A tangata whenua (people of the land) approach to conceptualising Māori health and wellbeing

Introduction

Due to the ongoing effects of colonisation, Māori (Indigenous to New Zealand), like many Indigenous peoples, disproportionately suffer from more ill-health and at an earlier age in almost every health and social indicator than their non-Indigenous peers (1). As a result, Indigenous peoples are often targeted as key groups in health initiatives. Indigenous peoples are commonly treated as dependent consumers of a service as opposed to designers and drivers of their own wellbeing. Indigenous worldview, language and preferences are therefore often not integrated into such initiatives. With this consumer approach, Indigenous health has not significantly improved, suggesting there is opportunity for transformation.

Most analyses of ‘Māori health’ have focused on relatively contemporary Māori ill-health and disparities as measured by a comparison with Pākehā (non-Māori) health standards (2). While such an equity approach that focuses on grouping populations by ethnicity has helped to expose Māori health inequalities, it still emphasises majority non-Indigenous standards and compares Māori against these standards, often resulting in deficit approaches, and ‘whitestream’ measurements and solutions (3). This also contributes to the stigmatisation and problematisation of Māori who are deemed ‘less than’, ‘at-risk’ or ‘vulnerable’ to worse health outcomes (4).

To effectively engage Māori and transform Māori health outcomes and experiences requires more than a focus on inequalities and addressing social determinants of health. The broader social determinants of health are essentially controlled by colonisers, with Indigenous peoples often required to work within non-Indigenous systems. The extent to which Indigenous peoples can achieve their own aspirations of optimum health and wellbeing within such frameworks is limited.

Rights-based approaches to wellbeing for Indigenous peoples, such as those confirmed in the United Nations Declaration of the Rights of Indigenous Peoples and in Aotearoa New Zealand’s Te Tiriti o Waitangi, ensure the prioritisation of improving outcomes specifically for Māori. Rather than being viewed as consumers, this rights-based approach promotes Māori as the drivers of wellbeing enabling Māori to be involved in every component of the funding, planning, implementation and evaluation of health and wellbeing initiatives. It also prioritises Indigenous notions of wellbeing. Indigenous people’s notions of health and wellbeing are embedded in their worldview, culture and language, pursuit of self-determination, diverse identities, aspirations and colonised realities. A strong cultural identity and self-determination have both been linked with health and wellbeing outcomes (5). The purpose of this article is to provide readers with a broader understanding of Māori health and wellbeing sourced from considering Māori ways of knowing expressed in narratives, language, practices, lived experience and Māori led responses to health issues.

Framing Māori health and wellbeing

Our combined experiences are as members of whānau (extended family) who are actively pursuing wellbeing, teachers of Māori health in a university setting, researchers in our Māori communities, and kaimahi (workers) in local community health initiatives in Aotearoa New Zealand. We draw on knowledge about Indigenous and Māori rights, mātauranga (Māori ways of knowing) expressed in pūrākau (epistemological narratives), tikanga (Māori principles that inform practice), and te reo (Māori language) to conceptualise Māori health and wellbeing. Knowledge synthesis is about reflecting and combining different sources of knowledge in order to produce new ideas and/or understandings (6). In this way it can be likened to rāranga (weaving) with each of the different sources of knowledge representing individual rau (leaves) that are woven together to create something new. Rāranga requires careful preparation and attributes such as commitment, patience and creativity, all of which align to the process of knowledge synthesis. Rather than dissecting knowledge into smaller elements, it is through the interweaving of multiple sources, where connections are made to wider dimensions and layers of knowledge, that mātauranga emerges (7).

Mātauranga (Māori ways of knowing) expressed through te reo (Māori language), and tikanga (Māori principles that inform practice) can help to provide an insight into Māori worldviews as well as understanding of health and wellbeing for Māori. Māori language enables us to use the terms that most adequately describe notions of wellbeing associated with our spiritual, social, physical and mental capacities. Māori principles enable us to continue to manifest the aspirations and wisdom of our ancestors who successfully navigated the Pacific Ocean to live sustainably in Aotearoa. Māori ways of knowing enable us to contextualise wellbeing within a Māori worldview founded upon kinship relationships with the environment through atua (god, primal energy sources). Pūrākau (epistemological narratives) about creation, culture and human endeavour provide meaningful and contextualised explanations of the origins of these relationships.

