Dreaming of a Māori hospital: Mehemea, ka moemoea ahau, ko ahau anake. Mehemea, ka moemoea tātou, ka taea e tātou

Three years ago, in April 2021, the kaumātua hauora research team from James Henare Research Centre met with kaumātua and kuia from Waikato iwi (see Glossary for list of te reo Māori terms).¹ The first day of our noho wānanga coincided with the official announcement of the establishment of a Māori Health Authority, or Te Aka Whai Ora as it came to be known.

Two of our kaumātua participants, Matua Taitimu and Whaea Ramari Maipi, arrived late after being present at the Māori Health Authority announcement in Wellington. They were full of the news, and we rearranged our programme to allow for a presentation from Matua Taitimu on the history of Māori health activism. He spoke to us about a number of initiatives, going back to the historic fern collection of King Tāwhiao, the second Māori king. This collection identified rongoā uses of different species. Prepared as koha to a Canadian doctor in 1888, it is now housed in Te Papa Tongarewa.² He spoke of Princess Te Puea Herangi’s mission to improve the health of Waikato Māori, which is well acknowledged^3,4 and well remembered. Matua Maipi then reminisced on his own involvement with championing Māori health, beginning in the 1970s with the activist group Ngā Tamatoa. He and Whaea Ramari have worked alongside others to promote the development of hauora services, and, more recently, Matua Taitimu played a central role in initiating a series of hauora claims to the Waitangi Tribunal.⁵ That initial claim led to a kaupapa inquiry of greater scope, whose first report was released in 2019 and later finalised in 2023.^6,7 The first report, coupled with the then Labour Government’s 2020 Health and Disability System Review,⁸ prompted the creation of the Māori Health Authority in 2021. The Authority was recently disestablished by the new Coalition government.

Matua Taitimu told our wānanga that through their Waitangi claims Māori have made three demands: 1) Mana Motuhake, or Māori control of Māori initiatives, 2) an apology from the Crown for 200 years of suppression, genocide and racism, and 3) a legislative act for Māori control of their health. That their third demand was realised in the new Māori Health Authority announcement gave him hope for the future.

Recognising the efforts of Matua Taitimu and Whaea Ramari, our kaumātua endorsed their kaupapa with a rousing waiata. A champion of the group paid tribute, saying (in te reo) that Te Puea’s legacy is “steeped into your heart. You saw the condition of your people who were dying around you. You devoted yourself to this legacy. I pay tribute to you [Taitimu].” She concluded, “Today all your dreams have become a reality … The challenge in my heart is, how do we set up the house that Tāwhiao envisaged?” The house refers to a proverb by King Tāwhiao, the second Māori king, about the need for reconstruction following the severe losses of the Waikato people after confiscation of their lands, a project that became Princess Te Puea’s life work.

Princess Te Puea, who was a living presence during the youth of the kaumātua, continues to be of great significance to the Waikato group, who have devoted much energy and aroha throughout their lives to the Kīngitanga. Princess Te Puea was the mokopuna of King Tāwhiao, who dedicated her life to safeguarding the Kīngitanga and its people. She followed the Pai Mārire faith, opposed conscription in the First World War, envisioned and built Tūrangawaewae Marae and did much to develop an economic base for Waikato Māori. Following the influenza pandemic of 1918, when a quarter of the population at Mangatāwhiri died, Princess Te Puea organised the historic move from Te Paina/Mercer to Ngāruawāhia. There she established makeshift homes for the many orphans and supporters who followed her. Concerned about future epidemics, she began fundraising for a hospital for Māori, and this led to the erection of the tūpuna whare at Tūrangawaewae, Māhinārangi. Opened in 1929, Māhinārangi was to provide rongoā as well as Western medical treatments in a building that looked reassuringly like a meeting house. In the hospital, tikanga would be observed. It would be open to any Māori, not just those from Waikato.^3,4,9

It was devastating that, after all of Princess Te Puea’s efforts, the application for a licence for Māhinārangi to be used as a private hospital was declined by the health authorities.^3,4,9 Māori had apparently been refused treatment at Waikato Hospital when it first opened, seeding decades of mistrust in public health services and providing a further argument for a hospital at Tūrangawaewae.⁴ After this disappointment, Māhinārangi was repurposed as a place for Waikato Ariki to host manuwhiri. Hers was not the only disappointment, however. During the early twentieth century, Dr Māui Pōmare promoted the vision of a network of Māori hospitals, consulting iwi leaders. The plans were supported by Dr Peter Buck/Te Rangi Hīroa, Āpirana Ngata and James Carroll, funds were raised and sites donated, but government funding, despite promises, never came through.^4,10

