A smile and more: Improving Asian health in Auckland

Many years ago I remember talking to an older Chinese woman in Wellington about a presentation I was going to give about cultural safety. When I gave her a slightly academic and jargon laden explanation, she said to me: “Ruth, it’s really simple, you just have to smile at people”. I’ve never forgotten her words and I agree with her. A smile communicates several things, it says “I am going to look after you and care for you, you will be safe with me”. I’ve been teaching students to remember to smile ever since. I’ve also been interested in what makes a good experience for patients/service users/tangata whai ora and three words come to mind. These are competence (we need to know that nurses have the skills and resources to provide care), communication (we need to feel informed about what is happening to us, so that we can make informed decisions) and caring (we need to feel cared for and important).

A new discussion paper launched by The Human Rights Commission last month  examines how structural discrimination or institutional racism perpetuates inequalities and outlines government initiatives with potential to achieve systemic change. Four areas receive attention: health, justice, education, the economic system and the public service. In the section on health, the discussion paper cites the 2006/07 New Zealand Health Survey which found that the experience of feeling treated with respect and dignity by their primary health care provider varied by ethnicity, Asian, Pacific and Māori adults:

were significantly less likely than adults in the total population … to report that their health care professional treated them with respect and dignity ‘all of the time’.

Cultural competence has been enshrined in the Health Practitioners Competence Assurance Act (2003), but focuses on the ‘differences’ between the giver and recipient of care rather than broader macro-processes. Māori and Pacific experience the greatest health disparities in New Zealand. Consequently their dissatisfaction with mainstream services that don’t meet their needs has been chanelled into developing innovative, effective and responsive parallel services which have invigorated the health landscape and called mainstream services to account for better outcomes for racialised groups. However, the numbers of Māori and Pacific health workers are small which means that invariably Māori and Pacific people will be nursed by someone from a different ethnic background. Given the globaI recession, it is unlikely that parallel services will become available for Asians and the growing population group of MELAA so it is incumbent for all health professionals to develop skills for working inter-culturally. Hence, I am grateful for the development by nurses in New Zealand of the concept of cultural safety, requiring that nurses pay attention to their own social location and to account for their own role as a culture bearer and having an awareness of the colonising impacts of the culture of health care. Rather than other approaches where learning a laundry list of cultural preferences is the thing.

I’ve been a nurse since 1984 (including being a nursing student, dropping out and coming back). There was a time when I was the ‘go to’ person for anything related to culture and health, thankfully there are now lots of great people around. Our expertise is growing as is our evidence base about the health needs and experiences of Asians and other groups in Aotearoa. Hence my delight at the launch of a new Asian health needs assessment . It comes on the back of several other reportsHealth needs assessment of Middle Eastern, Latin American and African (MELAA) people living in the Auckland region (pdf 2.84 MB)A health profile of young Asian New Zealanders who attend secondary school (pdf, 2.71 MB)Asian Public Health Project Report (pdf, 819 KB)Asian Health Chart BookHealth Needs Assessment for Asian People in Counties Manukau (pdf, 2.2 MB)Health Needs Assessment for Asian People in Waitemata (pdf, 1.2 MB)Asian Health in Aotearoa in 2006–2007: trends since 2002–2003 (pdf, 2.23 MB) and Talking Therapies for Asian PeopleBuilding Evidence for Better Practice in Support of Asian Mental WellbeingAsian Mental Health and Addiction Research Agenda for New Zealand 2008-2012Service Responsiveness to Asian, Refugee and Migrant Populations: Factsheet seriesSpotlight on: Asian, refugee and migrant mental health and addiction supportTe Pou Research Update – May 2011 – Issue 2 – Asian Mental Health Service Responsiveness Mental Health Issues for Asians in New Zealand: A Literature Review.

Health needs assessments (HNA) involve collecting and analysing data about a population’s demand and need for health services (rather than individuals) in order to help prioritise health needs and services and determine strategic priorities for the medium and long term. Collecting information also involves talking to people about their priorities and gaps in services. The New Zealand Public Health and Disability Act 2000 requires that District Health Boards (DHBs) regularly assess the health and disability service needs of local populations.

