Kumanan Rasanathan and Sarah Hill: There is more to it than simply choice

Why do Maori have poorer health than non-Maori New Zealanders? National Party leader Don Brash has recently said these statistics reflect personal choices and have nothing to do with Crown responsibilities. As public health doctors, we think there is a lot more to the differences between Maori and non-Maori death rates than personal "choice".

Dr Brash uses the example of lung cancer to substantiate his claim that negative health and social statistics for Maori are unrelated to the Crown's Treaty obligations. These negative health statistics are widely known in our field of public health.

The major point is that Maori die on average much earlier than non-Maori (eight years for males, nine years for females). This difference is only partly explained by socio-economic status - poor European New Zealanders still live longer than rich Maori.

Regardless of their so-called "blood quanta", those who identify as Maori (and are identified as Maori) suffer significantly worse health than non-Maori as a group.

What explains these differences? Dr Brash correctly identifies smoking as a key contributor to lung cancer, and it is true that Maori have higher rates of smoking than non-Maori. However, the view that smoking is purely an "individual choice" is usually promoted by the tobacco industry.

People do not exercise their "choice" to smoke in a vacuum but instead, as with other choices, are influenced by social circumstances. For example, smoking has not declined in any group as drastically as in medical doctors, amongst whom levels of smoking have decreased from 50 per cent 50 years ago to about 5 per cent now. This compares with about 25 per cent in the general population.

It is not surprising that doctors are less likely to "choose" to smoke, but it is worth thinking about why this is so. Knowledge about the effects of smoking; social pressures from colleagues; having sufficient income to manage stress in other ways; and, increasingly, not being exposed to cigarettes early in life - these are probably some of the reasons doctors have changed their smoking behaviour. It is simplistic to subsume all of these factors into "individual choice".

Maori share their higher smoking rates with disadvantaged groups in other settings - including Australian Aboriginal people, African Americans, and low-socio-economic groups in most Western countries. These patterns have more to do with poverty, deprivation and discrimination than with individual choice.

We know that Maori face higher levels of racism when using health services and that they have worse rates of survival than non-Maori across a range of cancers - including lung cancer. This is not something anyone would choose.

One of the few aspects of the Treaty that all New Zealanders seem to agree on is that Article Three confers equal rights and privileges to all citizens in their treatment by the Crown. When we recognise that injustices were committed in the past, especially in terms of Maori property rights, we are recognising not only violations of Article Two of the Treaty, but also violations of this pledge of equal treatment.

These injustices have significant ongoing effects on the economic base of Maori communities, but more than that, on their psychological, spiritual and physical well-being. It seems highly plausible that these outcomes are related to higher rates of smoking in Maori.

Moreover, there is increasing evidence that Maori do not receive equal medical treatment. This may not be intentional on the part of health professionals, but the result is that the health system, as a whole, delivers better care to most non-Maori than to Maori.

This constitutes a modern, continuing violation of Article Three.

We agree with Dr Brash that health services should be provided to all New Zealanders according to need. There is clear evidence that the greatest health needs in this country are for Maori and it seems unlikely to us that Treaty violations have made no contribution to the unequal state of Maori health. According to need, there would be a case for prioritisation of Maori health needs whether or not the Treaty existed.

If we want to organise our health institutions according to need, and aim to respect the guarantees made in the Treaty, we have to prioritise Maori health and allow that this might require "special" treatment for Maori communities - to enable them to enjoy an equal level of health to most other New Zealanders.

If we keep our heads in the sand about ethnic inequalities in health, we are saying that it is okay for Maori to have worse health than other New Zealanders. And that is just plain unfair.

* Dr Kumanan Rasanathan is a public health doctor and researcher at the School of Population Health, University of Auckland. Dr Sarah Hill is a public health doctor and researcher at the Wellington School of Medicine, University of Otago.