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The Maori are the largest minority group of

indigenous New Zealanders. The scenic beauty of New

Zealand shores, and the Kapa Haka performances of
the Maori, are a feast to the eyes. Time has not
always been a friend of the Maori, and there are
inequities on various levels. In this article, we examine
how these inequities have caused a negative impact
on the health of the Maori.

Being Mori
Influence of Social Determinants on the
Health of the Mori


The Mori of New Zelnd

The Maori are the largest minority group of indigenous New Zealanders. The scenic beauty of New
Zealand shores, and the Kapa Haka performances of the Maori, are a feast to the eyes. Time has not
always been a friend of the Maori, and there is inequity on various levels. Nevertheless , as a famous
local saying says,
Turn to the sun, and let the shadows fall behind you !
the Maori have always been fearless and faced the problems head on, smiling.
In a world today, we have indeed accepted our indigenous people into our societies. But have we
accepted them into our hearts? Despite legal enforcements and numerous government policies, hidden
inequities still persist. Mere granting of 4g in the Maori neighborhoods (McNeill, Canny, & McNeill,
2016) and admiring their sporting capabilities is furtive mockery. We need embrace their culture and
understand the health dynamics in order to address the causes of increasing morbidity, lower life
expectancy and higher incarceration rates of the Maori population.
Historians believe that the Maori people share their roots of origin with Polynesia and the Americas
(Oliver, 1981). They travelled via the South Pacific and finally reached Aotearoa (New Zealand) around
950 1130 AD. Their voyages constituted the long canoes called The Great Fleet. Although scholars do
believe it to be a myth that has been passed from generation to generation, there is not much historical
evidence to prove otherwise.

(Kerry-Nicholls, 1886) The name "Mori, means the local people. It is also the name of the language
spoken by the people and was officially recognized in 1987 by the Parliament of New Zealand.
The term Pakeha, refers to the European settlers that arrived in 1815.

According to the National statistical data, as of 2013, there were 682,200 Maori people which roughly
constitutes about 15.4 % of the total New Zealand population. The median age of the males is 22 and
the females is 24 years. Whereas it is 35.7 and 38.2 in respectively in the remaining New Zealand
population (Statistics New Zealand, 2012).
It is not just the median age that is alarming. According to data from 2010-12, the Mori life expectancy
at birth was 72.8 years for males and 76.5 years for females. This is comparable with 80.2 years for nonMori males and 83.7 years for non-Mori females. One could argue that the rates have steadily
improved over the past 10 years, however there is no significant change in the morbidity rates. Over the

last 7-10 years, the Maori have significantly urbanized and are wide spread along Auckland, Waikato and

The Treaty of Waitangi

(New Zealand History, 2016) In the 1800s after the arrival of the Europeans, trade was widespread
along the North Eastern coast of the islands. Initially, most of the trade took place between the Maori
and the newly established state of New South Wales. The trading goods constituted natural resources
like timber and flax in return for pigs, potatoes and seeds. However, as there was no supervising body,
disputes and violence became more widespread. When major voyages like the Venus and the Boyd were
destroyed, it was believed by the British that the crew members were killed and eaten by the Maori.
This alleged barbaric reputation, caused much dismay in the trading world. The British tried to introduce
spirituality into the Maori by sending preachers with the motto of peace and tranquility. However, the
Maori were more interested in the commercial aspect of the deal.
The Maori learnt the art of farming and use of blankets to substitute traditional clothing. In the 1830s,
whaling began to gain importance and the extracted oil and bones were exported to Sydney & England.
This was a time when about a 1000 ships visited New Zealand every year. Slowly, natural resources,
lands and fisheries were being exploited by the settlers. Traders also included sailors, escaped convicts
and adventurous. Violence was on the rise and insecurities grew even more when a few French ships
were spotted at the Bay of Islands.
Keeping these concerns in mind, on the 6th of February 1840, a treaty was signed between 35 Maori
chiefs and a settled British resident, Sir James Busby, who promised them partnership and protection.
The translated form of the document is still considered to be biased and unfair. Primarily, because the
chiefs gave up sovereignty of the land to the British empire in understanding that they received equal
rights in establishment of a directorate.

Language and Literacy:

The Maori have always given special importance to literacy and education since generations. From
sculptures to tattoos, the art always defined teachings and traits.
According to Dr.Ngahuia Te Awekotuko, a Professor of Psychology at Waikato University, the Maori
tattoos describe,
Who we are, where we come from, and where we are going

Despite the high level of importance given to literacy, the overall education rates in the Maori
population are considerably low. A mere 12.3 percent of Mori women and 7.4 percent of Mori men
have reported to hold a Bachelors degree or a diploma qualification, and a staggering 33 percent hold
no qualification at all, according to the 2013 census.

Furthermore, 52 percent of the men and 35 percent of the women over the age of 15 were employed.
But, the unemployment rate has risen from 11 percent in 2006 to 15.6 percent in 2013. However, trends
have been changing recently with the New Zealand government reporting the rate of unemployment
has slowed down as of 2016 (Ministry of Business, 2016).We need to acknowledge that education is a
key building block in determining the socio-economic and environmental situation of a person. These
factors further influence the health status of an individual.

The problem does not halt there. A fall in employment rates and increased suicidal tendencies, denote
an unaddressed element of mental trauma. The families being joint and larger, have increased incidence
of domestic violence.
Alcohol and drug intoxication, rising crime rates, and unease in society has been observed. When
compared to the rest of the New Zealand population, the incarceration rates of the Maori are
significantly high. A few theorists (Hook, 2009)believe this is due to a Warrior gene hypothesis, a
defective Monoamine Oxidase gene expression. However, labeling groups as genetically impaired is
immoral, racist and should be promptly disregarded.
Since the 1900s, the Pakeha, (European settlers) have not been completely legitimate in aspects of
governance. Trade did exist between the groups consisting agriculture and tobacco products which later
on became a cause of depreciation of health in the Maori.
Treaties were broken and remade constantly. Most parts of the land were confiscated by the Pakeha in
this process. One could argue that, had the Maori been more educated and aware of the consequences
of trade at that time, perhaps there would have been a better today.