The health needs assessment is aimed at “identifying the health needs, including inequalities in health status, of the main Asian ethnic groups living in the Auckland region”. Commissioned by the Northern DHB Support Agency on behalf of the Auckland Regional Settlement Strategy Migrant Health Action Plan it’s an acknowledgement of the size of the Auckland Asian population which represents 22% of the total population in the Auckland region: 310,000 Asian people live in the Auckland region, made up of 127,000 Chinese, 100,000 Indians, and 84,000 Other Asian people according to 2010 figures. These numbers are expected to increase, so that Asians make up more 60% of the total population in the Auckland region by 2026. Asian people comprise 9.2% of the total New Zealand population and are seen to have similar or better health than European New Zealanders. Many complain that the term Asian is confusing and problematic homogenising a diverse group of people with a range of migration and social histories whose needs can be disguised and subsumed. This needs assessment addresses concerns about the need to disentangle the category while maintaining the strategic importance of the umbrella term in advocating for health services.

Ahem, we already know from the from the New Zealand Health Survey and Youth ’07 that Chinese, Indian and Other Asian adults and youth eat fewer fruit and vegetables and do less physical activity (we’re studying actually) and we have a higher prevalence of adult obesity compared to other ethnic groups (cough!) This week we found out we had even more problems. I’ve tried to summarise them here, but you should really check out the full report.

Health concerns among Asian populations in Auckland include:

Chinese: diabetes prevalence among older men and middle-aged and older women, diabetes in pregnancy, child oral health, cervical screening coverage, cataract extractions and terminations of pregnancy.

Indians: CVD, diabetes (including during pregnancy), child oral health, child asthma, low birth weight deliveries, terminations of pregnancy, cervical screening coverage, family violence, hysterectomies, cataract extractions and total knee joint replacements.

Other Asian populations: stroke and overall CVD hospitalisations, diabetes (including during pregnancy), child oral health, child asthma, cervical screening coverage, terminations of pregnancy and cataract extractions.

Access issues:

Asians generally do pretty well, except in primary care (Chinese have low rates of PHO enrolment rates among Chinese across Auckland), but Asian women have lower cervical screening coverage across Auckland compared with European/Other rates. Asian people have lower rates of access to mental health services, disability support services and aged residential care compared to other ethnic groups.

Recommendations for the Three Auckland DHB’s to:

There’s no point trying to summarise all the key findings as you can go to the Executive summary for that. But the following recommendations are important and timely:

1) Notice Asians are here:

  • Advocacy for the health needs of Asian people in health-related policy, planning, monitoring and reporting at a regional and national level.
  • There should be better ethnicity data collection for the ‘Asian’ group and for Asian ethnic sub-groups, particularly with regard to CVD and diabetes and consistent use of ethnic coding for Asian ethnic groups at all levels.
  • Review whether the ‘Indian’ ethnic group should be replaced by ‘South Asian’.

2) Get Asians to be more healthy

  • Promoting healthy eating, adequate physical exercise, being smoke-free and cervical screening
  • Targeting CVD, diabetes, oral health (particularly among children), child asthma, family planning and contraception. Especially the ones that carry stigma such as disability, mental illness, and family violence.
  • Enabling health literacy by providing culturally-appropriate written information and providing this through community sessions and utilising local community media.
  • Educating health professionals about the key health needs for Asian communities.

3) Offer targeted health services for Asian people (within mainstream services):

  • Asian-focussed CVD and diabetes nurse practitioners (and how are they going to do this?)
  • Expanding and further developing existing Asian mental health service models .
  • Early intervention for family violence.
  • Family planning and contraception advice, including for Asian international students
  • More culturally-appropriate disability respite services.
  • More culturally-appropriate residential care facilities for older Asian people
  • Culturally-appropriate community oral health services, particularly for Asian children.

4) Improve PHO enrolment data and access to primary care services for Asian people

  • Better coding of ethnicity data
  • Increasing PHO enrolment rates for Chinese people across Auckland, and Indian and Other Asian people in WDHB.

