Inequalities – Page 4 – ruthdesouza-dreamhosters

Faith, Feminism, Inequalities, Islamophobia, language, Media, Mental health, Migration, Multiculturalism, Racism, Refugees, Women, Writing

Refugee women in New Zealand: Findings and recommendations

Today on International Women’s Day, it seems apt to share this article that I wrote on behalf of our research team for the Women’s Health Action Update, volume 16, Number 43, December 2012. Women’s Health Action is a charitable trust, that works to “provide women with high quality information and education services to enable them to maintain their health and make informed choices about their health care”. Their focus is on health promotion and disease prevention and they are particularly supportive of breastfeeding and screening. Their vision is ‘Well women empowered in a healthy world’.

More than 80 per cent of the world’s refugees are women and their dependent children. Often women of refugee backgrounds [1]are constructed within deficit frames as having high needs. This representation is problematic as it deflects attention from considering broader historical, social, systemic and political factors and the adequacy of resettlement support.

Little is known about the experiences of women who enter New Zealand through the Women at Risk category identified by The Office of the United Nations High Commissioner for Refugees (UNHCR). This category constitutes up to 75 places (10%) of New Zealand’s annual refugee quota of 750. Refugee Services worked with AUT University and the three Strengthening Refugee Voices Groups in Auckland, Wellington and Christchurch to undertake a project to examine the resettlement experiences of women who enter New Zealand through this category or become sole heads of households as a consequence of their resettlement experiences. This project was funded by the Lotteries Community Sector Research Fund.

The project was important not only for its findings but also for the research process, which focused on strengths, social justice, community development and transformative research. This transformative agenda aimed to enhance the wellbeing of refugee background women by focussing on the roots of inequality in the structures and processes of society rather than in personal or community pathology (Ledwith, 2011). Within this frame we were committed to constructing refugee women as an asset rather than deploying a deficit model of refugee women as a burden for the receiving society (Butler, 2005).

Focus groups were held in 2009 and 2010 with women who entered New Zealand as refugees under the formal category ‘Women at Risk’ or became women who were sole heads of households once they arrived in New Zealand. Women that took part had lived in New Zealand from between five months to sixteen years. Lengthy consultations were held with the three Strengthening Refugee Voices groups in Auckland, Wellington and Christchurch prior to undertaking data collection, in order to scope and refine the research focus and process. These groups were subsequently contracted to provide services and support.

Key findings

Although support needs are similar to all refugees arriving in New Zealand, there were unique and exacerbated gender issues. Refugee background women experienced a double burden of stress with half the support, especially as they parented on their own. This is despite the tremendous unpaid and voluntary support provided by faith and ethnic community members. Women frequently postponed their own aspirations in order to assure the future of their children. When they were ready to take up further education (including English language classes) or employment, limited assistance was then available (given the focus on early resettlement) leading to women feel disadvantaged.

We have made several recommendations based around several specific themes. More broadly we recommended that:

More intensive and longer term instititutional support be made available from agencies such as Refugee Services.
Subsidised practical help be made available.
Assistance to broaden sources of support and networks is goven.
Subsidised English language lessons and childcare are available.
That a one stop shop/holistic support from culturally and linguistically skilled refugee community insiders be provided.

Parenting

Raising children in New Zealand brought new stresses. These included concern about the loss of culture, values and language and losing their children to less palatable values including the consumption of alcohol and drugs, gender mixing and loss of respect for elders. Women addressed these issues in a range of ways that included trying different less hierarchical styles of parenting, attempting to spend more time with their children, engaging them in broader supports eg mosque. However, a few women had the experience of losing their children through the intervention of CYFS and felt disempowered in their interactions with CYFS and with schools.

Programme for parenting for Refugee women, particularly around issues such as discipline, inter-generational gender issues
Programmes for young people.
Cultural competence training for CYFS.

Family reunification

Living in New Zealand is difficult for women who are conscious of their own comfort while other family members struggle. However, the cost of bringing family members over is prohibitive and the costs involved in providing support in the form of phone calls and remittances add a burden to already stretched lives of the women. The importance of extended family is highlighted for women on their own and the kinds of help that could be provided by family members. Additional stresses are the requirement that refugee women are able to support their families once they arrive in New Zealand. The process is also made difficult by the lack of transparency in the immigration process.

Prioritise the reunification with family for women who are here on their own.
Provide financial support to women.
Increase transparency of the processes and decisions that are made.

Health system

Women encountered a different health system that at times was difficult to navigate. Many women felt that their health concerns were not taken seriously and that the health system created new problems. In terms of some health beliefs and stigma there was value in having more culturally appropriate services available. The surfeit of refugee background health professionals was a potential resource that was not being used.

Train and employ a more ethnically, religiously, and linguistically diverse health workforce at all levels
Develop culturally responsive services.
Examine the affordability of services.
Develop cultural competence of staff working in health services.

Education

The cost and availability of day care for Refugee women on their own is prohibitive in some cases consuming the lion’s share of their income/benefit. Taking up loans in order to finance their own educations is also a problem. This prevents women from achieving their own goals such as learning English, driving or further education, which would assist them in the long term with employment and independence. Women generally considered their own advancement as secondary to their children. If women were resourced financially to gain an education this would assist them to also be a resource for their children. Having long-term support to enter the workforce would also be of benefit.

Subsidised day care for women on their own.
Mentoring.
Scholarships for further education.

Employment

Women were concerned that their children were not getting employed despite tertiary qualifications. Barriers to employment included: ‘lack’ of New Zealand experience, language barriers, their perceived difference (clothing, culture, skin colour) and paucity of appropriate childcare, poor public transport. The impacts of unemployment included losing their dignity, health impacts of taking inappropriate jobs, boredom

Subsidised driving lessons, support with transport
More work with employers to destigmatise refugee workers
Work mentoring/brokering services
Support for family members who come into New Zealand through the reunification category to obtain further education

Racism

Refugee women and their families experienced a range of racism related harms that were instititutional and interpersonal taking physical and verbal forms. Their clothes and accent marked them out, and verbal altercations saw stereotypes being invoked particularly around Islamophobia and discourses of war on terror. Women deployed a range of strategies to cope with racism including minimising the racism and helping their children to cope with it.

Social marketing campaigns
Community education
Addressing structural racism
National conversation on racism
National campaign against racism

The research team hope that this research provides a snapshot of the role and value of various sectors in enabling or constraining the resettlement of refugee background women. This could contribute to better informing theory, practice and policy in order that the self-determination and resilience of refugee background women and their communities is supported.

[1] Note that terms like ‘refugee background women’ and ‘communities’ refer to highly diverse groups of people (Butler, 2005). In capturing the experiences of refugee women as sole heads of households, we were mindful of the potential that using a category could imply a “single, essential, transhistorical refugee condition” (Malkki, 1995, p.511).

March 8, 2013/by ruth

Australia, Colonialism, Food, Indigenous, Inequalities, language, Media, Migration, Multiculturalism, Racism, Refugees, Writing

Unsettled in Australia: Reflections on my first Australia/Straya/Invasion day

My first stuffed toy as a child in Nairobi was a koala bear and I’ve been besotted with them ever since. So you can imagine that I was captivated by this meme where the koala realises that she’s not a bear but a marsupial. To draw a very long bow, I think her puzzlement captures the experience of so many visibly different migrants in settler societies who believe they are part of a nation and then find that they aren’t, whether it’s because their qualifications aren’t recognised which leads them to be unemployed or under-employed or they begin to realise that their skin colour doesn’t lend them to being neatly absorbed into the imagined community on national days of celebration. So here I am in Australia, not as a nine year old (when my family were looking to migrate from Nairobi) but as an adult in mid-career, here to live and work. Joining a multitude of other New Zealanders (the most common country of birth of Australian residents outside of Australia is the United Kingdom followed by New Zealand, you’ll find other interesting nuggets on cultural diversity on Esther Hougenhout‘s blogpiece) who’ve also crossed the ditch. I’ve visited Australia for conferences and to visit my partner’s family, but it’s been over twenty years since I lived somewhere other than Aotearoa. In my work and community life I’ve carefully considered how migrants engage with settler institutions and their relationships with indigenous communities, but I am having a powerful opportunity to examine my own complicity in forms of oppression (in the context of another settler society) as Harsha Walia so powerfully puts it in a video on anti-oppression, decolonization, and being a responsible ally.

From news.com.au

Courtesy of Brisbane Murri Action Group

We’ve arrived in time for Australia day which commemorates the 225th anniversary of the arrival of the First Fleet in Sydney Cove, New South Wales in 1788, when British sovereignty was also proclaimed over the eastern seaboard of Australia. It’s a day of festivals, concerts, citizenship ceremonies and acknowledgements of the contributions Australians have made with the recipients of honours and Australian of the year announced. Entrepreneur and electrical retailer Dick Smith even got into the jingoistic spirit with his casually racist advertisement for Aussie foodstuffs, beautifully critiqued by Sunili. I’m not sure if the stones that hit both our heads as we were walking along the Nepean highway to look at housing options were an important Australia day cultural tradition for young blokes in fast cars (I’d like to know how their aim was so brilliantly accurate). Nevertheless fervent nationalism is everywhere, cars and houses are adorned with Australian flags and there is an exacerbation in bogan behaviour as comedians Aamer Rahman from Fear of a Brown Planet and Robert Foster/Kenneth Oathcarn observe.

S Peter Davis who made a YouTube video Straya Day, notes that

as January 26 rolls around, you begin to see cars on the road with little Australian flags poking out the windows like a diplomatic cavalcade. In what is usually a pretty tolerant and multicultural nation, this is one day of the year when folks start casting suspicious and slightly disapproving glances toward brown people. Anti-immigrant slogans like “We grew here, you flew here,” and the somewhat more direct “Fuck off we’re full” begin to make the rounds. Understand, it’s the minority of people, and Australia does not hold the patent on racism. But when you combine this with a cocktail of youth, alcohol and barbecue…parts of the country just explode in a shower of beer, singlets and thongs.

Or not as the pictures below reveal.

Via Chalk Hotel’s Facebook page

This day of barbecues and beer is also called Invasion or Survival day. It represents “an undercurrent of division and inequality that belies the happy, egalitarian culture that the day is meant to convey, “a day of mourning for the land that was taken and the ensuing two centuries of social alienation and discrimination” as Robin Tennant-Wood puts it. There are also Survival Day celebrations like the 2013 Share The Spirit Festival featuring Indigenous music, dance and culture. Numerous Invasion day marches have also taken place across Australia.

Via Idle No More Facebook page

Hip hop artists Reverse Polarities recent release “Invasion Day” acknowledges the historical and continuing injustices faced by Indigenous Australians and pushes for Australians to understand their history rather than being immobilised by guilt (white Australians) or innocence (visibly different new Australians):

Many Australians feel guilt for the actions their white predesessors and claim non- involvement due to being new Australians. We must be active in our understanding of history. The past is not ours to change, but the future can be shaped.

