Abstract
A memorial lecture creates some incentive to look back in time, to remember those whose contributions have helped shape today's world and at the same time to reflect on the nature of their efforts and whether there might be some application to modern times and to the future.
The year 1997 was important in many respects. It may be remembered as the first year in which New Zealanders grappled with Mixed Member Proportional Representation and faced the realities of coalition governance. But 1997 was also a significant year in New Zealand's history; it was the centennial of an event which literally changed the course of history. In January 1897, a conference was held to discuss a variety of issues, many relating to health. The little-known conference was to be the start of a movement which played a major role in turning the tide on the greatest health threat that this country has ever known and in converting expectations of a final demise into a celebration of health. Although the threats to health which ran unchecked then were very different from the health problems that confront us today, the story is worth recalling because there are lessons to be learned from the conference and the activities which followed. Moreover, it is associated with one of the most remarkable recovery stories in New Zealand, if not in the world.
The Conference referred to was held at Te Aute Maori Boys College in Hawkes Bay and the participants were largely old boys from the College as well as some pupils still at school. The central concern in 1897 was whether or not the Maori race would survive into the 20th century. Popular predictions doubted that it was possible. Only the year before, the 1896 the census had estimated the total Maori population to be around 42 000, a reduction of 75% over the previous 100 years. But the Conference participants refused to accept that the end was nigh and committed themselves to a program of reform, focusing on health and sanitation, education, agriculture and the law. The Conference led to the formation of the Te Aute Association, which in 1909 became known as the Young Maori Party. It did not survive as a political party but its three main leaders all went on to become members of Parliament. Two of them also graduated as doctors, one, Maui Pomare from a university in Michigan, and the other, Peter Buck, Te Rangi Hiroa, from the University of Otago. The third, Apirana Ngata qualified in law and rose to be a cabinet minister and Deputy Prime Minister.
In the event, the Maori race did not succumb to the ravages of tuberculosis, malnutrition or pneumonia, and even by 1920 the depopulation trend had been turned into accelerated population growth. A hundred years later, it stands at 580 000.
It would of course be simplistic to attribute the change in Maori health entirely to Pomare, Buck and Ngata or to the small conference held at Te Aute in 1897. Nor should the large numbers of Maori today be confused with good health. However, I mention the event because it heralded an era of greatly improved standards of Maori health and recognised the importance of Maori people providing their own solutions to social, cultural and economic recovery.
Epidemiological transitions
When opening the 1897 Conference, the Te Aute Headmaster John Thornton observed, ‘Reform cannot be forced on a people, but the suggestion must come from within, from the people themselves’ [1]. His comments found a ready target in the youthful Maori audience who were not slow to translate the aspirations of tribes, and village into polices and broad strategies. Today, Thornton's words would be seen as consistent with the message of the Ottawa Charter, and the Draft Declaration of the Rights of Indigenous Peoples, as well as the central goal of tino rangati ratanga, Maori self-determination. But in 1897, the notion that Maori people might best devise their own solutions needed to compete with the rising power of professionalism, the arrogance of colonial frameworks and the powerful drive towards assimilation.
I do not want to dwell unnecessarily on 1897 and the very different problems which faced Maori health in those days. Then, tuberculosis, pneumonia, malnutrition were the substantive causes of suffering and death. Today, cancer, motor-vehicle accidents and heart disease fill similar roles. But there is also evidence that, although loss of life is less dramatic, the greatest threat to good health for Maori is now poor mental health.
Measurements of mental ill health are derived from several sources. The most quoted are hospital admissions and re-admission. According to a comprehensive review published by the Ministry of Maori Development [2], Maori are over-represented in crisis, acute inpatient and forensic services, and have substantially higher rates of re-admission than non-Maori. In the 20–29 years age group, Maori men are at greatest risk of mental illness. Their first admission rates are more than three times the overall rate. Alcohol and drug disorders account for much of the increase in hospital admissions and are still the major reason for Maori being admitted to a psychiatric facility for the first time [2]. They constituted 32% of all Maori first admissions in 1993 (although only 12% of readmissions). While hospital admissions are the main source of information about poor mental health, they are not by themselves a reliable estimate of prevalence. Indeed, they might say more about management than about prevalence. Increased hospitalisation rates are as much a commentary on ineffective primary health care, as on the actual rates of illness.
