A smile and more: Improving Asian health in Auckland

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

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

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

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

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

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

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

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

Health concerns among Asian populations in Auckland include:

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

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

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

Access issues:

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

Recommendations for the Three Auckland DHB’s to:

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

1) Notice Asians are here:

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

2) Get Asians to be more healthy

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

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

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

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

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

5) Reduce cultural and language barriers to care

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

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

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

7) Improving social capital among Auckland Asian communities

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

8) Future research

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

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

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

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

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

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

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

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

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

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

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

As Arundhati Roy articulates in a pointed essay:

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

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

The Dominion Post argues:

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

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

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

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

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

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

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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 

 

 

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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.

 

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Food and festivals: Consuming multiculturalism

Multiculturalism has acquired a quality akin to spectacle. The metaphor that has displaced the melting pot is the salad. A salad consists of many ingredients, is colorful and beautiful, and it is to be consumed by someone. Who consumes multiculturalism is a question begging to be asked.

Angela Y. Davis (1996, p. 45)

WOMAD main stage, March 2012

The New Zealand summer has ended, and as Autumn deepens there are a flurry of festivals making the most of sunshine hours and daylight saving before we turn to insular hibernation modes. In the last few weeks I’ve been to WOMAD in New Plymouth, Pasifika and the International Cultural festival in Auckland and a few smaller low key community functions. I’m interested in whether food and festivals, which are such visible and public celebrations of ‘culture’ (and especially culinary cultures) are anything more than what Duruz calls the appropriation of difference by a greedy white consumerist society.

The pretext of a cultural festival is that there is an ‘us’ and a ‘them’, a national culture and an alien culture.  Migrants then are people who try and enter something that has ostensibly already formed into something and solidified (that’s why it feels like you are banging your head against a wall when you can’t get a job, because it really is a wall or a bamboo ceiling). This imagined sameness might not be very clearly articulated by the dominant culture, but everyone knows what does and doesn’t belong. If you don’t know, the media or a politician will tell you. The latter are renowned for either demonising or exoticising diversity. Festivals as less scary manifestations of diversity bring out enthusiasm, as Mayor of Auckland Len Brown speaks about the Auckland International Cultural festival (made up of dance and musical performances, an Ethnic Soccer Cup and over 100 stalls of ‘traditional’  food): ” …a fantastic celebration of Auckland’s ever-growing cultural diversity …which highlights the dynamic contribution people from other cultures bring to our wider community, and to New Zealand. Come along and sample the many sights, sounds and tastes of Auckland diversity.”

Monte con Huesillo: Chilean drink of dried peaches and wheat

The celebration and sampling of this dynamic contribution can be read as an enabler of social cohesion and community building. As Uma Narayan points out, the combination of prejudice, neighborhood and occupational stratification and segregation can mean that we have very little do do with members of other ethnic groups beyond seeing them as service providers to the detriment of “collective possibilities”. The public consumption of food is a great mechanism for intercultural exchange. The sensual enjoyment of the food of others can help us gain an appreciation of them as part of our communities even if we don’t know very much about the cultural context of the food.

The aspect of consumption that is on display also has a ‘feel good’ aspect. Where the media and its three stooges (Paul Henry, Michael Laws and Paul Holmes) often lead us to view migrants (and Tangata whenua and several generations of Pacific peoples) as a political threat to the integrity of the ‘host’ white settler Pakeha nation. Festivals tame diversity into a strategic asset, that is managed and displayed for people to witness and enjoy. The elephant in the playing field or park though are the unanswered questions of racism and exclusion. The safe packaging inherent in festivals, where people embody their culture in a display allow ‘us’ to feel good about our city and the presence of ‘others’.  This low impact kind of engagement has very little performance pressure and even less demand for any kind of accountability or responsibility. Culture can be celebrated rather than acted upon as Arun Kundnani quips.

Hungarian Langos (Fried Bread) with a topping of pesto, tomato and feta-Yum!

The pleasures of consumption make diversity appealing, something to be shared and enjoyed as Sara Ahmed notes.  The consumption of ethnic food points to a desire to consume difference through appropriation of food and tradition as exotic, where ethnicity becomes spice for mainstream culture, losing its own legitimacy in the process. Instead of engagement, the other is consumed. Consuming diversity gets translated into ‘eating the other’. Heldke talks about a kind of “cultural food colonialism” where the food being cooked and eaten comes from economically dominated countries of the ‘third world’. Culture is there for the taking and “something to be be enjoyed, consumed at will and with discernment by the liberal subject.”. The new marker of sophistication is the latest ethnic restaurant find, a marker of street credibility and sophistication. Reflecting a desire for novelty and a sense of entitlement.