Via Idle No More Australia’s Facebook page

Peter Gebhardt a poet, retired County Court judge and former principal asks for accountability and reckoning with the history of genocide “What might an Aboriginal person say of Australia Day? Why should the Aborigines celebrate that day?” He adds:

It was the day that marked the theft of a land (terra nullius), the day that marked the theft and abduction of a people, of a culture, the day that initiated the pathways to the Stolen Children and, to our ultimate shame, the deaths in custody. It is a day that stands as a reminder of massacres. The wind-stench of bodies burned in bonfires hangs heavy upon the nation’s conscience and in the clouds…You can shuttle history, but you cannot shuttle facts. It would be a great Australia Day if it faced honesty, historical facts, abandonment, hypocrisy, shelved superiority and embarked upon an exercise of spiritual empathy rather than religious hubris.

A point supported by Tristan Ewins, who calls for celebration and critique of this national day:

There is a problem, here, in that there is still no formal resolution: comprehensively righting the injustices suffered by indigenous people. Without the closure provided by a just, representative and inclusive Treaty between the modern Australian nation and our indigenous peoples, it is hard to imagine a fully inclusive celebration of the Australian nation. Perhaps in the future – should such a resolution be achieved – then maybe this could become the focus of a new ‘national day’ for all Australians.

The desire for redress and accountability has a long way to go to being realised, but small steps toward reconciliation are evident. This year for the first time both the Aboriginal and Australian flags were simultaneously hoisted on the Sydney Harbour Bridge.

Picture: Sam Ruttyn Source: News Limited via new.com.au

Apparently, more than 17,000 people from 145 countries took the citizenship pledge to become Australians on January 26th. Without any sense of irony whatsoever, Tony Abbott Leader of the Opposition told an Australia Day breakfast and citizenship ceremony in Adelaide that change should be welcomed “when it’s in accordance with the customs and traditions of our people” and he added that new citizens were “changing the country for the better”.

Being a new arrival in Australia myself has been interesting, there are many similarities with New Zealand. The neoliberal multicultural success stories of refugees and migrants loom large both in media and in private conversations. Take Akram Azimi, Young Australian of the Year 2013 who arrived in Australia 13 years ago from Afghanistan and went from being ‘an ostracised refugee kid with no prospects’ to becoming his school’s head boy. Or diasporic Maori, Frank (name changed) who repeatedly called himself and other Maori “niggers”in front of his car salesman colleagues. He told me that his wife wanted to return home six months into their stint here and he insisted they “tough it out”, he quipped “things are fine if you just work hard”. He’s taught his children important aspects of Te Ao Maori and has disdain for the various groups that have formed stating that “if you want to learn about your culture you should go home to do it”. Rauf Soulio (chair of the Australian Multicultural Council and a judge of the District Court of South Australia) peppers an opinion piece with words and phrases like “enterprise”, “courage and commitment” and talks about people who “strove to build new and prosperous lives”. Extolling a neoliberal narrative combined with a commitment to reconciliation:

It is one of the hallmarks of our multiculturalism that we work hard to ensure that those who come here have every opportunity to become fully participating members of Australian society, rather than remaining guests or temporary visitors. It doesn’t matter that you don’t have Australian lineage or ancestry when you arrive – as long as you contribute.

Illustration: Ben Sanders/The Jacky Winter Group in the Sydney Morning Herald

Yup, I’m here to work and become a “fully participating member” of Australian society, and to that end have also been consuming multiculturalism with relish and delight. I am blissfully happy at being able to access ingredients and cuisines that are difficult to find in Aotearoa. But consumption aside, I do want to find a way to engage ethically with this place. Shakira Hussein‘s incisive critique of Scott Morrison’s speech at the Menzies Centre for Australian Studies in London brilliantly skewers Morrison’s selective consumption of multiculturalism:

Morrison doesn’t spell out which aspects of “diversity” would be considered acceptable under a more balanced post-multicultural regime, but I’m guessing he subscribes to the consensus view that multiculturalism has had a beneficial effect on the Australian diet. (Sharia tribunals? No thanks. Homous and baklava? More, please.) Even those most ardent racists participate in the multiculturalism of consumption. But while enjoying our pizza and laksa, we need to “send a message” that such tolerance “is not a licence for cultural practices that are offensive to the cultural values and laws of Australia and that our respect for diversity does not licence: the primacy of the English language”.

His comments come just in time for Geert Wilder’s visit to Australia next month. See Deborah Kelly’s kit below.

I was in Sydney almost seven months ago when I caught up with a friend of the family who asked me why I hate white people. I had to explain to him that my work is about critiquing white hegemony and that is a different thing. Critiquing hegemony and racism and advocating for indigenous rights is viewed decidedly un-Australian, as effectively parodied by Don Watson:

We’re pragmatists. It comes with being Australian that we don’t upset ourselves about things of no practical consequence. Of course, for some people the wine’s always corked. You’ll hear them from Ballarat to Bali, running the country down. Fair dinkum, you want to deck the bastards sometimes. But, as I said, we don’t upset ourselves. Poor things, they can’t think of the foundation of the country without thinking of the people it was taken from. They can’t think of dear old decent Arthur Phillip without thinking of the time he sent out men with bags to collect half a dozen Aboriginal heads. Nothing in the manifold benefits of British rule, British institutions, British customs and British capital cheers them up or excites a little gratitude.

Remind them of the nation’s progress, show them how human health and happiness have in general flourished here, and in return you’ll get the vale of tears it has been for the Aborigines, or the grave injustices to women, or the treatment of refugees arriving on boats: as if because some people got the rough end of the pineapple we are all supposed to be abraded by it.

Michel Foucault the French philosopher said that the point of “a critique is not a matter of saying that things are not right as they are. It is a matter of pointing out on what kinds of assumptions, what kinds of familiar, unchallenged, unconsidered modes of thought the practices we accept rest”. For me, as an academic with a commitment to social justice, blindly supporting the status quo is not an option. I know that I have a long journey of learning and unlearning ahead of me, without the reassurance of state sanctioned biculturalism or a biculturalism grounded in treasured processes and relationships in Aotearoa that have inflected my adult life. But this grounding from the place I’ve called home for most of my life will be fundamental to examining my complicity in the maintenance of oppression, my understanding of the multicultural project and to forging my own rather than received understandings of indigineity here in Australia. Luckily there are many who’ve already walked this path. Between their wisdom and those of my global intellectual and political community I think I am koalified to undertake this next adventure.

Via Colourfest film festival

January 28, 2013/by ruth

Colonialism, Indigenous, Inequalities, Migration, Multiculturalism, Power relations, Te Tiriti o Waitangi/Treaty of Waitangi, Women, Writing

Migrant support for Idle No More

When my parents were considering migrating from East Africa, their focus was on the white settler contexts of Australia, New Zealand, Canada and the United States. For a bunch of reasons I won’t go into here, they settled on Aotearoa New Zealand. A part of me always felt like my life would have been better if we’d moved to Canada or the United States, because there would have been a bigger Goan community and more support for my family. I reasoned I might have felt more culturally confident, more capable at speaking Konkani. My visit to Canada in October helped me accept the gift that my parents had given me in migrating to Aotearoa New Zealand. By not being wrapped in the comforting cocoon of an insular diasporic community, I had to figure out my own relationship with my personal and cultural history but also what Ghassan Hage terms, an ethical relationship with colonisation and living on colonised land. Visiting Canada and meeting terrific indigenous people and migrant scholars allowed me to see the contrast between Canada’s genocidal history and its self-representation as a benign, civilised and benevolent nation. The parallels between Aotearoa and Canada of a colonial history supplemented by exploited migrant labour to meet settler ends mirrored the clearly unfair outcomes in measures of health, well-being and prosperity for indigenous peoples that I see in Aotearoa New Zealand as a health professional. For the first time I began to see how the issues I’d been grappling with as a migrant were replicated across seemingly disparate white settler contexts.

Image courtesy: Aaron Paquette

The Idle No More movement which began on Great Turtle Island on December 10, 2012 was initiated by four women Nina Wilson, Sylvia McAdam, Jessica Gordon & Sheelah McLean in response to legislation (Bill C-45) affecting First Nations people and gained momentum with the hunger strike by Attawapiskat First Nation Chief Theresa Spence. Impressively the United Church of Canada has acknowledged it’s complicity in colonization, inequality and abuse, through being one of the bodies that ran Indian Residential Schools. In 1986 they apologized to Aboriginal peoples for confusing “Western ways and culture with the depth and breadth and length and height of the gospel of Christ.” Apologizing to former residential schools students in 1998. Their response to the Idle No More movement has been to fully support Chief Spence’s statement that “Canada is violating the right of Aboriginal peoples to be self-determining and continues to ignore (their) constitutionally protected Aboriginal and treaty rights in their lands, waters, and resources.”

Other activists have also taken note of the commonalities of the struggle, noting how how what is particular, has universal relevance. Naomi Klein notes that

During this season of light and magic, something truly magical is spreading. There are round dances by the dollar stores. There are drums drowning out muzak in shopping malls. There are eagle feathers upstaging the fake Santas. The people whose land our founders stole and whose culture they tried to stamp out are rising up, hungry for justice. Canada’s roots are showing. And these roots will make us all stand stronger.

International support has come from the occupied lands of Palestine and indigenous communities around the globe. In Aotearoa New Zealand a Facebook page has been developed called Aotearoa in Support of Idle No More: Maori women’s group Te Wharepora Hou, a collective of wāhine based in Tāmaki Makaurau Auckland with a commitment to ensure a stronger voice for wāhine have also pledged support. As a migrant occupying a disquieting position in a country working through issues of biculturalism and mutliculturalism in a monocultural context. Diasporic migrant communities and organisations have also backed the Idle No More movement, with South Asian activists and BAYAN-Canada, an alliance of progressive Filipino organizations noting the similarities between migrant experiences and indigenous struggles.

Immigrants in Support of Indigenous Rights via Harsha Walia
Photo credit: Cameron Bode

How do we do engage with an indigenous struggle when we do and don’t belong at the same time? Himani Bannerji notes in a Canadian context (but one that readily resonates through various white settler contexts):

So if we problematize the notion of ‘Canada’ through the introjection of the idea of belonging, we are left with the paradox of belonging and non-belonging simultaneously. As a population, we non-whites and women (in particular, non-white women) are living in a specific territory. We are part of its economy, subject to its laws, and members of its civil society. Yet we are not part of its self-definition as ‘Canada’ because we are not ‘Canadians.’ We are pasted over with labels that give us identities that are extraneous to us. And these labels originate in the ideology of the nation, in the Canadian state apparatus, in the media, in the education system, and in the commonsense world of common parlance. We ourselves use them. They are familiar, naturalized names: minorities, immigrants, newcomers, refugees, aliens, illegals, people of color, multicultural communities, and so on. We are sexed into immigrant women, women of color, visible minority women, black/South Asian/Chinese women, ESL (English as a second language) speakers, and many more. The names keep proliferating, as though there were a seething reality, unmanageable and uncontainable in any one name. Concomitant with this mania for naming of ‘others’ is one for the naming of that which is ‘Canadian.’ This ‘Canadian’ core community is defined through the same process that others us. We, with our named and ascribed otherness, face an undifferentiated notion of the ‘Canadian’ as the unwavering beacon of our assimilation.

