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| Journal of the New Zealand Medical Association,
13-December-2002, Vol 115 No 1167
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Tauiwi general practitioners’ talk about Maori health:
interpretative repertoires
Timothy McCreanor and Raymond Nairn
Our project, investigating the talk of Auckland general
practitioners and Maori users of general practitioners’ services about
Maori health, is part of the “discursive turn” in social
science1,2 toward qualitative,
language-oriented investigations of trenchant social issues. Underpinning this
work is the growing understanding of the role of talk in negotiating, confirming
and challenging social realities.3,4 Diverse
methodologies, referred to as “critical discursive”
approaches,5 for investigating effects of talk
in social life, including medical
practice,6–8 are now well
developed.9 One of these approaches, discourse
analysis, the primary tool for this research, has been described in detail by
various authors10–12 and outlined in
action in the current project by McCreanor and
Nairn.13
Using such approaches, we were interested to see if patterns
would emerge in talk on the topic of Maori health generated as part of
relatively free and unstructured interviews with our participants. We went into
the interviews with some general topics – health disparities, historical
contexts, traditional Maori health practices, gender issues – but deployed
these mainly as starting points. The aim was to have doctors speak freely and,
as much as possible, formulate the issues in their own terms. In the current
paper, we present a sketch of the research project and an overview of common
patterns of talk in the database we gathered.
We wish to stress that we are not interested in
personalising the findings that we report, preferring to regard the data and the
analyses that flow from them as reflecting and constructing a particular niche
within a broader environment of cultural relations. Far from feeling that our
participants were wanting in sensitivity or humanity, we know them by reputation
and through our interactions with them to be concerned, caring people who are,
both in the interviews and in their profession, aiming to enhance and improve
the lives of all the people with whom they work.
MethodsThe database consists of the
transcripts (and audiotapes) of interviews with 25 female and male Tauiwi
general practitioners working in Auckland; some 501 pages of text. We used
discourse analysis,3,9 which is based upon
multiple, detailed readings of the database, to develop a systematic and
comprehensive description of the ways in which language was deployed to
establish and defend specific arguments or positions within the general topic.
Verbatim texts or sections of text that use recurrent themes (at first rather
loosely defined) were collated into files. Patterns of lexicon, syntax, grammar
and semantics – known as interpretative repertoires in discourse analysis
– within each file were clarified by further intensive reading, allowing
the researcher to describe and illustrate the content and function of these
common elements. Our recent publication13
details the application of this method to the current database and a paper
published in this journal in 19962 is also
valuable in explaining some of the methodological issues.
ResultsThe following are outlines of the
repertoires that we read from the data. These sketches are summaries of more
lengthy analyses, consisting of detailed descriptions of themes illustrated by
verbatim excerpts from transcript. They are derived from the files of data
sorted by repertoire as described above. Each is worthy of considerable
elaboration and further analysis; for example the first repertoire reported here
is the subject of an entire paper recently published
elsewhere.13
Maori morbidity Most
participants agreed that their experience of Maori health was congruent with the
position indicated by nationally collated data for Maori, and on this basis that
Maori health is in crisis. Maori were seen more commonly and were more severely
afflicted by serious and mundane conditions. While some participants argued that
Maori under their care were much better off than Maori in general, most
concurred with the view that there was a real problem nationwide.
Most participants’ explanations of the differential
between the health of Maori and that of the rest of the population turned upon
interactions between genetics and environment (primarily socioeconomic status
and culture) in a conventional medical analysis. A minority argued that there is
no significant difference between Maori and Tauiwi health and justified their
claim especially by reference to uncertainties over Maori identity and the
confounding effects of socioeconomic status. Both sets of arguments focus on the
constitution and behaviour of Maori people and thus minimise the significance of
the historical and political context of Maori health.