This differs to how might I think of food and festivals, as a diasporic subject. For me attending the cultural festival and more low key community events creates is a way of being at home in the context of a community far from ‘home’, being able to express aspects of my life that don’t often get a public viewing. As Ghassan Hage points out, cooking and eating familiar food is a way of making a home in the present. Food represents comfort, enjoyment, social life, memories and stories. As someone whose food choices were derided until they became fashionable (why did it take so long for curries to become popular in New Zealand? and what is wrong with tongue sandwiches anyway?). The advent of cultural food colonialism inflicts an old pain, food shapes us physically and emotionally, creating possibilities for enjoyment and pleasure. However, we must be mindful that power relations accompany our consumption choices and have implications for how we are to live in a multicultural society founded on biculturalism.

Cartoonist Alexyz and the author in Auckland at an exhibition of his work with members of the Goan community. February 2012.

So how do we reconcile these diverse ways of looking at food and its consumption? Perhaps we can use the gustatory pleasures we experience to build more powerful bonds between us as Uma Narayan proposes. These pleasures can have more power than intellectual understanding or knowledge. The sensual pleasures of food can counter our physical alienation in the unpressured form of contact that a festival allows. Perhaps the journey to greater openness and acceptance and building of bonds begins at the venue where we eat the food where we can be provoked into a process of reflexivity  and begin to care for the cooks as much as we are willing to enjoy the food.

 

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Celebrating African women in Aotearoa New Zealand

I was honoured to be invited by the African Community Forum Incorporated to attend and speak at an event on March 10th 2012 to celebrate International Women’s Day. I have written elsewhere about my links with East Africa. Briefly, I was born in Tabora Tanzania and lived in Nairobi, Kenya until the age of ten, when my family migrated to New Zealand. Originating from Goa, India, both sets of grandparents moved to Tanzania in the late 19th Century and both my parents were born there. Until moving to New Zealand I was fluent in both Swahili and Maragoli.  The African part of my identity rarely gets the opportunity to play, so I was thrilled to attend the event.

 

Indians in Africa

Many people might be surprised to know that the Indian connection to Africa goes back three thousand years. Indians were traders and later sojourners. The British indentured labour scheme which replaced slave labour, ushered a new era of cheap and reliable labour for plantations and the building of railways. The construction of the great railway from Mombasa to Lake Victoria in Uganda in the late nineteenth century brought fifteen thousand (of the sixteen thousand) workers or ‘coolies’ from India. Tragically one quarter of them died or returned disabled (Sowell, 1996). Indians (especially Goans) were also recruited to run the railways after they were built (as my grandparents were) and Goans came to dominate the colonial civil services.

Africans in New Zealand

The history of African migration to New Zealand is much more recent. Te Ara online encyclopedia notes that the first black African in New Zealand was travelling on James Cook’s second voyage as a servant (no name is provided) and later killed by Maori in 1773. The 1871 New Zealand census recorded 34 people who were born in ‘British African Possessions’ and another 31 from other African countries. The 1911 census recorded 92 African-born people. However, these African born people were likely to have been white given the mobility of white settlers through the then British Empire. The 1916 census recorded 95 “Negroes” referring to African Americans and six African born people, four Abyssinians (Ethiopians) and two Egyptians. The Colombo Plan saw the arrival of Black Africans as students in the 1960s, some of whom remained in New Zealand and had families. During the 1970s two groups of Africans arrived in New Zealand. White Rhodesians who were escaping from the war and two hundred Ugandans (not sure if they were all Asian Ugandans) who were ejected by Idi Amin. The number of African born residents (mainly from Commonwealth countries) increased to 3,939 Africans by 1986, but again were mainly white. It was not until the changes in migration policy of 1987 that there were significant demographic changes as a result of the development of a formal refugee quota  which saw arrivals especially from Ethiopia (1991-3), Somalia (1992-4), Rwanda (1994) and the shift to a migration points policy which saw a greater number of African people coming New Zealand as migrants. The 2006 Census 10,647 or 0.3% of the population identified as African. 4,806  Africans reside in Auckland and 5,841 outside of Auckland. In the 10 years between 1991 and 2001 the number of women from African countries increased considerably with numbers of women from South Africa, Zimbabwe and Somalia more than quadrupling in that time (Statistics New Zealand, 2005).

The growth of the African community is an exciting development and the event organised by ACOFI was a fantastic celebration of Pan-African culture and the vitality and energy of the community. I look forward to taking part in more events and improving my now very rusty Swahili! By the way, the art work is from a drawing competition run on the night. My big thanks to all the organisers especially Carlos Carl, Boubacar Coulibaly and Sharon Sandra Paulus and all the people that worked hard to make the event happen.

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When activists become oppressors: Nurses and migrant mothers.