The experiences of marginalisation that Bannerji elucidates can guide our responses to the Idle No More movement. Gurpreet Singh from Vancouver, notes that South Asian seniors have always referred to the indigenous peoples as Taae Ke (family of elderly uncle). If we see a familiar connection between what we ourselves experience as migrants and extend that empathy to the struggles of indigenous people who have experienced an inter-generational slow genocide, we might be able to see beyond our own oppression and our view that we are too far outside the structures of power to claim a space. Privileged in some ways, disadvantaged in others, our futures are tightly imbricated in this indigenous struggle. Our presence has sometimes diffused indigenous claims and we must consider our complicity in the continuing colonisation of indigenous people. We must put pressure on governments to recognise the rights of indigenous people and their unique place as guardians of the lands we stand upon, our futures depend on it.

At the asset sales March in Auckland in April 2012. Banner by YAFA-Young Asian Feminists Aotearoa. Photo by Sharon Hawke.

December 27, 2012/by ruth

Inequalities, Media, Migration, Refugees, Women, Writing

Refugee women on their own in New Zealand: Uncommon courage

Recently the report “Doing it for ourselves and our children: Refugee women on their own in New Zealand” was launched in Auckland, New Zealand. The project was jointly undertaken by AUT University and Refugee Services New Zealand with the support, guidance and practical assistance of the three Strengthening Refugee Voices groups in Auckland, Wellington and Christchurch. It was an honour for me to write the report.

The purpose of this project was to examine the resettlement experiences of women who entered New Zealand through the category of Women at Risk (identified by the Office of the United Nations High Commissioner for Refugees (UNHCR). This category constitutes up to 75 places (10%) of New Zealand’s annual refugee quota of 750 applicants) or who became sole heads of households as a consequence of their resettlement experiences. The terms ‘refugee women’ and ‘communities’ refer to highly diverse groups of people and in this report we don’t assume a “single, essential, transhistorical refugee condition” (Malkki, 1995, p.511).

A focus on strengths and principles of social justice, community development and capacity building were central to this investigation. Specifically, we had a transformative agenda, which was to enhance the wellbeing of refugee women by focussing on the roots of inequality in the structures and processes of society rather than in personal or community pathology. Within this frame, we were committed to constructing refugee women as assets rather than deploying as replicating deficit models where refugee women are represented as burdens for the receiving society.

You can read the whole report on the Refugee Services website

August 16, 2012/by ruth

Cultural safety, Feminism, Indigenous, Inequalities, Migration, Multiculturalism, Nursing, Power relations, Professional development, Racism, Te Tiriti o Waitangi/Treaty of Waitangi, Women, Writing

Sisters, friends or whānau?

This is a lengthier version of an editorial published in this month’s Kai Tiaki New Zealand Nursing Journal. It is based on an invited address I gave at the 10th Annual Conference of the Women’s Health Section:’Divine Secrets of the Sisterhood’ on April 26th 2012.

I recently spoke at the NZNO Women’s health conference about sisterhood. Not that I don’t care about men (I do deeply), but as one of three sisters and as a woman who has spent most of my adult life working in the female dominated profession of nursing, relationships between women are of great personal and professional interest. The call to action in the women’s movement almost thirty years ago emphasised sisterhood and demanded the end of oppression and the commitment to women as a social group (Klein & Hawthorne, 1994). However, the movement also raised questions of difference. Many suggested that in order to understand what women had in common they also needed to pay attention to what they didn’t have in common such as race, gender and sexuality. Focusing on similarity erased and overlooked important differences, but only focusing on difference led to the “othering” of others, stereotyping and pushing people away.

I believe these questions remain important for nursing, because I think our differences can make nursing stronger. An understanding of our differences can help us to better understand our similarities. As Audre Lorde points out “it is within our differences that we are both most powerful and most vulnerable, and some of the most difficult tasks of our lives are the claiming of differences and learning to use those differences for bridges rather than as barriers between us”. So I believe an important question for nurses is how can we capitalise on the energy and movement in difference and resist the coercive force of sameness?

One of the challenges is that differences raise critical issues of power, because differences are often institutionalised (Crenshaw,1994, p.411). Take the idea of the implicit ideal nurse-typically the ideal nurse is female, white, middle class, heterosexual, able bodied, nice, obedient and nurturing (Giddings, 2005; Reverby, 2001). Those nurses that fit the norm experience privilege and those that don’t are marginalised. Internationally, women of colour are present in practice settings with less prestige, lower wages, less security, and less professional autonomy (Gustafson, 2007). While, a disproportionate number of white men and women are ensconced in nursing management, academia and research, whose world view is supported by the dominance of white, Western, biomedical interpretations of health and illness. Grada Kilomba defines whiteness as “a political definition, which represents historical, political and social privileges of a certain group that has access to dominant structures and institutions of society”. As Ang-Lygate (1997, p,2) points out “political sisterhood is suspect unless those sisters who enjoy privileges denied to other sisters are seen to share the responsibility of dismantling the differences”.

This dominance of whiteness in our workforce and our ideas about health and illness are present in nursing in New Zealand too. We are undergoing a period of unprecedented diversity. Transitioning from largely New Zealand-born European to being increasingly ethnically diverse, our dependence on overseas-born migrant nurses is evident in their composition of 29% of the workforce- one of the highest proportions in the OECD. At the same time Māori and Pacific Islands nurses are under-represented in our workforce while these communities experience the greatest health need. This inequity is challenging and as Margaret Southwick notes provides “justification (if one be needed) for the claim that nursing needs to take seriously the challenge of working with diverse and marginalised groups within society is to be found in the health status of these very same groups of people.” (Southwick, 2001).

So given the diversities in nursing and the health inequities that confront our communities, new strategies are necessary. I’m proposing moving away from sisterhood which implies the shared experience of being a woman and experiencing gender oppression to consider a new metaphor that allows greater consideration of our differences so that we can better articulate our similarities (Simmonds, 1997). There’s friendship for a start, a relationship based on equals who have affection, and interest in each other (Friedman, 1993, p.189). Its etymology is in the word free. It means to love, to love our own freedom, and to love and encourage the freedom of the other (Mary Daly, 1987). Friendship allows us to work in each other’s interests because part of what is compelling is our differences.

The notion of friendship as an alliance within the context of difference can be seen in this brilliant blog post entitled Queer Sisters Keep Saving Me: The Brilliantly Selfish Act of Being an Ally by Black Artemis

Heterosexual people especially women owe a tremendous debt to the LGBTQ struggle for some of the sexual freedoms we enjoy…the boundaries queer people bend and bust at the risk of their own lives in many ways expand our heteronormative privilege. Their radical decision to be simply who they are makes it much safer for the rest of us to redefine who we may want to be. We have a broader range of acceptable sexual expression because of the queer liberation movement for every time they push the envelope, they set a new “normal,” and it’s not even they who benefit the most for their courage. Rather it is those of us whose sexual identity is already validated.

If we are going to use the metaphor of sisterhood we consider the idea of a “chosen family” used by LGBTQ communities or the Māori concept of whānau. It too is based on love rather than biology and includes people as who are a source of love and support outside the heteronormative idea of family.

I’d like us to strengthen nursing by strengthening ourselves, for creating space for all nurses to be able to come together with our diverse traditions and values, to be united based on solidarity not sameness. I’d like us to be able to articulate our shared beliefs and practices while acknowledging how we differ.

I’m proud to be a nurse in New Zealand, I value the shared commitment to caring and to social justice in the shape of cultural safety. I’d like to build on our legacy and see nurses critically examine the values, goals, and intents shaping our profession. I’d like us to have some challenging conversations about power and privilege, to deconstruct our own classism, racism, and homophobia and to think about recognition and reparation. I leave my final words to Audre Lorde:

So this is a call for each of you to remember herself and himself, to reach for new definitions of that self, and to live intensely. To not settle for the safety of pretended sameness and the false security that sameness seems to offer. To feel the consequences of who you wish to be, lest you bring nothing of lasting worth because you have withheld some piece of the essential, which is you.

References

ANG-LYGATE, M., CORRIN, C. & HENRY, M. S. 1997. Desperately seeking sisterhood: Still challenging and building, London, Taylor and Francis.

CRENSHAW, K. 1994. Mapping the margins: Intersectionality, identity politics, and violence against women of color. In: FINEMAN, M. A. & MYKITIUK, R. (eds.) The public nature of private violence. New York: Routledge.

DALY, M. (1978) Gyn/Ecology: The Metaethics of Radical Feminism, Boston: Beacon.

FRIEDMAN, M. 1993. What are friends for?: feminist perspectives on personal relationships and moral theory, New York: Cornell University Press.

GIDDINGS, L. S. 2005. Health disparities, social injustice, and the culture of nursing. Nursing Research, 54, 304.

GUSTAFSON, D. L. 2007. White on whiteness: Becoming radicalized about race. Nursing Inquiry, 14, 153-161.

HAWTHORNE, S. & KLEIN, R. 1994. Australia for Women: travel and culture, New York, Spinifex Press.

LORDE, A. 2009. Difference and Survival: An Address to Hunter College” Rudolph, New York:, Oxford University Press.

REVERBY, S. 2001. A caring dilemma: Womanhood and nursing in historical perspective. In: HEIN, E. C. (ed.) Nursing issues in the twenty-first century: Perspectives from the literature. Philadelphia: Lippincott, Williams and Wilkins.

SIMMONDS, F. N. 1997. Who Are the Sisters? Difference, Feminism, and Friendship. 19-30. In ANG-LYGATE, M., CORRIN, C. & HENRY, M. S. 1997. Desperately seeking sisterhood: Still challenging and building, London, Taylor and Francis.

SIMMONDS, F. N. 1997. Who Are the Sisters? Difference, Feminism, and Friendship. Desperately Seeking Sisterhood: Still challenging and building, 19-30.

SOUTHWICK, M. R. 2001. Pacific women’s stories of becoming a nurse in New Zealand: A radical hermeneutic reconstruction of marginality. Unpublished Doctoral thesis, Wellington: Victoria University of Wellington.