Maori identity Maori
identity was very often seen as deeply problematic, and was defined by different
parameters in different settings. Scientific definitions based in genetics were
routinely offered, but regularly conflicted with social constructions of Maori
identity. Most participants assumed that genetic mixing through intermarriage
meant that there was no objective standard. Identity was socially determined,
and dependent upon diverse criteria such as self-identity, appearance, lifestyle
and world-view. In practical terms, this ambiguity was often manifest in doctors
simply not knowing whether their patients were Maori or not, and there were some
participants who reported instances in which the patients themselves either did
not know or could not decide upon a fixed identity. Some participants thus
argued that there was insufficient justification for doctors to practise
differently with Maori and Tauiwi patients.
Compliance
Participants widely reported that one of the key issues in working with
Maori was non-compliance. Compared with the rest of the practice population,
Maori do not do the right things in relation to their health. In terms of a
standard medical definition of compliance, they do not take their medication, do
not follow prescribed regimes of treatment, do not arrange for repeat courses of
medication, do not attend to follow up. A complex of social or organisational
factors was seen as surrounding non-compliance, and exacerbating or contributing
to it. Maori present late, and do not attend regularly or sufficiently
frequently. They have diffuse lines of personal responsibility, which means for
example that you cannot be sure who is a child’s caregiver, or that whanau
members may present instead of the actual patient. They do not know their
personal medical history, they do not know what medications they have taken or
what the medications they take are for. They have different attitudes and
expectations about health, based in a present-focussed, laissez faire
world-view. They do not embrace preventive medicine and they expect a quick-fix
solution in a crisis. Maori men almost never come to the doctor.
Doctors did their best for Maori, but unless patients
complied with the treatment they could not reasonably expect to achieve results.
Explanations of the non-compliance phenomenon were diverse, and ranged from
those cast in terms of ignorance and poverty, to attributions of wilfulness and
self-destructiveness. Accounts of Maori compliance included ascribing it to
assimilation, wealth and/or education, and to a positive Maori identity. A small
proportion of participants could point to some groups of Maori (eg, the ones in
their own practice) with whom they experienced no problems of compliance. In
some instances, this led to the splitting of Maori into compliant and
non-compliant groups.
Style of working with
Maori A small number of participants held strongly to the position that
there was no difference between working with Maori and non-Maori patients. This
stance drew upon the ideas about Maori identity canvassed above and on an
egalitarian discourse, which suggested that this was a just, non-discriminatory
way of doing things.
More commonly, participants reported important differences
in the ways in which they would work with Maori and Tauiwi patients. At a
pragmatic level, participants noted the need for allow more time with Maori
patients to facilitate the building of rapport and to allow for a more flexible
unfolding of the medical history. A key element was the presentation of
information as clearly and simply as possible, with the use of pictures and
repetition favoured. The observation was frequently made that work with Maori
patients often involved group consultations with different lines of
communication and responsibility (especially via the senior women).
Consultations were felt to necessarily focus on the individual in context and
avoid an abstract ‘disease-on-legs’ approach. In general, there was
a feeling that extra effort was needed on the part of the doctor to achieve
equitable outcomes for Maori patients, especially concerning issues such as
follow up and preventive medicine. Flexibility over punctuality and payment was
also commended.
Some participants with knowledge of Maori culture spoke of
protocols for touching or examining patients, and of appropriate ways of asking
permission, explaining treatments or conditions. The call was for greater
cultural sensitivity on issues specific to Maori, with appropriate use of reo,
kaumatua, ritual and protocol.
Maori conceptions of
health Many participants were clear that Maori thought about health in
quite different ways than do Tauiwi, but were able to give only a general
outline of what Maori conceptions were. Very few had knowledge of formal Maori
models of health such as Whare Tapa Wha14 and
many resorted to listing practical manifestations of a supposed conceptual
model. Participants interpreted their observations of Maori apathy, lack of
motivation and lower prioritising of health issues as arising from symptomatic
rather than preventive management of health. This approach was derived from a
laissez faire world-view and a ‘quick fix’ approach to
illness.
While most participants professed ignorance of traditional
Maori health practices, they also declared that their basic approach would be
one of tolerance, regarding rongoa (traditional Maori medicines) as either
harmless or of limited efficacy. Participants named few actual remedies or
practices from Maori traditions, and felt that acquiring such knowledge was not
their responsibility or interest. A discourse about complementary medicine was
drawn upon to argue that if there was no harm done in the course of such
practices they were to be accepted and even encouraged. Most participants
reported that they had not come across such practices in their work, but many
had heard about them indirectly from patients and other sources.