Determinants at large :
The algorithm begins with the lack of education and unemployment. With more stomachs to feed per
family, a depressed mind often seeks the transient pleasure of intoxicants and drifts further from the
reality of depreciating health. Consequent rage, crime and domestic violence have contributed to the
increased levels of incarceration among the Maori.
One observes inequalities across high level indicators ranging from life expectancy to infant mortality.
Cardiovascular disease, cancer and asthma are ailments expressed downstream as a result of these
inequities. The government has provided funding only for oral health of the children and primary health
care. However, as per a study (Jansen & Smith, 2006), the fact that the Maori are less likely to be
involved in treatment where partial or complete out of pocket expense is required, denotes the
presence of a burden.
In order to address a burden and propose reforms that induce recovery and augment the health status
of a population, we need to focus at levels that need attention. This article will take a look at the

following determinants of health in the Maori, evaluate the current trends, and propose reforms that
augment their health status.

Early life influences on health

Socio Economic and Environmental well being

Housing and infrastructure

Gender based discrimination

Effects of Racism on health

Erly-life influences on Helth

Danny brown grown up-
Danny Brown, a quarter Filipino born to teenage parents in Detroit, America (Ahmed, 2012). The start of
Remember when my first meal was school lunch; All we ate for dinner was Captain Crunch this
highlights struggles that are faced by young children from low socio-economic backgrounds in trying to
obtain equitable education, when they have no breakfast and a nutritionally poor dinner.
Danny Brown also comments on the teachers in Teacher always ask me, what was I doing; Scribbled in
my notebook and never did homework; Low attention span. Guess these Adderall work these lines
comment that while the school did provide lunch, when he wasnt paying attention, they resorted to
tertiary treatment in prescribing Adderall rather than focus on the issues of nutrition.
Whilst Danny Brown should be commended on his use of rap to increase his socio-economic standing,
the accumulation of risks and looking at the effects of childhood social class by identifying specific
aspects of the early physical or psychosocial environment (such as exposure to air pollution or family
conflict) or possible mechanisms (such as nutrition, infection or stress) that are associated with disease
over an individuals life course.

Children are largely dependent on others and are sometimes vulnerable; they are continually learning
and developing the skills to make responsible decisions in terms of looking after themselves and their
community. These children are citizens in their own rights and need to be given proper unbiased
representation. It is becoming increasingly evident that maternal health and wellbeing during pregnancy
and even before conception can affect foetal health. Early life influences later-life health through social
trajectories, such as educational opportunities, socioeconomic and health circumstances. Adverse
childhood circumstances are shown through lower birth weights, poor diet, infections and passive
New Zealand has one of the highest levels of inequality in educational outcomes of all OECD countries
(OECD Publishing 2010). In 2012 the New Zealand government announced its slogan for address this
issue as Every Child Thrives, Belongs, Achieves in a paper for vulnerable children and includes a 10
year plan (Childrens Action Plan 2016). This report addresses this Mori health inequality of that
prevent children from thriving and belonging by critically analysing health care access, food insecurity
and home/cultural environments. Mori are overrepresented in New Zealands child poverty statistics. It
is evident that there is a need to address this as a source of inequality, with one in three Mori children
living in poverty.

According the Sustainable Development Goals (SDGs), early life influences relates directly to goals 3
healthy lives and well-being for all at all ages, 4 inclusive and equitable quality of education and
promote lifelong learning (WHO 2015). 28% New Zealand kids are living in poverty (Statistics New
Zealand, 2015). Children in poverty are living in cold, damp, over-crowded houses, they do not have
warm or rain-proof clothing, their shoes are worn, and many days they go hungry. Poverty can also
cause lasting damage. It can mean doing badly at school, not getting a good job, having poor health and
falling into a life of crime. Short term impacts are lesser health outcomes, social exclusion and live with
life-time scars, with reduced employment prospects, lower earnings, poorer health and higher rates of
criminal offending.
Early life influences are defined as the time from conception to early childhood at 12 years old when
children complete primary school (Figure 1). There are many significant life events during this time,
ranging from essential literacy, numeracy and motor skill development to general growth from a foetus
to the start of puberty. In 2015, 1 in 3 Mori are under 15 years of age and only 1 in 17 are over 65;
comparatively 1 in 6 non-Mori are aged under 15 and 1 in 6 are over 65 (Statistics New Zealand, 2015).
This highlights the disparity between Mori and non-Mori populations and the potential impacts poor
early-life experiences have on later life. A critical development stage is when children are under 5 as it
sets the basis for health behaviours that children will carry throughout their life course.

Figure 1 Life course history with early-life stages highlighted in (beige), middle life (green) and later life (blue)

At the individual level, education can make a huge difference. For example, an educated girl is likely to
increase her personal earnings potential, be more likely to delay marriage and pregnancy and be more
likely to access health support, leading to lower rates of maternal mortality (DFID 2012). Additionally,
this will increase outcomes for future generations with approximately 50% worldwide reduction in child
mortality is due to increased education of women at reproductive age (Gakidou., Cowling, Lozano &
Murray 2010).
This report will focus on solutions that take a whole-child approach to improve equality between Mori
and non-Mori populations. Three SDoH identified that can be improved to reduce health inequalities
are addressed, being the perinatal period (three weeks pre- and post-birth), lack of immunisation, and
poor nutrition.