August 2, 2012/by ruth

Africa, Colonialism, Goa, Indians, Inequalities, Migration, Multiculturalism, Power relations, Racism

A level playing field? Sport and racism

At the weekend it was my parents’ wedding anniversary. They got married in Dar es Salaam and one of the distinguishing features of their wedding was the hockey stick “guard of honour” that their friends created for them outside the church after the service (my Mum played hockey for Tanzania). The family capability and Goan cultural propensity to excel at sport (take Seraphino Antao the first Kenyan athlete to win a gold medal at the 1962 Commonwealth Games) skipped right past me. Mostly I enjoy the social, political and cultural issues in relation to sport like the national anthems, the medals and the underdog winning. The recent completion of a PhD (yes really) has also given me some confidence and time to begin to explore questions like the neocolonial exploitation of African players by European football clubs and how raw materials in the form of players are sourced, refined and exported for consumption and wealth generation in Europe leaving the African periphery impoverished. But that’s another blogpost. This post is about racism and sport, but I needed to do a geneaological manouevre and trace my own relationship with sport through my experience of being a Goan via East Africa now resident in Aotearo New Zealand. I’ve mapped some of the ways in which sport has been mobilised such as the re-shaping of personhood for colonised peoples and in turn the ways in which western sport has been appropriated by diasporic and marginalised communities as a form of resistance. I then talk about the prevalence of racism in sport, the contributing factors and what can be done.

Photo of Goans in Dar es Salaam via Jo Birkmeyer-submitted to Mervyn A Lobo’s blog

The establishment of sport in colonial contexts was linked with Western Christian church activity and colonialism. Sports were introduced to meet both the needs of churches and colonial governments in transforming bodies into desirable shapes and capabilities so imperial reform could be undertaken by locals thereby creating physical and moral reform against existing less palatable indigenous norms. Games like cricket and football were intended to reinforce the superiority of colonial culture and transmit a particular moral order and values that were seen lacking in the colonised group such as team spirit, commitment, the sacrifice of individual aspirations to the group, bravery and so forth. Particular versions of masculinity were also being promulgated in a context where many Asian men were seen as effeminate.

In the diaspora, Goans formed clubs and institutions replicating village ties and loyalties back home which helped to allay loneliness, cultural alienation and the challenges of navigating a new country. In 1921 it was estimated that almost half a million Goans lived in Goa, Dama and Diu and that up to 200,000 Goans lived in British India, East Africa or Mesopotamia (James Mills, 2002). One quarter of that number lived in Bombay. Expatriate sports confirmed ties with the homeland, created a sense of community and provided an oasis from the demands of navigating belonging in racially stratified communities. Every Saturday after mass at the Holy Family Cathedral in Nairobi my parents would make their way with us to the Railway Goan Institute founded in 1909 which later became the Railway Institute in 1967. I have great memories of hurtling around (we seemed to do a lot of running along those wooden floors) and being spoiled rotten by my parent’s friends who would provide us with bottomless supplies of coke and crisps. Goans in Kenya also formed other clubs like The Goan Institute Mombasa in 1901, Goan Institute Nairobi in 1905 and the Goan Gymkhana in 1936 with sports an important focus of diasporic life.

Closer to where I live now in New Zealand, Indians in Wellington formed their own hockey team in 1936, which also marked the year that the Auckland Indian Sports Club (AISC) was established.

Photo reproduced with permission from Te Ara. Original article: Nancy Swarbrick. ‘Indians’, Te Ara – the Encyclopedia of New Zealand, updated 1-Sep-11
URL: http://www.TeAra.govt.nz/en/indians/5/5

Many other communities also made sport a focus of their activities, for example the New Zealand Chinese Association Annual Sports Tournament (AKA Easter Tournament) started in 1947 and runs every Easter Weekend. It consists of a sports tournament and cultural event for Chinese members and competitive sports like basketball, volley ball, touch rugby, netball, lawn bowls and golf are enjoyed. Similarly pan-ethnic events like the Ethnic Soccer Cup at the Auckland International Cultural festival are eagerly awaited and full of good natured fun and tough competition.

Photo by the Localist

Sport seemingly offers a transcendent space, where cohesion and connection is possible not only within and across diasporic communities, but also across dominant and minority communities. A phrase bandied around frequently last year was the way in which hosting the Rugby World cup in New Zealand “brought us together as a nation”. Who of us will ever forget the ferocious and irrepressible passion of the Tongan community in New Zealand supporting their team? I love the ideal that sport can be a place where people with diverse interests, histories and values can be unified in one setting. I’ve watched with growing feelings of warmth the ways in which our Pacific players have infused “the game” of rugby with flair and energy and increased the ratio of tattoos, dreadlocks and eye-liner.

This illusion that sport can be a connecting force is challenged in Sara Ahmed‘s critique of the “happy” multicultural film Bend it Like Beckham. Directed by Kenyan-born, Punjabi British filmmaker Gurinder Chadha, Ahmed suggests that the central message of the film is that “the would-be- citizen who embraces the national game is rewarded with happiness”. The feel good vibe of this film ignores the negative affects surrounding racism and unproblematically represents visibly different migrants as patriarchal, closed, traditional, fixed and unchanging. White people can be inspired and warmed by Jess’ migrant success, as she bends the ball (a metaphor for disrupting cultural barriers) without needing to feel guilty about racism. The film plays into the notion that success is the reward for integration and is also proof that racism can be overcome.

My fantasy that the arrival of the first Asian All Black will give Asians more street cred and admiration has taken a battering with the racist responses to the “Linsanity” phenomenon. Jeremy Lin, the Asian American son of Taiwanese immigrants and graduate of Harvard has experienced spectacular NBA basketball success but the headline “Chink in the Armor,” or the tweet by Jason Whitlock referring to “two inches of pain” have deeply hurt many Asian Americans. Understandable, given the limited representation of Asian Americans in mainstream media and because the blatant racism provided a barometer reading of how this group are viewed in a racially charged landscape. But as Long, Tongue, Spracklen and others have noted, we live in a racist society so why should there not be racism in sport? Racist taunts and chants at matches and the throwing of banana skins at players have been supplemented by attacks via social media adding a new viciousness. A Welsh student was recently been imprisoned for using twitter to spread racist rants about acritically ill footballer Fabrice Muamba and locally, unhappy fans took to twitter to racially denigrate Blues coach Pat Lam.

Sport media coverage contributes to inequity by not reflecting social and cultural diversity. The MARS – Media against racism in sport programme– developed by The Council of Europe and the European Union recognises the following inequalities in representation in sports news stories:

Gender under-representation -where women comprise only one quarter of all stories despite making up half the population.
Migrants making up around 10% of the EU population but representing less than 5% of the main actors in the news in Europe.
Lesbian, Gay, Bisexual and Transgender (LGBT) people representing roughly 6% of the population of the United Kingdom but accounting for less than 1% of the population seen on TV.
20% of the British population has an impairment or disability but less than 1% are represented on British TV.

These inequalities in sports media coverage reflect broader societal inequalities. The New Zealand Human Rights Commission’s annual review of race relations Tūi Tūi Tuituiā, Race Relations in 2011 released in March 2012 noted a “continuing degree of racial prejudice, significant racial inequalities, and the exclusion of minorities from full participation in all aspects of society”. The Commission identified racial prejudice in the form of: “negative attitudes to the Treaty, to indigenous rights, to Māori, Pacific peoples, Asians, migrants and refugees”. The report noted that these prejudices were implicated in discrimination, marginalisation, and inequalities, ultimately proving a barrier to the realisation of the social and economic benefits of diversity.

The racist soup of Pakeha media culture not only excludes particular groups but it also reproduces pathological, deficient and destructive representations of groups that are already discrimiinated against and marginalised. Take the “common sense” racism of Paul Henry, Michael Laws and Paul Holmes who all compete for New Zealand’s top racist.Take the comments by the former All Black and World cup Rugby Ambassador Andy Haden, who referred to a “three darkies”selection policy by rugby franchise The Crusaders. When Haden made an apology it was “to anyone who was offended” by the comments. He received a smack on the hand with a wet hanky from our Prime Minister John Key despite the outrage and I don’t think he had to resign. Key defended Haden’s actions as having a precedent in Paul Holmes‘ “cheeky darkie” comments in 2003. The gutless and useless Broadcasting Standards Authority refused to uphold 10 complaints over the comments on Radio station Newstalk ZB. They acknowledged that the comments went beyond the limits of acceptability and breached broadcast standards, but they were happy that the actions taken internally by broadcaster were adequate. Thank goodness for writers with a conscience like Tapu Misa who is my only reason for continuing to purchase the morning newspaper and the long missed Karlo Mila from the Dom Post who can still remind us through her poetry that words scar.

Poster by Dudley Benson (2012)

Where there is power, there is resistance (Thanks Foucault). Racism (and anti-Semitism) in sport have also provided a space for protest and resistance. American sprinters Sam Stoller and Marty Glickman who were the only two Jews on the USA Olympic team, were pulled from their relay team on the day of the competition in the 1936 Berlin Olympics,. There was speculation that the American Olympic committee did not want two Jews to win gold medals in the context of Nazi Germany and Hitler’s Aryan pride. These are the same games where Jesse Owens won four gold medals. Fast forward to the 1968 Olympics when Tommy Smith and John Carlos powerfully raised their fists on the podium in a Black power salute. The symbolism of this gesture referenced the black American community (black gloves); black American poverty (black socks, no shoes), black American lynching (Smith wore a scarf and Carlos a bead necklace).

Source Jonny Weeks:The Guardian

Closer to home, look at the stand many New Zealanders took against the Springbok rugby tour of 1981. 150,000 people took part in over 200 demonstrations in 28 centres and 1500 people were charged with protest related offences. The protests were in response to New Zealand opposition to the apartheid and segregation practiced in South Africa. These apartheid policies had impacted on team selection for the All Blacks, and Māori players had been excluded from touring South Africa by the New Zealand Rugby Football Union (NZRFU) until 1970. I take my inspiration from this event that “New Zealanders” might take their history into account and challenge the unacceptable comments against Pat Lam and show leadership over such behaviour.

So what are we to do about racism in sport? How can we use the values of sport, ostensibly fairness, teamwork, a fair go, equal opportunity, respect and care for each other to help us create a real level playing field, locally and globally? We can protest the sponsorship of the London Olympics by Dow (Union Carbide was merged into Dow and responsible for the tragedy at Bhopal not least 25,000 deaths and much much suffering). We can ask much more of our junk food media and not consume it as Jennifer Sybel suggests. We can ask that the groups in our communities that are under-represented (disabled, women, LGBTQ, visibly different) get a fairer go and that stories that purport to represent them contribute positively to our cultural and social diversity. We can take more responsibility for the actions of racist tweeters and taunters and recognise their actions come from consuming the same junk food media that we do. Rather than individualising their behaviour we can ask questions about what kind of playing field we have created and whether we want to put any effort into creating an alternative.

Illustration by Jim Sillavan for the Guardian

April 17, 2012/by ruth

Cultural safety, Inequalities, Power relations, Writing

Adapting to New Zealand’s super-diversity

Originally published in Contact: Newsletter for members of the Pharmacy Guild of New Zealand, December 2011-January 2012 (Issue 11), Pages 8-9.