The way that Māori define themselves as tangata whenua (people of the land) provides some insight into a Māori worldview and Māori conceptualisations of health and wellbeing. Understanding the meaning of the phrase ‘people of the land’ signifies connection with land as central to Māori identity, as opposed to a stronger connection with the sea for Pasifika peoples, for example. This connection with the land for Māori is re-enacted through practices such as reciting pēpehā (form of introduction establishing identity), which locates us within places of tribal significance that provide physical and spiritual nourishment such as mountains that protect and bodies of water that cleanse. Another meaning of the word whenua is placenta. This dual meaning emphasises land as the source of all sustenance for people, just as the placenta provides for a child in the womb. A pūrākau about the creation of the first human form from the sacred pubis of Papatūānuku, earth mother, explains how Māori were literally created from the land. This understanding of the Māori term tangata whenua for people Indigenous to Aotearoa New Zealand provides the foundation for an exploration of health and wellbeing.

Māori ways of knowing about health and wellbeing: hau, mauri, mana, tapu

The authors draw on mātauranga as a unique Māori way of knowing and being in the world. Māori philosopher Marsden and colleagues (8) describe mātauranga as the knowledge, comprehension or understanding of everything visible or invisible that exists across the universe according to Māori. Embracing individual, local and collective knowledge, mātauranga places importance on Māori histories and experiences and refers to Māori ways of thinking, doing and acting (9). It is the basis for a Māori worldview which is founded upon kinship relationships between people and the natural world and the interrelationship of all living things as dependent on each other. Mātauranga is constantly evolving as each new generation learns and adds to the body of knowledge (7,10). Valuing Indigenous knowledge on its own terms, mātauranga is not framed in the epistemes of others and does not depend on looking for legitimacy or endorsement from other perspectives to determine credibility (11). Te reo is an important medium to express mātauranga.

Te reo is considered a taonga (treasure) gifted to tūpuna (ancestors) by atua and carries with it its own life force, power and vitality (12). Language is a vehicle through which we communicate our thoughts, knowledge, values and beliefs from one person to another. Therefore, having a knowledge of te reo and its unique nuances is an important part of understanding the depth and breadth of mātauranga (12). For example, hauora is often used to refer to Māori notions of health. It is not a translation of the English word health or necessarily equivalent to its definition, which is ‘to be free from illness or injury’ or a ‘person’s mental or physical condition’ (Oxford English Dictionary online). Understanding the Māori language enables us to consider the individual terms that comprise the word in order to explain its full meaning. One of the meanings of hau is the vital essence embodied in all persons and living things according to a Māori worldview. An expression of hau in people is breath. Ora means to be alive, to be well. The word hauora can therefore be defined as the totality of vital elements that contribute to a flourishing, dynamic and vital spirit of life. Hauora is holistic in that all aspects of a person are included, such as their spirituality and cultural identity. According to a Māori worldview, a person’s health is also connected to the health and wellbeing of their whānau (extended family or social grouping) and the natural world through the influence of mauri (physical vitality).

Mauri is the physical manifestation of hau and embodies the lifeforce. It is present in all things and binds people to the environment (taiao) and primal energy sources (atua) (13). It is the physical integrity, vitality and synergy between people (M. Durie, personal communication, 28 September 2020). An elevation of mauri in one realm (between people) also positively affects the mauri of everything surrounding. Different states of mauri can also help to explain different levels of wellbeing. For example, when people are disconnected, their vitality can languish, compromising their wellbeing. This can be referred to as a state of mauri noho (languishing). A state of awakening, where something has sparked a person’s interest and willingness to engage, can be referred to as mauri oho (activated) (14). Mauri rere (unsettled) refers to a state where the mauri is distinctly unsettled and where rejuvenation or renewal may not be possible. Mauri tau (in balance), on the other hand, can describe a state whereby the mauri, or lifeforce, of a person is settled and open to a process of renewal and rejuvenation. Mauri ora is about being in a state of flourishing and this is the aspiration for our whānau and communities. Mauri is not static and we may transition fluidly across all of these states of mauri at different times depending on different influences impacting our wellbeing.