Conditions during the perinatal period

In New Zealand, neonatal mortality rates are 40 percent higher in Mori than Pkeha/European
populations (Simpson, 2016). The greatest cause of infant mortality in Mori populations is Sudden
Unexplained Death in Infancy, with Mori populations having 5.74 times higher than Pkeha populations
(Craig E, 2012). The potential causes of this have been identified as more than half of pregnant Mori
women smoking during pregnancy, potentially unsafe objects in the crib and bed sharing (Tipene-Leach,
Hutchison, Tangiora, et al. 2010).
Tobacco smoking during pregnancy has been linked to the following adverse health effects in child birth;
miscarriages, low birth-weights, placental abruption and birth defects (Flenady, Koopmans, Middleton,
et al. 2011). The rates of pregnant women smoking are declining but there is still a significant disparity
between Mori (43%) and non-Mori (14%) populations (Flenady et al. 2011). One positive is that most
Mori women will cease smoking after being discharged from hospital, showing that they are want to do
what is best for their child. However, these women return to homes and social settings with smokers
and often start smoking again (Dixon, Aimer, Fletcher, et al. 2009). Having children in environments with
high levels of smoking also has been estimated to contribute to 15, 000 episodes of Asthma and over 27,
000 consultations for respiratory problem annually (Woodward & Laugesen 2001). As such this
indicates that involving the Whnau, Mori political units/elders, in reducing rates of smoking
throughout the community.

Lack of immunisation
To show the importance of immunisation the Depart of health and Aging Australia estimates that if in a
childcare centre, including schools, of 500 children that had not been immunised for the Measles,
Mumps, Rubella (MMR) Vaccine the following would occur; (Department of Health and Ageing
Publications, 2012)

Almost every child would get measles

20 children with pneumonia
25% of at least 1 child developing inflammation of the brain (Encephalitis)

Comparatively, if every child was vaccinated with MMR the vaccine will cause 1 case every 2000 years.
This is great that departments are being transparent but facts like this are often changed by the antivaxer movement to just Vaccines causes encephalitis or the famous vaccines cause autism and
contain poisonous mercury. Such statements as these are incredibly damaging to population approach
provided in using vaccines and require further education or upstream policies to enforce immunisation.
This could be through access to subsidised healthcare, children must be vaccinated; this approach is
often met with comments of nanny-states interfering in home life.

Immunisation rates between infant Mori and non-Mori populations are generally lower particularly at
the key age of 6 months (fig. 2). At six months the conferred mothers immunity becomes less effective
if breastfeeding is stopped. Breastfeeding in Mori culture is socially important and is considered a
treasure or taonga and family support is strong with about 80% breastfeeding rates until 6 months
(Unicef NZ 2015). New Zealand Health that breastfeeding continues until at least one year when a
followed immunisation program will provide protection for infants.
The increase in immunisation rates after six months are likely due Health (Immunisation) Regulations
1995 this requiresearly childhood services to keep a record and for them to contact their doctor and
inform them of free immunisations for under two year old. This free immunisation program should be
extended for all ages for cruical immunisations such as MMR. This regulation does not provide the
power for exclusion of non-immunised children and as such these children can habour and allow the
proliferation of mutant

Figure 2. Immunisation coverage by Milestone Age and Ethnicity. (source (Simpson, 2016))

Poor Nutrition
Food insecurity is a global issue and is identified as Goal 2 (Zero Hunger) of the Sustainable development
goals (UN 2015). As New Zealand is an affluent nation and welfare support is available, food security is
often considered to not be a significant problem (Else 2000). Behavioural and cognitive research has

shown the need for children to have adequate nutrition. The issue of whether this responsibility is the
governments or parents debated vehemently; often polarising people.
Current policy aims to educate children on healthy food choices, reduce access to poor nutrition foods in
school tuckshops, such as pies and soft drink, and ensuring children take all uneaten food home so
parents can see what is being eaten (Breakfast, 2016). Yet, the quality and type of food in low socioeconomic families are often nutritional poor, being high in salt and sugar with low amounts of fresh
produce. It is evident that there is a need to address this as a source of inequality, with one in three
Mori children living in poverty and only one-in-ten lunchboxes meeting nutritional standards (Craig et
al. 2013). As more onuses are on parents, the more likely the perpetuation of inequality and
intergenerational poverty. This section will analyse the potential changes that could be adapted at the
institutional level.
In combating the nutritional inequalities of Mori children will also address other races, which are likely
to have the same problems and attending the same low decile schools. Currently, the kickstart breakfast
program exists that are sponsored by milk and cereal companies, Fonterra and Sanitarium, in
conjunction with the government to all schools (Kickstart Breakfast 2016). Whilst, it is great that all
schools are receiving funding for breakfast the usefulness of this in the schools above the 6th decile is
somewhat limited and it currently has a waiting list. With the limited funding that is available, a greater
result is likely to be achieved if the populations that are at risk are targeted.
This pragmatic approach does not adequately meet the needs of the lower decile schools and may
exasperate obesity problems associated with the developed world. Presently, 74% of lower decile
schools (1-4) are providing sandwiches or a light cooked meal for lunch at least sometimes (Carne and
Mancini 2012). This shows that the schools are willing and the demand is there for this project but the
current methods incorrectly address the issues by providing free breakfasts to all schools. A population
approach is ideal; however it is important to define what the population is rather than simply all schools
as parents in higher socio-economic schools may choose not to provide a lunch where they normally
would. A more ideal approach is to assist 1-4 decile schools. Approaching this problem on a wholeschool basis prevents stigmatism from other students and those requiring assistance are more likely to
use the service if it does not highlight who are the haves and the have nots. Parents will not feel
shame that they are not able to provide for their children. If parents feel embarrassed they may keep
their child home to avoid scrutiny, further exasperating intergenerational inequalities. Parents in low
decile schools that are able to provide lunch for their child(ren) will also benefit from this program as
they are likely to be poorer and the program will allow them to allocate funds elsewhere, resulting in
reduced stress and improved well-being.

