Kaupapa Mäori Research and Päkehä Social Science ...Mäori Health Disparities The starting point...

In Aotearoa New Zealand, Mäori research capability has grown to

the point at which Kaupapa Mäori (“by Mäori, for Mäori”) research

is a reality. However, there are situations in which health disparities

between Mäori and Päkehä (New Zealanders of European descent)

can be better understood through innovative research collaborations

that examine the contributions of both cultures to Mäori health issues.

In the cooperative independence approach described here, Mäori and

Päkehä research teams think of themselves as “parties” to research

about Mäori patient and Päkehä primary care physician conceptions

of Mäori health. The research relationship was both satisfying and

productive. The findings highlight the cultural gulf between Päkehä

physicians and Mäori clients, suggesting the need for cultural

competency training for physicians.

Kaupapa Mäori Research and Päkehä Social Science: Epistemological Tensions in a Study of Mäori Health

Fiona Cram, Tim McCreanor, Linda Tuhiwai Smith, Ray Nairn,

and Wayne Johnstone

correspondence may be sent to: Fiona Cram, Katoa Ltd. 21 Reuben Avenue, Brooklyn, Wellington, Aotearoa New Zealand Email: [email protected]

HüLiLi Vol.3 No.1 (2006)

CRAM | MÄORI–PÄKEHÄ RESEARCH

Ko koe ki tena, ko ahau ki tenei kiwai o te keteYouatthatandIatthishandleofthebasket

Inthisarticlewefocusontheprocessesinvolvedinabiculturalresearchproject(hereafterthephysicianproject),fundedbytheHealthResearchCouncilofNew

Zealand, in which independent but collaborating Mäori1 and Päkehä2 researchteamsinvestigatedthewaysinwhichMäoriusersofprimaryhealthcareservicesandPäkehäphysicianstalkaboutMäorihealthandtheirexperienceswitheachotherinhealthencounters.Theaimofthisresearchprojectwastoinvestigatethediscursivepracticesatplayinthisdomainofinterculturalrelationstounderstandany impacts they may have on the persistent health disparities between MäoriandPäkehä.

Alongsideadescriptionofthestudyitself,wepresentamethodologicalanalysisof our own research process as a reflexive commentary on the epistemologicaltensions inherent in research across power differentials, and as a contributionto some unanswered challenges presented by Päkehä and Mäori researchersundertakinghealthresearchof interest toMäori.Thepurposeof thisapproachistoilluminatetheepistemological,theoretical,andpoliticalcommitmentsthatMäoriandPäkehäresearchersbroughttotheproject.Assuch,thearticlerelatestoestablishedcriticaltraditionsthatcountreflexivity,awareness,andsensitivitytotheplaceoftheresearcherinknowledgecreationasimportantissuesinvalidatingandinterpretingresearchfindings(L.T.Smith,1999;Wetherell,Taylor,&Yates,2001).AnadditionalgoalofthisarticleistostimulatemethodologicalandpoliticaldebatesonmodelsofMäori–Päkehäresearchrelationsinthesocialsciences inAotearoaNewZealandand toadd toconversationsabout indigenous–nonindig-enousresearchrelationsinthesocialsciencesglobally.

Astheresearchcapacityofindigenousgroupscontinuestoincrease,therewillbeagrowingneedforsuchchallenges tocurrentnotionsofresearchrelations. InHawaiÿi,programssuchasÿImiHale–NativeHawaiianCancerNetworkarestrivingtobuildNativeHawaiianhealthresearchcapacity(Tsark&Braun,2004).Someof thereflections in thisarticlemaywellconnectwith theexperienceofNativeHawaiianhealthresearchersontwofronts:thecreationofresearchcollaborationswithnonindigenousresearchersandtheexaminationofhealthcareencountersbetweenindigenouspatientsandnonindigenousphysicians.

Mäori Health Disparities

ThestartingpointforourresearchwasthesharpeningofourgeneralknowledgeaboutMäorihealth.ThehealthdisparitiesbetweenMäoriandPäkehäpopulationswithinAotearoaNewZealandarewelldocumented(Howden-Chapman&Tobias,2000;Pömareetal.,1995).Mäorihavepooreroutcomesacrossawiderangeofhealthstatistics,andthisdisparityhasbeenreflectedinofficialstatisticsformanydecades(e.g.,Turbott,1940).Thegapmayhavebeenreducedover thedecadesofthe20thcentury,butitstillremains.Mäorihealthresearchersarguethatthegovernmentalreformsofthelate1980sandearly1990sledtoanincreaseinthedisparity(Ajwani,Blakely,Robson,Tobias,&Bonne,2003;Pömareetal.,1995).

Health disparities between indigenous and nonindigenous peoples are anenduring legacyofcolonization (Smylie,2005). In the1990s,NativeHawaiianshadthelowestlifeexpectancyintheUnitedStatesandsuffereddisparateratesofheartdisease,cancer,anddiabetes.Withinadominatingcultureofbiomedicine,acommonlyheldviewisthatNativeHawaiiansareinnatelyunhealthy(Blaisdell,1998;McMullin,2005).ThisisnotdissimilartoPäkehärepresentationsofMäori(McCreanor&Nairn,2002a,2002b).

Common Päkehä representations of Mäori health, based on the reductionistbiomedicalmodel,facilitateblamingMäori,orsometimesMäoriculture,forthecurrentstateofaffairs.InsuchtalkMäoriarerepresentedasignorant,shy,super-stitious, or backward (Beaglehole & Beaglehole, 1946). Historically, the PäkehäresponsebasedonsuchconstructionshasbeenmanifestinattacksontraditionalMäorimedicalpracticesoreffortsto“educate”Mäoripeople(Simon&Smith,2001).Intheearlydecadesofthe20thcentury,healthworkerspersuadedMäorimothersnottobreastfeedor,alternatively,toboiltheirbreastmilktoreducetuberculosis.Turbott’s(1940)accountoftyphoidamongMäoriisanotherexample,stressingtheneedfor“education…todevelopthedesireforimprovedhygieneandbetterhomes”(p.247).Amorerecentexampleoftheprocessofblamingculturalpracticeswasfoundinthediscussionsofcotdeath.Thepublishedpreventionstrategiesinthe1990sledtomarkedreductionsinthedeathsofPäkehäbabies,whiledeathratesamongMäoribabiesremainedvirtuallyunchanged(PublicHealthCommission,1993).Facedwith this failure,someauthoritiesattemptedtopinMäorirates tobed-sharing (see, e.g., “Coroner has Warning,” 1993). Blaming Mäori for theirown ill-health serves to avoid consideration of the impacts of Päkehä systems,ideologies,andpractices(i.e.,theentirecolonialprocess)ontheissue.

Ko koe ki tena, ko ahau ki tenei kiwai o te keteYouatthatandIatthishandleofthebasket

Inthisarticlewefocusontheprocessesinvolvedinabiculturalresearchproject(hereafterthephysicianproject),fundedbytheHealthResearchCouncilofNew

Zealand, in which independent but collaborating Mäori1 and Päkehä2 researchteamsinvestigatedthewaysinwhichMäoriusersofprimaryhealthcareservicesandPäkehäphysicianstalkaboutMäorihealthandtheirexperienceswitheachotherinhealthencounters.Theaimofthisresearchprojectwastoinvestigatethediscursivepracticesatplayinthisdomainofinterculturalrelationstounderstandany impacts they may have on the persistent health disparities between MäoriandPäkehä.

Alongsideadescriptionofthestudyitself,wepresentamethodologicalanalysisof our own research process as a reflexive commentary on the epistemologicaltensions inherent in research across power differentials, and as a contributionto some unanswered challenges presented by Päkehä and Mäori researchersundertakinghealthresearchof interest toMäori.Thepurposeof thisapproachistoilluminatetheepistemological,theoretical,andpoliticalcommitmentsthatMäoriandPäkehäresearchersbroughttotheproject.Assuch,thearticlerelatestoestablishedcriticaltraditionsthatcountreflexivity,awareness,andsensitivitytotheplaceoftheresearcherinknowledgecreationasimportantissuesinvalidatingandinterpretingresearchfindings(L.T.Smith,1999;Wetherell,Taylor,&Yates,2001).AnadditionalgoalofthisarticleistostimulatemethodologicalandpoliticaldebatesonmodelsofMäori–Päkehäresearchrelationsinthesocialsciences inAotearoaNewZealandand toadd toconversationsabout indigenous–nonindig-enousresearchrelationsinthesocialsciencesglobally.

Astheresearchcapacityofindigenousgroupscontinuestoincrease,therewillbeagrowingneedforsuchchallenges tocurrentnotionsofresearchrelations. InHawaiÿi,programssuchasÿImiHale–NativeHawaiianCancerNetworkarestrivingtobuildNativeHawaiianhealthresearchcapacity(Tsark&Braun,2004).Someof thereflections in thisarticlemaywellconnectwith theexperienceofNativeHawaiianhealthresearchersontwofronts:thecreationofresearchcollaborationswithnonindigenousresearchersandtheexaminationofhealthcareencountersbetweenindigenouspatientsandnonindigenousphysicians.

Mäori Health Disparities

ThestartingpointforourresearchwasthesharpeningofourgeneralknowledgeaboutMäorihealth.ThehealthdisparitiesbetweenMäoriandPäkehäpopulationswithinAotearoaNewZealandarewelldocumented(Howden-Chapman&Tobias,2000;Pömareetal.,1995).Mäorihavepooreroutcomesacrossawiderangeofhealthstatistics,andthisdisparityhasbeenreflectedinofficialstatisticsformanydecades(e.g.,Turbott,1940).Thegapmayhavebeenreducedover thedecadesofthe20thcentury,butitstillremains.Mäorihealthresearchersarguethatthegovernmentalreformsofthelate1980sandearly1990sledtoanincreaseinthedisparity(Ajwani,Blakely,Robson,Tobias,&Bonne,2003;Pömareetal.,1995).

Health disparities between indigenous and nonindigenous peoples are anenduring legacyofcolonization (Smylie,2005). In the1990s,NativeHawaiianshadthelowestlifeexpectancyintheUnitedStatesandsuffereddisparateratesofheartdisease,cancer,anddiabetes.Withinadominatingcultureofbiomedicine,acommonlyheldviewisthatNativeHawaiiansareinnatelyunhealthy(Blaisdell,1998;McMullin,2005).ThisisnotdissimilartoPäkehärepresentationsofMäori(McCreanor&Nairn,2002a,2002b).

Common Päkehä representations of Mäori health, based on the reductionistbiomedicalmodel,facilitateblamingMäori,orsometimesMäoriculture,forthecurrentstateofaffairs.InsuchtalkMäoriarerepresentedasignorant,shy,super-stitious, or backward (Beaglehole & Beaglehole, 1946). Historically, the PäkehäresponsebasedonsuchconstructionshasbeenmanifestinattacksontraditionalMäorimedicalpracticesoreffortsto“educate”Mäoripeople(Simon&Smith,2001).Intheearlydecadesofthe20thcentury,healthworkerspersuadedMäorimothersnottobreastfeedor,alternatively,toboiltheirbreastmilktoreducetuberculosis.Turbott’s(1940)accountoftyphoidamongMäoriisanotherexample,stressingtheneedfor“education…todevelopthedesireforimprovedhygieneandbetterhomes”(p.247).Amorerecentexampleoftheprocessofblamingculturalpracticeswasfoundinthediscussionsofcotdeath.Thepublishedpreventionstrategiesinthe1990sledtomarkedreductionsinthedeathsofPäkehäbabies,whiledeathratesamongMäoribabiesremainedvirtuallyunchanged(PublicHealthCommission,1993).Facedwith this failure,someauthoritiesattemptedtopinMäorirates tobed-sharing (see, e.g., “Coroner has Warning,” 1993). Blaming Mäori for theirown ill-health serves to avoid consideration of the impacts of Päkehä systems,ideologies,andpractices(i.e.,theentirecolonialprocess)ontheissue.