Socioeconomic status
Many participants reported that socioeconomic status was a key issue in Maori
health and that Maori were mainly afflicted with diseases of poverty.
Socioeconomic status was seen to have an impact via diet, accommodation, access
to healthcare, low educational attainment, chaotic social organisation and
related factors in a multifactorial way. To varying degrees, this interpretation
confounded the image of a crisis in Maori health per se, and supported the
de-emphasis of cultural factors.
Maori health
initiatives Participants were ambivalent about Maori-driven initiatives
in health. Conceptually, this stance was rooted in arguments for scientific
hegemony and against any form of political or cultural dualism. In practical
terms, there were reservations about both fiscal and ideological competition
with the established services. However, some participants were clear that,
provided Maori took the responsibility as well as the power and resources, Maori
self-determination in health was a positive and possibly crucial
development.
This talk often coincided with acknowledgement that
established healthcare systems had failed Maori, with health disparities cited
as prima facie evidence for the claim. The scope of the failure ranged from the
ideological error of not ensuring Maori control of their own health institutions
and practices, to the political interpretation that noted widespread and
entrenched anti-Maori attitudes and practices within Tauiwi institutions. Other
concerns focussed specifically on various barriers to Maori use of services such
as rigid and formal structures, unacceptable waiting lists, impersonal style,
lack of cultural sensitivity and lack of understanding of Maori needs. Several
participants recorded particular areas of concern, especially with Maori youth
in the areas of drugs and unwanted pregnancy, and in general with
diabetes.
History Few
participants spontaneously raised accounts of the state of Maori health prior to
the arrival of outsiders to Aotearoa. Of those who did talk about the history of
Maori health, there was a split between those who believed Maori life in this
era to be brutish and short and those who held the opinion that Maori health was
probably exceptionally good. However, most expressed the opinion that the
arrival of Europeans in the country spelt the beginning of the current crisis in
Maori health. Disastrous changes were seen to have followed from the
introduction of infectious diseases, weaponry, drugs and foodstuffs to which
Maori were unaccustomed.
Gender While some
participants saw no differences in style between Maori women and men, most
reported that they either rarely saw Maori men or that when they did they were
much harder to communicate with than the women. In contrasting Maori women and
men, most participants reported that Maori men were much more difficult to
communicate with and that Maori women were more open and trusting.
Multiculturalism Two
complementary lines of argument emerged in the area of culture. Speakers argued
against targeting services to Maori, as this represented a form of
privilege15 that was unfair and unethical. The
perceived ambiguity over Maori identity bolstered the idea that no distinction
should be made between Maori and Tauiwi on principle. However, some participants
argued consciously against this latter position, advocating a bicultural stance
that gave priority to the indigenous people and sought to deliver equal health
outcomes through culturally appropriate services.
DiscussionThe patterns of talk and argument
sketched above represent interpretative repertoires that constitute a
significant part of the discursive resources that can be drawn upon by Tauiwi
doctors in their work with Maori patients within general practice. We note that
our findings may represent only part of the resources available and that in
circumstances apart from the research interview different elements may appear
and play crucial roles. We stress that the form in which these materials are
presented is generalised and collated to the extent that no speaker would
necessarily reproduce all or any of the elements in the manner that they are
rendered here. However, it is the case that these patterns account for a very
high proportion of our data and that there are no substantial ideas from the
data set that are not represented here.
It is very difficult to see how to use these resources in
ways that do not blame Maori for their own condition or variously justify
established approaches that doctors take to their work with Maori. The
‘Compliance’ repertoire provides a powerful example of these
features, combining as it does explanations which account for Maori ill-health
in terms of Maori behaviour and culture, with the caveat that without compliance
doctors cannot be held accountable for outcomes. The ambiguity entailed in the
‘Maori identity’ repertoire generated a tension with a central
paradox of primary healthcare; all patients must be treated equally, that is,
they must all be treated as individuals, yet all individuals are different!