The health inequalities that arise in childhood can cause life-long damage to the ability for people to
achieve their fullest potential. This damage is largely financially driven and the burden of this health
inequality suggests future widening in the gap as the capacity for primary health care is not matching

the needs of Mori populations, particularly those from a low socio-economic background. It is evident
that while the obvious answer to solving these problems is to reduce out of pocket expenses it does not
fully acknowledge the Treaty of Waitangi which requires consultation with Mori Whnau.
The major challenges in implementing the strategies outlined in this report are in dealing with the
ideological viewpoint that governments should not be interfering in home life. This could be the
government forcing people to help vaccinations, controlling what will be eaten. However, the
government has an international obligation to all New Zealand children through the Treaty of Waitangi
1840. Governments should move quickly to reprioritise investment towards achieving best practice in
the areas of: reproductive health; prenatal, natal, postnatal, and whole-of-life nutrition; maternity and
postnatal care; and health, early childhood education and social service interventions for the first three
years of life, with a focus on the vulnerable, particularly indigenous Mori and Pasifika children.
Incorporating Whnau into decision making with likely increase the use of native Mori language into
the school curriculum and the best methods of causing a cultural change in how Mori individuals will
assist those at risk, particularly pregnant women and children in achieving the best health outcomes.
The result would be more culturally specific shared understandings of acceptable behaviour, rather than
the universal program design by the government.

Effect of Housing on helth of the Mori

Place effect The effects of place on health
Airs, Waters, Places. - Hippocratic Medical Corpus, 5th Century BCE.
Medical practitioners have been working on the causes of disease and realized the association between
the health condition and the places that patients live at. The issues regarding the place effect arouse
during the 17th century urbanization gradually become one of the most important topics in the
population heath field (Macintyre & Ellaway, 2003). The place effect has been studied throughout the
world, and researchers have found some clear associations between housing factors and health.
However, argues remains that whether the place effect is merely a mark of result under multiple
socio-economic health determents factors, or it has its own influence on the general household health.
Nowadays, there are many studies confirmed the place effect is one of the causation of household
health and the place effect can be both directly influence the physical aspect of health (Barker, 1990;
Cubbin, Hadden, & Winkleby, 2000) and indirectly on the psychological/social wellbeing(Evans, Wells, &
Moch, 2003).

The universal recognition on the place effect offers some fundamental ground for looking into a
particular group of population. However, rather than there being one single, universal area effect on
health there appear to be some area effects on some health outcomes, in some population groups, and
in some types of areas.(Macintyre, Ellaway, & Cummins, 2002) Macintyre described the place effect
in such a way to express its nature of complication. It is almost impossible to provide a universal place
effect rule and it requires highly specific information on the group to explain how the place effects
have influence on the groups health. Therefore, it demands great focus on a particular group to have an
overview on the particular issue without applying wrong experiences, and ultimately produce a potential
solution to the problem.

The huge gap of health between Maori population and Caucasian population (link to intro) are caused
by varies factors including early childhood influence, gender, instrumental racism, housing issues, and in
general Socio-economic status. In this report, we are going to have a close look at the place effect on
Maori population in New Zealand, examine the causation of the huge gap of health between Maori
households and Caucasian households caused by the different housing issues, and trying to explore the
potential remedies to close the gap. The place effect is an enormous topic and has its influence on
almost all aspects of life. It also interacts with other health factors. For example, the housing effects on
parental behaviors has deep influence on early childhood mental and physical development. Therefore,
it is hard to cover all aspects of the place effect in this report. As a result, only few selected aspects,

which with good indication of the gap between Maori and Caucasian households including
overcrowding, tenure type, home quality and neighborhood deprivation, are presented in this work. The
place effect influence on health is also discussed according to Turrells population health model.
(Turrell & Mathers, 2000)

Wharepuni A brief history the Maori housing/health problem:

Maori traditional house is called Wharepuni, which is literally means sleeping house. Maori families
gathered together and form a Kaniga (village), with Wharepuni and other structures like Pataka (storage
house), Kauta (kitchen house) and Wharenui (meeting house). The old fashioned Wharepuni is built with
local materials including timber, bark, ferns, earth and etc. and does not have windows or internal
separation. Wharepunis dont have windows or glasses until the western settler introduced these
building elements/materials(Sissons, 2010).

The traditional Maori Wharepuni create many health concerns which have been raised back in 1800s,
including the health problems caused by drinking water safety, lack of sewerage and hygiene
installations, overcrowded space without separation and ultimately inadequate house. The government
tried to address the Maori health problem (especially the diseases introduced by westerners) caused by
housing through introducing sanitation facilities including tap water and sewers system in 1880s which
decreased the bacterial infectious disease rate, and Whare Pakeha which the order instructed the
demolishment of 1,256 Wharepuni. 2,103 new cottages were constructed throughout New
Zealand(Lange, 1999). However, the vast majority of Maori population was still living in traditional
Wharepuni without ventilation and modern sanitation installations.

The 1918 influenza epidemic is a catastrophic event on local Maori population that made New Zealand
government realized the tremendous gap of health, in which the Maori death rate was 4.5 times that of
Europeans(Pool, 1973) and led to new initiatives (e.g. Native Housing Act 1935 etc.) to improve Maori
housing and public health. The Maori population started migrating towards city during the period, and
by 1926 there were only less than 20% of entire Maori population. The urban place effect on Maori
population including overcrowding and home quality started to became an issue for the Maori
household. However, the problems did not discourage the migration due to the job opportunities in the
cities. The number tremendously increased during the post-WWII period and reached 84% in 2013 and
one fourth of the urban Maori population live in Auckland.(Meredith, 2015).

The Place effect factors:

Overcrowding, Tenure type, Housing quality, and Neighborhood deprivation
The disadvantaged position of Maori household, including overcrowding, house quality, house
ownership/affordability, and neighborhood, makes Maori population more vulnerable towards, both
mental and physical, health problems through the place effect on psychosocial factors and health
behaviors, or directly on the health of Maori population.(Turrell & Mathers, 2000)
Note: The flowcharts only include the factors discussed in the text.