GeneralMäoriconceptionsofhealth,ontheotherhand,areknownfromanumberofwrittendescriptionsidentifyingintegrated,holistic,community-basedconceptsthatdifferfundamentallyfromthestandardPäkehäapproach(e.g.,Pere,1988).Inthisway,MäoriconceptionsofhealthareclosetothoseofNativeHawaiians(e.g.,Mayberry,Affonso,Shibuya,&Clemmens,1998;McMullin,2005).Mäoriconcep-tions of health tend to cohere around resilient cultural concepts and practices,suchastherelationshipbetweentinana(body)andwairua(spiritualessence),theconceptsoftapu(sacred)andnoa(ordinary),andtheritualoftangi(mourning),tonameafew(Dansey,1992;Marsden,1992).Theserepresentationspromoteholistic,integratedpracticesbasedonself-sufficiencyandMäoriempiricalknowledgeabouthealthandhealing.Theyincludediet,exercise,herbalandtraditionalmedicines,theuseofkarakia(prayer),whänau(family)involvement,andotherpracticesthathave been frequently criticized, undermined, and sometimes outlawed by thedominantPäkehäviewsonhealth.

In the past 20 years, Mäori views of health have crystallized older, culturalunderstandings, to conceptualize a holistic schema encompassing tinana (thephysicalelement),hinengaro(thementalstate),wairua(thespirit),andwhänau(theimmediateandwiderfamily)withinthehealtharea(Murchie,1984).AlsoknownastheWhare Tapa Wha,orfourcornerposts(Durie,1994),theseaspectsoccurinthecontextofTe Whenua(landprovidingasenseofidentityandbelonging),Te Reo(thelanguageofcommunication),Te Ao Turoa(environment),andWhanaungatanga(extendedfamilyrelationships;seePublicHealthCommission,1993,p.24).Thedisruptionofsuchtheoreticalstructuresandthepracticestheysustain,byPäkehäideologiesofhealthinthecourseofthecolonialprocess,meansitisunclearifandhow these ideologiesareactiveamongMäori in thecontemporarysetting.TheMäorisectionofthephysicianprojectsoughttodiscoverifanyoftheseresourcesareusedinthetalkofMäoriparticipantsinconstructingMäorihealth.

MäorialsoreportunderstandingsaboutPäkehähealthcarethatarethelegacyofpastexperiencesbetweenMäoriclientsandPäkehähealthprofessionals.Theseinclude suspicions about treatment, the reluctance to engage in an interactionwithhealthprofessionals,andbehavior referred to in thesociological literatureasresistance(L.T.Smith,1985).Suchactionshavebeeninterpretedbysomeasevidenceofwhakamä,thenotionofshameorshyness(Metge,1986),buttheymayalsobepartofamoregeneralreactiontobeingtreatedinpatronizingorpaternalisticways(Awatere,1984).Considerationofthislastpoint,alongsidehistoricalaccounts

ofMäorigoodhealthpriortoEuropeanincursionintothecountry,madeuslessinclinedtoacceptthevictim-blamingconclusionsofindividualizingbiomedicineasasatisfactoryexplanationofMäorihealthdisparities.Instead,wewantedtolookatwhatthemedicalsystemcouldbecontributingtothesituation.WeknewthatMäoriutilizationofprimaryhealthcareserviceswasdifferentinnature,ifnotinlevel,tothatofPäkehä(McAvoy,Davis,Raymont,&Gribben,1994).Mäoriwereshowntopresentlaterandwithmorefloridsymptoms,suggestinganonspecificdiscomfortwith themedical system. If therewereproblems,wouldwebeabletoshedlightontheminthePäkehäsectionofthephysicianprojectbytalkingtomedicalpractitionerswho,afterall,aretheempowered,authorizedpartiestothisinterfacebetweenMäoriandPäkehä?ItwaswiththisquestioninmindthatweturnedourattentiontoprimaryhealthcareinAotearoaNewZealand.

Primary Health Care

Mäori seeking primary medical care will invariably end up in the consultingroomsofPäkehäphysicians,because thenumberofMäoriphysicians is small.TheconsultingroomcanbeviewedasasiteofstrugglebetweenMäoripatientsand Päkehä physicians. The struggle occurs because of the meeting of twodifferentkindsof“livedideologies,”namely,PäkehäandMäori.It isastruggleoverpowerandoverwhoseideologyinformsandcontrolstheinteraction.Withinthiscontext,theinteractionbetweenMäoripatientandPäkehäphysicianbecomesmorethanjustgettingalongwellandcommunicatingonaninterpersonallevel;itisalsoaboutnegotiatingculturalboundaries.Thecentralfocusofourstudyishowbothpartiesthatengageintheseinteractions—MäoriaspatientsandPäkehäasphysicians—talkaboutMäorihealthandtheirexperiencesofinteractingwithoneanother.

Theliterature(Silverman,1987;Simpsonetal.,1991)pointsoutthatthequalityofsuchtalkhasprofoundimpacts—evenonapparentlyphysicalsymptomssuchasbloodpressure—andisofcrucialimportanceinpsychosocialandpsychiatricproblems.Communication is also strongly implicated in treatment complianceinchronicdiseasessuchasdiabetes(Kaplan,Greenfield,&Ware,1989).Inthis

GeneralMäoriconceptionsofhealth,ontheotherhand,areknownfromanumberofwrittendescriptionsidentifyingintegrated,holistic,community-basedconceptsthatdifferfundamentallyfromthestandardPäkehäapproach(e.g.,Pere,1988).Inthisway,MäoriconceptionsofhealthareclosetothoseofNativeHawaiians(e.g.,Mayberry,Affonso,Shibuya,&Clemmens,1998;McMullin,2005).Mäoriconcep-tions of health tend to cohere around resilient cultural concepts and practices,suchastherelationshipbetweentinana(body)andwairua(spiritualessence),theconceptsoftapu(sacred)andnoa(ordinary),andtheritualoftangi(mourning),tonameafew(Dansey,1992;Marsden,1992).Theserepresentationspromoteholistic,integratedpracticesbasedonself-sufficiencyandMäoriempiricalknowledgeabouthealthandhealing.Theyincludediet,exercise,herbalandtraditionalmedicines,theuseofkarakia(prayer),whänau(family)involvement,andotherpracticesthathave been frequently criticized, undermined, and sometimes outlawed by thedominantPäkehäviewsonhealth.

In the past 20 years, Mäori views of health have crystallized older, culturalunderstandings, to conceptualize a holistic schema encompassing tinana (thephysicalelement),hinengaro(thementalstate),wairua(thespirit),andwhänau(theimmediateandwiderfamily)withinthehealtharea(Murchie,1984).AlsoknownastheWhare Tapa Wha,orfourcornerposts(Durie,1994),theseaspectsoccurinthecontextofTe Whenua(landprovidingasenseofidentityandbelonging),Te Reo(thelanguageofcommunication),Te Ao Turoa(environment),andWhanaungatanga(extendedfamilyrelationships;seePublicHealthCommission,1993,p.24).Thedisruptionofsuchtheoreticalstructuresandthepracticestheysustain,byPäkehäideologiesofhealthinthecourseofthecolonialprocess,meansitisunclearifandhow these ideologiesareactiveamongMäori in thecontemporarysetting.TheMäorisectionofthephysicianprojectsoughttodiscoverifanyoftheseresourcesareusedinthetalkofMäoriparticipantsinconstructingMäorihealth.

MäorialsoreportunderstandingsaboutPäkehähealthcarethatarethelegacyofpastexperiencesbetweenMäoriclientsandPäkehähealthprofessionals.Theseinclude suspicions about treatment, the reluctance to engage in an interactionwithhealthprofessionals,andbehavior referred to in thesociological literatureasresistance(L.T.Smith,1985).Suchactionshavebeeninterpretedbysomeasevidenceofwhakamä,thenotionofshameorshyness(Metge,1986),buttheymayalsobepartofamoregeneralreactiontobeingtreatedinpatronizingorpaternalisticways(Awatere,1984).Considerationofthislastpoint,alongsidehistoricalaccounts

ofMäorigoodhealthpriortoEuropeanincursionintothecountry,madeuslessinclinedtoacceptthevictim-blamingconclusionsofindividualizingbiomedicineasasatisfactoryexplanationofMäorihealthdisparities.Instead,wewantedtolookatwhatthemedicalsystemcouldbecontributingtothesituation.WeknewthatMäoriutilizationofprimaryhealthcareserviceswasdifferentinnature,ifnotinlevel,tothatofPäkehä(McAvoy,Davis,Raymont,&Gribben,1994).Mäoriwereshowntopresentlaterandwithmorefloridsymptoms,suggestinganonspecificdiscomfortwith themedical system. If therewereproblems,wouldwebeabletoshedlightontheminthePäkehäsectionofthephysicianprojectbytalkingtomedicalpractitionerswho,afterall,aretheempowered,authorizedpartiestothisinterfacebetweenMäoriandPäkehä?ItwaswiththisquestioninmindthatweturnedourattentiontoprimaryhealthcareinAotearoaNewZealand.

Primary Health Care

Mäori seeking primary medical care will invariably end up in the consultingroomsofPäkehäphysicians,because thenumberofMäoriphysicians is small.TheconsultingroomcanbeviewedasasiteofstrugglebetweenMäoripatientsand Päkehä physicians. The struggle occurs because of the meeting of twodifferentkindsof“livedideologies,”namely,PäkehäandMäori.It isastruggleoverpowerandoverwhoseideologyinformsandcontrolstheinteraction.Withinthiscontext,theinteractionbetweenMäoripatientandPäkehäphysicianbecomesmorethanjustgettingalongwellandcommunicatingonaninterpersonallevel;itisalsoaboutnegotiatingculturalboundaries.Thecentralfocusofourstudyishowbothpartiesthatengageintheseinteractions—MäoriaspatientsandPäkehäasphysicians—talkaboutMäorihealthandtheirexperiencesofinteractingwithoneanother.

Theliterature(Silverman,1987;Simpsonetal.,1991)pointsoutthatthequalityofsuchtalkhasprofoundimpacts—evenonapparentlyphysicalsymptomssuchasbloodpressure—andisofcrucialimportanceinpsychosocialandpsychiatricproblems.Communication is also strongly implicated in treatment complianceinchronicdiseasessuchasdiabetes(Kaplan,Greenfield,&Ware,1989).Inthis

vein,oneprominentstudy(Mishler,1984)hastakenadiscourseanalyticapproachfocusedprimarilyonthediagnosticinterview,highlightingthematerialimpactsofsuchspecificdiscourse.Althoughdoctor–patientcommunicationisanimportantfacet of our concerns in this project (and a likely subject for detailed investiga-tionbeyondit),wewerekeentocast thenetwidertodrawinotherfeaturesofdiscourse that constituteamoregeneral context toMäorihealth.Aspreviouslyoutlined,history (bothpersonal andsociopolitical), relationsofdominanceandoppression,worldviewandspirituality,areallexpectedtoinfluenceconstructionsofhealthanalyzedinthisstudy.

Thesecondstrandofthisprojectstory,areflexivecommentarythatweavesinandoutofourteamdiscussionsoftheresearchtopic,beganwithourdeliberationofwhoshouldconductMäorihealthresearch.

Who Should Do Mäori Health Research?

Inmanyfieldsofsocialscienceresearch,includinghealth—whereresearchersareconducting investigations with groups who are comparatively disadvantaged ormarginalized—itisrecommendedthatresearchpartnershipsbeformedtoreducetheperceiveddistancebetweenthosedoingtheresearchandthosebeingresearched.Sucharrangementsaredescribedasa vehicle throughwhich researchers, theirwork,andtheknowledgeproducedcanbemore“useful”toparticipantcommuni-ties(MoewakaBarnes,2000).Forexample,intheAustraliancontext,Humphery(2001)highlightedcallsforindigenousinvolvementinthedirectionandconductof research important to indigenous communities. Furthermore, First NationspeoplesinCanadahavecalledforresearchtobedecolonized(TenFingers,2005),andinHawaiÿi,movesareafoottofirmlyrecenterNativeHawaiianswithinresearchandevaluationwithindigenouscommunities(Cook,2001;Kahakalau,2004).