An understanding of mauri is derived from one account of the pūrākau (narrative) about the creation of the first human form, Hineahuone (earth formed maiden). The construction and retelling of pūrākau is one way Māori preserve knowledge and embody their worldviews and can provide some insight into health and wellbeing from a Māori perspective. Though often referred to as myth or legend, pūrākau are best understood as deliberate constructs employed to encapsulate mātauranga, informing human endeavour, and a view of the world comprising the whakapapa (genealogical) connections shared between tangata (people), atua (gods, primal energy sources) and taiao (natural environment). In the pūrākau about the creation of the first human form, Hineahuone, an additional energy source to those already provided from different atua was required in order to bring her to life. Tāne (god of the forests) was instructed to share his energy source (hau) with Hineahuone in the practice of hōngi (to press noses and share breath). The contemporary re-enactment of hongi, such as during the welcoming ceremony, acknowledges the sharing of hau of both people involved and is an act of revitalisation. It is often accompanied by the saying ‘Tīhei mauri ora!’ (let there be life). Mauri is also connected with mana (spiritual vitality).

Māori believe mana to be a sacred force, originating from atua (M. Durie, personal communication, 28 September 2020) connoting dignity, integrity, identity, self-esteem and spiritual vitality. Royal (15) defines mana as spiritual authority and power. Mana resides outside the control of the individual, recognising that there are obligations created externally from ourselves, and provoking us to appreciate the interconnectedness of all things at many levels (14,16). There are different types of mana that can enhance mauri. Mana atua is derived from primary energy sources, mana tūpuna inherited from ancestors, mana whenua sourced from the land and mana tangata based on our human endeavours. Barlow (12) defined these associations in terms of ‘mana mauri’, or the capacity for enlightenment, growth and development. Actions that diminish mana will have negative effects while actions that enhance and uplift mana will have a positive effect. The potency of mana and mauri is upheld through the observation of tapu (state of influence) (M. Durie, personal communication, 28 September 2020).

Tapu can be likened to an invisible forcefield that protects things that we deem to be critically important to both our physical and our spiritual wellbeing. Tapu with the addition of noa (unrestricted state), supports balance and the achievement of mauri ora, an essential component of overall health and wellbeing from a Māori worldview (10). As a result, efforts have been made to expand our comprehension of tapu within the health arena to prohibit and restrict potentially harmful protocols, including conduct with patients, kai, contagious diseases, pregnant and menstruating women, and the deceased (12,16). Tikanga or Māori principles also guide our interactions with others and the environment in order to fulfil cultural expectations.

Having an understanding of tikanga also opens up our understanding of mātauranga. Stemming from collective value, tikanga are cultural principles exercised by Māori in their daily lives. The concept is derived from the Māori word ‘tika’ which means ‘right’ or ‘correct’ so, in Māori terms, to act in accordance with tikanga is to behave in a way that is culturally appropriate. Principles are commonly based on experience and learning that has been handed down through generations and are based on commonly held beliefs associated with a Māori worldview.

Concepts such as mauri, mana and tapu help to explain a unique Māori view of health and wellbeing. Pūrākau help to contextualise and give meaning to these Māori concepts and practices. Cultural practices, such as kaitiakitanga (guardianship), rāhui (a conservation measure) and taonga tuku iho (cultural inheritance), for example, collectively highlight our role as tangata whenua to engage with the environment in mutually beneficial ways, which maintains and preserves natural integrity and customary resources for the health benefits of ensuing generations (10,17). The integrity and good health of the natural world, after all, cannot be divorced from our own good health and wellbeing as tangata whenua. The health and wellbeing of Māori was significantly impacted by the arrival of settlers.

Poor Māori or Pomare? Responses to colonisation

The first European surveyors in the early 1800s noted the good health and resilience of Māori to environmental challenges (16,18). The collective lifestyle of Māori resulted in an effective form of social organisation in which knowledge and values were preserved and passed down, providing a strong sense of identity and a keen understanding of linkages with each other and the environment around them (19). It also led to the evolution of a public health system based on a set of values previously discussed that reflected the close and intimate relationship between people, the natural environment and energy sources.