In 2006, there were 13% of Maori households living in overcrowded accommodations with about 23% of
Maori population. And 4% of Maori households are severely crowded. The overall trend of crowding
issue in Maori population indicates a decline; however the disparity between Maori and Europeans
remains huge. There is almost 6 times more Maori population as Caucasian population lived in
overcrowded accommodations(Flynn, Carne, & Soa-Lafoa'i, 2010). Studies suggest that both subjective
and objective experiences on Household crowding(Gove, Hughes, & Galle, 1983) has negative impact on
life quality and furthermore on the both mental and physical aspect of health(Gomez-Jacinto &
Hombrados-Mendieta, 2002)

Overcrowding can be interpreted as a mental environmental stressors caused by the unsatisfied need
for space. A person living in an overcrowded environment experiences the lack of privacy and over
exposure to other individuals behaviors which together lead to chronic mental concerns, including

frustration, depression and aggression which sometimes leads to violence. Along with the physiological
influence, study also suggests that household crowding influence peoples behavior, usually in a harmful
way. For instance, people tends to adopt social withdraw as a coping strategy as a respond to chronic
crowding. And social withdraw comes with a high price breakdown of socially supportive relationships
and in turn elevate psychological stress.(Evans, Rhee, Forbes, Allen, & Lepore, 2000) As a result, more
health damaging behaviors, including smoking, alcohol/drug abusing, domestic violence and etc.,
become more attempting for the people under crowding stress, and ultimately lead to chronic health
issues including high blood pressure, asthma, arthritis and etc..

Overcrowding is also one of the major factors that influence the spread of infectious diseases. Factors
including lack of space in the household and highly frequent interpersonal contact provide ground for
infectious disease, especially airborne and vector-borne ones. Tuberculosis is an important bacterial
infectious disease in New Zealand. It spreads through air when people cough (which is one of the major
symptoms), spit, speak, or sneeze. An overcrowded house cannot provide enough space for quarantine.
Therefore, if one of the family members caught TB, he/she will most likely infect the whole family. As a
result, the CAU level of TB associate with the crowding level in the household, and research suggests
that the TB incident can be reduced by reducing the overcrowding in the households. (Michael Baker,
Das, Venugopal, & Howden-Chapman, 2008). Another example of bacterial meningitis spreading among
overcrowded households is Meningococcal disease. Its not as contagious as common cold but can be
transmitted through saliva and prolonged general contact with infected person, and it caused more
severe health morbidity than TB. Research suggests that overcrowding issue is the major factor of
Meningococcal disease infection and it has highest incident rate in Maori children living
Auckland(Michael Baker et al., 2000).

Tenure Type:










Table 1 Housing problems, Housing Satisfaction and Tenure by Ethnicity(NZ.Stat, 2012)

In 2008, 75% of EZ European household owns their accommodation meanwhile the number for Maori
household is 45%. The house ownership is under the influences of varies Social-Economic Status (SES)
factors including employment, income, education and etc.. The difference between two ethic groups on

housing ownership is a result of all the SES factors. Refers to SES section? Furthermore, house
ownership influences other housing factors, e.g. crowding, housing quality and etc., as well. For
example, the household with owner-occupied housing usually can affords a higher-quality residential
environment than rental housing(Megbolugbe & Linneman, 1993).

Tenure is a both a marker of household SES and a factor that influence health. Though tenure type is
only responsible for 5.4% of clinical health measure variance, it limits the health agencies for the
renters. Renters are more likely to be exposed to health damage factors including dump, noise, etc.
(which is linked to housing quality) and less likely to have health promoting features like gardens etc.
(which is linked to neighborhood quality)(Macintyre et al., 2003). As a result, the place effect on the
downstream of population health caused by different tenure types is hard to define considering the
variety of health damaging/promoting factors and their multitude impact on both physical and mental
aspect of health. Therefore, it is only fair to explain the tenure type influence on clinical level by general
health measurements, e.g. life expectancy, DAILY and etc..

Housing quality:
Major Problem(s) with Housing


No Problems




1,805,000(63%) 776,000(37%)





Table 2 Housing problems, Housing Satisfaction and Tenure by Ethnicity(NZ.Stat, 2012)

The housing problems cover cold, dampness, and need for repair. There are 45% of Maori household
have housing problems mentioned above, meanwhile the percentage of NZ European household having
problems is only 37%, though the absolute number is higher. Maori households are also most likely to
have problems relevant to a need for immediate or extensive repairs on home.(NZ.Stat, 2016) The
house quality is identified as one of the major impact factors on health(HowdenChapman, Isaacs,
Crane, & Chapman, 1996).

Home quality has direct link to the physical aspect of health, as problematic houses can increase both
the chance and severity of home injuries. The most common cause of home injuries result in
hospitalization is fall, which usually caused by slips, trips, entrapments, collisions, poor lighting and poor
ergonomics.(Braubach, Jacobs, & Ormandy, 2011). The home injury can result in cuts, bruises, broken
bones etc. and sometimes with severe cases can result in paralysis, long-term physical constraints and
death, which contributes to both morbidity and mortality. Kool identifies Maori population with a
significantly higher portion in hospitalization caused by home injury in his study(Kool, Chelimo,
Robinson, & Ameratunga, 2011) and the result is largely due to the poor home quality among the vast
majority of Maori households.

Lower house quality also provides ground for respiratory morbidity (i.g. asthma and etc.) as well as
airborne infections (which is discussed in the previous section), especially the houses with dump and
mould issues. Dump is a significant health risk factor which causes not only respiratory morbidity but
also tiredness, headache and airborne infections(Bornehag et al., 2001). Mould is usually considered as a
mark of dump. However, it is also, most of the time accompanied with dump condition in the house,
leads to both allergic asthma caused by the fungus, and non-allergic asthma caused by the mycotoxin
produced by fungus(Zock et al., 2002).