The announcement of Te Aka Whai Ora – Māori Health Authority gave hope to kaumātua in our study that health inequities and discriminatory health services, experienced over their lifetimes in the Waikato and by Māori across Aotearoa, might finally be remedied.^3,11,12 In 2022, following on our initial wānanga with a whakahoki kōrero, we discussed the report we had prepared.¹ It was at this kōrero that the James Henare Research Centre was challenged to investigate the concept of a Māori hospital. What would be key for the success of a Māori hospital? We were told that it must operate according to tikanga and that it should serve the health needs of Waikato Māori. Further, our group emphasised that it is kaumātua who are the guardians of tikanga, so they should be central to decision-making in any project to develop a hospital.

From the original Waikato wānanga, and in our kānohi-ki-kānohi interviews with participants, we heard of unpleasant experiences in our public hospitals. Their stories were echoed at other sites (in Te Tai Tokerau, Tāmaki Makaurau and Tauranga Moana) of our ongoing research programme on kaumātua health and wellbeing. There is a common thread in these narratives of adverse hospital experiences, identifiable from our database of kaumātua discourse on health and wellbeing. This is the lack of manaakitanga shown to our kaumātua, as well as other breaches of tikanga, including some experiences labelled by participants as racist. Access to hospitals and treatment delays, particularly experienced by northern kaumātua living at a distance from services, were also perceived as lacking manaakitanga.

Manaakitanga, or respectful reciprocal relationships, is fundamental to Māori life. It is the culturally appropriate ways of doing things. Not putting effort into manaakitanga or breaching tikanga in other ways can hurtfully diminish mana and cause whakamā, embarrassment or shame,¹³ resulting in mistrust and reluctance to engage with hospitals.

Kaumātua tell us that in hospital they like someone to sit with them and talk slowly, taking the time to explain things. Instances of kindness and thoughtfulness from Pākehā as well as Māori staff were recounted, but they love to see Māori faces: “I go to the brown face because I feel safe.” In Tāmaki Makaurau hospitals, we were told with pride, there are “clever people like our mokopunas who graduate … we have heaps of our mokopunas working in there [the hospital] now.”

Two sites of hospital care spoken highly of by our participants were Hokianga (Rawene) Hospital and the kaupapa ward at Tauranga Hospital. Hokianga, a small cottage hospital, was founded early in the twentieth century and is now run by the Hokianga Health Enterprise Trust, a Māori-owned hauora health provider. Hokianga participants included kaumātua who had served on the Trust or modelled culturally appropriate patient care such as karakia, blessings, comforting patients with te reo and ensuring appropriate protocol around deaths. At Tauranga:

“… The kaupapa ward is different because when we have patients that are really māuiui, they do put you into a separate place so that your whānau can come in and awhi you and do the grieving before.”

 One participant said that, when discharged from a regional hospital:

“I could not wait until they discharged me into Rawene. When I got to Rawene I was quite content there. Felt like you were important and they cared about you. The other place seemed like you were in a factory and you were passed on to the next part.”

At the regional hospital a nurse had “chucked in the bin” a rongoā preparation his wife had brought in, saying, “We don’t allow that sort of thing here.” Now that Rawene is relaxed about Māori patients using rongoā, he told us, “… The old people are frequenting the hospital a lot more than they were before … They never went before.”

We also heard stories of kaumātua, as patients or visitors, helping other Māori:

“… As Māori we do respond to a brown face. One of my football mates died when I was in hospital with pneumonia too. I got out of my bed and went down to the room because I could hear them all crying … when they settled a bit I ran a karakia for them.”

One said about a friend that “the kōrero had come back that he was being a hōhā to his caregivers, to the nurses.” Three of them went in, saw that the nurses were Pākehā, waited until they had finished what they were doing and “started with a karakia,” and then spoke to him in te reo:

“Once he heard te reo Māori away he went. He started talking about whatever you wanted to talk about. We just let him talk. I’d just prod him along and then away he went again.”

Hospitals were described as busy places where communications were inadequate: “They don’t understand what I’m saying, where I’m coming from”; “They don’t help you understand.” Seeing a number of different specialists could be confusing. Staff busyness meant that whānau sometimes had to help with care, such as showering. Pressure on services could also mean waiting for admission. As one said, “I could be dead by then.” Early discharges occurred, too, because “they needed the bed.”