Individuality was privileged over cultural (or any other) aspect of identity,
providing a rationale for the failure to address health issues that fall outside
this focus.
More generally, these interpretative resources lend
themselves to explanations of the poor health status of Maori as a function of
being Maori and so naturalise or legitimise a situation that is ethically,
socially, and economically unacceptable. The dominance of such accounts means
that alternative explanations of Maori health and morbidity are marginalised.
These alternatives could, for example, emphasise the social and political
impacts of colonialism, or of contemporary contexts and processes of health
practice, on Maori health.
Key exceptions to this tendency arise from the
‘Style’ and ‘Maori health initiatives’ repertoires. In
the former, participants were strongly articulating accounts of practices that
they claimed made their work with Maori more effective. In the latter, minority
affirmation of systemic failures in health services and the importance of Maori
self-determination in health could help build positive alternatives.
If the repertoires we have described are widely used among
general practitioners, they represent a cause of concern, as they may shape
actual interactions between Maori patients and their Tauiwi doctor. The impact
of doctor–patient communication on health7,
8 and links between discrimination and
health16 are part of the research literature.
Communication between doctor and patient is increasingly regarded as central to
the practice of primary healthcare, directly and indirectly determining the
outcome and therefore the efficacy of such enterprise.
We argue that our findings have serious implications for
Maori health outcomes from primary care, for the education and training of
primary healthcare workers and for the development of policies on Maori
health.
We notice that our participants’ explanations of the
state of Maori health rarely relate to widely available Maori theories of
health.17,18 These holistic, communitarian
frameworks emphasise social, cultural and economic interconnection as the basis
and context of individual health, so that such factors take a crucial role in
the explication of Maori health status. Our interpretation of Maori theory is
that particular historical, political processes and social contexts should be
interrogated for their contributions to the established power relations within
which the interactions and practices of primary healthcare are located. In the
case of Aotearoa/New Zealand, such perspectives invite us especially to consider
the colonial context of healthcare services in general.
The profound negative impact of 160 years of colonisation
upon all aspects of Maori life19–21 and
especially upon Maori health and wellbeing is clear. As well as diverse sources
of introduced mortality and morbidity, Maori have experienced open warfare, land
confiscation, destruction of their economic base, legislative injustice, social
discrimination, and racism. These multiple assaults have resulted in severe
disruption of diverse Maori cultural forms and institutions across the board.
Maori have been effectively reduced to the status of second-class citizens in
their own country, as reflected in the differential health statistics that are
the subject of the participants’ talk in this paper, and other indicators
such as wealth, education and social status. In the context of Maori health, the
marginalisation of the cultural infrastructure that once cohered around Maori
healing and medical practices, amounts to damage that can only have compounded
the more obvious losses.
We argue that the interpretative resources highlighted in
this research and discursive practices that draw upon them, are problematic to
the population-level improvement of Maori health. Such talk, when it identifies
the causes of disparities in Maori health in characteristics of Maori or Maori
social organisation, stands in direct contradiction of the findings and
recommendations of Maori scholarship and thinking. This tension needs to be
addressed if general practice is to optimise its potential contribution to Maori
health. What is needed is work in both theoretical and applied fields that
addresses the contexts and processes within which Maori health is constituted,
and enhances understanding of the role of general practice in these dynamics. Of
critical importance to this effort will be the consideration of the paradigms
within which doctors operate, and analyses of the power relations that underpin
the everyday interactions of general practice.
Author information:
Timothy McCreanor, Lecturer, Gender and Discourse Research Unit,
Department of Psychology; Raymond Nairn, Senior Tutor, Department of Behavioural
Science, University of Auckland, Auckland.
Acknowledgements:
The work described in this article was supported by the Health Research Council
of New Zealand, HRC grant 94/298. Special thanks to Drs S Crengle, N Turner, P
Woolford and F Cram, who read and commented on drafts of this paper.
Correspondence: Dr
Tim McCreanor, Gender and Discourse Research Unit, Department of Psychology,
University of Auckland, Private Bag 92019, Auckland. Fax: (09) 373 5450; email:
t.mccreanor@auckland.ac.nz
References:
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