Nonetheless, although there are relatively few prevalence studies, the Christchurch Epidemiology Study estimates that the prevalence of drug and alcohol disorders in young Maori adults is as high as 30–40% and has also produced findings to support a high prevalence of both internalising disorders (e.g. depression) and externalising disorders (e.g. conduct disorders) in 18-year-old Maori males and females [Fergusson D: personal communication].
A further indicator of the seriousness of the problem, apart from actual numbers of hospital admissions, is the acuity measure. Using an acuity rating based on severity of illness, impairment of functioning, the levels of lethality, and the influence of relevant stressors, a recent report [3] has demonstrated that Maori are over-represented in acute mental disorders, accounting for 23% of admissions. As well, it was evident from the report that Maori were not accessing services early enough, and were particularly disadvantaged by a dual diagnosis.
Mental health status is also reflected in the alarming rise in suicide and attempted suicide among Maori youth. While the actual number of deaths is not large (27 in 1995), the Maori rate (for males it was 58.4 per 100 000 in 1995) has increased to the point that it is now similar to [4] (and perhaps higher than [5]) the non-Maori rate. And for every suicide there are at least eight or nine times more hospital admissions for attempted suicide. In 1993, the Maori youth female rate of hospitalisation for self-inflicted injury (544.2 per 100 000) was the highest for the whole population [5].
Further, although the link is not straightforward, rates of offending and imprisonment (and the high Maori rates are well documented) have some correlation with poor mental health. Similarly, abuse within families and the creation of risk-filled environments for children have mental health implications of their own, adding to the size of the problem.
At the same time, the way in which behavioural and psychological phenomena are conceptualised leaves some room for concern. While there is little doubt that Maori are over-represented in psychiatric facilities, and while there is absolutely no doubt that improved care and treatment for Maori are needed, there is also some concern that the medicalisation of behaviours may not be the most helpful approach. Unlike the conceptualisation of depression, mania, schizophrenia and anxiety syndromes as disorders akin to other medical problems, the labelling of personality types and patterns of conduct as disorders has done relatively little to guide management or to improve comprehension. Instead, it has conjured up an expectation that ‘treatment’ is possible and that a DSM-IV diagnosis will somehow lead to a resolution. Moreover, other approaches which make greater sense at least in cultural terms have been discredited while funding options have largely been constrained by medically based purchasing plans. More work is needed to understand the parameters of behaviour among Maori youth without necessarily presuming that the phenomenon will be best understood by recourse to models of illness and disease.
Improving mental health
Prior to 1972, and in contrast to a public health approach, the focus for improving mental health was on large mental hospitals which offered long-term care and for many, life-time incarceration. In their absence, it is sometimes tempting to idealise those institutions, believing that the current problems of community care, insufficient inpatient beds and variable access to services would be solved if the mental hospital system could be re-established. The truth is that for any advantages they may have had, the big hospitals had many more serious failings: too large, impersonal, restrictive of freedom and blind to the abuse of the very people they were supposedly helping. And if gaining admission to hospital is a problem today, being able to leave hospital was a more pernicious problem then. No one who experienced life in the institutions of yesterday, apart from a few whose livelihoods depended on it, would seriously wish for a return to that system.
In any event, by 1972 change was afoot. The wholesale discharge of patients into the community and the parallel development of mental health services based on general hospitals, ushered in the era of community care. It pre-supposed that the community did care and that families were ready and able to pick up where the hospital left off. Moreover, there was a deliberate effort to separate treatment from care and in that process some shift in responsibility occurred though seldom in an explicit manner. Nor were resources allocated in a fair manner. Any economic savings by hospitals ignored the fact that the burden of care fell disproportionately on families and community support workers. In the transfer of responsibility from the Division of Mental Hygiene to Hospital Boards in 1972, the mental hospitals were allowed to run down with little, if any comprehensive forward planning. In effect, for a process which required careful and coordinated planning, the deinstitutionalisation transition was poorly managed and largely ad hoc [6].