5) Reduce cultural and language barriers to care

  • Training up the health and disability workforce across the Auckland region using culturally and linguistically diverse (CALD) cultural competence training and providing freely available resources.
  • Expanding cultural support services for Asian people in the Auckland region.
  • Providing additional resources for development of the Asian health workforce reflecting the ethnic composition of the populations served including: scholarships for further training of Asian health professionals; more bridging courses in nursing and allied health, for overseas-qualified Asian health professionals to register and work. Having language-matched carer-support workers for non-English speaking families in the home-based support sector.
  • Encouraging health service providers, particularly GPs to use qualified interpreters.
  • Additional funding for English as a Second Language (ESOL) courses, to increase the number of Asian people attending these courses.I don’t understand this)

6) More collaboration between health service providers in the Auckland region

  • •Better awareness among health service providers of the Auckland Asian, migrant and refugee services, programmes and initiatives currently available.
  • Sharing service delivery models of evaluation and research for Asian population health outcomes between the three DHBs in order to plan services.

7) Improving social capital among Auckland Asian communities

  • Funding to initiate and maintain community support groups for Asian people affected by disability, mental illness, family violence and other key health issues should be considered by Auckland DHBs.
  • Better awareness of charitable organisations that provide support services to Asian people, including Shanti Niwas (for older Asian people) and Umma Trust (for women and children), is required.
  • Better publicity about the community centres, libraries, public transport and other public facilities available to Asian communities in Auckland to reduce social isolation among migrants.
  • Consultation with Asian community leaders and community groups should be sought when evaluating existing health services or planning additional health services.

8) Future research

Another health needs assessment of Asian people across the Auckland region in 4-5 years; consultation with Auckland Asian communities regarding health needs and barriers to accessing appropriate health care; further examination of the effects of acculturation on the health of Asian migrants and subsequent generations in Auckland; a comparison of the health profiles of Fijian Indians as compared to other ‘Indians’ to determine if there are important differences; further analyses around the health of older Asian people as data for Asian ethnic sub-groups becomes available; the prevalence of disability in Auckland Asian communities; and ethnic-specific analyses of falls and pressure sores occurring in residential care, as well as osteoporosis and sun exposure.

Things I like about the report:
  • It confirms in writing what many of us who are passionate about health already know, it gives legitimacy to this knowledge, provides a benchmark and starting point for action.
  • The needs assessment considers Asian health within the context of broader determinants of health, I like the attention to improving social capital among Asian peoples and health literacy.
  • The report implies that the three Auckland DHB’s need to make a better effort at seamlessness and integration, collaboration and so on which are good things. The report also asks the DHB’s to take more action at Regional and National levels.
  • The recommendation to consult Asian communities when re-evaluating or starting new services.
  • The identification of health priorities eg mental health, reproductive health, services for older people etc.
  • The emphasis on developing a culturally responsive workforce.
  • Ensuring that future health professionals reflect the workforce and supporting the transition of the exisiting workforce who have struggled to get their qualifications recognised.
  • Better ethnicity data collection.
  • The desire to sharpen up terms (eg South Asian versus Indian) and to disentangle and fine tune the analysis of the largest groups of Asians that is Chinese and Indians.
  • The HNA consulted with “insiders” for their perspectives.
I’d be interested in how some of the recommendations are realised given the current financial climate of health service prudence and how pivotal upskilling our workforce is to making services engaging, safe and acceptable for Asian communities. I am not sure how prepared our workforce is for working with the kind of superdiversity we have in New Zealand and for me this is an enormous gap that I’ve worked hard to address in my research, teaching, presentations and publications.
One of my favourite definitions of health is from the Ottawa Charter which defines health as the “full personal development and participation in balanced and independent social, economic and cultural life”. I like the way it allows health to be considered in the context of health structures and systems as well as wider social, cultural, economic and political environments. Considering the social determinants of health, that is the conditions in which people are born, grow, live, work and age, including the health system is important, because these conditions are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries. It is my hope that this needs assessment and the report on structural discrimination contributes to an agenda that allows everyone to flourish and to enjoy “full personal development and participation in balanced and independent social, economic and cultural life” in Aotearoa, New Zealand.

Mehta S, Health needs assessment of Asian people living in the Auckland region. Auckland: Northern DHB Support Agency, 2012.

A fair go? Using liberal principles to support Islamophobia and racism.

