of physiotherapy to recover. She used willpower to quit and believes she saved herself from chronic illness and “quite probably” lung cancer.

“I have been smokefree long enough now that I can expect to live as long as a never smoker would,” she says.

The Ministry of Health New Zealand Health Survey revealed 39 percent of Māori adults were current smokers in 2012/13, down just 1 percent since 2006/07. A current smoker smokes at least once a month and has smoked more than 100 cigarettes in their lifetime. The overall adult rate was 18 percent.

It’s the history of colonisation. You know, the gun and the Bible and alcohol are three of the primary tools that have been used to dispossess.

Tuari Potiki

Glover says, historically, Māori smoking rates had long been stuck at around 50 percent, and the rates had been even higher for Māori women. In fact, Māori women have had among the highest rates for smoking (and smoking-related diseases) for women in the world, mirroring rates of other indigenous groups of women such as Aboriginal Australians and Canada’s First Nations.

Glover says, in explanation, smoking was introduced to Māori by sealers and whalers in the late 1700s and early 1800s, and it became an item of trade. Māori women had been smoking for more than a century by the time it become fashionable for women in Europe, England and America during the 1920s and 1930s. Māori children had been exposed to both parents smoking for generations, making it much more likely for them to smoke. Since the first concerted quit-smoking campaigns in the 1980s, all groups had come down at a similar rate, but the Māori rate started higher. However, recent Otago University research suggests the disparity gap for Māori is starting to widen again, Glover says.

While she has long since quit – she doesn’t even drink coffee now – her sister still smokes, despite trying everything from quit-smoking medication Champix to nicotine patches and gum.

“It always keeps in mind for me how the work we’re doing nationally for a lower socioeconomic solo mum on the benefit is in the wops! It’s not working for them. We’ve got to do something else. And not just for my sister, but for all the other Māori who are not touched by the mainstream smokefree activities.”

Glover says Māori need extra resources to address the inequality, though there is always a backlash when Māori are seen to be given extra.

“People actually think we get extra, but you really see it in the outcome. We’re getting the same, and now we’re possibly getting less. It really comes down to that.”

Potiki says just about every major health statistic, including for alcohol and drugs, sees Māori suffering more than Pākehā, and it is easy to become “immune” to seeing it reported all the time.

“The problem is, though, that sometimes you have to make the problem explicit before people will do anything. I think there’s a fine line between being deficit focused and pointing out why something needs to change.”

Potiki says that, for many Māori going through drug and alcohol treatment, a self-awareness occurs that includes cultural, historical and political awareness of why things are the way they are.

“With alcohol, it’s part of the history of colonisation. You know, the gun and the Bible and alcohol are three of the primary tools that have been used to dispossess,” Potiki says. “When you look across Australia or North America or anywhere where there is an indigenous population, you see exactly the same pattern and the same results. There are socioeconomic factors, absolutely, but there are historical reasons why those socioeconomic conditions exist.”

In his current role, Potiki has been analysing the NZQF results of 2,800 Otago University entrants. They had achieved NCEA credits at the same rates as non- Māori, but it appeared they had been given poor advice regarding the right credits to take for their chosen careers. While this might not appear to be linked to drugs and alcohol, Potiki says it is very much linked.

Citing other examples, Potiki says Māori today are more likely than non-Māori to be imprisoned rather than given a communitybased sentence, are more likely to be convicted of a crime than given diversion and are accessing doctors at similar rates but are more likely to be told to exercise rather than given medication and referrals to specialists.

“There are absolutely systemic issues that contribute to the stats being the way they are now. You can concentrate on the person and their treatment, but there is a political and societal context to this as well, which to me is about human rights.”

Nahi agrees inequality in the system needs to be addressed. “These issues are complex, and usually, the presenting health issues are the tip of the iceberg. What’s under the water is this huge complex social issue. We can’t focus on the top presenting issue without addressing these other things.”

Nahi is a member of the National Waipiro Harm Action Group, which was formed at the end of 2013 to address the lack of progress for Māori on drugs and alcohol. The group aims to inform and engage Māori.

“We saw there was a lack of a voice for Māori in this area. It’s the start of a process to help Māori be involved in decision making around drugs and alcohol.”

Glover has seen how “institutional racism” and inequities across the health system have held Māori back over the last two decades of her career.