In Aotearoa New Zealand, where the indigenous Mäori have been displacedanddispossessed in thecourseof160yearsofPäkehäcolonization,guidelinesfor Päkehä researchers wanting to research Mäori health issues urge theestablishment of collaborative research approaches and partnerships. Ethicsguidelineswithinsomedisciplineshavealsobeenformulatedwiththenotionof

partnershipbetweennon-MäoriresearchersandMäoriresearchcommunitiesinmind(e.g.,TeAwekotuku,1991).Theseinitiativesaretobeadmiredbecausetheyhavepromptedallresearcherstoquestiontheirpracticeand, indeed, theirviewoftheworld,sothatinoursituationthereisemergingconsensusthatresearchshould be at least culturally sensitive, if not fully vested with the provisions ofculturalsafety(Ramsden,1997).However,suchmovesarepremisedonashortfallinMäoriresearchcapacitythatrequiresnon-MäoriresearcherstoconductMäoriresearch.ThisshortfallislessandlesslikelyasMäoriresearchcapacityisgrowingrapidly.Assuch, theguidanceoffered to researchersdoesnot fullyexplore theissuesfacedbyMäoriresearcherswhoareconductingresearchwithMäori.Thisisnotasituationofresearchersresearching“down”;rathertheseresearchersmustnegotiatethemultipleandoftensubtlewaysinwhichtheyarebothaninsiderandanoutsidertotheirparticipantgroup(L.T.Smith,1999).

In addition, the guidelines on partnership research do not speak to Päkehäresearcherswhowanttodoresearch“for”Mäorithatisnotnecessarilyresearch

“with”or“on”Mäori;inotherwords,Päkehäresearcherswhowanttheirresearchto support a Mäori epistemological framework through the development of aresearch-basedcritiqueofPäkehä theories,policies, andpractices, especially astheyrelatetoMäori–Päkehärelations.Inresponsetothefirstofthesegaps,L.T.Smith(1999)outlinedsevenethicalprinciplesthatarerelevantforMäoriresearch.Cram(2001)expandedtheseprinciplesingeneralresearchguidelinesforMäoriresearchers (seeTable1).ThesecondissueofPäkehäresearcherssupportingaMäori kaupapa (framework) remains largely unaddressed (Cram & McCreanor,1993;Huygens,1993).Inseekingguidanceonthisissue,weturnedtothefoundingdocumentofAotearoaNewZealand:Te Tiriti o Waitangi(TheTreatyofWaitangi;Orange,1987).

vein,oneprominentstudy(Mishler,1984)hastakenadiscourseanalyticapproachfocusedprimarilyonthediagnosticinterview,highlightingthematerialimpactsofsuchspecificdiscourse.Althoughdoctor–patientcommunicationisanimportantfacet of our concerns in this project (and a likely subject for detailed investiga-tionbeyondit),wewerekeentocast thenetwidertodrawinotherfeaturesofdiscourse that constituteamoregeneral context toMäorihealth.Aspreviouslyoutlined,history (bothpersonal andsociopolitical), relationsofdominanceandoppression,worldviewandspirituality,areallexpectedtoinfluenceconstructionsofhealthanalyzedinthisstudy.

Thesecondstrandofthisprojectstory,areflexivecommentarythatweavesinandoutofourteamdiscussionsoftheresearchtopic,beganwithourdeliberationofwhoshouldconductMäorihealthresearch.

Who Should Do Mäori Health Research?

Inmanyfieldsofsocialscienceresearch,includinghealth—whereresearchersareconducting investigations with groups who are comparatively disadvantaged ormarginalized—itisrecommendedthatresearchpartnershipsbeformedtoreducetheperceiveddistancebetweenthosedoingtheresearchandthosebeingresearched.Sucharrangementsaredescribedasa vehicle throughwhich researchers, theirwork,andtheknowledgeproducedcanbemore“useful”toparticipantcommuni-ties(MoewakaBarnes,2000).Forexample,intheAustraliancontext,Humphery(2001)highlightedcallsforindigenousinvolvementinthedirectionandconductof research important to indigenous communities. Furthermore, First NationspeoplesinCanadahavecalledforresearchtobedecolonized(TenFingers,2005),andinHawaiÿi,movesareafoottofirmlyrecenterNativeHawaiianswithinresearchandevaluationwithindigenouscommunities(Cook,2001;Kahakalau,2004).

In Aotearoa New Zealand, where the indigenous Mäori have been displacedanddispossessed in thecourseof160yearsofPäkehäcolonization,guidelinesfor Päkehä researchers wanting to research Mäori health issues urge theestablishment of collaborative research approaches and partnerships. Ethicsguidelineswithinsomedisciplineshavealsobeenformulatedwiththenotionof

partnershipbetweennon-MäoriresearchersandMäoriresearchcommunitiesinmind(e.g.,TeAwekotuku,1991).Theseinitiativesaretobeadmiredbecausetheyhavepromptedallresearcherstoquestiontheirpracticeand, indeed, theirviewoftheworld,sothatinoursituationthereisemergingconsensusthatresearchshould be at least culturally sensitive, if not fully vested with the provisions ofculturalsafety(Ramsden,1997).However,suchmovesarepremisedonashortfallinMäoriresearchcapacitythatrequiresnon-MäoriresearcherstoconductMäoriresearch.ThisshortfallislessandlesslikelyasMäoriresearchcapacityisgrowingrapidly.Assuch, theguidanceoffered to researchersdoesnot fullyexplore theissuesfacedbyMäoriresearcherswhoareconductingresearchwithMäori.Thisisnotasituationofresearchersresearching“down”;rathertheseresearchersmustnegotiatethemultipleandoftensubtlewaysinwhichtheyarebothaninsiderandanoutsidertotheirparticipantgroup(L.T.Smith,1999).

In addition, the guidelines on partnership research do not speak to Päkehäresearcherswhowanttodoresearch“for”Mäorithatisnotnecessarilyresearch

“with”or“on”Mäori;inotherwords,Päkehäresearcherswhowanttheirresearchto support a Mäori epistemological framework through the development of aresearch-basedcritiqueofPäkehä theories,policies, andpractices, especially astheyrelatetoMäori–Päkehärelations.Inresponsetothefirstofthesegaps,L.T.Smith(1999)outlinedsevenethicalprinciplesthatarerelevantforMäoriresearch.Cram(2001)expandedtheseprinciplesingeneralresearchguidelinesforMäoriresearchers (seeTable1).ThesecondissueofPäkehäresearcherssupportingaMäori kaupapa (framework) remains largely unaddressed (Cram & McCreanor,1993;Huygens,1993).Inseekingguidanceonthisissue,weturnedtothefoundingdocumentofAotearoaNewZealand:Te Tiriti o Waitangi(TheTreatyofWaitangi;Orange,1987).

The treaty was first signed at Waitangi on February 6, 1840, by Mäori chiefsand British officials. It paved the way for British settlement in Aotearoa NewZealand while at the same time guaranteeing social and economic rights andprivilegestoMäori (McCreanor,1989).TheprincipalrightguaranteedtoMäoriwastino rangatiratanga,whichdenotesnotonlypossessionbutalsocontrolandmanagementoflands,dwellingplaces,andotherpossessions(WaitangiTribunal,1983). However, disputes over the treaty have occurred because of differencesbetweentheEnglishandMäoriversionsofthetreaty.IntheEnglishtextMäoricede “sovereignty” to the Queen, whereas in the Mäori version they cede onlykawanatanga,therighttogovern.

Controversy and debate still surround the role of the treaty in Aotearoa NewZealandsociety,butithascertainlycometotheforefrontofcurrent-daydiscussionsabout Mäori–Päkehä relations and Mäori aspirations for self-determination(Dyck&Kearns,1995;Jackson,2004).Itthereforestandstoreasonthatthetreatyshouldalsobeconsideredcentraltoadiscussionofresearchconductedwithinthis

Note: From “Researching in the Margins: Issues for Mäori Researchers—A Discussion Paper,” by L.T. Smith, 2006, AlterNative: An International Journal of Indigenous Scholarship, (Special Supplement 2006–Marginalisation), pp. 4–27. Copyright 2006 by Ngä Pae o te Märamatanga.

TAblE 1 “Community-Up” approach to defining research conduct

Cultural values (L. T. Smith, 1��)

Researcher guidelines (Cram, 2001)

Aroha ki te tangata A respect for people; allow people to define their own space and meet on their own terms.

He kanohi kitea It is important to meet people face to face and to also be a face that is known to and seen within a community.

Titiro, whakarongo… körero

Looking and listening (and then maybe speaking); develop understanding in order to find a place from which to speak.

Manaaki ki te tangata Sharing, hosting, being generous.

Kia tupato Be cautious; be politically astute, culturally safe, and reflective about insider/outsider status.

Kaua e takahia te mana o te tangata

Do not trample on the “mana” or dignity of a person.

Kia mahaki Be humble; do not flaunt your knowledge; find ways of sharing it.

country.ItwastemptingtousethecommonterminologyinAotearoaNewZealandoftreaty“partnership”andapplythistotherelationshipbetweentheMäoriandPäkehäresearchteams.However,wewerewaryoftreadingthenegativepathwaysthathavecometobeassociatedwiththetermpartnership(Torjman,1998).Itistoo easy to conceal important power differentials beneath the egalitarian glossofpartnership,afactorwidelyexperiencedinbureaucraticresponsestoPäkehätreatyresponsibilities.

Instead,weprefertodefinepartnershipasagoalratherthanasanexistingstate.We have therefore chosen to base our thinking within an analysis that viewsMäoriandPäkehäaspartiestotheTreatyofWaitangi,andwehaveappliedthisterminologytoourresearchrelationships.Bothpartiestotheresearchthereforehaveastake in itandhaveconsequentrightsandresponsibilities.Theserightsand responsibilities were to be negotiated between parties throughout theproject.3Being“partiestoaresearchproject” isalsoterminologythatcanapplymore generally to indigenous–nonindigenous research collaborations, even intheabsenceof anoverarching treaty.The followingsectiondescribesonesuchresearchcollaboration.

The Present Project

Thepresentprojectexaminedhowtwogroupsofparticipants,MäoripatientsandPäkehä physicians, talk about Mäori health. These speakers constitute a givenentitysuchasMäorihealthindifferingways,dependingontheirunderstandingofthecontextinwhichtheyarespeaking.Todothis,theymustdrawonanarrayofresourcesprovidedwithintheircommunity.Theseresourcesaretheobjectofthisstudy.Forthisproject,itmeanswedonotseektoprovideadefinitiverepresenta-tion of the single coherent entity, “Mäori health,” but to identify the resourcestwodistinctgroupsofinformantsuseinconstitutingtheentityintheirtalk.Wefeltthatifwecoulddescribetheseresources—andparticularly,ifwecouldunder-standcriticaldifferencesbetweenthem—thenwewouldbeinapositiontoinformandencourageactioninbothgroupstoimproveoutcomes.Acriticalelementofthe present project was the relationship between the two research teams, withthePäkehäresearchteamtakingresponsibilityforexaminingthetalkofPäkehäphysicians and the Mäori research team taking responsibility for talking withMäoripatients.

The treaty was first signed at Waitangi on February 6, 1840, by Mäori chiefsand British officials. It paved the way for British settlement in Aotearoa NewZealand while at the same time guaranteeing social and economic rights andprivilegestoMäori (McCreanor,1989).TheprincipalrightguaranteedtoMäoriwastino rangatiratanga,whichdenotesnotonlypossessionbutalsocontrolandmanagementoflands,dwellingplaces,andotherpossessions(WaitangiTribunal,1983). However, disputes over the treaty have occurred because of differencesbetweentheEnglishandMäoriversionsofthetreaty.IntheEnglishtextMäoricede “sovereignty” to the Queen, whereas in the Mäori version they cede onlykawanatanga,therighttogovern.