At the time of the signing of Te Tiriti o Waitangi 1840, the settlement agreement between the British Crown and rangatira (chiefs), there was already evidence of the influence of new settler technology and practices on Māori health (18). Māori lifestyle (āta noho), including rangatiratanga (sovereignty) and tikanga, were therefore included in Te Tiriti to ensure that Māori would continue to determine their own health and wellbeing. However, almost immediate dismissal of Te Tiriti o Waitangi, tribal warfare, disease and rapid colonisation negatively affected the Māori population. Māori suffered a significant loss of land and economic base, autonomy, te reo and culture, as well as their way of life and wellbeing. Māori, like many Indigenous peoples, have suffered significant ill health as a result of colonisation, urbanisation and globalisation (20).

Nevertheless, Māori have continued to pursue wellbeing, which is reflected in the work of our tīpuna (ancestors), such as Sir Maui Pōmare KBE CMG. Graduating as a doctor from California medical school in 1899, Pōmare understood the link between cultural beliefs, attitudes and lifestyle and how these factors influenced the day to day practice and health status of Māori (16). He also advocated strongly for western democracy, justice, education and modern health practices, believing it was possible to retain a secure Māori identity while also embracing Pākehā education and technologies. Pōmare understood that health was not something that was prescribed by a doctor but rather something that should be led by the community. His work therefore focused on engaging with, and empowering, Māori communities.

Pōmare’s legacy is reflected in the work of subsequent Māori health leaders with the development of Māori health models and frameworks (such as the more commonly referred to Te Whare Tapa Whā, Te Pae Māhutonga, Te Wheke, and Whānau Ora). Māori models of health incorporate values and knowledge such as those discussed earlier that are integral to a Māori worldview. While there is diversity amongst different Māori health models, there are also several similarities. These include the interconnectedness between the physical, the spiritual, the environment, the individual and the whānau. Another commonality is the use of symbolic metaphors to represent the health of a people such as the whare used in Te Whare Tapa Whā. For example, the concept of the whare is laden with meaning associated with a physical structure as well as an esoteric resource (21). Whare are often viewed metaphorically as representing a living ancestor characterised through the symbolic design of the building. Whare can also symbolise a repository, such as a whare wānanga being a source of learning. This use of metaphor enables complex themes to be thought about in simplistic ways and is a useful tool for teaching different principles and for remembering different aspects of health.

While these Māori health models have been developed within the context of contemporary Māori life, all draw upon Māori ways of knowing about health and wellbeing. Having an understanding of mātauranga, te reo, tikanga and pūrākau helps with the correct pronunciation and use of Māori terminology, a deeper appreciation of the underpinning values, and ensures the integrity of the application of Māori health models. English translations within a western biomedical worldview will limit the comprehension of Māori models. For example, translated into English, the four pillars of wellbeing in Te Whare Tapa Whā are often referred to as spirit, body, mind and family, which falls far short of the full meaning of the Māori words wairua, tinana, hinengaro and whānau and their significance to wellbeing. While there are benefits to the mass dissemination and utilisation of Māori health models, without understanding the Indigenous knowledge and practices that underpin such models, application can be misinterpreted, superficial and potentially detrimental to the mana (spiritual vitality) and overall mauri (physical vitality) of Māori (21).

To further improve Māori wellbeing and position in society necessitates a shift away from the deficit and narrow focus of reducing disparities that a needs-based approach such as equity might foster (4). What is required is the promotion of cultural constructs of wellbeing as prescribed by our own Māori leaders such as Pōmare, situated within positive Māori-led notions of self-determination, cultural identity and collectivity. The recent response in Aotearoa New Zealand to the COVID-19 pandemic provides an example of the need for Māori leadership and expertise to improve the health and wellbeing of Aotearoa New Zealand.