Far from uniting people who had psychiatric disorders with their communities of origin, the more frequent experience was the creation of an illusion of integration, while retaining barriers based on stigma, discrimination, inadequate social functioning and limited financial means. Further, left to the unsympathetic forces of the market, ghettos developed in most communities and the ongoing shortage of appropriate residential accommodation described by McClellan and Warren [7], meant that homelessness was to become a significant problem for the mentally ill. It was underpinned by the lack of a basic standard of living [8].
The goal of locating people within the community largely ignored the wider aim of integrating people with society. Instead, the dual pre-occupations were finding accommodation in the community and reducing the size of the large hospitals. Missing was any ready recognition that living in the community was by itself an insufficient goal and that good mental health demanded not only a roof over the head, but also a strengthened cultural identity and enhanced social cohesion. In that respect, Maori ran the risk of being twice alienated, from community and from culture. Cultural alienation was, however, not only a product of mental disorder and community alienation; it was as much a cause of distress as a sign of illness. By the 1990s, it was abundantly clear that Maori youth at risk for mental disorders were not closely linked to family networks, to cultural resources or to the institutions of Maori society. Nor did they have strong links with the mainstream, including mainstream health services. Their entry to the mental health system was frequently through law enforcement agencies and very often characterised by unsatisfactory brief admissions alternating with piecemeal community care which added to an overall fragmentation of identity. Continuity of care and longer-term treatment plans, beyond the acute ward, were the exception rather than the rule.
It is one thing to have people live within the community; it is another to include people as part of a community. The reality for many Maori who have a mental disorder is that inclusion is more apparent than real. The deinstitutionalisation and community care paths have not lead to greater community cohesion or an enhanced sense of belonging: rather, for many, they have produced a continuing sense of estrangement. Has the process (of deinstitutionalisation) gone too far? Has it simply created institutionalised segregation? Is it time to turn back the clock and reinstate the certainty for which mental hospitals were renowned?
While a case could be made along those lines, it is also worth asking the opposite question. Has deinstitutionalisation gone far enough? Or has it become ground down in a dysfunctional system, whereby mental health remains largely outside the primary care arena and focused instead on a secondary care system which is unable to cope?
My view is that deinstitutionalisation has not gone far enough. The treatment and care of people with mental health disorders remains fixated at a level which is out of touch with the needs of a dynamic and energetic Maori society. Although not geographically isolated, there is a high level of conceptual isolation. That is no better illustrated by the inability to deal with patients who have a dual diagnosis or a mixture of comorbidities, or the need to invoke the law to gain access to treatment, or the use of motels and cheap boarding houses as places of care and treatment.
The simple fact is that seldom in New Zealand does community care and treatment actually belong to the community, even though it may take place within the community. Public hospitals have taken over from the asylum but without the same legacy of long-term care and guardianship; they cannot cope with the demands but society has been slow to accept other approaches which might complement them, and which are closer to the action. I do not say this without being mindful of the efforts of mental health services to meet impossible demands and to do so within tightly capped budgets. But a mental health system which pivots around specialists from a hospital base is not working and we should look in other directions if we are to make serious progress, at least for Maori. The point is that by focusing mental health interventions around secondary care we continue to undermine the role of families and communities themselves and perpetuate the illusion that mental health problems and dubious disorders are best left to the specialists. If that were so, then hospital services would by now have gained recognition and approval from consumers and families. Instead, 25 years after the Division of Mental Health services were devolved to hospital boards (in 1972), there is no guarantee that a Maori client will receive quality and timely treatment. Nor is there discernible Maori confidence in the system. The hospital record is essentially one of failure.
Strategies for addressing Maori mental health
At the commencement of this paper, reference was made to the 1897 Conference and the work of Ngata, Pomare, Buck and others. While the strategies they came to promote in order to turn around standards of Maori health and alarming rates of mortality cannot be readily transferred to modern times, there are some lessons to be learned from the approaches they encouraged. They argued for education, for Maori participation in the wider society, for the retention of a secure cultural identity, for better access to and utilisation of Maori resources such as land, for stronger Maori institutions, and for active roles in governance and leadership. Building on those broad goals, it is possible to suggest five strategies for improving Maori mental health.