Controversy and debate still surround the role of the treaty in Aotearoa NewZealandsociety,butithascertainlycometotheforefrontofcurrent-daydiscussionsabout Mäori–Päkehä relations and Mäori aspirations for self-determination(Dyck&Kearns,1995;Jackson,2004).Itthereforestandstoreasonthatthetreatyshouldalsobeconsideredcentraltoadiscussionofresearchconductedwithinthis

Note: From “Researching in the Margins: Issues for Mäori Researchers—A Discussion Paper,” by L.T. Smith, 2006, AlterNative: An International Journal of Indigenous Scholarship, (Special Supplement 2006–Marginalisation), pp. 4–27. Copyright 2006 by Ngä Pae o te Märamatanga.

TAblE 1 “Community-Up” approach to defining research conduct

Cultural values (L. T. Smith, 1��)

Researcher guidelines (Cram, 2001)

Aroha ki te tangata A respect for people; allow people to define their own space and meet on their own terms.

He kanohi kitea It is important to meet people face to face and to also be a face that is known to and seen within a community.

Titiro, whakarongo… körero

Looking and listening (and then maybe speaking); develop understanding in order to find a place from which to speak.

Manaaki ki te tangata Sharing, hosting, being generous.

Kia tupato Be cautious; be politically astute, culturally safe, and reflective about insider/outsider status.

Kaua e takahia te mana o te tangata

Do not trample on the “mana” or dignity of a person.

Kia mahaki Be humble; do not flaunt your knowledge; find ways of sharing it.

country.ItwastemptingtousethecommonterminologyinAotearoaNewZealandoftreaty“partnership”andapplythistotherelationshipbetweentheMäoriandPäkehäresearchteams.However,wewerewaryoftreadingthenegativepathwaysthathavecometobeassociatedwiththetermpartnership(Torjman,1998).Itistoo easy to conceal important power differentials beneath the egalitarian glossofpartnership,afactorwidelyexperiencedinbureaucraticresponsestoPäkehätreatyresponsibilities.

Instead,weprefertodefinepartnershipasagoalratherthanasanexistingstate.We have therefore chosen to base our thinking within an analysis that viewsMäoriandPäkehäaspartiestotheTreatyofWaitangi,andwehaveappliedthisterminologytoourresearchrelationships.Bothpartiestotheresearchthereforehaveastake in itandhaveconsequentrightsandresponsibilities.Theserightsand responsibilities were to be negotiated between parties throughout theproject.3Being“partiestoaresearchproject” isalsoterminologythatcanapplymore generally to indigenous–nonindigenous research collaborations, even intheabsenceof anoverarching treaty.The followingsectiondescribesonesuchresearchcollaboration.

The Present Project

Thepresentprojectexaminedhowtwogroupsofparticipants,MäoripatientsandPäkehä physicians, talk about Mäori health. These speakers constitute a givenentitysuchasMäorihealthindifferingways,dependingontheirunderstandingofthecontextinwhichtheyarespeaking.Todothis,theymustdrawonanarrayofresourcesprovidedwithintheircommunity.Theseresourcesaretheobjectofthisstudy.Forthisproject,itmeanswedonotseektoprovideadefinitiverepresenta-tion of the single coherent entity, “Mäori health,” but to identify the resourcestwodistinctgroupsofinformantsuseinconstitutingtheentityintheirtalk.Wefeltthatifwecoulddescribetheseresources—andparticularly,ifwecouldunder-standcriticaldifferencesbetweenthem—thenwewouldbeinapositiontoinformandencourageactioninbothgroupstoimproveoutcomes.Acriticalelementofthe present project was the relationship between the two research teams, withthePäkehäresearchteamtakingresponsibilityforexaminingthetalkofPäkehäphysicians and the Mäori research team taking responsibility for talking withMäoripatients.

Methodology

Bymethodology,wemeanthetheoreticalapproachthatdeterminesthewayweundertake research, including, for example, our relationship with participantsandthecommunitieswhereweworkandlive.Methods,ontheotherhand,aretools thatcanbeused toproduceandanalyzedata, forexample, in-depth inter-viewingandquestionnaires(L.T.Smith,1999).Themethodologyforthepresentresearch is sourced inKaupapa Mäori (“byMäori, forMäori”) theory.KaupapaMäoriresearchisanattempttoretrievespaceforMäorivoicesandperspectives,methodologies,andanalyses,wherebyMäorirealitiesareseenaslegitimate.ThismeansworkingoutsidethebinaryoppositionofMäoriandPäkehäandcenteringTe Ao Mäori(theMäoriworld;seePihama,1993).

KaupapaMäoritakesforgrantedthelegitimacyofbeingMäoriandthevalidityofMäoriworldviews.Mäori languageandcultureare thereforeseenascentral.Inaddition,KaupapaMäoriacknowledges,andisunderpinnedby,Mäoristrugglesfor autonomy and self-determination (G. H. Smith, 1997). An integral part ofKaupapaMäoritheoryisalsothecritiqueofsocietal“commonsense”understand-ingsofwhatitistobeMäori.Theseunderstandingshaveinvariablybeenbuiltupoverdecadesofcolonization,arebasedondeficitmodels,andprovidejustificationsforpoliciesandpracticesthatoppressMäori(Pihama,1993).

WithinKaupapaMäoriresearch,theroleofresearchersisthereforetwofold.First,researchersneedtoaffirmtheimportanceofMäoriself-definitionsandself-valu-ations. Second, researchers need to critique Päkehä/colonial constructions anddefinitionsofMäoriandarticulatesolutionstoMäoriconcernsintermsofMäoriknowledge. Linda Smith (1999) argued that while Päkehä researchers cannotdo Kaupapa Mäori research, they can support Mäori Kaupapa (also see Cram,1997).OurresearchdiscussionsoftheseissueshavealsorestedonthepremisethatPäkehäresearcherswouldnotbedoingresearchwithMäoriparticipantsbutwouldbedoingresearchthatwouldbeofbenefit(oratleastrelevance)toMäori.Nevertheless, a joint approachwasvaluablebecauseofour conception that the

“problemofMäorihealth”wasatleastasmuchaPäkehäproblemas(ifnotmorethan)aMäoriproblem.BythiswemeanthattherearesignificantcontributionstoMäorihealth frombothMäoriandPäkehä,given thePäkehädomination inthe process of colonization and alienation of Mäori resources, not to mentionthelong-standingtheoreticalandapplieddominationofhealththeory,practices,andservices.

Inseekingtounderstandthedisparitiesbetweenthegoalsofbothhealthauthori-tiesandconsumergroupsandtheoutcomesdescribedinthereports,theresearchprojectfocusesontheconstructionofMäorihealthinthetalkofphysiciansandMäoriclients.Toappreciatethevalueofsuchwork,itisnecessarytorecognizethelinksbetweensuchdiscourseandthesocialpracticesofthoseforwhomtheserepresentationsconstitute“reality.”Thereisasubstantialbodyofresearchdemon-stratingthatthewayinwhichpeople,asindividualsorgroups,definerealityisamajordeterminantof theirbehavior. Inproblemsolving (Johnson-Laird,1983),interpersonalbehavior(Snyder,1984),amongscientists(Gilbert&Mulkay,1984),and in thecommunity (Potter&Reicher,1987), theway inwhichsituationsoreventsareunderstoodhasbeenshowntoshapeparticipants’actions.

Recentdevelopmentsinsocialsciencehaveinspiredagrowingbodyoflanguage-based research in areas of social dominance and inequality (van Dijk, 1993;Wetherell & Potter, 1992; Wetherell et al., 2001). There are two assumptionsunderlyingthisworkthatmustbeunderstoodifthepowerofitsfindingsistobeappreciated.First,itisassumedthattherealityofobjects,events,andsituationsisconstitutedthroughthediscoursesaboutthem.Thesecondassumptionisthatthewayinwhichtherealityofaparticularobject,event,orsituationisconstituteddependsontheinterestorconcernofthespeakingindividualinthatsituation.Itfollowsfromthefirstassumptionthatresearchinthistraditiondoesnotseektouncoverordefinetheessentialnatureofthetargetedentity; indeed,itassumesthatsuchadescriptionwouldbemerelyanotherwayofconstituting theobject.In doing so, research introduces the realm of power relations into knowledge-basedenterprises,tomakeexplicitthewaysinwhichdifferentialsinmaterialandpoliticalpoweraremanifestinmaterialdifferencesinthesituationsofdifferentlyempowered groups. In this context, the ideologies of those with power will bedominantoverthoseofpeoplewhohaveless.

Theoriesofideology(Bordieu&Passeron,1990)emphasizetheroleoflanguageinthereproductionofideologyandtheimportanceofthelattertotheestablish-mentandmaintenanceofsocialrelations.However,initsconventionalcontextofclassstruggle,ideologyischaracterizedasthetoolofrulingelitesandisevokedtoexplainthecontrolofthemasses.WearemoreinterestedintheformulationbyBilligetal.(1988),whichpresentstheideaoflived ideology—thearrayofideas,beliefs,andexplanationsdrawnontointerpreteverydayexperience.

Methodology

Bymethodology,wemeanthetheoreticalapproachthatdeterminesthewayweundertake research, including, for example, our relationship with participantsandthecommunitieswhereweworkandlive.Methods,ontheotherhand,aretools thatcanbeused toproduceandanalyzedata, forexample, in-depth inter-viewingandquestionnaires(L.T.Smith,1999).Themethodologyforthepresentresearch is sourced inKaupapa Mäori (“byMäori, forMäori”) theory.KaupapaMäoriresearchisanattempttoretrievespaceforMäorivoicesandperspectives,methodologies,andanalyses,wherebyMäorirealitiesareseenaslegitimate.ThismeansworkingoutsidethebinaryoppositionofMäoriandPäkehäandcenteringTe Ao Mäori(theMäoriworld;seePihama,1993).

KaupapaMäoritakesforgrantedthelegitimacyofbeingMäoriandthevalidityofMäoriworldviews.Mäori languageandcultureare thereforeseenascentral.Inaddition,KaupapaMäoriacknowledges,andisunderpinnedby,Mäoristrugglesfor autonomy and self-determination (G. H. Smith, 1997). An integral part ofKaupapaMäoritheoryisalsothecritiqueofsocietal“commonsense”understand-ingsofwhatitistobeMäori.Theseunderstandingshaveinvariablybeenbuiltupoverdecadesofcolonization,arebasedondeficitmodels,andprovidejustificationsforpoliciesandpracticesthatoppressMäori(Pihama,1993).

WithinKaupapaMäoriresearch,theroleofresearchersisthereforetwofold.First,researchersneedtoaffirmtheimportanceofMäoriself-definitionsandself-valu-ations. Second, researchers need to critique Päkehä/colonial constructions anddefinitionsofMäoriandarticulatesolutionstoMäoriconcernsintermsofMäoriknowledge. Linda Smith (1999) argued that while Päkehä researchers cannotdo Kaupapa Mäori research, they can support Mäori Kaupapa (also see Cram,1997).OurresearchdiscussionsoftheseissueshavealsorestedonthepremisethatPäkehäresearcherswouldnotbedoingresearchwithMäoriparticipantsbutwouldbedoingresearchthatwouldbeofbenefit(oratleastrelevance)toMäori.Nevertheless, a joint approachwasvaluablebecauseofour conception that the

“problemofMäorihealth”wasatleastasmuchaPäkehäproblemas(ifnotmorethan)aMäoriproblem.BythiswemeanthattherearesignificantcontributionstoMäorihealth frombothMäoriandPäkehä,given thePäkehädomination inthe process of colonization and alienation of Mäori resources, not to mentionthelong-standingtheoreticalandapplieddominationofhealththeory,practices,andservices.