New Zealand has earned the right to call itself super-diverse. this term refers to an unprecedented level and kind of complexity that surpasses anything previously experienced in a particular society. This super-diversity leads to new conjunctions and interactions, and outcomes that extend beyond the usual ways of understanding diversity.

Super-diversity is a relatively new phenomenon given the relative homogeneity of the New Zealand population. The arrival of super-diversity, its impacts and the relevance of super-diversity to pharmacy are the focus of this article.

Why is ethnic diversity and super-diversity relevant to pharmacy? And why is a nurse with a PhD writing about it? Perhaps it is because nurses and pharmacists have a lot in common. We see a lot of people and we tend to have very regular, intimate and long- term relationships with people (if we are doing something right). If we are not, people vote with their feet. Given this ubiquity, how can we ensure that we make a difference in the context of super-diversity?

New Zealand’s super-diversity kicked in with Asian migration in the 1990s. Prior to that, New Zealand had preferred particular “source countries” to select migrants from (Great Britain and Ireland). This homogeneity of migrants was altered by Polynesian Pacific migration from the 1960s, but it was the migration policy changes of 1987 that paved the way for skilled migrants from a range of countries to arrive, notably Asia.

These demographic changes led to a philosophical shift from assimilation to multiculturalism in the context of biculturalism. The expectation of newcomers to assimilate (give up their ways to fit into a new culture) was changed to reflect the notion of New Zealand as an inclusive society where the integration of newcomers was supported by “responsive services, a welcoming environment and a shared respect for diversity”.

But the effects of assimilation can be seen on the health of Maori and Pacific people who experience health inequalities and a lower life expectancy than Pakeha. We are beginning to see these same trends in Asian and MELAA (Middle-Eastern, Latin American and African) communities. It is easy to write-off the poor health of particular groups to their individual behaviour or their culture. But there is growing evidence that health professional behaviour contributes to creating and reproducing disparities as seen by the differential quality of healthcare different racial and ethnic groups receive.

Cultural competence is a strategy for reducing health disparities and activating health gain. The American Society of Health-System pharmacists (ASHP) suggests that medication therapy management is central to many health disparities including diabetes or end-stage renal disease which disproportionately affects particular groups (for example, Maori) that pharmacists are in a position to directly address these disparities or to change the language away from deficit to health benefit or gain.

The Health Practitioners Competence Assurance Act 2003 requires that all health professionals are competent and fit to practice. There are seven standards for New Zealand pharmacists that articulate the knowledge, skills, attitudes and behaviours necessary for competence. The standard that is most relevant to cultural competence is Standard One which requires that pharmacists practice pharmacy in a professional and culturally competent manner.

Cultural competence approaches require the health professional and the institutional system of health to adapt the ways in which they deliver services in order to accommodate difference. these require the health professional to focus on three main areas.

The first is to be aware of how the patient or client’s health beliefs, values and behaviours are shaped by their culture or religion.
The second is a focus on learning about what shapes health behaviours, disease epidemiology, ethno-pharmacology and complementary health practices located in different groups.
The final area is that of communication where the role of the health professional is to elicit the client’s health beliefs, develop a therapeutic alliance and utilise strategies that enhance communication such as working with professional interpreters (funded in some areas) or using the pharmacy translation Kit developed by the guild, for example.

New Zealand also has an indigenous strategy called cultural safety. The emphasis, here, is on the beliefs and attitudes of the health professional rather than that of the client. Careful reflection on the assumptions that underpin the culture of the profession or the service is required because these very assumptions can be assimilatory and disempowering for people who are not invested in them. Such assumptions as the belief that the individual is solely responsible for their own health, that Western medicine is the only valid mechanism for dealing with ill-health require conforming to the system, rather than the system adapting to the needs of the patient or client. These assumptions might pose a barrier to caring for someone who does not hold those beliefs.

Instead of doing what we’ve always done, we might be inspired to develop new ways of thinking and practicing that could benefit all people and communities in this super- diverse New Zealand.

January 17, 2012/by ruth

Colonialism, Indigenous, Inequalities, Multiculturalism, Racism

Identity politics: A response to Garth George

My response to a piece by Garth George (August 5th 2010) where he argues that [we] “have become unthinking victims of the doctrine of multiculturalism, in all its politically correct dissimulation and deception”.

There are some good reasons for the rise in identity politics among minority groups, dismissed by Garth George as a “culture of victimhood. The idealised portrayal of liberal democracy (with values such as freedom and equality) ignores three key issues. First, the destructive and dehumanising practices of slavery and colonisation occurred within liberal frameworks. Liberal values were withheld from the colonised as well as many Western subjects (women for example). Secondly, while liberal agendas of freedom and equality, and conceptions of universal human rights have been powerful and central to liberation struggles, often Eurocentric, Western norms have been privileged and the universal person taken to mean white, male and middle class. Finally, the deployment of notions of equality and universalism for ameliorating conflicts between groups of people, has created new problems such as unequal power relations and differential health and social outcomes. The location of culture in the public or private sphere is an important conversation. When it suits, the metaphor of enrichment is used to consume diversity, through festivals, restaurants and more. Placing cultural needs firmly in the private sphere reflects a reluctance to extend a reciprocal courtesy and make our institutions more responsive.

August 7, 2010/by ruth

Inequalities, Mental health, Migration, Racism, Women

Submission to the New Zealand Suicide Prevention Strategy 2008

Congratulations on a wonderful job in developing the New Zealand Suicide Prevention Strategy. I am pleased to see an inter-sectoral approach that is both evidence and strengths based. It is also encouraging to see mention of diverse communities and an approach that integrates protection, promotion, early identification, crisis support, attention to families and support in the aftermath of suicide. Thanks for the opportunity to add my rather swiftly developed submission to the New Zealand suicide prevention strategy. I am focussing this submission on Asians and South Asians in particular, but am aware (as per our teleconference on Friday) that these issues pertain to other migrant and refugee groups as well.

My key points are:

Asians are a high risk group for suicide and attempted suicide according to overseas research (especially South Asian young women).
We need better ethnicity data collection practices as data is limited.
There are issues with the umbrella term Asian which disguise differenceswithin groups.
There are significant barriers in accessing services, particularly mental health services.
Further research is needed that is clinical and epidemiological in order to identify prevention and intervention strategies that may vary from other groups.

Asians and statistics

Asians are a growing population in New Zealand. By 2016 they are expected to make up 9% of New Zealand’s and 20% of the Auckland Region’s total population. As such the health and social service needs of Asians must be considered by service providers. As you are aware there is limited research data available in New Zealand, 12 Asian people died by suicide (10 males and two females) in 2002, compared to 20 deaths

in 2001 and 21 deaths in 2000 (Ministry of Health, 2005). In our teleconference we also expressed concern the underreporting of suicide and coronial issues. I am concerned about the category as there is diversity within the people subsumed into the category Asian, with some groups especially at risk and others well protected) and the concept has limited use (Aspinall, 2003; Henare & Ehrhardt, 2004).

High rates of suicide and attempted suicide

Disproportionally high rates of suicide and attempted suicide have been found among South Asians in the diaspora (Batsleer, Chantler, & Burman, 2003; Bhugra & Desai, 2002; Bhugra & Hicks, 2004; Burr, 2002; Hicks & Bhugra, 2003). The highest were in young women of South Asian origin who have rates that are double that of the White population in the United Kingdom of completed suicide and 1.6 times more likely to attempt suicide(Hicks & Bhugra, 2003). Hicks and Bhugra examined perceived causes of suicide attempts in 180 ethnic South Asian women living in the London area. The three factors endorsed most frequently and strongly as causes of suicide attempts in South Asian women were violence by the husband, being trapped in an unhappy family situation, and depression. South Asian women are also two and a half times more likely to attempt suicide that South Asian men.

Barriers to accessing services

Recent New Zealand research has found that barriers for Chinese people accessing services include a lack of English language proficiency leading to communication difficulties and knowledge gaps, for example, being unaware of what services are available; the important role of primary healthy care and General Practitioners in particular as a first point of contact and a lack of awareness of the health and civil rights of citizens in New Zealand (Ruth DeSouza & Garrett, 2005). The research identified regional differences in terms of the place of birth of respondents and, in particularly, it was noted that Chinese-born respondents experienced more communication difficulties than those born in Hong Kong or Taiwan. Some of the strategies recommended in the report which are pertinent here include: encouraging cultural competence in health services (clinical, systemic and organisational), staff training and workforce development, developing partnerships with ethnic communities and community organisations, involving ethnic communities in strategic planning and linguistic competence. The latter involves not only ensuring that resources are available in several languages but also that interpreting and translation services are available.

Accessing mental health services

There are issues in attempting to access mental health services as well which are compounded by stigma within ethnic communities and anxiety from the mental health workforce. Increasingly mental health services are being called on to provide culturally appropriate care, but little is known about what that constitutes. Such a call cannot be answered if mental health professionals are not prepared for working in ways that are culturally competent. Despite the emphasis on cultural safety as part of the curricula of undergraduate health professional preparation, it has largely been concerned with Treaty obligations to Tangata whenua rather than evolving to meet the needs of ethnic communities (R. DeSouza, 2004). Burman, 2003, p.106) found in a research project investigating suicide and self-harm in the United Kingdom among South Asians that staff working with the women were caught in ‘race anxiety’ whereby white staff were hesitant and silent around issues to do with race, gender and mental health and were concerned that their actions were not misinterpreted. Their responses were to pass on issues to their South Asian counterparts or to avoid them. For the South Asian workers there was concern that discussing issues like this would reinforce or add to the existing stereotypes. This culture of silence within mainstream services was viewed as frustrating and annoying.

Ruth DeSouza Centre Co-ordinator/Senior Research Fellow Centre for Asian and Migrant Health Research Faculty of Health & Environmental Science Auckland University of Technology Address: Private Bag 92006, Auckland 1020

Ethnicity data collection

There is a need for improvements in quality ethnicity data collection so as to more clearly ascertain health needs and dispraities (Aspinall, 2003; British Medical Journal, 1996; Klajakovic, 1993; Latimer, 2003; McLeod et al., 2000; Ministry of Health, 2001, 2003, nd-a, nd-b; New Zealand Health Information System, 1996; Pringle & Rothera, 1996; Senior & Bhopal, 1994; Statistics New Zealand, 1996; Thiru, Hassey, & Sullivan, 2003; D. R. Thomas, 2000; S. B. Thomas, 2001). Several reports and research findings confirm that ethnicity data collection is poorly conducted by staff. A Waitemata District Health Board review found that staff were unaware of national guidelines for collecting data, had not received training on why and how ethnicity data was collected and consequently collected it inconsistently (Latimer, 2003). An internal paper for the Ministry of Health based on interviews with key stakeholders and a literature review found that there was inconsistency in the way in which data was collected and that what was collected was inaccurate and incomplete and that the concept of ethnicity was misunderstood (Ministry of Health, nd-a). These factors point to the need for support and training to facilitate accurate data collection. In order that ethnicity data is collected consistently and accurately ethnicity questions need to be aligned with Statistics New Zealand Census question for 2001 so that they are standardised. Variation exists across health providers around the method of ethnicity data collection, ranging from not asking and using previous admission information, to asking verbally to postal or using a show card. Furthermore, in secondary care, staff rely on information from GP’s which has been found to be problematic. A national survey of 1,062 members of the Royal New Zealand College of General Practitioners (RNZCGP) found that only 20% of practices collected ethnicity data. A recent study of 12 South Island practices found ethnicity was recorded for only 5% of patients (McLeod et al., 2000). Other problematic areas include the assumption of ethnicity by a provider.