I am interested in the issue of fairness. Anyone with siblings might be I would think. Whether it’s about making sure everyone gets an equally sized piece of cake or equal chances to speak, fairness has been a driving force in my life that I might have inherited.  As one of three daughters it was very important to our parents that we were treated fairly. So every birthday and Christmas we got the same kinds of presents, matching housecoats, matching crockery and so on. I kinda like the way I can go to both my sisters’ houses and enjoy drinking from the same cups. But over the years I’ve realised that treating people the same (is universalism) isn’t always all it’s cracked up to be and sometimes we need to treat people differently (particularism) to support them to get their needs met. For example, my parents have a prolific avocado tree and out of all my sisters I like avocados the most (hint hint), therefore is it fair that we all get the same number of them? This issue has resonance in health too, treating everyone the same can result in differential outcomes and sometimes you need to treat people differently to get the same outcome-for example for different population groups to have a long life different strategies might be needed. Which brings me to the issue that’s driving this blog post. How can we ensure that what we do is fair? and how do we define what fairness is? How might discourses invoking equality reinforce inequity and oppression?

The backlash against KONY 2012 did something useful. It made people think twice before re-posting items on their newsfeed and drew attention to the ways in which activism through social media can go horribly wrong. Joshua Foust says KONY 2012 accentuated the challenges “of enthusiastic support for someone who seems to be doing the right thing without really investigating whether their methods are the best, and privileging the easy and fun over the constructive”. In the case of the social media whirl around Russian punk band Pussy Riot, Foust’s criticism is that a serious concern about the erosion of political freedoms and civil liberties has been converted into a celebration of feminist punk music and art, detracting from the brutality and mistreatment being meted by Putin’s government to Russian activists or political prisoners.

It’s been a lousy few weeks for women in the west. The Julian Assange saga, Republican Todd Akin’s stupidity and comments that women can’t get pregnant from rape and more. But even more grump inducing has been the appearance on my Facebook feed of more white saviour complex campaigns, this time run by white feminists. Feminism is supposedly about building a fairer and more just society for women, but these campaigns only reinforce the limitations of western feminisms for engaging with axes of oppression such as ethnicity, racialisation and social class. This isn’t my only beef with western feminisms, the others are that they have a decidedly liberal tone with a focus on individual rights and also the frequency with which feminist discourses are co-opted for neoliberal ends. For example, the way in which western feminisms have legitimated expansionist neoliberalism, think Muslim women needing to be rescued from the Taleban by the Enlightened West in Afghanistan.

This hero/martyr narrative in this annoying image from Feminists United is illustrative of a hierarchy that pits western women against non-Western women.

The advert represents a white woman as a hero, both educated and modern and able to freely exercise choice and control over her own body. In contrast, the ‘non Western woman’ is represented as oppressed by her culture, other women and tradition, all of which impinge on her sexuality. The comments on this image included:”Indeed, a horrific practice that comes from satan’s kingdom of darkness and needs to end; ” and “In Africa 3000 girls every day!!!”. Thankfully commentators also pointed out the racist and imperial assumptions of this advert. The comments recentre Western feminisms rather than expose the limitations of Western epistemological frameworks for making sense of women’s experiences outside the West. Given my own health background, I’m conscious of the ways in which FGM/C is constructed as a health issue. The image implicitly reifies the superiority of Western medicine for having the values most emblematic of Western civilisation such as enlightenment, benevolence and humanitarianism. We’ll just ignore the collusion of Christian missionary medicine and biomedicine in the advancement of colonialism and imperialism.

One of my intellectual and political concerns is with the ways in which certain practices and subjectivities are privileged through liberal feminist discourses that actually replicate the colonising impacts of heteropatriarchy (even though feminism was developed to critique it). These liberal feminist discourses construct femininity within particular norms such as being liberated that are within normative modes of middle class white behaviour. Racialised “oppressed” women are constituted as a threat to the liberal and neoliberal projects of self regulation and improvement which in turn reinforce the centrality of a white world view

The comments on the second set of images that popped up on my feed were also disturbing, viewing Muslim women as victims of their male partners. The comments framed the woman as unagentic and Muslim males as dominating and unable to control their sexual drives. The inability to recognise sexism and misogyny closer to home in the context of Todd Akin talking about “legitimate rape” were interestingly absent. This ‘fighting sexism with racism’as Sherene Razack (1995) calls it fills me with dismay, especially when differences are framed as a civilisational clash between western liberal values of equality and individualism versus the patriarchal, hierarchical and communal values of the ‘other’.