Inseekingtounderstandthedisparitiesbetweenthegoalsofbothhealthauthori-tiesandconsumergroupsandtheoutcomesdescribedinthereports,theresearchprojectfocusesontheconstructionofMäorihealthinthetalkofphysiciansandMäoriclients.Toappreciatethevalueofsuchwork,itisnecessarytorecognizethelinksbetweensuchdiscourseandthesocialpracticesofthoseforwhomtheserepresentationsconstitute“reality.”Thereisasubstantialbodyofresearchdemon-stratingthatthewayinwhichpeople,asindividualsorgroups,definerealityisamajordeterminantof theirbehavior. Inproblemsolving (Johnson-Laird,1983),interpersonalbehavior(Snyder,1984),amongscientists(Gilbert&Mulkay,1984),and in thecommunity (Potter&Reicher,1987), theway inwhichsituationsoreventsareunderstoodhasbeenshowntoshapeparticipants’actions.

Recentdevelopmentsinsocialsciencehaveinspiredagrowingbodyoflanguage-based research in areas of social dominance and inequality (van Dijk, 1993;Wetherell & Potter, 1992; Wetherell et al., 2001). There are two assumptionsunderlyingthisworkthatmustbeunderstoodifthepowerofitsfindingsistobeappreciated.First,itisassumedthattherealityofobjects,events,andsituationsisconstitutedthroughthediscoursesaboutthem.Thesecondassumptionisthatthewayinwhichtherealityofaparticularobject,event,orsituationisconstituteddependsontheinterestorconcernofthespeakingindividualinthatsituation.Itfollowsfromthefirstassumptionthatresearchinthistraditiondoesnotseektouncoverordefinetheessentialnatureofthetargetedentity; indeed,itassumesthatsuchadescriptionwouldbemerelyanotherwayofconstituting theobject.In doing so, research introduces the realm of power relations into knowledge-basedenterprises,tomakeexplicitthewaysinwhichdifferentialsinmaterialandpoliticalpoweraremanifestinmaterialdifferencesinthesituationsofdifferentlyempowered groups. In this context, the ideologies of those with power will bedominantoverthoseofpeoplewhohaveless.

Theoriesofideology(Bordieu&Passeron,1990)emphasizetheroleoflanguageinthereproductionofideologyandtheimportanceofthelattertotheestablish-mentandmaintenanceofsocialrelations.However,initsconventionalcontextofclassstruggle,ideologyischaracterizedasthetoolofrulingelitesandisevokedtoexplainthecontrolofthemasses.WearemoreinterestedintheformulationbyBilligetal.(1988),whichpresentstheideaoflived ideology—thearrayofideas,beliefs,andexplanationsdrawnontointerpreteverydayexperience.

For thePäkehäresearch team, thepoststructuralistperspective thathasencom-passedthecritiqueofempiricismhasalsoinspiredthedevelopmentofqualitativeresearchstylesfocusedontheexplicationoflanguageinareasofgender(Gavey,1989;Lather,1991)andculturalrelations(Essed,1988;Nairn&McCreanor,1990).Methodsbuiltaroundthediscourseanalysisoftranscriptionsofsemistructuredinterviews (Potter & Wetherell, 1987) offer detailed understandings of thecomplexity anddynamicsof intergroup relations that are lost in the traditionalsocialscienceapproachesofexperimentandquestionnaire.

For the Mäori research team, this perspective offered one tool for the analysisof Mäori talk. Mäori theories of knowledge encompass empirical traditionsfor enumeration, measurement, and comparison, yet the historical storage,retrieval,andtransmissionofknowledgethroughoralculturemeansthat thereis an ongoing orientation toward talk as data. The everyday understandingof knowledge as constructed/enacted is cemented in the institutions andpracticesofMäorisocieties, suchaswhakapapa (genealogy),waiata (song),andmany others. While these practices are continually undermined and derogatedthrough the colonial imposition of Western worldview, culture, and science,therenaissance inMäorisocietyat largehasseen theresurgenceof interest indiscourse,reclaimingtestimony,lifestory,andstorytellingaslegitimateformsofknowledge(L.T.Smith,1999).Inthisproject,theresearchinterviewsincorporatemanyoftheseelements,providingaparticularlyrichanddeepbaseofexperientialmaterialfromwhichtodrawthethemesandpatterns,aswellasthevariationsinparticipants’encounterswithprimaryhealthcareinkeepingwiththeimperativesofthechosenresearchquestion.

PotterandWetherell(1987)arguedthatapproachingsuchdataasatopicofstudy“intheirownright”istheoreticallyjustified,methodologicallypossible,andsociallysignificant.Itisanaturalisticoptionthatacknowledgesthepossibilitythatpeopleare positioned within heterogeneous and contradictory discourses, and thatthesediscoursescanreflectthemannerinwhichpowerrelationsinafieldsuchas Mäori health may be manifest. Discourse databases are designed to samplethekindsoflinguisticresourcesavailable,ratherthantoassignindividualsintopreconceivedcategories(asdosurveystudies)ortoprovideasingle,apparentlycoherentaccountofaconceptsuchasMäorihealththatisvariouslyconstitutedin

participants’talkandpractice.Thismeansthatdiscoursestudiestypicallydrawonrelativelysmallnumbersofparticipants,whosetalkcentersoncommontopicsandparticulartaskssuchasexplainingandjustifying.Forthisreason,itisassumedthatfewerindividualsspeakinginmoredepthwillprovideaglobalimpressionofthediscursiveresourcesavailable.

Anarrayofbroadlycriticaldiscursiveapproachestothescientificstudyofsociallifehasemerged(Wetherelletal.,2001).Theseincludepoststructuralistdiscourseanalysis, conversation analysis, and critical discourse analysis (van Dijk, 1993),offering a comprehensive approach to the dimensions of text that need to beexamined to provide rigorous descriptions of the structure and function ofdiscourse. In addition, a theoretical rationale for critical study of the discourseof both the empowered and the disempowered, as a means of highlightingsocialinjustice,isbeginningtoappear(Wodak&Matouschek,1993).Studiesoftheproductionofdominancemainly focuson thediscourseof theempoweredin the enactment of their ideologies. For example, Wetherell and Potter (1992)analyzedPäkehätalkabout“racialissues”andshowedthatspeakersuseavarietyofdiscursive resources to justify the relativepositionsofMäori andPäkehä, topresentthemselvesinapositivelight,andtolegitimatethestatusquo.

However,beyondtheparticularcommitmenttoworktoward“depowering”elites(Huygens,1993),discourse theoryalso identifiesakeyrole for thestudyof thediscourseoftheoppressedinchallengingexistingsocialrelations(Essed,1988).Thenotionofhegemony(Gramsci,1971)foregroundswaysinwhichdisciplinarypowermaybeinternalizedintheideologiesoftheoppressed,leadingthemintobeliefs and practices that entrench their condition (Awatere, 1984). Knowledgeof the discourses of the disempowered may act as a catalyst in the politicaldevelopmentandeducationalprogramsamongoppressedgroups,whichinturnchallengesestablishedideologyandleadstosocialchange.

For thePäkehäresearch team, thepoststructuralistperspective thathasencom-passedthecritiqueofempiricismhasalsoinspiredthedevelopmentofqualitativeresearchstylesfocusedontheexplicationoflanguageinareasofgender(Gavey,1989;Lather,1991)andculturalrelations(Essed,1988;Nairn&McCreanor,1990).Methodsbuiltaroundthediscourseanalysisoftranscriptionsofsemistructuredinterviews (Potter & Wetherell, 1987) offer detailed understandings of thecomplexity anddynamicsof intergroup relations that are lost in the traditionalsocialscienceapproachesofexperimentandquestionnaire.

For the Mäori research team, this perspective offered one tool for the analysisof Mäori talk. Mäori theories of knowledge encompass empirical traditionsfor enumeration, measurement, and comparison, yet the historical storage,retrieval,andtransmissionofknowledgethroughoralculturemeansthat thereis an ongoing orientation toward talk as data. The everyday understandingof knowledge as constructed/enacted is cemented in the institutions andpracticesofMäorisocieties, suchaswhakapapa (genealogy),waiata (song),andmany others. While these practices are continually undermined and derogatedthrough the colonial imposition of Western worldview, culture, and science,therenaissance inMäorisocietyat largehasseen theresurgenceof interest indiscourse,reclaimingtestimony,lifestory,andstorytellingaslegitimateformsofknowledge(L.T.Smith,1999).Inthisproject,theresearchinterviewsincorporatemanyoftheseelements,providingaparticularlyrichanddeepbaseofexperientialmaterialfromwhichtodrawthethemesandpatterns,aswellasthevariationsinparticipants’encounterswithprimaryhealthcareinkeepingwiththeimperativesofthechosenresearchquestion.

PotterandWetherell(1987)arguedthatapproachingsuchdataasatopicofstudy“intheirownright”istheoreticallyjustified,methodologicallypossible,andsociallysignificant.Itisanaturalisticoptionthatacknowledgesthepossibilitythatpeopleare positioned within heterogeneous and contradictory discourses, and thatthesediscoursescanreflectthemannerinwhichpowerrelationsinafieldsuchas Mäori health may be manifest. Discourse databases are designed to samplethekindsoflinguisticresourcesavailable,ratherthantoassignindividualsintopreconceivedcategories(asdosurveystudies)ortoprovideasingle,apparentlycoherentaccountofaconceptsuchasMäorihealththatisvariouslyconstitutedin

participants’talkandpractice.Thismeansthatdiscoursestudiestypicallydrawonrelativelysmallnumbersofparticipants,whosetalkcentersoncommontopicsandparticulartaskssuchasexplainingandjustifying.Forthisreason,itisassumedthatfewerindividualsspeakinginmoredepthwillprovideaglobalimpressionofthediscursiveresourcesavailable.

Anarrayofbroadlycriticaldiscursiveapproachestothescientificstudyofsociallifehasemerged(Wetherelletal.,2001).Theseincludepoststructuralistdiscourseanalysis, conversation analysis, and critical discourse analysis (van Dijk, 1993),offering a comprehensive approach to the dimensions of text that need to beexamined to provide rigorous descriptions of the structure and function ofdiscourse. In addition, a theoretical rationale for critical study of the discourseof both the empowered and the disempowered, as a means of highlightingsocialinjustice,isbeginningtoappear(Wodak&Matouschek,1993).Studiesoftheproductionofdominancemainly focuson thediscourseof theempoweredin the enactment of their ideologies. For example, Wetherell and Potter (1992)analyzedPäkehätalkabout“racialissues”andshowedthatspeakersuseavarietyofdiscursive resources to justify the relativepositionsofMäori andPäkehä, topresentthemselvesinapositivelight,andtolegitimatethestatusquo.

However,beyondtheparticularcommitmenttoworktoward“depowering”elites(Huygens,1993),discourse theoryalso identifiesakeyrole for thestudyof thediscourseoftheoppressedinchallengingexistingsocialrelations(Essed,1988).Thenotionofhegemony(Gramsci,1971)foregroundswaysinwhichdisciplinarypowermaybeinternalizedintheideologiesoftheoppressed,leadingthemintobeliefs and practices that entrench their condition (Awatere, 1984). Knowledgeof the discourses of the disempowered may act as a catalyst in the politicaldevelopmentandeducationalprogramsamongoppressedgroups,whichinturnchallengesestablishedideologyandleadstosocialchange.

Data and Analysis

IndigenoustheoriesofknowledgechallengeWesterntheoryinacontestforspacetodeterminewhat counts asdata (L.T.Smith,1999).Thereareechoesof thistension within Päkehä thinking as positivist and constructionist philosophiesbattle over the legitimacy of methods—and thus conceptions—as to what willcount as data. The former regards data as deriving from empirical observationandexperiment,whereasthelattercreatesnewpossibilitiesbasedonexperience,especiallyasrepresentedindiscourseandtalk.Inthecontextofthelargerconflictbetweenindigenousandcolonizingepistemologies,thereareresonancesbetweentheconstructionistandindigenousapproaches toknowledge,whichpredisposebothtoorienttotalkandtextasdataforunderstandingandinterpretingthelivedexperienceofpopulationgroups.