The emotional tenor of interactions in a busy ward could lead participants to feel that “nobody cared.” One who spent “the worst five days of my life” in a busy hospital said “nobody smiles.” She responded to other patients when they called for help, and nobody came. On one occasion, after being “rushed out of the room and put with another person,” she came back to the ward where there was an empty bed. She asked a nurse if the patient had died, but despite our participant having “spent a day and most of a night with them” the nurse told her, “I’m sorry we can’t divulge that information.”

Other stories involved not allowing someone who wanted to “put her feet on Papatūanuku” to leave the ward; not allowing a carer to provide food for her father when the whānau had been waiting for hours in emergency; and being told, when someone wanted to complain about their treatment, that there were no forms in the ward.

Participants felt badly if they were “spoken down to,” or if staff treated them as “slow,” or if they “don’t take your word for what’s wrong.” One kaumātua with cancer said he would tell the doctor he felt fine even if he didn’t. His wife usually intervened, but when he was told by doctors that there was nothing more they could do for him, he was on his own. “I was fine until I sat down in the car and then it hit me, and I was crying because I realised that we weren’t expecting that.”

Mixed gender wards could be distressing, especially for kuia. One felt so strongly that she would now refuse to go to the local hospital after her campaign about mixed wards as culturally unsafe did not lead to changes.

Transport was a major issue for those living in rural areas. Discharges could involve being placed, while still quite ill, on a shuttle bus for a trip of several hours. Whānau caring for kaumātua found it difficult to fit hospital visits around work and obligations to other whānau, let alone transport and accommodation expenses, which could be higher than the reimbursements available. We were also told by one kaumātua, holidaying in a city several hours away from home, that he was refused treatment at a local GP practice and at the local hospital despite severe pain. His wife drove him for 3 hours to a small hospital near home, where he was immediately put into an ambulance and driven an hour back in the direction they had come from to the regional hospital, where immediate surgery identified bowel cancer. While difficulties in rural service provision may not be understood by providers as lacking in manaakitanga, it may well be experienced by patients that way.

We were told that a common attitude among older Māori was that “you only go to hospital to die.” Some participants felt that was changing, but that it nevertheless explained reluctance of some to go to hospital.

The experiences we heard about while conducting our research are documented in other studies. Wilson,¹⁴ in a New Zealand case study, found that:

“Marginalisation of Indigenous peoples in public hospitals was evident in both the interviews undertaken and the literature reviewed. Participants believed hospitals were not conducive to healing and negative experiences contributed to decisions to seek an early discharge.”¹⁴

Espiner,¹⁵ summarising relevant literature, described hospital services for Māori as hostile and racist. Graham and Awatere,¹⁶ examining the literature on adverse events experienced by Māori in health settings found that “for many Māori, the existing public health system is experienced as hostile and alienating.”

Therefore, it is not surprising that many studies show that Māori, when compared with non-Māori, arrive later at hospitals, present with more serious symptoms, have more avoidable hospitalisations, are more likely to receive suboptimal care, have more preventable adverse events in hospital, more often discharge themselves early, are admitted more frequently after discharge and have poorer health outcomes after surgery.^17,18,19 Focussing specifically on older Māori, research found that, particularly in rural areas, they were significantly more likely to experience “treatment injury and complication hospitalisations” than non-Māori.²⁰ Negative events experienced by kaumātua themselves, whānau and friends, and historical memories of such experiences, diminish trust in hospital care,¹⁵ and surely have a causal relationship to these documented disparities. They also feed into the wider picture of health and longevity inequities for older Māori compared with non-Māori.²¹

Now is the time, we argue, for Māori organisations to develop hospitals to provide Māori, particularly older Māori, with culturally safe care. Moreover, kaumātua must play an authoritative role in the development of Māori hospitals, as it is they who carry the responsibility for tikanga.

The idea of an Indigenous hospital is not without precedent. There are examples from other countries, the 170-bed Alaskan Native American hospital at Anchorage being the most often cited. That hospital and its associated Southcentral Foundation health clinics took over local control from the nationwide Indian Health Service and developed the innovative Nuka System of Care for the 70,000 Native American population of the district.^11,22,23 The Cherokee Indian Hospital in South Carolina, serving a smaller population of 12,000 Cherokee Indians, is another example, a 20-bed hospital with associated specialist clinics and a hospice. It was developed with finance from the tribe’s own resources, breaking away from the Indian Health Service.^24,25 Both these hospitals embed tribal values into their patient-centred systems of care.