This Sunday I’ll be doing a Picnic lecture where I’ll be sharing stories from nurses and migrant mothers from my PhD to discuss how well intentioned activism can become a form of oppression. The lecture will be held in the Albert Park rotunda in Auckland on Sunday 1st April at 3pm and is linked with Te Tuhi’s What do you mean, we? exhibition which brings together an international selection of artists to examine prejudice.

The kinds of questions that my work has been concerned with are:

  • What subjectivities and beliefs and values are being reproduced when a woman has a baby in neoliberal Aotearoa New Zealand?
  • How does a maternal health care system provide services for birthing women whose subjectivities have been partially or significantly formed outside a white settler nation context and specifically outside the colonial dyad of settler and indigenous?
  • Do the policy rhetoric of biculturalism in response to Treaty of Waitangi obligations and the requirement for culturally competent practice actually improve the care migrant mothers receive?
  • Do the liberal feminist aspirations for birth as an empowering experience extend to women outside the world of white middle-class feminism?
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When helping does not help: Invisible children and colonialism

In almost thirty years of being a nurse I’ve learned that what one person thinks is helpful can be coercive to another. “Help” is complex, raising questions such as: how has the helper negotiated the relationship? Does the helper understand the problem? Do the people being helped agree with the helper’s framing of the problem? There is also the issue of power in the helping relationship. How did the helper get the power to help? What access to resources and knowledge does the helper have? Does helping disempower the helped?

The film and campaign KONY 2012 by Invisible Children and directed by Jason Russell about the Lord’s Resistance Army (LRA) led by the “monster” Joseph Kony has generated passionate pleas from a range of “friends” to support the “people” of Uganda. I am excited about the democratisation of information through social media, but I’ve been frustrated that this video has made us all “experts” about Africa. There is a bigger social and political backdrop to this story which has been tracked by Blackstar news and Akena Francis Adyanga.

My concern with this video is that it valorises the story being told by Invisible children (and other white people) at the expense of African leaders, without access to the same power structures or resources. The  documentary repeats the colonial imperative for Africa to be saved by white people. This video smacks of yet another colonial “civilising” project,  where the old binaries of colonialism are revived. These frame Africa as backward, while the west is modern; “we” are positioned as free while “they” are oppressed and so on. In this binary of good and bad, Africans are represented on the not so good side of the binary. Therefore, the solution must be a good one, a white one, and in this hierarchy Africans lose out. Local efforts and voices go unacknowledged in favour of the white saviour complex, which as Teju Cole suggests “supports brutal policies in the morning, founds charities in the afternoon, and receives awards in the evening”. Even the name  “Invisible Children” as the Sojourner project points out “denies and co-opts the agency of Ugandans – many of whom have organized to protect child soldiers”.

I have a stake in this propaganda video on several fronts. One is my personal experience of being born in Tanzania to parents who were also born in Tanzania and and having two sisters who were born in Kenya. My own life has been shaped by three versions of colonialism: German, Portuguese and British, and continues to be shaped by colonialism’s continuing effects in the white settler nation of Aotearoa/New Zealand. Secondly, in my doctoral studies, I investigated the colonial legacies of health and nursing in the context of migrant maternity. My profession of nursing is not only an altruistic and caring enterprise, but is also complicit with biomedicine in the advancement of colonialism and imperialism. Medicine has used imperial claims to modernity and universalism, while the concept of “health” has in turn has lent moral credibility to the colonial enterprise. Consequently, one of my theoretical and political commitments is the resistance to imperial cultural analysis. I abhor the white saviour narrative, where vulnerable children or women of colour must be rescued from men of colour by “culturally superior” white men or women.  We need less individualising narratives, where the full social, political and historical contexts of a situation can be considered.

So what does a process such as colonialism have to do with this video? European colonialism put in place hierarchies of superiority/inferiority and structures of domination and subordination. The conquest and control of other people’s land and goods has recurred throughout human history, but European colonialism in the 19th century allowed for the growth of European capitalism and industry through the economic exploitation of raw materials, cheap, indentured or slave labour and profitable land in the colonies. Profits always returned to the imperial centres. Domination and authority were supported by defence and foreign policies and internalised so that ordinary “indeed decent men and women accepted their almost metaphysical obligation to rule subordinate, inferior, or less advanced people” (Said, 1993, p.10). These imperial ventures were justified on the basis of developmental and pedagogical notions of progress and improvement. They created the template for contemporary production under globalisation. So none of us are outside of or immune from postcolonial relations, values and belief systems whether our ancestors were colonisers or colonised. We are all influenced by colonialism.