Theresearchquestionispitchedinsuchawaythatcallsforqualitativedata,becauseit bears on and illuminates the situated interpretative resources and common-sense,livedideologiesofparticularcommunities.Wewantedtoknowaboutthewaysinwhichtwointeractinggroupsconstructandinterpretthoseinteractions.Qualitativedatagiveustherichnessanddepthfromwhichtobuildaccountsoftherecurrentpatternsandvariationsinsuchtalk.AskingparticipantsdirectlyaboutthetopicofMäorihealth(inwhichbothgroupshaveaninterest)evokesthesharedvocabularies, grammar, imagery, ideas, and meanings available and current intheirconstructionsandinterpretationsofthetopic.Thesedatawillhaveintegrityandmeaningontheirown;whentheyarebroughtinto“conversation”witheachother,thedatawillpotentiallyrevealimportantinsightsaboutthebasisandnatureoftheinteractionbetweenMäoriclientsandPäkehädoctors.

Wedecidedthatinthefirstinstance,asthestudywasexploratoryandinductive,wewouldconductface-to-faceinterviews.Wewantedthedatatobeableto“speakfrom two sides” as a way of approaching the different experiences of the twogroupsaroundthecommontopicratherthanasabasisforasimplisticcompare-and-contrastexercise.Forthisreason,wetookaflexibleapproachtoboththeformandthecontentofinterviewsgatheredbytheteams,beingpreparedforwhatcameforth from a relatively negotiated, organic process rather than trying to dictateuniformityforcomparability.

Mäori Participant Interviews

WhiletheMäorisideofthephysicianprojectchoseindividualinterviews,therewasaflexibilitythatwassensitivetoapreferenceenactedinsomeinstancesofpartici-pants contributing in pairs rather than alone. Twenty-eight Mäori participants(ages17to74)wereinterviewed.Theinterviewswerelooselystructuredtoallowtheparticipantstobeinthedriver’sseatregardingthedirectiontheinterviewstook,areasthatwereopentodiscussion,andthelengthoftheinterviews.ParticipantswereinvitedtotalkaboutMäorihealthandtotelltheirstoriesaboutinteractingwithnon-Mäoriphysicians.Wewouldbehesitanttocallourmethod“talkstory,”but we definitely have an affinity for this as a way of engaging with researchparticipants.Theinterviewswerefullytranscribed,andthetranscriptsformedthedataforathematicanalysis.

Päkehä Participant Interviews

While Päkehä researchers have had to struggle to establish the legitimacy ofqualitativemethodsingeneral—anddiscursiveapproachesinparticular—withinthese emerging traditions there is a central concern with talk and text as data.In the case of the Päkehä doctors, we decided to pursue individual interviewsfor pragmatic reasons, because our connections indicated that getting doctorstogether in groups would be more difficult owing to their busy schedules. WefeltclearthatfollowingtheleadofWetherellandPotter(1992),thiswouldbethepreferredmodeofcontributiontotheprojectforthisgroup.Inaddition,itseemedthatitmightbeeasiertomanageanypowerdynamicsonetoone,ratherthanwithagroupofrelativelyassertiveandarticulateindividuals.

Twenty-six physicians were interviewed. For the purpose of data that can beused to identify interpretative repertoires, individual interviewsareassumed toinvolvetheparticipantinthearticulationofcommonformsoftalk,withoutthecomplicatingfactorsofinteractivephaseswithcoparticipants.Whileitistruethattheinterviewer—toagreaterorlesserextent—coconstructstheinterview,inthisinstancetheinterviewer(TimMcCreanor)wasrelativelyunfamiliarwiththetopic.Further,withparticipantsspeakingfromapositionofstrength,wewereconfidenttherewouldbecleararticulationsoftheresourcesavailabletophysicianstotalkaboutMäorihealth.

Data and Analysis

IndigenoustheoriesofknowledgechallengeWesterntheoryinacontestforspacetodeterminewhat counts asdata (L.T.Smith,1999).Thereareechoesof thistension within Päkehä thinking as positivist and constructionist philosophiesbattle over the legitimacy of methods—and thus conceptions—as to what willcount as data. The former regards data as deriving from empirical observationandexperiment,whereasthelattercreatesnewpossibilitiesbasedonexperience,especiallyasrepresentedindiscourseandtalk.Inthecontextofthelargerconflictbetweenindigenousandcolonizingepistemologies,thereareresonancesbetweentheconstructionistandindigenousapproaches toknowledge,whichpredisposebothtoorienttotalkandtextasdataforunderstandingandinterpretingthelivedexperienceofpopulationgroups.

Theresearchquestionispitchedinsuchawaythatcallsforqualitativedata,becauseit bears on and illuminates the situated interpretative resources and common-sense,livedideologiesofparticularcommunities.Wewantedtoknowaboutthewaysinwhichtwointeractinggroupsconstructandinterpretthoseinteractions.Qualitativedatagiveustherichnessanddepthfromwhichtobuildaccountsoftherecurrentpatternsandvariationsinsuchtalk.AskingparticipantsdirectlyaboutthetopicofMäorihealth(inwhichbothgroupshaveaninterest)evokesthesharedvocabularies, grammar, imagery, ideas, and meanings available and current intheirconstructionsandinterpretationsofthetopic.Thesedatawillhaveintegrityandmeaningontheirown;whentheyarebroughtinto“conversation”witheachother,thedatawillpotentiallyrevealimportantinsightsaboutthebasisandnatureoftheinteractionbetweenMäoriclientsandPäkehädoctors.

Wedecidedthatinthefirstinstance,asthestudywasexploratoryandinductive,wewouldconductface-to-faceinterviews.Wewantedthedatatobeableto“speakfrom two sides” as a way of approaching the different experiences of the twogroupsaroundthecommontopicratherthanasabasisforasimplisticcompare-and-contrastexercise.Forthisreason,wetookaflexibleapproachtoboththeformandthecontentofinterviewsgatheredbytheteams,beingpreparedforwhatcameforth from a relatively negotiated, organic process rather than trying to dictateuniformityforcomparability.

Mäori Participant Interviews

WhiletheMäorisideofthephysicianprojectchoseindividualinterviews,therewasaflexibilitythatwassensitivetoapreferenceenactedinsomeinstancesofpartici-pants contributing in pairs rather than alone. Twenty-eight Mäori participants(ages17to74)wereinterviewed.Theinterviewswerelooselystructuredtoallowtheparticipantstobeinthedriver’sseatregardingthedirectiontheinterviewstook,areasthatwereopentodiscussion,andthelengthoftheinterviews.ParticipantswereinvitedtotalkaboutMäorihealthandtotelltheirstoriesaboutinteractingwithnon-Mäoriphysicians.Wewouldbehesitanttocallourmethod“talkstory,”but we definitely have an affinity for this as a way of engaging with researchparticipants.Theinterviewswerefullytranscribed,andthetranscriptsformedthedataforathematicanalysis.

Päkehä Participant Interviews

While Päkehä researchers have had to struggle to establish the legitimacy ofqualitativemethodsingeneral—anddiscursiveapproachesinparticular—withinthese emerging traditions there is a central concern with talk and text as data.In the case of the Päkehä doctors, we decided to pursue individual interviewsfor pragmatic reasons, because our connections indicated that getting doctorstogether in groups would be more difficult owing to their busy schedules. WefeltclearthatfollowingtheleadofWetherellandPotter(1992),thiswouldbethepreferredmodeofcontributiontotheprojectforthisgroup.Inaddition,itseemedthatitmightbeeasiertomanageanypowerdynamicsonetoone,ratherthanwithagroupofrelativelyassertiveandarticulateindividuals.

Twenty-six physicians were interviewed. For the purpose of data that can beused to identify interpretative repertoires, individual interviewsareassumed toinvolvetheparticipantinthearticulationofcommonformsoftalk,withoutthecomplicatingfactorsofinteractivephaseswithcoparticipants.Whileitistruethattheinterviewer—toagreaterorlesserextent—coconstructstheinterview,inthisinstancetheinterviewer(TimMcCreanor)wasrelativelyunfamiliarwiththetopic.Further,withparticipantsspeakingfromapositionofstrength,wewereconfidenttherewouldbecleararticulationsoftheresourcesavailabletophysicianstotalkaboutMäorihealth.

Findings

Todate, therehavebeen threepublications fromthisstudy.Thefirst,which isprimarilymethodological,appearedintheJournal of Health Psychology(McCreanor&Nairn,2002a),whereasthesecondandthirdarticlesreportingoverviewsoftheMäoriandPäkehäfindingsappearedseparatelyintheNew Zealand Medical Journal(Cram,Smith,&Johnstone,2003;McCreanor&Nairn,2002b).Thelatterarticlesreportwidelydivergent themes fromdiscursive analysesofdatagathered fromMäori and Päkehä participants. Further publications will elaborate these differ-encesandconsidertheimplicationsforequitableandrealisticpoliciesforhealthservicedeliveryinacolonialsituationwithentrenchedhealthdisparitiesbetweenMäoriandPäkehä.

ThefindingsrepresentacontributiontoasocialanalysisofmedicineinAotearoaNewZealandthathashistoricaldimensions(Nicholson,1988)andcontemporarycomponents(Westbrooke,Baxter,&Hogan,2001).Thefindingsalsodemonstratesimilaritieswiththewidelyavailablecritiqueofracisminhealth,whichfuelsethnichealthdisparitiesworldwide(Karlson&Nazroo,2003;Krieger,2003).MäoriandPäkehähaveverydifferentwaysofconstructingandtalkingabouthealth,whicharguablyplayoutinprimaryhealthcareconsultationsandhaverealimpactsonthehealthofMäoriindividuals,communities,andpopulations.

Mäori Patients

Thissectionprovidesanoverviewof5ofthe10recurrentthemesthatarosefromtheinterviewswithMäoripatients.(SeeCrametal.,2003,forafulloverview.)

MäORI HEAlTH.Whenansweringthequestion“WhatisMäorihealth?”manyoftheparticipantsemphasizedtheimportanceofdefininghealthholistically.Theyacknowledgedboththeinterconnectednessandtheimportanceofbalanceamongthephysical,mental,andspiritualaspectsofhealth.Thesignificanceofwhänauor family (see below) was also stressed. Some participants also talked aboutthe impact of social and economic well-being on Mäori health, the disparitiesbetweenMäoriandPäkehähealth,andtheroleofMäorihealthcareprovisionsinmaintaininghealth.

TRADITIONAl wAyS.Theholistic,relationalnatureofMäorihealthwascloselylinkedtoparticipants’discussionoftraditionalMäoriapproachesto,andknowledgeabout,healing. Many of the participants had engaged in traditional healing practicesrelatedto,forexample,rongoäandwairua(seebelow).ThesepracticesthereforecontinuetohavearoleinMäorihealth.

RONGOä.Rongoäincludesremedies,therapies,andspiritualhealing.Olderpartic-ipantstoldstoriesfromtheiryouthaboutrongoäbeingusedintimesofillness.RongoäwerealsocurrentlybeingusedbybothyoungandoldparticipantswhosawthisascompatiblewiththeiruseofWesternmedicines.Twoofthekuia(olderwomen)spokeabouttheirownspecializedknowledgeofrongoäandofsharingthisknowledgewithothers.

wAIRuA.Wairua,orspirit,wasthemostcommonlymentionedelementofMäorihealth.Itwasseenbyparticipantsaskeytounderstandinghealthandillnessasitprovidesinsightintothewholeperson,notjusttheperson’smanifestsymptoms.Without such insight, healing cannot occur as a person’s physical or mentalsymptomsmaywellhaveother,underlyingcauses.ThisunderstandingwasseenasbeingfundamentalinMäorihealthpractitioners,whereasPäkehäpractitionerswereseenaslesslikelytounderstandit,oftentreatingonlythesymptoms.

wHäNAu. Participants spoke about the whänau, or family, as the foundationalstructureforMäori.Whänaubuffersitsmembersfromthewiderworld,includingexperiencesofillness,treatment,andhospitalization,andisthereforeintegraltoMäori health and well-being. Participants were in agreement about the impor-tanceoftheleadershiproleskuiaandkoroua(oldermen)havewithinwhänau.Itwasalsoacknowledgedthatsomewhänaudidnotfunctioninthiswaybecauseoffamilystresses(e.g.,economic,social).Thesewhänauwereseenascopingthebesttheycouldandinneedofbothreliefandhope.