The Queen’s Medical Center in Honolulu offers a different model. It is a city hospital of the highest quality, with 575 acute care beds and a comprehensive range of specialties, open to patients of all ethnicities. A non-profit, founded in 1859 by Queen Emma and King Kamehameha IV, it is now the backbone of the Queen’s Health System, which runs several smaller hospitals and delivers “comprehensive health care services and programs to Native Hawaiians and all people of Hawai’i.”²⁶ Indigenous frameworks of healthcare are recognised in its programmes.

In Canada there was once a network of Indian hospitals, historically connected with missionary endeavours. Their poor reputation (understaffing, overcrowding, abusive practices) led to closures from the 1970s onwards.²⁷ This unfortunate legacy may well be the reason that there does not appear to be a movement in Canada towards culturally appropriate Indigenous hospitals. Australia also seems to provide few, if any, models.

In Asian countries where colonisation never occurred or where independence put Indigenous people in charge again, many fine hospitals provide services equivalent in most respects to those in Western countries. These may incorporate treatments seen as “alternative” in the West, with acupuncture in Chinese hospitals as a well-known example.²⁸ In an example of incorporating cultural values, Thai respect for elders has led to the interesting phenomenon of some Western families sending elders to Thailand for quality end of life dementia care.²⁹

In Aotearoa hauora is embedded in a system of primary care for Māori, underfunded though it is.⁷ We have mentioned two hospital settings, albeit small, that provide kaupapa Māori services, and as well, there is the historic Te Puia Springs hospital, a Ngāti Porou hauora. A mixture of iwi, private and public health funding could provide for the development of new, state-of-the-art hospitals. On the disestablishment of Te Aka Whai Ora – Māori Health Authority, the current government promised to devolve that health funding to iwi and should be held to its promise. The private hospital system in this country is expanding, meaning that there is investor capacity and expertise to be sourced. It is worth noting that some iwi already provide health insurance for kaumātua, and one at least provides for all its members, another way of making a private hospital model affordable. Imagination is required. Looking to overseas models of Indigenous hospital financing may not be helpful, as historical backgrounds and current policy settings are very different in Aotearoa New Zealand.

A key feature of current hauora services for Māori is that they are available to non-Māori as well, and that policy could be necessary for successful Māori hospital development. A service emphasising manaakitanga and tikanga Māori could well be attractive to non-Māori patients.

Scope, as well as funding, is an issue requiring much thought. A hospital can be a small facility, these days usually no less than 60 beds. It could offer specialised care for mate wareware, surgical specialties, maternity or end of life, to name several possibilities. However, any visions for a large general hospital should not be dismissed out of hand. In the Waikato, possibilities arise from pressures on Middlemore and Waikato hospitals, populations of Auckland expanding southwards and Hamilton northwards, and the prospect of a new medical school at the University of Waikato. In the north, smaller general hospitals, guided by tikanga Māori, could be repurposed and enlarged into providing a wider range of services. Staffing, of course, would be a major issue, but just as with patients, we would expect that a Māori hospital would be staffed by suitable professionals of any ethnicity.

Historically, hospitals in many cultures were located in healing places, such as near springs, rivers or other natural or cultural features imbued with significance. Design of a Māori hospital should incorporate tikanga Māori, a realistic goal since Māori architecture is blossoming, with private practices and incorporation of Māori expertise into some of the larger firms. Accessibility is a key aspect of hospital location, but placing hospitals in the midst of a city centre is not the only solution to transport issues.

Thinking about Indigenous hospitals in this country is already underway. Shortly before the nationwide hui for Māori in January 2024, Rahui Papa, a spokesperson for Kīngi Tūheitia, called for a Māori hospital, referencing Princess Te Puea and saying:

 “In her view, and the argument still stands strong today, that if Māori can see themselves in the medical system, then they will engage a little bit better.”³⁰

At the hui Kīngi Tūheitia concluded his speech:

“Be who we are, live our values, speak our reo, care for our mokopuna, our awa, our maunga, just be Māori. Māori all day, every day … Our time is now, kotahitanga is the way.”³¹

And the last words to Princess Te Puea, who famously said, “Mehemea, ka moemoea ahau, ko ahau anake. Mehemea, ka moemoea tātou, ka taea e tatou,” “If I dream, I dream alone; if we dream together we shall achieve.”³²

View Glossary.