The first strategy is the development of a secure identity. Identity is a necessary prerequisite for mental health. And a secure Maori identity requires more than a superficial knowledge of tribal affiliation or ancestry. It depends on access to the cultural, social and economic resources of te ao Maori (the Maori world), especially Maori language, family networks and customary land. All three underlie identity and can reinforce positive mental health. In a current household study known as Te Hoe Nuku Roa, 700 representative Maori households are being tracked over a 10-year period in order to measure aspirations, achievements, levels of participation in society, standards of health and education, and access to Maori resources [9]. Results so far suggest that as many as two-thirds of the study group have limited access to Maori resources such as language and land, and where access is the lowest, poor health coupled with lower educational achievement seem more likely. Conversely, where identity is most secure and where access to Maori culture and resources is assured, health is best.
The task is to ensure that Maori access to culture and other resources can be enhanced. Especially important for mental health is access to a supportive extended family. Positive family development must rank as an urgent goal for Maori health. Linking Maori with Maori resources and in the process building a secure identity is primarily a task for Maori at local, tribal and national levels. Treaty of Waitangi settlements must also take into account the needs of Maori who are dispossessed. Treaty settlements are about righting the wrongs of last century when large tracts of land were alienated contrary to guarantees of the 1840 Treaty of Waitangi. Often the beneficiaries of redress are those who have retained tribal links, as opposed to Maori families who have become alienated from tribe and tribal networks. Not infrequently, they are given the least consideration and lack advocacy when negotiations are in progress. Nor is it a simple question of being urban or rural. Te Hoe Nuku Roa shows that alienation from Maori resources can occur regardless of place of residence.
A second strategy for mental health is the active participation of Maori people in society and in the economy. Good mental health is not compatible with unemployment, demeaning and unrewarding work, negative experiences at school and powerlessness. Neither is it consistent with article three of the Treaty of Waitangi with its guarantee of equality between Maori people and other New Zealanders. Marginalisation within society leads to trapped lifestyles where alcohol, drugs, abuse, violence, rejection, parental abandonment and self-fulfilling prophecies of failure are the rule. By almost any indicator, Maori participation in society and the economy is low and disparities between Maori and non-Maori remain at unacceptably high levels [10]. Poor mental health is a not unexpected consequence. Full participation also means Maori participation in decision-making, at policy and service levels. Even though Strategic Result Area 8 (SRA8) requires Government departments to demonstrate to Cabinet how they have reduced disparities between Maori and non-Maori, it is unlikely that equitable Maori participation will be realised by Government action alone. Instead, at least for matters of national importance such as mental health, a concerted Maori approach will be necessary. The recently established Maori Health Commission will have an important role to play but further consideration ought to be given to the establishment of a national Maori policy making body, outside Government, to provide guidance from a Maori perspective and in a way which might make more sense to Maori. The Minister of Justice, Hon Douglas Graham has suggested a similar step in his recent book Trick or Treaty [11]. His proposal is for a national Maori body which might meet with Cabinet to guide the formulation of effective policies for Maori.
Strategy Three is about improving the quantity and quality of mental health services so that Maori access and Maori outcomes are enhanced. The Blueprint for Mental Health Services in New Zealand [12] contains the first comprehensive description of what is needed to provide effective services for the 3% of the adult population and 5% of the children and young people, who need specialist services. The Blueprint breaks new ground and warrants support from Government as well as the community generally in order to overcome the glaring inadequacies which have marred mental health services for two or more decades. Attention to the needs of Maori forms a significant part of the Report, and better Maori access to mainstream services, as well as the establishment of specific Maori services are recommended. There are now more than 30 special Maori mental health services. Known as kaupapa Maori services because their focus is on cultural as well as clinical goals, Maori elders work alongside Maori (or sometimes non-Maori) clinicians to bring a more comprehensive approach to treatment than is possible in usual treatment settings. Maori language, family support and involvement, and Maori culture are integral to the programs.