Recommendations

• Further research and exploration of factors is needed in clinical and epidemiological studies of suicidality in South Asian women which might then contribute to prevention and intervention strategies.

• Better collection of ethnicity data (McKenzie, Serfaty, & Crawford, 2003). • Access to information in commonly used languages. • Encouraging cultural competence in health services (clinical, systemic and

organisational). • Staff training and workforce development. • Developing partnerships with ethnic communities and community

organisations. • Involving ethnic communities in the design of services.

References

Aspinall, P. J. (2003). Who is Asian? A Category that Remains Contrived in Population and Health Research. Journal of Public Health Medicine, 25(2), 91-97.

Batsleer, J., Chantler, K., & Burman, E. (2003). Responses of health and social care staff top South Asian women who attempt suicide and/or self-harm. Journal of Social Work Practice, 17(1), 103-114.

Bhugra, D., & Desai, M. (2002). Attempted suicide in South Asian women. Adv Psychiatr Treat, 8(6), 418-423.

Bhugra, D., & Hicks, M. H.-R. (2004). Effect of an Educational Pamphlet on Help- Seeking Attitudes for Depression Among British South Asian Women. Psychiatric Services, 55(7), 827-829.

British Medical Journal. (1996). Style Matters: Ethnicity, race, and culture: guidelines for research, audit, and publication. British Medical Journal, 312, 1094. Burr, J. (2002). Cultural stereotypes of women from South Asian communities: mental health care professionals’ explanations for patterns of suicide anddepression. Social Science & Medicine, 55(5), 835-845.

DeSouza, R. (2004). Working with refugees and migrants. In D. Wepa (Ed.), Culturalsafety (pp. 122-133). Auckland: Pearson Education New Zealand.

DeSouza, R., & Garrett, N. (2005). Access Issues for Chinese People in New Zealand(draft). Auckland: Accident Compensation Corporation.

Henare, K., & Ehrhardt, P. (2004). Support for Maori, Pacific and Asian Family,Whanau, and Significant Others who have been bereaved by suicide: Findings of a literature search. Wellington: Ministry of Youth Development.

Hicks, M. H. R., & Bhugra, D. ( 2003). Perceived Causes of Suicide Attempts by U.K. South Asian Women. American Journal of Orthopsychiatry, 73(4), 455-462.

Klajakovic, M. (1993). Is it easy collecting ethnicity data in general practice? NewZealand Medical Journal, 106, 103-104.

Latimer, S. (2003). Waitemata District Health Board: Ethnicity Data Collection Baseline Review. Auckland: Waitemata District Health Board.

McKenzie, K., Serfaty, M., & Crawford, M. (2003). Suicide in ethnic minoritygroups. British Journal of Psychiatry, 183(2), 100-101.

McLeod, D., Harris, R., Bailey, T., Dowell, A., Robson, B., & Reid, P. (2000). The collection of patient ethnicity data: a challenge for general practice. New Zealand Family Physician, 27(3), 51-57.

Ministry of Health. (2001). Monitoring Ethnic Inequalities in Health. Wellington:

Ministry of Health. Ministry of Health. (2003). Health and disability sector ethnicity data protocols. Wellington:

Ministry of Health. Ministry of Health. (2005). Suicide Facts: Provisional 2002 All-Ages Statistics. Wellington: Ministry of Health. Ministry of Health. (nd-a). Environmental scan: Ethnicity data collection issues.Wellington: Ministry of Health.

Ministry of Health. (nd-b). Submission on the review of the measurement of ethnicity. New Zealand Health Information System. (1996). Recording patient information:Ethnicity. Wellington: New Zealand Health Information System.

Pringle, M., & Rothera, I. (1996). Practicality of recording patient ethnicity in general practice: descriptive intervention study and attitude survey. Retrieved 8th February, 2004, from http://bmj.bmjjournals.com/cgi/content/full/312/7038/1080

Senior, P., & Bhopal, R. (1994). Ethnicity as a variable in epidemiological research. British Medical Journal, 309, 327-330.

Statistics New Zealand. (1996). Ethnicity – Standard Classification 1996. Retrieved 8th February, 2003, from http://www.stats.govt.nz/domino/external/web/carsweb.nsf/Classifications/Ethnicity+-+Standard+Classification+1996

Thiru, K., Hassey, A., & Sullivan, F. (2003). Systematic review of scope and quality of electronic patient record data in primary care. BMJ, 326(7398), 1070-1070.

Thomas, D. R. (2000). Assessing Ethnicity in New Zealand Health Research. New Zealand Medical Journal, 114, 12-14.

Thomas, S. B. (2001). The color line: Race matters in the elimination of health disparities. American Journal of Public Health, 91(7), 1046-1049.

April 7, 2008/by ruth

Inequalities, Mental health, Migration, Multiculturalism, Nursing

Sailing In A New Direction

First published by: Australian Network for Promotion, Prevention and Early Intervention for Mental Health (Auseinet) – www.auseinet.com/journal and then republished in Mindnet Issue 11 – Spring 2007

Abstract

Migrants and refugees make up an increasingly significant number of Aotearoa/New Zealand’s population with one in five New Zealanders being born in another country compared with one in eight people in the United States and one in fifteen in Europe. Increasingly efforts are being made to ensure that settlement services are provided and that mental health service delivery is cognisant of their needs. This paper describes some of the efforts being undertaken in Aotearoa/New Zealand and the implications of such efforts; in particular the mental health of Asians, a growing group, is explored. The author suggests that there is a need to learn from Pacific people’s ventures, to broaden the bicultural dialogue and finally to expand the new focus from Asians, refugees and migrants to also include the needs of long term settled communities and international students.

Keywords

multicultural, bicultural, multicultural mental health, mental health policy, Māori, Pacific peoples, Asian people

Simply by sailing in a new direction You could enlarge the world. (Curnow, 1997, p.226)

A sailing metaphor seems apt as the focus of this paper is on the people who have crossed the ocean to reach Aotearoa/New Zealand. Around 1300 AD the ancestors of Māori used the stars and the winds to sail southward from Hawaiiki in their waka (canoes) to Aotearoa/New Zealand. Thousands of years earlier, the world’s first seafarers had set off from South-East Asia, sailing into the Pacific on rafts. Tasman’s arrival in 1642, followed by Cook in 1769 marked the arrival of Europeans. Organised settlement followed the signing of the Treaty of Waitangi in 1840. Pacific migration increased from a trickle after World War II as manufacturing and service industries grew. Asians too had been coming to New Zealand since the 1800s but their numbers were small until after 1987.

Young Chinese men from Guangdong province travelled to the goldfields of Otago in the 1860s (Ip, 2005) and Indian connections with New Zealand began in the late 1800s with Lascars (Indian seamen) and Sepoys (Indian soldiers) arriving after deserting their British East India Company ships (Swarbrick, 2005). The earliest refugees arrived between 1870-1890 and included Danes, Russian Jews and French Huguenots. Subsequently, refugees from Nazism (1933-39), Poland (1944), Hungary (1956-58), ‘handicapped’ refugees (1959), Chinese (1962-71), Russian Christians from China (1965), Asians from Uganda (1972-73), Chileans, Soviet Jews, Eastern Europeans, people from the Middle East, South-East Asia (Indo-Chinese), Somalia, Zimbabwe, Afghanistan, Bosnia, Ethiopia, Eritrea, Iran and the Sudan have resettled in New Zealand. More recently, Asian foreign fee-paying students have impacted on the education system, becoming important to the national economy and more visible in society (International Division & Data Management and Analysis, 2005).

It’s time to enlarge our world

Migrants to New Zealand are caught between two charged agendas: the colonial ideal of a homogeneous society, replicating Britain, and the desire of Māori for recognition as people of the land, or Tangata whenua, with specific rights. New Zealand’s founding document, The Treaty of Waitangi and the social policy principle of biculturalism have become an explicit template for relationships between indigenous Māori and subsequent migrants. The racialising and othering of migrant groups, along with past migration policy designed to keep the country white (Beaglehole, 2005), have implicitly shaped the treatment of migrants.

Changing migration patterns

The 2001 Census found that Europeans/Pākehā (Māori name for white New Zealanders) made up 79.6% of the population, followed by New Zealand Māori with 14.5%, people from the Pacific Islands 5.6%, and Asians 6.6% (adds to more than 100% because ethnicity is self-defined; people could select more than one ethnicity). Of the Asians, the largest groups are Chinese who make up 2.2% and Indians who make up 1.2% of the total New Zealand population (Statistics New Zealand, 2002b). Asians are the fastest growing ethnic group, increasing by around 140% over the last ten years and predicted to increase by 122% by 2021. In comparison, Pākehā will increase by 1%, Māori 28% and Pacific People 58%. This new diversity is in stark contrast to the previous assimilationist post-1945 migration policy which positioned the ideal migrant as ‘invisible’. Linguistic and religious diversity were also a hallmark of the 2001 Census which noted a 20% increase in the number of multilingual people and an increase in the percentage of people whose religion was non-Christian, including Hindu 56%, Buddhist 48% and Islam 74%.

Policy changes: From monocultural to bicultural to multicultural

Canada and Australia embraced multiculturalism during the 1960s, transforming the notion of settlement into a two way process; change was required by both migrants and the host society. New Zealand policy made this strategic move only as recently as 1986. The 1980s were a pivotal period in discussions of New Zealand identity, featuring biculturalism and its incorporation into social policy in New Zealand (Bartley & Spoonley, 2004). Discussions of multiculturalism began with the arrival of Pacific peoples in the 1970s and required Pākehā to cede the monopoly on power and decision making and the allocation of resources (Bartley & Spoonley, 2004). An attempt to address the bicultural/multicultural relationship came about with proposals that biculturalism should take precedence and subsequent arrivals to Aotearoa needed to negotiate a primary relationship with Māori (Bartley & Spoonley, 2004). Multi-culturalism would then be the outcome of a network of completed bicultural negotiations; however, no process was ever suggested for this to occur (Bartley & Spoonley, 2004). The bicultural/multicultural debate remains un-resolved and problematic (DeSouza, 2004a; Mohanram, 1998; Thakur, 1995; Walker, 1995; Wittman, 1998). However, rather that biculturalism being a barrier to multiculturalism, I believe that it has paved the way for the majority culture to consider cultural issues at large. The Immigration Act 1987 eased access into New Zealand from non-traditional source countries and replaced entry criteria based on nationality and culture with criteria initially based on skills. The policy changes led to unprecedented cultural diversity. In particular, Asians became a sizable majority of migrants, increasing from 18.7% of permanent and long term arrivals in 1987 to 48% in 1993 (Bartley & Spoonley, 2004).