Päkehä Physicians

Inthissection,weoutline5ofthe10repertoiresthatemergedthroughouranalysesofthedata.Thesesketchesaresummariesofmorelengthyanalyses(McCreanor&Nairn,2002a,2002b)consistingofdetaileddescriptionsofthemesillustratedbyverbatimexcerptsfromtranscripts.

Findings

Todate, therehavebeen threepublications fromthisstudy.Thefirst,which isprimarilymethodological,appearedintheJournal of Health Psychology(McCreanor&Nairn,2002a),whereasthesecondandthirdarticlesreportingoverviewsoftheMäoriandPäkehäfindingsappearedseparatelyintheNew Zealand Medical Journal(Cram,Smith,&Johnstone,2003;McCreanor&Nairn,2002b).Thelatterarticlesreportwidelydivergent themes fromdiscursive analysesofdatagathered fromMäori and Päkehä participants. Further publications will elaborate these differ-encesandconsidertheimplicationsforequitableandrealisticpoliciesforhealthservicedeliveryinacolonialsituationwithentrenchedhealthdisparitiesbetweenMäoriandPäkehä.

ThefindingsrepresentacontributiontoasocialanalysisofmedicineinAotearoaNewZealandthathashistoricaldimensions(Nicholson,1988)andcontemporarycomponents(Westbrooke,Baxter,&Hogan,2001).Thefindingsalsodemonstratesimilaritieswiththewidelyavailablecritiqueofracisminhealth,whichfuelsethnichealthdisparitiesworldwide(Karlson&Nazroo,2003;Krieger,2003).MäoriandPäkehähaveverydifferentwaysofconstructingandtalkingabouthealth,whicharguablyplayoutinprimaryhealthcareconsultationsandhaverealimpactsonthehealthofMäoriindividuals,communities,andpopulations.

Mäori Patients

Thissectionprovidesanoverviewof5ofthe10recurrentthemesthatarosefromtheinterviewswithMäoripatients.(SeeCrametal.,2003,forafulloverview.)

MäORI HEAlTH.Whenansweringthequestion“WhatisMäorihealth?”manyoftheparticipantsemphasizedtheimportanceofdefininghealthholistically.Theyacknowledgedboththeinterconnectednessandtheimportanceofbalanceamongthephysical,mental,andspiritualaspectsofhealth.Thesignificanceofwhänauor family (see below) was also stressed. Some participants also talked aboutthe impact of social and economic well-being on Mäori health, the disparitiesbetweenMäoriandPäkehähealth,andtheroleofMäorihealthcareprovisionsinmaintaininghealth.

TRADITIONAl wAyS.Theholistic,relationalnatureofMäorihealthwascloselylinkedtoparticipants’discussionoftraditionalMäoriapproachesto,andknowledgeabout,healing. Many of the participants had engaged in traditional healing practicesrelatedto,forexample,rongoäandwairua(seebelow).ThesepracticesthereforecontinuetohavearoleinMäorihealth.

RONGOä.Rongoäincludesremedies,therapies,andspiritualhealing.Olderpartic-ipantstoldstoriesfromtheiryouthaboutrongoäbeingusedintimesofillness.RongoäwerealsocurrentlybeingusedbybothyoungandoldparticipantswhosawthisascompatiblewiththeiruseofWesternmedicines.Twoofthekuia(olderwomen)spokeabouttheirownspecializedknowledgeofrongoäandofsharingthisknowledgewithothers.

wAIRuA.Wairua,orspirit,wasthemostcommonlymentionedelementofMäorihealth.Itwasseenbyparticipantsaskeytounderstandinghealthandillnessasitprovidesinsightintothewholeperson,notjusttheperson’smanifestsymptoms.Without such insight, healing cannot occur as a person’s physical or mentalsymptomsmaywellhaveother,underlyingcauses.ThisunderstandingwasseenasbeingfundamentalinMäorihealthpractitioners,whereasPäkehäpractitionerswereseenaslesslikelytounderstandit,oftentreatingonlythesymptoms.

wHäNAu. Participants spoke about the whänau, or family, as the foundationalstructureforMäori.Whänaubuffersitsmembersfromthewiderworld,includingexperiencesofillness,treatment,andhospitalization,andisthereforeintegraltoMäori health and well-being. Participants were in agreement about the impor-tanceoftheleadershiproleskuiaandkoroua(oldermen)havewithinwhänau.Itwasalsoacknowledgedthatsomewhänaudidnotfunctioninthiswaybecauseoffamilystresses(e.g.,economic,social).Thesewhänauwereseenascopingthebesttheycouldandinneedofbothreliefandhope.

Päkehä Physicians

Inthissection,weoutline5ofthe10repertoiresthatemergedthroughouranalysesofthedata.Thesesketchesaresummariesofmorelengthyanalyses(McCreanor&Nairn,2002a,2002b)consistingofdetaileddescriptionsofthemesillustratedbyverbatimexcerptsfromtranscripts.

MäORI IDENTITy.TheissueofwhoshouldbecountedasMäoriwasseenasdeeplyproblematic and was widely used as a discursive device for discounting claimsof racismorcultural insensitivity.Scientificdefinitionsbasedongeneticswereroutinely offered but regularly conflicted with social constructions of Mäoriidentity,leavingnoviableobjectivestandard.SomeparticipantsarguedtherewasinsufficientjustificationforconceptualorpracticaldifferencesintheirworkwithMäoriandPäkehäpatients.

MäORI MORbIDITy. In line with population data, Mäori were seen as morecommonlyandmoreseverelyafflictedbyawiderangeofseriousandmundaneconditions. Some participants argued that Mäori under their care were muchbetteroff,butmostconcurredtherewasarealproblemnationwide.Explanationsofthesedisparitieswerecastasinteractionsbetweengeneticsandenvironment(primarily socioeconomic status and culture) in conventional biomedical terms,withnoanalysisofracismorcolonialism.

COMplIANCE.ParticipantswidelyreportedthatoneofthekeyissuesinworkingwithMäoriwasnoncompliance,whichmeant thatMäorimustaccept responsi-bilitiesforfailuresorbreakdownsinhealthcare.Comparedwiththerestofthepracticepopulation,Mäorididnottakeaconsistentpreventativeapproachtotheirhealthcareandwere frequently locked intodistressing, reactive, crisis-orientedtreatmentregimes,towhichtheyhadlittlecommitment.Thiswassaidtoarisefrom a present-focused, laissez-faire worldview, seated in ignorance, willful-ness,orself-destructivetendenciesthatcharacterizedtheMäoriapproachtolifeingeneral.

STylE Of wORkING wITH MäORI.DespitethepreemptiveargumentsaboutMäoriidentity,mostparticipantsreportedimportantdifferencesinhowtheywouldworkwithMäoriandPäkehäpatients.Inparticular,participantsnotedtheneedtoallowmoretimewithMäoripatientstofacilitaterapport-buildingandtoallowforamoreflexible unfolding of the medical history. Specific issues included protocols forphysicalexamination,useofgroupconsultations, indirectcommunicationwithpatients(viaseniorwomen),simplepresentationsofinformationusingpictures,repetition, extra input on follow-up, and flexibility with respect to punctualityandpayment.

MäORI CONCEpTIONS Of HEAlTH.ManyparticipantswereclearthatMäorithinkabouthealth inquitedifferentways thandoPäkehäbutwereable togiveonlya general outline of what Mäori conceptions were. Very few had knowledge offormalMäorimodelsofhealth;somenamedafewactualremediesorpracticesfromMäoritraditionsandfeltthatacquiringsuchknowledgewasnottheirrespon-sibilityorinterest.Adiscourseaboutcomplementarymedicinewasdrawnupon,toarguethatiftherewasnoharmdoneinthecourseofsuchpractices,thentheyweretobeacceptedandevenencouraged.

Discussion

Thefindings from the studies are strongevidenceof the culturalgulfbetweenprimary care physicians and Mäori clients of these professionals. The findingshighlightthedifferentconceptualizations,practices,andexpectationsthatinformand shape the actual interactions of primary health care. The inevitable powerdifferentialatpersonal,systemic,andinstitutionallevelsthatexistsbetweenthegroups—and inmanyof theclinicalconsultationdyads thatconstituteprimaryhealth care—is a likely contributor to thedifferentialpatternsofhealth serviceusageandoutcomesforMäoriandnon-Mäori.

Addressing this power differential will require more than cultural competencetraininginitsnarrowsense.Rather,changewillrequireabroader,twofoldagendafor cultural competency such as that suggested by Symonette (2004). The firstcomponent,“Inside/Out,”wouldrequirephysicianstodevelopanunderstandingof power and privilege hierarchies, including how they and their patients arelocated within these hierarchies. The second component, “Outside/In,” wouldencompassthedevelopmentofdiversity-relevantknowledgeandskills.Politicallyandethically, it is incumbentonthephysicianstoworkforchange.ThisisnottosaythatMäorishouldnotalsoworkforchange,butthataheavyresponsibilitylieswiththeempoweredgroup.ForMäori,ourresearchisaboutvalidationandaffirmation.It isone thing tosuspect that the treatmentyoureceive fromyourphysicianisaffectedbecauseyouareMäori;itisanotherthingtohavethosesuspi-cionsconfirmedandanalyzedwithinabroader,ideologicalcontext.

MäORI IDENTITy.TheissueofwhoshouldbecountedasMäoriwasseenasdeeplyproblematic and was widely used as a discursive device for discounting claimsof racismorcultural insensitivity.Scientificdefinitionsbasedongeneticswereroutinely offered but regularly conflicted with social constructions of Mäoriidentity,leavingnoviableobjectivestandard.SomeparticipantsarguedtherewasinsufficientjustificationforconceptualorpracticaldifferencesintheirworkwithMäoriandPäkehäpatients.

MäORI MORbIDITy. In line with population data, Mäori were seen as morecommonlyandmoreseverelyafflictedbyawiderangeofseriousandmundaneconditions. Some participants argued that Mäori under their care were muchbetteroff,butmostconcurredtherewasarealproblemnationwide.Explanationsofthesedisparitieswerecastasinteractionsbetweengeneticsandenvironment(primarily socioeconomic status and culture) in conventional biomedical terms,withnoanalysisofracismorcolonialism.

COMplIANCE.ParticipantswidelyreportedthatoneofthekeyissuesinworkingwithMäoriwasnoncompliance,whichmeant thatMäorimustaccept responsi-bilitiesforfailuresorbreakdownsinhealthcare.Comparedwiththerestofthepracticepopulation,Mäorididnottakeaconsistentpreventativeapproachtotheirhealthcareandwere frequently locked intodistressing, reactive, crisis-orientedtreatmentregimes,towhichtheyhadlittlecommitment.Thiswassaidtoarisefrom a present-focused, laissez-faire worldview, seated in ignorance, willful-ness,orself-destructivetendenciesthatcharacterizedtheMäoriapproachtolifeingeneral.

STylE Of wORkING wITH MäORI.DespitethepreemptiveargumentsaboutMäoriidentity,mostparticipantsreportedimportantdifferencesinhowtheywouldworkwithMäoriandPäkehäpatients.Inparticular,participantsnotedtheneedtoallowmoretimewithMäoripatientstofacilitaterapport-buildingandtoallowforamoreflexible unfolding of the medical history. Specific issues included protocols forphysicalexamination,useofgroupconsultations, indirectcommunicationwithpatients(viaseniorwomen),simplepresentationsofinformationusingpictures,repetition, extra input on follow-up, and flexibility with respect to punctualityandpayment.