Neighborhood deprivation (NZDep 2013)

Ethnic Group

Non-Maori Ethnic Group

Maori Ethnic Group




































































NZDep 2013

Table 3 Populations by neighborhood deprivation(Kahukura, 2010)

NZDep 2013 is a set of decile system to evaluate the deprivation of a neighborhood. The higher NZDep
2013 score refers to a greater level of deprivation in the neighborhood(Atkinson, Salmond, & Crampton,
2014). The data indicates a larger total of Non-Maori ethnic group living in extreme deprived
neighborhood. However, the percentage of Maori population living in extreme deprived neighborhood
is larger. 23% of Maori population lives in extreme deprived neighborhood (NZDep2013: 10), and 72% in

deprived neighborhood (NZDep2013: 6-10). Meanwhile, the numbers for non-Maori population are 7%
(in extreme deprived neighborhood) and 44% (in deprived neighborhood).

Neighborhood influence population health with 4 major agencies, including Neighborhood institutions
and resources, physical stress, social stress and neighborhood based interpersonal dynamics. (Ellen,
Mijanovich, & Dillman, 2001). The four agencies, together, influence on health related behaviors and
mental health are both long term, with the weathering effect from accumulated stress, low
environmental quality, limited resources which make the household in deprived community more
vulnerable, and short term with its influence on health relevant behaviors, attitudes, and healthcare

Potential Solutions to a Wicked Problem:

Despite their smaller populations, Mori had more hospital admissions per year attributable to
household crowding than European/Others. For European/Others exposure to household crowding is
estimated to cause 5% of the hospital admissions a year for housing related diseases/conditions/injury.
For Mori the contribution from exposure to housing issues is higher, with an estimated 16.8% of the
total hospitalizations a yea. The contribution of exposure to household problem is particularly large for
some conditions affecting Mori population (e.g. Tuberculosis, asthma, home injury and etc. as
suggested in the previous text). And Mori children and elders are even more vulnerable due to their
exposure to housing issues. For example, an estimated at least 23% of Maori children disease burden
can be attributed to this exposure to housing issues. By comparison, the estimate is only 9% in

European/Other(M Baker, McDonald, Zhang, & Howden-Chapman, 2013). And Maori male elders is the
group which has been identified as the most vulnerable group against home injury (Kool, 2011).

There are few attempts to address the huge gap health between Maori population and Caucasian
population caused by housing issues, including Rural Housing Programme, Community Owned Rural
Rental Housing Loans, Special Housing Action Zones and etc. which target on Maori household and try
to improve Maori housing quality in general. However, it is such a problem that is difficult, if not
impossible, to solve due to its high resistant to resolution and the complexity to change the Maori
health behaviors in general, that it is can be identified as a Wicked Problem (Commission, 2012) and
therefore required interdisciplinary solutions (Brown, Harris, & Russell, 2010) more than policies only to
reach a sustainable result.

Most of the housing issues discussed above are the result of poor economic stands or in general the low
socio-economic status of Maori households, which is one of the most persistent social issues. Therefore,
it demands solutions that focus on mid-stream health determinants (e.g. behaviors and physiological
wellbeing) as well as in general improving Maori households socio-economic status. To tackling the
Wicked Problem of Maori health issues caused by housing problems, the following approaches are
1. Establishing targeted marketing campaign on Maori household to promote health promoting
behaviors (e.g. healthier diet and etc.);
2. Establishing targeted education campaign on Maori household to reduce health damaging
behaviors (e.g. smoking, drug/alcohol abusing and etc.);
3. Providing subsidies for house repairing/maintaining services;
4. Supporting community level non-governmental organizations to promote Maori physiological
5. Advertising the available public services to Maori household and encouraging their public
resource utilization;
6. Reduce the socio-economic status gap between Maori and Caucasian population through political
tools including tax and subsidies.

Influence of Rcism on helth of the Mori

From modern sport to Human Rights policies, racist behavior is condemned worldwide. The last decade
saw racism gain importance as a social determinant of health on an international scale, contributing to
significant disease burden across different populations. (Pascoe & Smart Richman, 2009)

The caste system in India, apartheid in South Africa and the slavery seen in early American colonies are a
few examples where people in higher authorities, treated the minorities with disgust and discrimination.
However, things were a bit different when it came to the Maori population. Unlike indigenous
communities in different parts of the world who were succumbed to have poorer health outcomes, the
Maori population were not entirely crippled by the effects of colonization. Largely due to the Treaty of
Waitangi which played a major role in negotiating governmental policies between the Maori and the
Nevertheless, (Robson & Harris, 2007) the Maori people have lower life expectancy rates and increasing
rates of morbidity even today. It is an understated notion, that racism is felt only at a personal level. The
history of colonization suggests that racism had been institutionalized and was expressed in discreet
forms of socio economic configurations. It had negative impacts on education, healthcare, employment
and pay grades. Land and various assets (Kokiri, 2000) were confiscated under the dogma of rapid
urbanization rendering more than half of the Maori (Kahukura, 2010) to live in more destitute
residential areas .

Extent of the issue:

The percentage of political partnership gained in the governance of New Zealand is debatable. However,
the Maori possessed strong rights to protect their community, when compared to other minorities
across the globe. Yet, according to a study conducted by (Bramley, Hebert, Tuzzio, & Chassin, 2005)
which reported inequities in health of New Zealand and the United States populations, there was a
larger gap between the life expectancies of the Maori and the European settlers (8.9 years) in
comparison to the native Indians and American settlers (7.4 years). This pattern repeated for all other
indicators included in the study.
Another survey based study (Harris et al., 2006) that was conducted exclusively in New Zealand, with
4108 people of Maori origin and 6269 settled Europeans, concluded that racism is one of the key factors
that is responsible for socio economic deprivation and plays a vital role in determining the inequalities in

The Element of Racism:

Racism (Bhopal, 1998; Williams, 1997) refers to a belief that a few races are superior to others. From the
discrimination of skin tone to ethnic prejudices, racism has many colors in itself. These practices trigger
and reinforce a system of oppression and inequality (Bhopal, 1998; Krieger, 2001).
Two main types of racism have been described: interpersonal and institutional by (Karlsen & Nazroo,
Interpersonal racism pertains to the discriminatory interactions that take place at an individual level.
These can be felt directly either physically or verbally. Institutional racism on the other hand, is invisible.
It refers to discriminatory policies which are ingrained within an organization (Karlsen & Nazroo, 2002;
Krieger & Berkman, 2000).