A growing Asian population

‘Asian’ is a term that has differing definitions depending on the geographical context in which it is used. In New Zealand ‘Asian’ tends to refer to people from South East Asia and there are debates about whether an umbrella term such as ‘Asian’ is useful or merely an expedient construct that potentially provides benefits but disguises disparities within groups (Rasanathan, Craig & Perkins, 2004; Workshop Organising Team, 2005). In the 2001 Census, 44% of Asians identified with the Chinese ethnic group, 26% with the Indian ethnic group, 8% Korean, 5% Filipino, 4% Japanese, 3% Sri Lankan, 2% Cambodian, 2% Thai, and 8% with other Asian ethnic groups (note that people could give more than one response; therefore, these percentages do not add to 100) (Statistics New Zealand, 2002a). Asians in New Zealand are a relatively young population and are generally in good health. Most live in the Auckland region and over half are aged between 25 and 65 years, around 20% are aged 15 to 24 years and 20% are aged below 14 years (Asian Public Health Project Team, 2003). This age-distribution is similar to Māori and Pacific people, but Asians are younger (on average) than Europeans. The rapid growth of the Asian population has exposed a lack of policy and structures to evaluate and address their needs (Workshop Organising Team, 2005).

Access issues and underutilisation of mental health services

A survey examining health status in a large representative sample of Asian people (Scragg & Maitra, 2005) found that Asians underutilise health services:

Asian people were less likely than other New Zealanders, Māori and Pacific people to have visited a health practitioner (or service) when they were first unwell.
Asian people were less likely than Europeans to visit a health practitioner about a chronic disease (doctor, specialist, nurse or complementary healer).
Asian women were less likely than other New Zealand women to have had a mammogram or cervical screening test in the last three years.
Asians were less likely than all New Zealanders to use any type of telephone helpline in the last 12 months.
Asians also only wanted to see their general practitioner for a short term illness or a routine check up rather than visiting for an injury, poisoning, or for mental or emotional health reasons.

Another study found that barriers to accessing services for Chinese people included lack of language proficiency of respondents, lack of knowledge about civil rights and problems accessing general practitioners (DeSouza & Garrett, 2005).

This underutilisation is further reflected in mental health statistics. Of the 87,576 mental health clients seen by District Health Boards in 2002, only 1.9% were Asian despite making up over 6.5% of the population (New Zealand Health Information Service, 2005). This could in part be due to the bias of New Zealand’s migration policy which selects young and healthy migrants but it is clear that Asians underutilise mental health services and this does not necessarily mean that they are keeping well (Ho, Au, Bedford & Cooper, 2002). A study among recent Chinese migrants using the General Health Questionnaire found that 19% reported psychiatric morbidity (Abbott, Wong, Williams et al., 1999). A study of older Chinese migrants aged over 55 found that 26% showed depressive symptoms (Abbott, Wong, Giles et al., 2003). Lower emotional supports, greater number of visits to a doctor, difficulties in accessing health services and low understanding and engagement with New Zealand society increased the risk of developing depression. Interestingly, while participants with depressive symptoms consulted general practitioners more than their counterparts without such symptoms, they reported greater difficulty in accessing health services. Research with Asian migrants, refugees and student sojourners in New Zealand shows that social supports can assist newcomers to cope with the stresses of migration and reduce the risk of emotional disorder (Abbott et al., 1999). Conversely, research shows that language and cultural barriers can limit access to health services (Abbott et al., 1999; DeSouza & Garrett, 2005; Ngai, Latimer & Cheung, 2001).

Need for workforce development

The cultural competence of mental health staff for working with Asian consumers has not been researched. However, a recent project investigating the intercultural experiences of social workers in New Zealand found that contact with migrants, refugees or asylum seekers was infrequent, especially outside of Auckland (Nash & Trlin, 2004), but that the majority of social workers felt competent or better than competent in terms of working interculturally. Respondents recommended that further training in cross-cultural social work, staff training and better support services be available, in tandem with improvements in community services and the education of the host community to see new settlers as valuable additions to society. In another study, psychiatrists were surveyed by Johnstone and Read (2000), who found that out of 247 psychiatrists surveyed, only 40% believed that their training had prepared them to work effectively with Māori. Some of the suggested recommendations for improving how they worked with Māori included needing to understand Māori perspectives of well-being, and increasing the number of Māori professionals and Māori run services. Of psychiatrists who responded to the survey, 70% believed that there was a need to consult with Māori when working with Māori. A training package is being developed by University of Auckland, funded by the Health Research Council, to develop cultural competence in mental health staff working with Asians. Further development in this area is signalled in the next mental health action plan discussed later in this paper.

Omission in health research

Asian ethnic groups have been largely neglected by New Zealand health policies and research, despite their population growth (Duncan, Schofield, Duncan et al., 2004). Duncan et al. cite the example of the 2002 National Children’s Nutrition Survey, where both over-sampling and separate analysis of Māori and Pacific Island children occurred while Asian children were subsumed with New Zealand Europeans. Large-scale studies are needed to determine health risk across all major ethnic groups in New Zealand, which will in turn enable development of ethnic-specific data. Even more critical is the need for data concerning ethnic variation in other areas of health so that effective interventions can be developed and implemented (Duncan et al., 2004). This omission and exclusion is by no means a rare occurrence in national surveys and prevents the development of an understanding of the public health needs of Asian communities in New Zealand, necessary for the development of appropriate preventative health strategies.

Settlement issues

A report commissioned by the New Zealand Immigration service found that migrants had four areas of need: everyday needs, learning English, employment, and supportive connections (Ho, Cheung, Bedford & Leung, 2000). Factors such as unemployment or underemployment, having experienced discrimination in New Zealand, not having close friends, being unemployed and spending most of one’s time with one’s own ethnic group were predictors for poor adjustment among migrant groups (Pernice, Trlin, Henderson & North, 2000). In the last few years, a range of settlement programmes have been funded nationally with the development of an Immigration Settlement Strategy (New Zealand Immigration Service, 2003) for migrants, refugees and their families. The strategy’s six goals provide a broad base for enhancing wellbeing and include appropriate employment; confidence with using English or accessing appropriate language support; accessing appropriate information and responsive services; supportive social networks and sustainable community identity; expressing ethnic identity and acceptance and inclusion of the wider host community; and participation in activities.

Visible but invisible groups

The arrival of primarily Asian fee-paying students has had an impact on the education system, a greater importance to the national economy in terms of providing increased funding to educational institutions, and higher visibility in society in that most of the international students have come from China (International Division & Data Management and Analysis, 2005). Asian enrolment numbers rose by 318% over a five year period (1999-2003) to nearly 119,000, with an estimated economic value NZ$2.2 billion New Zealand dollars and providing 40,101 jobs (Infometrics, 2006). These numbers declined in the 2003-2004 period, leading to concern about the rapid development of the sector and raising the need for better quality assurance systems, which are now implemented through the Code of Practice for the Pastoral Care of Foreign Fee-Paying Students (Section 238H of the Education Act 1989). Levies paid by institutions with international students are used to support activities and projects relating to the export education industry such as promotion, communications, capability development, quality assurance, research and the administration of the Code (Ministry of Education, 2003). However, other than being able to use counselling services within their institutions, most international students are not entitled to access publicly funded (mental) health services while in New Zealand and are liable for the full costs of treatment unless they are sectioned under the Mental Health Act, and then only for the duration of that process. Once they are no longer under the Act, they are charged. Remaining voluntarily on an acute unit can incur a charge of approximately NZ$900 a day. International students are required to have appropriate and current medical and travel insurance while studying in New Zealand as a condition of enrolment (including mental health as long as it is not a pre-existing condition); however, insurance cover is capped at NZ$2,000 so if students need access to in-patient services they must cover their own costs.

The needs of long term settled communities have been brought into focus with the launch of the Asian Health Chart Book (Ministry of Health, 2006a) which demonstrates the need to focus not only on new migrants but also on longer-term settled migrant Asian communities. Major differences in health and health service use between recent migrants and longstanding migrants show that recent or first generation migrants have better health status than longstanding migrants or the New Zealand born, demonstrating the acculturative effects of the dominant culture.

Mental health services: Sailing in a new direction

Mental health services are responding to new migrant populations to varying degrees. Following on from a report on the mental health of Asians in New Zealand (Ho et al., 2002) has been an increased responsiveness to the needs of those communities (Yee, 2003). Research activity, information provision, collaboration and Asian-focused operational activities and policy are some of the strategies that are being used by government agencies (Yee, 2003). Other developments that will assist in meeting this gap include the New Zealand Mental Health Classification and Outcomes study (Gaines, Bower, Buckingham et al., 2003), which includes a small number of Asians, and a planned mental health epidemiological survey which will also assist but is currently limited to the two largest Asian communities, Indian and Chinese. This section briefly reviews national, regional and local developments and initiatives.

Developing visibility and responsiveness in mental health services

Asian researchers (Lim & Walker, 2006; Tse, Bhui, Thapliyal et al., 2005) have outlined the legislative and policy frameworks that support culturally sensitive mental health service provision. These include The Health and Disability Commissioner Act 1995 and the Health and Disability Code of Rights 1996 which require that services acknowledge the needs of people from a range of cultures and provide for these needs while also protecting culturally diverse people from coercion, discrimination and exploitation. A culturally sensitive approach and acknowledgement of the person’s cultural and ethnic identity, language, and religious or ethical beliefs is also advocated in the Mental Health (Compulsory Assessment and Treatment) Act 1992 and the 1999 amendments. In addition, one of the objectives of the New Zealand Public Health and Disability Act 2000 is that health outcomes be improved for Māori and other population groups through the reduction of health disparities. The Human Rights Act 1993 requires that mental health and addiction services do not unlawfully discriminate on the grounds of culture and ethnicity. Lastly, the Health Professional Competency Assurance Act 2003 requires practitioners to demonstrate cultural competence.

National mental health strategy and recovery

Te Tāhuhu – Improving Mental Health 2005-2015: The Second New Zealand Mental Health and Addiction Plan (Ministry of Health, 2005b) builds on the current Mental Health Strategy contained in

* Looking Forward: Strategic Directions for the Mental Health Services (Ministry of Health, 1994); * Moving Forward: The National Mental Health Plan for More and Better Services (Ministry of Health, 1997); and * The Mental Health Commission’s Blueprint for Mental Health Services in New Zealand: How Things Need to Be (Mental Health Commission, 1998).