MäORI CONCEpTIONS Of HEAlTH.ManyparticipantswereclearthatMäorithinkabouthealth inquitedifferentways thandoPäkehäbutwereable togiveonlya general outline of what Mäori conceptions were. Very few had knowledge offormalMäorimodelsofhealth;somenamedafewactualremediesorpracticesfromMäoritraditionsandfeltthatacquiringsuchknowledgewasnottheirrespon-sibilityorinterest.Adiscourseaboutcomplementarymedicinewasdrawnupon,toarguethatiftherewasnoharmdoneinthecourseofsuchpractices,thentheyweretobeacceptedandevenencouraged.

Discussion

Thefindings from the studies are strongevidenceof the culturalgulfbetweenprimary care physicians and Mäori clients of these professionals. The findingshighlightthedifferentconceptualizations,practices,andexpectationsthatinformand shape the actual interactions of primary health care. The inevitable powerdifferentialatpersonal,systemic,andinstitutionallevelsthatexistsbetweenthegroups—and inmanyof theclinicalconsultationdyads thatconstituteprimaryhealth care—is a likely contributor to thedifferentialpatternsofhealth serviceusageandoutcomesforMäoriandnon-Mäori.

Addressing this power differential will require more than cultural competencetraininginitsnarrowsense.Rather,changewillrequireabroader,twofoldagendafor cultural competency such as that suggested by Symonette (2004). The firstcomponent,“Inside/Out,”wouldrequirephysicianstodevelopanunderstandingof power and privilege hierarchies, including how they and their patients arelocated within these hierarchies. The second component, “Outside/In,” wouldencompassthedevelopmentofdiversity-relevantknowledgeandskills.Politicallyandethically, it is incumbentonthephysicianstoworkforchange.ThisisnottosaythatMäorishouldnotalsoworkforchange,butthataheavyresponsibilitylieswiththeempoweredgroup.ForMäori,ourresearchisaboutvalidationandaffirmation.It isone thing tosuspect that the treatmentyoureceive fromyourphysicianisaffectedbecauseyouareMäori;itisanotherthingtohavethosesuspi-cionsconfirmedandanalyzedwithinabroader,ideologicalcontext.

In terms of research process, we have worked together as Mäori and Päkehäresearchers;aspartiestoahistoricalandlivingagreementtocooperate,TeTiritio Waitangi: as parties interested in exploring specific domains such as healthinpursuitofsocialjusticeinthiscountry;andaspartieswithinterestsinsocialjusticeforindigenouspeoplesworldwide.Theideawasthatwewouldbeapart,buttalkingtooneanother,andsomewheredownthetrackwewouldcometogethertolinkupthefindingsemergingfromthecomponents.Thishasrequiredalargeelement of trust, as we were simply unsure of what we were getting into. Weadopted a process of routine reporting, delivered through monthly meetingsonhoweachgroupwasfaring,supplementedbyextracontactswhenproblemsarose or significant insights emerged. “Cooperative independence” seems likeasimplecatchphrasetocharacterizethisstage.Similarpatternsemergedintheanalyticphasesastheteamsworkedtoprocesstheirdataandthentoseethattheapproachesweresufficientlycongruenttoallthedatasets(tospeaktoeachother).

ThedevelopmentofthisbiculturalknowledgeisfirmlysituatedwithinKaupapaMäori.Ontheonehand,theexplorationofMäoriexperiencesofprimarycarehaslookedinward,askingMäoritotalkabouttheirunderstandingsofMäorihealthand their experiences of engagement with non-Mäori physicians. On the otherhand, the exploration has looked outward, asking how these same experiencesareconstitutedwithinthetalkofPäkehäphysicians.Severalkeylessonsfromourresearchprocessarehighlightedbelow:

• Thereisanimportantrolefornonindigenousresearcherswhoarecommittedtosupportingindigenousresearchagendas.Thisroleisaboutworkingwithandalongsideindigenousresearchers,butnotnecessarilyresearchingwithinindigenouscommunities.Rather,nonindigenousresearcherscanturntheirgazeonnonindigenouscommunitiesinwhichtheunderlyingcausesofindigenousmarginalizationcanbefoundandchallenged.InHawaiÿi,thismightmeanthatnon-Hawaiianresearchersasksystemicquestionsaboutthepowerandprivilegethatisembeddedwithinnonindigenousinstitutions,andwhetherthispowerandprivilegeworksfororagainstHawaiianwell-beingandself-determination.

• Bytakingthestanceof“interestedparties”totheresearch—asdistinctfromresearchpartners—wewereabletokeepthepowerrelationsbetweenus,asMäoriandPäkehä,clearlyintheframethroughouttheresearchprocess.Onthewhole,thisencouragedamuchmorenegotiatedsetofresearchrelationsinwhichtheassumptionsofeitherpartywereavailableforscrutinythroughouttheresearchprocess.Thisaccountabilityprocessisimportant.Nonindigenousresearchers,forexample,shouldnotrushofftodotheresearchtheythinkwillserveanindigenousagenda,evenifthisresearchiswithnonindigenouscommunities.Rather,theresearchagendashouldbenegotiatedwith,andbeaccountableto,indigenouspeoples.Inthisproject,wehavefoundthatonesuchaccountabilityframeworkoccurswhenindigenousandnonindigenousresearchteamsworktogether.

• TheintellectualtraditionsofbothMäoriandPäkehäwerecomfortablyencompassedwithinthemethodologicalframeworkwesettledonforourinvestigation.Inaddition,theselectionofresearchquestionsassumedthattherewouldbetwoperspectivesatplayanddrewontheknowledge,expectations,andagendasofbothparties.Themostimportantelementsinthiswereourmutualrespectandthecommitmentweeachbroughttotheresearchrelationship.Throughthis,wehaveputintoeffectmanyofthepracticesthatguideMäoriresearchers(seeTable1),suchasarespectforoneanother,awillingnesstolistenandtoshareexpertise,andabeliefthatwecanlearnfromoneanother.Theseculturalvaluescanprovideusefulguidanceforhowindigenousandnonindigenousresearcherscanbehavetowardeachotherwhentheyaddressanindigenousconcernthroughjointresearch.

• Powerdifferencesbetweenthetwogroupssupplyingdatameantthateachteamtookitsownapproachinanalyzingthematerialswhilekeepingeachotherinformedandretainingtheoptionoffurthercollaborations.Theresultwasthatthefindings,whilereflectingtheverydifferentexperiencesandapproachesinformingthediscoursesofthetwogroupsonissuesofMäorihealth,neverthelessmirrorandanticipateeachotherinwaysthathavesignificantimplicationsforhealthservicedelivery.Theprospectofthesetypesofsynergiesisrealinthisresearchmodel,withoneoutcomebeingmultiplesites—bothindigenousandnonindigenous—atwhichthefindingsmightbebroughttobeartofacilitatesocialchange.

In terms of research process, we have worked together as Mäori and Päkehäresearchers;aspartiestoahistoricalandlivingagreementtocooperate,TeTiritio Waitangi: as parties interested in exploring specific domains such as healthinpursuitofsocialjusticeinthiscountry;andaspartieswithinterestsinsocialjusticeforindigenouspeoplesworldwide.Theideawasthatwewouldbeapart,buttalkingtooneanother,andsomewheredownthetrackwewouldcometogethertolinkupthefindingsemergingfromthecomponents.Thishasrequiredalargeelement of trust, as we were simply unsure of what we were getting into. Weadopted a process of routine reporting, delivered through monthly meetingsonhoweachgroupwasfaring,supplementedbyextracontactswhenproblemsarose or significant insights emerged. “Cooperative independence” seems likeasimplecatchphrasetocharacterizethisstage.Similarpatternsemergedintheanalyticphasesastheteamsworkedtoprocesstheirdataandthentoseethattheapproachesweresufficientlycongruenttoallthedatasets(tospeaktoeachother).

ThedevelopmentofthisbiculturalknowledgeisfirmlysituatedwithinKaupapaMäori.Ontheonehand,theexplorationofMäoriexperiencesofprimarycarehaslookedinward,askingMäoritotalkabouttheirunderstandingsofMäorihealthand their experiences of engagement with non-Mäori physicians. On the otherhand, the exploration has looked outward, asking how these same experiencesareconstitutedwithinthetalkofPäkehäphysicians.Severalkeylessonsfromourresearchprocessarehighlightedbelow:

• Thereisanimportantrolefornonindigenousresearcherswhoarecommittedtosupportingindigenousresearchagendas.Thisroleisaboutworkingwithandalongsideindigenousresearchers,butnotnecessarilyresearchingwithinindigenouscommunities.Rather,nonindigenousresearcherscanturntheirgazeonnonindigenouscommunitiesinwhichtheunderlyingcausesofindigenousmarginalizationcanbefoundandchallenged.InHawaiÿi,thismightmeanthatnon-Hawaiianresearchersasksystemicquestionsaboutthepowerandprivilegethatisembeddedwithinnonindigenousinstitutions,andwhetherthispowerandprivilegeworksfororagainstHawaiianwell-beingandself-determination.

• Bytakingthestanceof“interestedparties”totheresearch—asdistinctfromresearchpartners—wewereabletokeepthepowerrelationsbetweenus,asMäoriandPäkehä,clearlyintheframethroughouttheresearchprocess.Onthewhole,thisencouragedamuchmorenegotiatedsetofresearchrelationsinwhichtheassumptionsofeitherpartywereavailableforscrutinythroughouttheresearchprocess.Thisaccountabilityprocessisimportant.Nonindigenousresearchers,forexample,shouldnotrushofftodotheresearchtheythinkwillserveanindigenousagenda,evenifthisresearchiswithnonindigenouscommunities.Rather,theresearchagendashouldbenegotiatedwith,andbeaccountableto,indigenouspeoples.Inthisproject,wehavefoundthatonesuchaccountabilityframeworkoccurswhenindigenousandnonindigenousresearchteamsworktogether.

• TheintellectualtraditionsofbothMäoriandPäkehäwerecomfortablyencompassedwithinthemethodologicalframeworkwesettledonforourinvestigation.Inaddition,theselectionofresearchquestionsassumedthattherewouldbetwoperspectivesatplayanddrewontheknowledge,expectations,andagendasofbothparties.Themostimportantelementsinthiswereourmutualrespectandthecommitmentweeachbroughttotheresearchrelationship.Throughthis,wehaveputintoeffectmanyofthepracticesthatguideMäoriresearchers(seeTable1),suchasarespectforoneanother,awillingnesstolistenandtoshareexpertise,andabeliefthatwecanlearnfromoneanother.Theseculturalvaluescanprovideusefulguidanceforhowindigenousandnonindigenousresearcherscanbehavetowardeachotherwhentheyaddressanindigenousconcernthroughjointresearch.

• Powerdifferencesbetweenthetwogroupssupplyingdatameantthateachteamtookitsownapproachinanalyzingthematerialswhilekeepingeachotherinformedandretainingtheoptionoffurthercollaborations.Theresultwasthatthefindings,whilereflectingtheverydifferentexperiencesandapproachesinformingthediscoursesofthetwogroupsonissuesofMäorihealth,neverthelessmirrorandanticipateeachotherinwaysthathavesignificantimplicationsforhealthservicedelivery.Theprospectofthesetypesofsynergiesisrealinthisresearchmodel,withoneoutcomebeingmultiplesites—bothindigenousandnonindigenous—atwhichthefindingsmightbebroughttobeartofacilitatesocialchange.

This elucidation of understandings and power dynamics that influence Mäorihealthandwell-beinghasbeenonefruitofthisresearchrelationship.ChangeinthecurrentlivedideologyofthiscontextnowneedstofollowifMäoriaretobewellservedwithinprimaryhealthcareinthiscountry.WebelieveourexperiencesofcollaborationhavegeneratedinsightsofimportancetofutureresearchinAotearoaNewZealandand,wehope,ofinteresttoresearchersinHawaiÿiandelsewhere.

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