In public, there are often interactions and glances which may go unnoticed when lacking attention.
These convey impugnable messages to racial minority groups and are called as micro-aggressions (Sue &
Constantine, 2007).D Sue and her colleagues have described these micro-aggressions to occur in various
formats ranging from subtle derogatory looks and gestures to verbal assaults. These occur often
unconsciously, hurting the colored individual. She classified these into micro-assaults; which are readily
perceived by the victim, micro-insults; unintentional, rude actions which lack empathy and microinvalidations; when the people of the majority fail to accept the presence of such a phenomenon and its
consequences on minorities.

Racism and health:

Despite indifferences, the Maori accepted their fate and continued to carry on with their lives. It was not
until 2003, that the hidden element of racist behaviors was brought to light by the New Zealand Health
Survey which included questions on personal experiences of racial discrimination.
A number of studies across the world show the poorer outcomes in health as a result of interpersonal
racism (Collins Jr, David, Handler, Wall, & Andes, 2004; Karlsen & Nazroo, 2002) and institutional racism
(Collins, 1999; Jackson, Anderson, Johnson, & Sorlie, 2000).
(Krieger, 2003) conducted a research and identified five pathways through which racism affects the
health of a population.

Social and Economic deprivation

Exposure to environmental hazards
Socially experienced trauma
Use of harmful products
Health care

For deeper understanding of how these pathways determine health, it is important to understand the
upstream, mid-stream and downstream social determinants of health as proposed by (Turrell, 2006) in
relation to institutional and interpersonal racism.(Table R1 and R2)

Table R1 and R2 Influence of Racism on Social determinants of health. Adapted on the principles
proposed by Gavin Turell

1.Institutional racism
a)Employment :
This is one of the several reasons for a vast majority of Maori men and women to be
unemployed. Although the government and various private companies encourage graduates
with an indigenous origin to apply, and a significant number of people are attaining jobs, data
indicates that the unemployment rates for both men and women have increased steadily since
last year (Ministry of Business, 2016). An average of 12.2% Maori men and women population
are unemployed. With larger families to feed, and a racist notion, that the Maori are physically
fitter, they are given occupations which have hazardous effects on their health (Pearce et al.,

Table R3 The unemployment rates for both Maori men and women increased from March
2015 to March 2016
Adapted from Statistics New Zealand, Household Labor Force Survey, March 2016; MBIE

Schooling for children in the Maori has improved in the last five decades. However, there are
reports of Maori being looked upon in awe when they re-enter University after a semester
break.(Duff, 2015).This is due to a fact that only 25% of Maori who finish school, go to college.
This is 50% lower than the Non- Maori population (Marriott & Sim, 2015).Education and
employment are keys areas where the Maori have been termed as underachieving (Lock &
Gibson, 2008).Lesser the education, lesser the number of jobs or lower is the pay scale.

In aspects of housing, systematic racism has pushed the Maori away from neighborhoods with
proper sanitation and hygiene. Policies in the housing markets are constructed in a way that
most cannot afford the same (Kahukura, 2010). Racial discrimination has led to introduction of
pepper potting policies aimed at concentrating the Maori in particular neighborhoods
(Waldegrave, King, Walker, & Fitzgerald). This causes much ill health both physically and
d)Healthcare :
This section in racism deserves special importance because it can be perceived in an institutional
level and an interpersonal level by the medical staff themselves. Self-reported research on
racism which was conducted by (Harris et al., 2006)showed that the area where the Maori most
felt racial discriminated was in a medical setting. Identical discrepancies were found in a study in
Aotearoa, (Westbrooke, Baxter, & Hogan, 2001) which reported that less number of Maori
cardiac patients are likely to undergo surgical procedures when compared to Non-Maoris.
Similar is the case in caesarian section in pregnant Maori women (Harris et al., 2007).Although
people do acknowledge presence of such attitudes in the outer world, it is least expected from a
physician who has an ethical obligation towards his patient. This area has less research in New
Zealand, but a better example was seen in the hospitals of California, USA. Several women of
Arabic descent until 6 months after the 9/11 attacks, had pre term labour or gave birth to babies
with Low Birth Weight (LBW) whereas the outcomes of labour remained the same for rest of the
patients. (Lauderdale, 2006).
e)Criminal Justice:
Around 150 people per 100,000 are imprisoned in New Zealand every year. It has the highest
rate of incarceration per capita, only second to the United States (Department of Corrections,
2001). Despite being only 15% of the total population, they are over-represented in the prison
setting up to 6 times when compared to the European settlers(Workman, 2011). Up to 43% of
those convicted are Maori, 47% of violent offenders are Maori (Soboleva, Kazakova, & Chong,
2006) and a total of 51% of the total incarcerated are Maori (Doone & Unit, 2000; Workman,
Whether the criminal justice system is imparting longer sentences or whether the Maori are the
first to be suspects in case of any crime and hence convicted, requires further study. However,
these prisons often serve as a prison pool for various infectious diseases. Indulging in risky
behaviors (Patten & Gray, 1991) like sharing of needles and unprotected sexual intercourse
transmit infections like HIV, Hepatitis B and Tuberculosis. Upon release from the correctional
facility, these diseases are carried home. A more recent study (Stewart, Henderson, Hobbs,
Ridout, & Knuiman, 2004) also showed that all prisoners irrespective of their gender or ethnicity,
who were released from prison, died sooner. More so, when they had histories of risky
The Maori are spiritual people. They value their land as Papatuanuku ; Mother Earth (Durie,

1997). As a result of massive urbanization, various parts of Maori land were consfisicated. This
not only led to loss of occupations with respect to cultivation, but also added to psychological