Te Tāhuhu acknowledges that ‘there is no national strategy or policy to address the mental health issues of the full range of ethnic groups living in New Zealand. Building stronger relationships with people from diverse cultures and ethnic groups will be essential as we work towards developing strategies to address their particular needs’ (Ministry of Health, 2005b, p.37). Te Tāhuhu focuses on developing a comprehensive integrated mental health and addiction system that provides hope for developing a multicultural mental health agenda, compared to the other documents that make specific cultural mention of Māori and Pacific peoples but minimal reference to other groups. Te Tāhuhu emphasises early access to effective primary health care (a key entry point to mental health services for Asians), and an improved range and quality of specialist community based mental health and addiction services built on collaborative relationships (Ministry of Health, 2005b). It covers the spectrum of interventions from promotion/prevention to primary care to specialist services, and in particular the draft action plan (Ministry of Health, 2006b)

* acknowledges the presence not only of Asian peoples but also migrants and refugees, and the need for mental health services to be able to respond to the unique needs of all New Zealanders; * acknowledges the need for responsiveness to Asian peoples and other ethnic communities and refugee and migrant communities; * aims to build a quality mental health and addiction workforce that supports recovery, is person centered, and is culturally capable to deliver services for Asian peoples (that will require new skills and areas of specialised knowledge); * aims to strengthen the cultural capability of workers in mainstream services to work effectively with Asian, refugee and migrant populations through training programmes; * aims to increase the understanding of the mental health and addiction needs of Asian, ethnic, refugee and migrant communities through developing a profile of their mental health, and developing a mental health and addiction research agenda; * aims to implement national and local training for the mental health services workforce to work more effectively with them and use research evidence in service planning and delivery; and * aims to develop culturally responsive problem gambling intervention services for Asian peoples.

In addition, The Mental Health Commission’s Recovery Competencies for Mental Health Workers (O’Hagan, 2001) requires that a competent mental health worker acknowledges the different cultures of Aotearoa/New Zealand and knows how to provide a service in partnership with them. It suggests that every mental health and addiction service worker should demonstrate:

knowledge of diversity within Asian cultures;
knowledge of Asian culture, for example importance of family, religious traditions, duty, respect for authority, honour, shame and harmony;
the ability to articulate Asian views on health;
knowledge of traditional Asian treatments;
and the ability to involve Asian families, communities and service users in services.

In response to a report on Asian Public Health (Asian Public Health Project Team, 2003) the Mental Health Foundation have also created information sheets written in Chinese as a step towards meeting the mental health needs of Asians. They focus in particular on the mental health needs of Chinese adults and older Korean people. The emphasis on Chinese recognises that they comprise the largest of all Asian ethnic groups and the high number of Chinese international students in New Zealand, particularly in Auckland.

The potential of broader health policy

Developments in population based health policy offer promise in addressing barriers to accessing services by Asian communities. The New Zealand Health Strategy (NZHS) guides the development and provision of new services in the health and disability sector to improve the health of New Zealanders (Ministry of Health, 2000). Administered through District Health Boards (DHBs), the strategy aims to reduce inequalities in health status for Māori, Pacific peoples and people from lower socio-economic groups. It claims to focus on quality of service in order to ensure health outcomes are improved and health disparities reduced. There is scant reference to migrant health in the NZHS, other than a recommendation ‘to assess the health needs of refugees, asylum seekers and Asian immigrants’ (Ministry of Health, 2000, p.47) without any attempt to explain how this might be achieved.

A key strand of the NZHS involves improving responsiveness in the field of primary care. Primary Health Organisations (PHOs) have been established as ‘community-led’ organisations that guide the development of local services and their role defined in the Primary Health Care Strategy (Ministry of Health, 2001). The governance model is intended to involve local people in the planning and delivery of local primary health care services. This promotes the role of health workers as being to reduce health inequalities and address the causes of poor health status. Whilst accessibility, affordability and co-ordination are key, there is no mention of Asian and migrant populations in the strategy, which aligns with the NZHS focus on Māori, Pacific populations and lower socio-economic groups. The needs of Asian communities in New Zealand will need to be proactively considered given their projected population growth and evidence of different health needs to the wider population. Findings from the Asian Health Chart Book (Ministry of Health, 2006a) show that Asian people had positive health outcomes on a range of health indicators compared to the total New Zealand population. Of concern, however, was the lower usage of health services by the Asian population. The report provides a useful baseline on Asian health and it is hoped that it helps in identifying the health needs of Asian peoples in New Zealand and that it will be a tool for Asian communities themselves to advocate for appropriate health services.

Regional developments

The Northern Region Mental Health and Addictions Strategic Direction 2005-2010 (Northern DHB Support Agency & Network North Coalition, 2004) has two foci for its vision. The first is a specific focus on ‘equal opportunity to access quality services delivered in a culturally appropriate manner for refugee and recent Asian migrant clients and families’ and the second is ‘access to professionally trained and qualified interpreting services to meet the needs of migrant and refugees with experience of mental illness and their families’ (p.22). Recently a project was developed for training Asian interpreters and mental health practitioners who provide secondary mental health services for the diverse Asian immigrant population in the Auckland region, focussing on cultural competency and appropriate skills to work together effectively (Lim & Walker, 2006).

Local developments

At a local level, the twenty-one District Health Boards (DHBs) are responsible for deciding on the mix, level and quality of health and disability services to be provided for populations within government-set parameters. Some specialised mental health services, for example the ‘Refugees as Survivors’ (RAS) centres have been established, while others have developed ‘transcultural’ teams with clinicians who have an interest in the area or Asian mental health workers. Asian peer support workers are employed by consumer run organisations such as Mind and Body consultants to support Asian users of Auckland District Health Board Mental Health Services. There are also two Chinese consumers’ self-help groups: Bo Ai She and Yu Ai She. Community Alcohol and Drug services have two Chinese counsellors and non-governmental organisations (NGO) have begun responding to the needs of Asians by employing Chinese staff in community and family support roles such as Action for Mental Health Services, Supporting Families and Affinity. In the Auckland DHB there are two Asian community support workers with a focus on psychiatric rehabilitation. A great many of the developments have been in response to advocacy from ethnic community members and a desire to increase responsiveness to presenting clients.

Learning from the experience of Pacific peoples

There is much that newer migrant groups and mainstream services can learn from the experience of Pacific peoples, who are a diverse group representing over 20 different cultures. The largest group are Samoan making up 50% of Pacific peoples, followed by Cook Islanders (23%), Tongans (16%), Niueans (9%) Fijians (4%) and Tokelauans (2%) (self-identified; more than one response possible) (Mental Health Commission, 2001). A youthful population concentrated in the Auckland region with smaller numbers scattered throughout the country (Ministry of Health, 2005a), Pacific peoples make up 6% of the New Zealand population, which will rise to 12% by the year 2051. Pacific migration to New Zealand after the second world war increased as a result of growing industrialisation and demands for a manufacturing and service industry workforce (Spoonley, 2001). Large numbers of Pacific people migrated to urban areas of New Zealand, accelerating in the 1960s and early 1970s (Spoonley, 2001). The mid-1970s economic downturn led to many Pacific people losing their jobs. Unemployment, low income, poor housing, the breakdown of extended family networks, cultural fragmentation, and rising alcohol and drug problems have had a significant impact on the mental health of Pacific peoples, with rates of mental illness being generally higher among Pacific males and Pacific older people than the rest of the population (Ministry of Health, 2005a). However, Pacific peoples are a little less likely to use mental health services than any other group in New Zealand (Ministry of Health, 2005a).

Innovative health models such as the ‘Fonofale’ created by Fuimaono Karl Pulotu-Endemann (Crawley, Pulotu-Endemann, Stanley-Findlay & New Zealand Ministry of Health, 1995) have promoted holism and continuity. Similar to Durie’s (1994) Te Whare Tapa Wha, the Fonofale model uses the metaphor of a Pacific Island house and incorporates the values and beliefs of various Pacific Island groups. In addition, two key mechanisms have been advanced to improve social and economic outcomes for Pacific peoples. These are to improve ‘the responsiveness and accountability of public sector agencies to Pacific health needs and priorities, and to build the capacity of Pacific peoples, through provider, workforce and professional development, to deliver health and disability services and to develop their own solutions to health issues’ (Mental Health Commission, 2001, p.15). The key agencies in this task are The Ministry of Pacific Island Affairs, the Ministry of Health, District Health Boards and the Mental Health Commission. Other strategies are that services for Pacific peoples should: include Pacific views of mental health and wellbeing (which also includes all other aspects of health); take into account the relatively young Pacific population; acknowledge that there are isolated communities throughout New Zealand; consider the socioeconomic status of Pacific peoples; consider the diverse needs of New Zealand-born versus Island-born people and people of mixed ethnicity; and include the issue of alcohol and other drug use. In parallel, mainstream providers need to incorporate practices that properly address the above issues which will require building networks with Pacific organisations and groups able to advise on culturally acceptable methods of treatment (Mental Health Commission, 2001).

Conclusion: Exploring uncharted waters

Parts of the journey ahead are charted clearly. There are legislative and policy imperatives in place for mental health services to ensure that they are responsive in both policy and practice for ‘migrants, refugees and Asians’. How this is operationalised varies around the country but developments are promising, particularly in Auckland where the population of Asians is 12%. However, there are murky waters ahead that must be navigated. Further discussion is needed about the terms ‘migrants, refugees and Asians’ which are referred to in Te Tāhuhu and are an attempt at inclusion. The diversity contained within labels will have to be disentangled, so that the needs of the diverse people within labels such as ‘migrants, refugees and Asians’ are identified. Consideration must also be given to the needs of long term settled ethnic communities and international students, both of whom are neglected. Diving even deeper, the intersection of ethnicity, religion and socioeconomic status needs exploration. Consideration also needs to be given to how we work with the ‘buzz words’ such as cultural safety, cultural capability, cultural awareness and cultural competence and how they sit together (DeSouza, 2004b, 2006; Wood, Bradley & DeSouza, 2004).

Finally, a more strategic response to New Zealand’s changing demographics is required as until now the majority of developments have been ad hoc, reactive and operational, based on lobbying from ethnic community groups and non-governmental organisations such that responses are geared to our current situation rather than our future. It is necessary to address the place of the Treaty of Waitangi in the context of how multiculturalism is to be accommodated. Some see biculturalism as an obstacle to the acknowledgement of a more diverse society; however, I suggest that multiculturalism through biculturalism remains a possible solution that has been under-explored and under-operationalised. Future developments in Asian, migrant and refugee health need to heed the unique status of Māori and learn from the experiences of Pacific peoples, who have charted these waters already and know the currents and prevailing winds.

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September 9, 2007/by ruth