“It’s always been there, and we still grapple with it. Who’s making the decisions, and how do they interpret the data? Pākehā are still dominant, and they’re still making the decisions for Māori. They’re still not listening to us or our analyses.”

Glover, however, remains hopeful. She argues the smoking-cessation sector is on the cusp of a worldwide revolution. Fresh from hearing speakers at the Global Nicotine Forum in Warsaw in late June, she says the vaporiser (e-cigarettes) industry has the potential to end the grip of the tobacco industry and save countless lives. You can buy e-cigarettes here but have to import the nicotine e-liquid (which goes inside to produce the vapour), as it is classed under our current laws as an oral tobacco product.

This creates a barrier to the product for lower socioeconomic groups who may not have access to a credit card or the internet, Glover says. The simple reason it has proved popular among smokers trying to quit is it carries nicotine in higher concentrations than other products such as patches or gum, Glover says.

She says one of the problems with smoking-cessation products is that none, until now, have measured up to the real thing. Her sister had texted recently to report vaporisers were “better than smoking”, which further steeled Glover’s support for the products.

“We can’t keep doing what we’re doing. We have some smokers out there, and nothing impacts on them. Then along comes e-cigarettes and, I mean, my mind is blown. We are on the edge of a revolutionary product that could set fire to everything, and the traditional combustible market really is facing its end.”

Glover says e-cigarettes are essentially a clean syringe, with minimum harm, that could help the last group of smokers for whom nothing else had worked. She is calling for an amendment to the Smokefree Environments Act to allow new non-combustible, non-therapeutic nicotine products to be able to be imported and sold in New Zealand. They could then be added as options to smoking-cessation programmes.

However, New Zealand has never embraced a harm-reduction approach with smoking, Glover says. A harm-reduction approach has always been interpreted as “it’s okay to cut down”, but with smoking, the next cigarette could be the one that triggers a cancer, she explains. She also says it seems nicotine has been “demonised” by the health sector even though it is the toxins in a cigarette’s smoke that kills rather than the nicotine. Yes, nicotine is addictive, but so is coffee, she argues. She is excited by the potential for e-cigarettes but also “very afraid” that some of her public health colleagues will succeed in having it shut down.

“It’s almost like it’s just about power and control, and that’s not what it should be about. The ones especially against e-cigarettes have no skin in the game. Yes, I’m Māori, and I have skin in the game. Lots of Māori do. We want to save all of our people. And these people who are against it, I hope, in the end, they will end up on the margins in this.”

Potiki says the drug courts, which were started in late 2012 in Auckland with a focus on recovery rather than punishment, have been “incredibly positive”, but he would also like to see the Misuse of Drugs Act overhauled to become more health focused rather than punitive. He argues the people who import or deal illegal drugs would still be identified and punished, but it would mean the people who use drugs, or the easy-to-pick “lowhanging fruit”, were not saddled with the irreversible stigma of criminal convictions.

“[The Act] needs to include in its description of alcohol and drug-related harm the harm that occurs through application of the Act. Once you’ve got a criminal conviction, you’re stuffed to do a lot of things for the rest of your life. For most people, it’s a time in their lives or it’s an occasional thing, and it doesn’t cause any problems. For some, it does, and they’re the ones who need a bit of help.”

Graham says there is enough help there for people in her community who need it and for those she counsels and that it’s hugely rewarding seeing them turn their lives around.

“Some clients come in, and their head’s down, and they’ve got their hoodie over their head, just real whakamā. But maybe after the fourth or fifth session, we see a dramatic change in them. They come in, and they’ve washed, and they’ve got nice clothes on, and they’ve really made an effort with themselves, [and] they’re talking more with their whānau.”

While she employs specific counselling techniques at Waipareira, there is nothing fancy about the values underpinning a successful approach. What works has always worked – making people feel welcomed, loved, connected and accepted.

“We have a couple of lovely ladies on the desk who are the first people our clients see. We offer them a cup of tea or coffee and say there’s kai available. [We tell them] ‘It’s a safe place. It’s confidential. We’re not here to judge you, to tell you what to do. Basically, our role is to support you, educate you and give you some resources.’ Once they actually hear that, you see the barriers drop from there.”

Matt Calman is a freelance journalist based in Christchurch.