If they are to be effective, mental health services must coincide with Maori realities. According to the Treaty of Waitangi principle of options, Maori should be able to access services which are geared to their own cultural expectations if that is what they wish. While the closure of large mental hospitals led to community centred programs, more often than not Maori experience was at odds with the systems which delivered the new mental health services. Although geographically located within the community, for the most part the hospital focus militated against any sense of active Maori participation in the process. There was the occasional exception, Whaiora at Tokanui Hospital, Te Whare Paea at Carrington Hospital, but it was not really until the 1993 health reforms that Maori centred programs began to evolve. The evolution, however, is slow and there remains a need to realign services in at least four key directions.
Alignment with primary health care
Skills in assessment and management must become part of the repertoire of primary health care centres so that early intervention is maximised and referral out minimised. The National Health Committee's Guidelines for the Management of Depression [13] was a deliberate attempt to shift the focus of mental health services into general practice, drawing on other community skills as necessary and using the specialist services sparingly.
Alignment with Maori health care
An increasing number of Maori health programs are confronted with a mix of primary health care and mental health needs. Referral for specialist assessment and treatment sometimes leads to missed opportunities for early intervention and in the process engenders mistrust. Further, the model used by many Maori health centres, locates health within the wider context of Maori development so that it becomes an integral part of a Maori matrix of services and networks. Bearing in mind the wide range of resources needed to adequately manage mental health disorders, it makes sense to incorporate aspects of mental health care within the broad framework of Maori health. It may be more appropriate to focus the major mental health thrust on Maori health centres, purchasing specialist advice only when needed. By extension planning for Maori mental health at local levels should therefore be a function of Maori. The continuing role of the large hospitals as the primary planners is a further sign that the deinstitutionalisation process has become stuck at an institutional level.
Alignment with rangatahi (Maori youth)
The age group most at risk for mental health disorders is between 15 and 29 years yet few mental health services are geared to meet their particular needs. At these ages comorbidities are the norm and dual diagnoses, far from being exceptional, are the most common presentation. In addition, the group is mobile, not well attuned to professional and middle-class values and not necessarily keen to make commitments to treatment beyond the immediate future. Rather than trying to add on a youth program to an otherwise conventional mental health service, more attention needs to be given to services which are primarily aimed at youth. The earlier comments about alignment with primary health care and Maori health care are especially relevant for Maori youth.
Alignment with Maori-centred frameworks
When the National and New Zealand First parties formed a coalition government after the 1996 General Election, one of their more ambitious aims was to move towards funding outcomes rather than purchasing services [14]. Even though at this stage adequate outcome measures are not available, the intention is logical and increases the urgency for the development of outcome measures based on frameworks that are capable of reflecting Maori notions of wellbeing and good health [15]. Services designated as Maori health services should be measured according to agreed upon outcome measures which make sense to Maori. Similarly, assessment measures should be more than a simple statement about DSM-IV categories. They should also be capable of measuring the degree to which cultural and spiritual factors are associated with the problem.
Alignment with evidence-based practices
Clinical research forms the basis for best practice and although a cultural focus is contained in some research, there is also a need for methodologies which can give expression to Maori health perspectives and to Maori priorities. In this respect the Health Research Council of New Zealand has made some progress. Applicants for research funding from the Council are routinely asked to comment on the relevance of the Treaty of Waitangi to their proposals. In addition, the Council provides core funding for three Maori health research units all of which promote the training of Maori researchers and the development of methodological frameworks that are relevant to Maori situations [16]. However, relatively little clinical research has been undertaken and opportunities for partnership between clinicians and Maori researchers abound.
The fourth strategy for improved mental health requires accelerated workforce development. Disparities between Maori and non-Maori standards of health are matched by disparities between Maori and non-Maori in the workforce. Across the range of professions and mental health disciplines Maori are grossly under-represented. Fewer than one percentage of clinical psychologists, nurses or occupational therapists are Maori and only 1.6% of New Zealand doctors are Maori. Two responses to that situation have occurred. Anew category of worker has emerged: not necessarily possessing formal qualifications but being well qualified in terms of culture and customary knowledge, accessing Maori networks and interacting with family networks. The so-called Maori community mental health worker has many skills which professionals do not possess and in that sense is invaluable. However, there has also been a tendency to exploit those skills by failing to provide career pathways and not encouraging the acquisition of formal qualifications on top of existing competencies. That situation must change. There is a serious need to facilitate entry into programs of study so that Maori community workers are not trapped or unable to transfer to other work situations and better long-term prospects.