2.Interpersonal Racism
a)Physical assault:
Interpersonal racism is more visible when it occurs in the form of a physical attack. Direct
injuries to the victim may result in disability and death. This fact remains and understatement
given the associated mental factors during this racist transition.
Post assault instillation of fear, misery and a feeling of helplessness later convert into depression
and stress. A study (Paradies, 2007) showed that psychological stress, is expressed by adolescent
victims of racism in forms of violence, smoking, substance abuse or increased alcohol
consumption. Violence leads to jail while others only increase the existing burden of disease in
the society.
b)Sexual Assault:
In New Zealand, (Fanslow, Robinson, Crengle, & Perese, 2007) one in three teenagers under the
age of 16 are likely to be victim to sexual assault with approximately 70% of the cases involving
contact of genitals. Moreover, the likelihood for a Maori female to be a victim to sexual assault
is twice as high as a non-Maori (Mayhew & Reilly, 2007).
Literature suggests (Thomas, 1993) that rates of sexual assault on Aboriginal women by nonAboriginal men were higher in the past. However, evidence regarding the current traits is lesser.
Abuse of this kind has devastating effects on the mind, body and soul.
c)Verbal Assault:
Micro-aggressions in the form of involuntary degrading gestures do exist, however, it is when
the verbal abuse has targeted intent, the effects are mentally traumatizing. Subsequent
psychological stress often impedes vital decisions in their lives. A feeling of hostility warrants
unwantedness in social gatherings. These emotions later convert to depression which works in a
negative feedback mechanism, leading to isolation. Rage, stress and depression are emotions
which direct young Maori adults to adopt unhealthy behaviors like smoking and substance
abuse. History also suggests that when parents try to protect their children from being victim to
racism, by trying to impose restrictions, results have been calamitous with children turning to
suicide (Goldberg & Hodes, 1992).
The lack of appropriate education, increased poverty, longer periods of incarceration, psychosocial
factors, risky behaviors and decreased access to healthcare have added effects on the health of the
person. Products of risky health behaviors pathologically influence the human body via inflammation or
infection. Hypertension and hyperlipidemia increase the chances of cardiovascular disease whereas

immunosuppression leads to systemic and bronchopulmonary infections both of which add to the
morbidity and mortality of the population (Harris et al., 2006).

To combat Racism:
Given the fact that the element of racism exists since the time of the prophets, it is not easy to
tackle the situation with mere reforms and appeals to human right commissions. In the 1980s
an attempt was made to dethrone institutional racism, by introducing recommendations from
Puao te Ata Tu. (Table R4). These recommendations were accepted by the Minister of Social
Welfare and are till date the fundamental basis of anti-discrimination in all levels of public
services (Tennant, 2005). However, there still exist loop holes in the system. A targeted
approach to bring reform to the structure (institutional racism) and the agency (interpersonal
racism) is necessary.

Table R4 Summary of recommendations from Puao te Ata Tu

Adapted from Puao Te Ata Tu, Ministerial Advisory Committee. 1988,
p.9-14. Wellington, New Zealand; Department of Social Welfare

1.Education :
Mass movements of intellectual resistance indeed existed in the history of the Maori which tried
to rebalance inequities. One such movement was the rejuvenation of Te Reo me ona tikanga by
developing educational institutions and universities for the Maori (Cram & Pipi, 2001).
Thus historically, it can be acknowledged that a good place to start reform, is to begin with
education. Education not only eliminates racist attitudes, but also teaches methodologies to
recognize its patterns and advocate against them. Educational programs initiate cultural
familiarization and understanding upon which relationships that thrive can be constructed
among societies.

2.Law and the media:

Racial harassment laws do exist (Ministry of Justice, 2002)for the benefit of the minorities that
prohibit all kinds of mockery. Despite this, there are reports of racial abuse which indicate the
lack of public awareness. Social media should enlighten the society regarding the active and
passive effects of racism and subsequent punishment against violators. A dedicated
telecommunication hotline for reporting racial abuse of any form can be incorporated.
3.Professional Training:
As the commonest place of social interaction are the offices and commercial centers, all the
staff should be trained to handle cultural incompetency with extreme care and professionalism.
Caution should be practiced to not illustrate involuntary signals of micro-aggression. Institutions
play a vital role in advocating such strategies (Grant et al., 2009). Ethical guidelines ought to be
included in the terms and agreements across all occupations, breach of which would lead to
The National Rugby League and FIFA soccer federation are examples of organizations who have
utilized media to advocate against racism. They undertake strict action against all forms of
derogatory racist actions in sport. Similar anti-racism advocacy can be adopted by television
celebrities and other organizations who set examples and trends in modern society.
5.Leadership and voice to the victims:
A study conducted by (Pack, Tuffin, & Lyons, 2015) in New Zealand reported the resistance that
is encountered in speaking up against racist behaviors. Some subjects conveyed difficulty in
expressing the abstract assault, a few chose to ignore and some vocalized. This indicates that
there is a lack of confidence in the Maori, who have acclimatized to oppression. Leadership
development programs paired with telephone hotlines can serve better in imparting a voice to
the community.
Despite having well accomplished recommendations from Puao te Ata Tu, the system lacks
vigilant monitoring protocols. Frequent surveys ,awareness polls against racist experiences and
adaptation of evidence based research in elimination racial discrepancies can help in making the
system full proof.

The Maori have been victim to political sabotage and continue to endure the subsequent effects of
racial discrimination till date. Deeply embedded within the structure of organizations, it has adversely
altered the thought process and existing dynamics of the Maori population, leading to disparities in
health. With historic origins so deep, abolishing racism may not be entirely feasible. However, a large

scale, multi-modal and vigilant system that can bring substantial change in the structure, transform the
agency; the perpetrators and develop bold leadership qualities in the oppressed, is mandated.
Life does not grant us options to choose family, intellect or skin tone for that matter. By dismantling
discrimination, we would be a step closer in redeeming ourselves.

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