As Arundhati Roy articulates in a pointed essay:

Western-liberal feminism (by virtue of its being the most funded brand) [has become], the standard-bearer of what constitutes feminism. The battles as usual, have been played out on women’s bodies, extruding Botox at one end and Burkhas at the other. (And then there are those who suffer the double-whammy, Botox and the Burkha.) When, as happened recently in France, an attempt is made to coerce women out of the burkha rather than creating a situation in which a woman can choose what she wishes to do, it’s not about liberating her, but about unclothing her. It becomes an act of humiliation and cultural imperialism. Coercing a woman out of her burkha is as bad as coercing her into one. It’s not about the burkha. It’s about the coercion. Viewing gender in this way, shorn of social, political and economic context, makes it an issue of identity, a battle of props and costumes. It’s what allowed the US Government to use western feminist liberal groups as moral cover when it invaded Afghanistan in 2001. Afghan women were (and are) in terrible trouble under the Taliban. But dropping daisy-cutters on them was not going to solve the problem.

These coercive aspects reeking of cultural imperialism and humiliation have been close to home this week in Aotearoa with the furore over the decision by Lower Hutt’s Dowse Art Museum to ban men from seeing a video work by Qatari-American Sophia Al-Maria. The video Cinderazahd: For your eyes only was filmed in a woman only section of her grandmother’s home in Doha and shows Muslim women preparing for a relative’s wedding without their veils. Al-Maria requested that it only be shown to women and children in keeping with the belief that male strangers should not see their faces. However, this ban on mail viewers has resulted in complaints of gender discrimination to the Human Rights Commission.

The Dominion Post argues:

The real issue is that the Dowse is a ratepayer-funded organisation. As such, it should not be using the public purse to stage exhibits from which some ratepayers are excluded. The sum involved in this case – $6000 for the complete exhibition of 17 artists – is small, but the principle is important.

Clearly, the conflict between Al-Maria offering a work that can be seen only by women and the gallery’s duty to ensure equal access to all those who contribute towards funding it cannot be reconciled. That being the case, the Dowse should withdraw the video from the exhibition and Al-Maria should find a private gallery in which to show it.

Luckily there’s been some great responses from the blogosphere. Especially from QOT who says:

There’s a lot of argument going down around the fact that the Dowse is publicly-funded, is this discrimination, do we owe it to the poor oppressed brown women to tear away their autonomy because they’re too stupid to know they’re oppressed … yeah, guess where I fall on that one.

QOT checks our Human Rights legislation and notes that it is not unlawful to discriminate on the ground of religious belief (within particular circumstances). QOT acidly remarks that this legislation is what enables Catholics to ban women from the priesthood, but who’s complaining? If the primary complainant was a male student taking a third-year compulsory Art History paper where half the final exam marks were based on the film this would then disadvantage the males in the class. But is not being able to see that exhibit going to disadvantage the complainant really? Wise words also from Gaayathri, pointing out how important it is for those who are marginalised to be able to create and have access to safe spaces. Gaayathri cynically notes how the incident smacks of using Islamic women’s rights as a political football and if we indeed gave a damn then listening to their wishes would be a great start, and even better respecting the boundaries that have been set for the viewing of the work.

Contemporary racism is covert and subtle, a response to the social taboo against the open expression of racist sentiments. It is also more likely to be denied by majority group members.What I find most interesting about the Dowse drama is how the parameters of cultural consumption can only be set by the dominant culture. Whether it’s invoking the white saviour discourse or railing against so-called Islamic oppression, it’s the dominant white settler culture who decides how much culture is palatable and in what form. Setting boundaries results in the range of devastating comments that you can see on the interweb and it shows me that the veneer of civility is wafer thin. Kiwis can indeed hold negative views of particular groups in tandem with liberal principles of equality, tolerance, fairness and justice and just as quickly invoke these liberal values of fairness and equity in the service of  Islamophobia and racism. Our attitudes and beliefs in New Zealand haven’t been tested in the same way Australians have. They are forever in the spotlight about asylum seekers, but what it does make me think is that we should not be too complacent in New Zealand about the moral high ground. In all of this, what I am most grateful for is that like KONY 2012, these frustrating and painful incidents provide an opportunity to consider more deeply questions of freedom and liberation and more importantly to find out who our allies are.