The second response to the low numbers of Maori health professionals has been to periodically canvas secondary schools in search of potential Maori students. Few initiatives have made any significant change but the Vision 2020 project floated from the Auckland Medical School [17] could result in a massive increase in the number of Maori medical practitioners, from six a year to 50 per year, for 10 years. And a Government objective is to increase the Maori mental health workforce (including clinicians) by 50% by the year 2005. There is no shortage of concern about the problem; the Ministry of Health, Mental Health Commission, Clinical Training Agency, the Government's Committee Advising on Professional Education, the Health Funding Authority, and various professional groups are all embarking on strategies to improve the Maori health workforce. The Mental Health Commission has assumed a coordinating role in respect of the mental health workforce. However, there is also a need for Maori health workforce planning to be conducted within a Maori development needs framework. Given the limited human resources, Maori workforce planning across all sectors, professions, and disciplines, needs to be well coordinated and relevant to actual Maori needs.
The final strategy for improved mental health is related to autonomy and control. The principle of autonomy defined by the Waitangi Tribunal in the Taranaki Report [18] applies well beyond considerations of land and has implications for improved Maori mental health. Increased control by consumers, families and communities is recognized in Moving Forward [19] as a desirable principle and is consistent with the Ottawa Charter's emphasis on empowerment. Autonomy and control are also important for Maori development and refer not only to service delivery but also to policy formulation, planning and key decision-making. Applied to mental health services, purchasing, budget holding and managing a full continuum of care will enable Maori to make more effective use of a range of services and assert appropriate pressures on the large providers. Greater autonomy will require stronger links between Maori mental health interests and other Maori groups such as tribal organisations or community trusts and may lead to partnerships with national and international agencies who have experience in independent health management.
Increased autonomy does not necessarily mean ‘going it alone’ but it does mean being able to exercise choice when finding a partner and combining local needs with the best international standards and practices.
Conclusions
It cannot be emphasised enough that mental health problems are among the most serious health problems facing Maori today. There are no signs that the trends first evident in 1975 are reversing. Instead, compared with non-Maori and compared with earlier generations of Maori, the prevalence of poor mental health continues to rise, especially for young adults.
While a range of personal mental health services is necessary, the problem is so extensive that the broader parameters of the Treaty of Waitangi and the principles of public health must be applied. Importantly, any remedial strategies must be linked to the wider context of positive Maori development.
Drawing on the visionary approaches initiated in 1897 and continued by Maori community, professional and tribal leaders, five interrelated strategies to improve Maori mental health have been suggested: a secure identity through improved access to Maori resources such as land, language, family networks; active participation in society and the economy; alignment of mental health services with primary health care, Maori health services, services for youth; accelerated workforce development; autonomy and control.
Government responsibility for improving Maori mental health is clear and given the seriousness of the problem and the intersectoral and interdisciplinary implications there is a need for improved coordination, monitoring and strategic planning. Despite central Government attempts to provide leadership and coordination, the results have generally been disappointing. The task cannot be left solely to a funder/purchaser, or providers of services, or a single Government department. While the Ministry of Health, the Ministry of Maori Development (Te Puni Kokiri), the National Health Committee, the Health Funding Authority, the Mental Health Commission and the Maori Health Commission have key roles to play, none is able to adopt a broad enough perspective, nor are they firmly located within the Maori world. What is urgently needed is an independent group with a solid Maori base which is able to monitor Government progress in SRA 8, plan for Maori development in a coherent way, and implement broad strategies for mental health which are linked to actual Maori situations and aspirations. The fact that no such group exists should not be used as an argument to continue to rely on sectoral governmental planning. Clearly that approach has failed and it is time for macro Maori-driven solutions to be formulated by Maori in a coordinated manner.
Discussions about advances in health, and mental health, requires a broad vision. The need for high quality mental health services, along the lines recommended by the Mental Health Commission in the Blueprint Report, is critical. But a focus which equates better mental health only with mental health services runs the risk of missing the core determinants of good health.