COVID-19 response as a case study

Failure of the government to meaningfully include Māori in the response to the COVID-19 pandemic demonstrates how Indigenous knowledge is undervalued in Aotearoa and raises questions around how the government engages and makes decisions on behalf of Māori communities (22). Limited consideration for the specific needs of Māori as Treaty partners was apparent (23). Māori were noticeably absent from any genuine form of decision making, with government defaulting to mainstream approaches with a one size fits all mentality (22,23). This type of approach fails to take into account health inequities that already exist within our communities and the disproportionately negative impact the consequences of the pandemic and its aftermath is likely to have on Māori communities. Privileging Pākehā voices as ‘authoritative experts’ also diminishes the mana of the many Māori health specialists in Aotearoa whose breadth and depth of knowledge would have contributed much to the response and recovery phase not only for Māori but for the general public also.

Conversely, the effectiveness of how a tangata whenua approach to health and wellbeing could be utilised can be seen through the Māori-led responses during the COVID-19 pandemic. Drawing on intergenerational knowledge of historical epidemics and introduced diseases to Aotearoa, Māori were acutely aware of the potentially devastating effects of COVID-19 (24). Remembering the past to inform our future is a key tenet in Māori culture affirmed by the whakataukī ‘Titiro whakamuri kia anga whakamua’. The devastating impact of the 1918 influenza is remembered through different artforms, such as waiata, haka, carved pou and the many gaps in our whakapapa which share the story of both grief and survivability. In light of this, Māori communities were quick to respond.

Beyond government driven initiatives, iwi (extended kinship group) effectively mobilised networks within their communities to establish a number of rāhui (restrictions) to prevent travel of non-essential persons to areas with high Māori populations (24,25). Through processes of whanaungatanga (interwoven web of balanced relations), vulnerable members of the community were identified with a number of initiatives put in place to support not only physical wellbeing but also spiritual and mental wellbeing of whānau throughout the lockdown period. Different platforms for karakia (incantation) to be shared, finding ways to increase internet connectivity for isolated whānau, and distribution of care packages are some of the examples around how Māori sought out ways to protect the mana and mauri of their communities during this time. Guided by key tenets such as tino rangatiratanga (sovereignty), kaitiakitanga (guardianship) and manaakitanga (generosity and caring for others), these types of responses demonstrate the effectiveness and capabilities of Māori being readily able to identify public health risks within their communities and to drive locally grounded solutions. It also highlights the holistic approach evident in Māori models of health where Māori were able to think beyond the epidemiological impact of COVID-19 to incorporate fundamental aspects of hauora such as mana, mauri and whānau support.

Despite the success of Māori to respond to the first wave of COVID-19 and lockdowns, the government unfortunately (but not surprisingly) did not follow Māori health expertise around the vaccination roll-out to prioritise Māori as a population with disproportionate vulnerability to the virus. As a result, the younger Māori population were disadvantaged through a narrow age approach which meant that fewer Māori were eligible to get the vaccine compared with the general population. This privileging of a larger non-Māori elderly population has predictably resulted in Māori having lower vaccination rates and higher positive cases, hospitalisations and deaths for the Delta variant (26).

The current reform of the health system and establishment of the New Māori Health Authority in particular presents an opportunity for the government and New Zealand to create space for Māori determination of health and wellbeing needs and aspirations. The new Health NZ, national public health agency, and locality groups could also make the most of the leadership and expertise inherent within iwi and Māori communities.

Conclusion

To improve Māori wellbeing and position in society, a transition in the health system from a deficit-based approach that treats Māori as at-risk customers to one that allows Māori to determine their own needs and aspirations is necessary. Such a shift requires an Indigenous understanding of health and wellbeing that includes more than the western medicalised notion of physical and mental (ill) health. By taking a tangata whenua approach to health and wellbeing, which is grounded in Māori rights and ways of knowing expressed through narratives, language, practices and lived experience, it becomes clear that wellbeing is holistic and inextricably linked to self-determination and the natural environment. We argue that as Indigenous peoples, we should seek solutions and understandings from our own Indigenous knowledge base and leaders rather than from a culture that has historically marginalised us. Improved health outcomes for Indigenous peoples can be achieved by the inclusion of Indigenous peoples’ traditional knowledge and language in public health curriculums, research, policy and practice. The current restructuring of New Zealand’s health system, as well as the COVID-19 pandemic response and future planning present opportunities to prioritise and embed Māori health leadership and expertise, as well as to integrate a tangata whenua conceptualisation of health and wellbeing into the way we consider our health care.