Narratives produced about the colonies have historically defined the West in contrast with the “Orient”. The Orient was represented in a denigrating and negative way, in order to represent a civilised and positive Britain. Generalisations were made about groups of people who were treated as a homogenous mass (rather than communities of individuals) about whom knowledge could be obtained or stereotypes created – for example ‘the inscrutable Chinese’. The video plays into this oppositional dichotomy of “us” and “them”, constructing two social groups as distinct and internally homogenous. It begins with a sense of connection, it targets our desire to belong and connect by talking about social media, emphasising what we have in common. However, the “we” that it refers to is white. The video then moves to the “other” and the mobilisation of social movements that social media allows in the form of the Arab Spring. The director Russell then shares a very personal experience of the birth of his son and how his son takes part in his father’s film work and activism. The son embodies Russell’s desire for a better world than the one he came into “because he [my son] is here, he matters”. Russell then takes us to Uganda and the experience of another young man who has had a different life from that of his son. A young man who has experienced loss and unimaginable suffering, who has no future because of Joseph Kony. Russell says something like “you mean this has been happening for years? If this happened in America for one day it would be on the cover of Newsweek”. How can we fail not to be moved? Rusell takes us through the journey he makes with his friends of trying to raise the attention of the United States government of the plight of this young man and eventually through the advocacy and donations of lots of young people who donate small amounts of money every month, the government takes action. Of course this might have nothing to do with the fact that oil was found in Uganda in 2009. Russell in his voice over says they did not wait for governments, they’ve built schools, created jobs, created warning systems to keep people safe. All funded by young people.  Russell invokes liberal humanist arguments (the very ones that were central to colonial capitalism) about the right of the individual to have a good life. As Teju Cole righly points out “the White Savior Industrial Complex is not about justice. It is about having a big emotional experience that validates privilege”.

The video enacts the binary colonial script of the civilised and liberated white person who rescues Ugandan children, thereby affirming the superiority of the former. Russell reproduces the narrow representations of people of colour as a mass of oppressed people who live in a world without freedom, ruled by oppressive vain tyrants (oops that sounds like the West!). He reproduces a flattened and familiar “single story” of Africa. As Chimamanda Ngozi Adichie says “the single story creates stereotypes, and the problem with stereotypes is not that they are untrue, but that they are incomplete. They make one story become the only story.”  In the process, the complexity and diversity of people’s lives are lost and local activism is hidden from view in favour of camera crews with resources and magnanimity. Think about Binyavanga Wainana’s essay, How to Write about Africa:

Never have a picture of a well-adjusted African on the cover of your book, or in it, unless that African has won the Nobel Prize. An AK-47, prominent ribs, naked breasts: use these. If you must include an African, make sure you get one in Masai or Zulu or Dogon dress

The effect is that we focus on the other, instead of looking at the monsters in our own communities. Rather than offering our support to the efforts of indigenous people who are quietly attempting to right wrongs without a television camera present, we get carried away in a tide of righteous indignation about “stopping the monster”.The video provides a depository for our own feelings of powerlessness and frustration. It demands very little of us. We don’t need to be accountable to a faceless mass, because we can trust Russell, we’ve seen the birth of his boy child, we’ve seen him in his kitchen, we’ve seen him in the family bed with both his children. He is trustworthy. Never mind facts such as Kony is no longer in northern Uganda, that the Ugandan army have also contributed to the violence meted out to civilians, that General Museveni used child soldiers way back in 1986 or that only 31% of funds that Invisible children receive go into this charity work.

So what does helping really mean in a different social context? How does sharing a link to a video to an organisation that is barely transparent about its funding, that uses the bodies of children to make a point, that carries us away with the injustice of it all, help? How does the fact that the focus now in Northern Uganda is about repatriating child soldiers who are being held in DRC, Sudan and the Central African Republic, on postconflict rehabilitation and the reintegration of child soldiers? What impact will this film have on former child soldiers who have now reintegrated into  their communities? Can something with good intentions lead to misconceived interventions? Hell yes! The history of modern Africa is replete with aid failures and poorly allocated resources.

I am not against standing up and fighting for what is right, but only when we really understand what we are standing up for, not on “zero knowledge and maximum hysteria” as Elliot Ross argues. So we must make the most of this technology that is available to us and to critically interrogate the sources of this new media, their motivations and their operations . We need to do the research, to ask questions about our own complicity in contemporary geopolitics and to support the people who understand the problem.

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New mothers in a new land: Indian migrant mothers talk

Originally published in: DeSouza, R. (2010). New mothers in a new land: Indian migrant mothers talk. In S. Bandyopadhyay (Ed.), India in New Zealand: Local identities, global relations (pp. 207-217). Dunedin: Otago University Press.

Ethnic identity and acculturation become important issues in the transition to parenthood. The birth of a child presents parents with the opportunity to consider what values are important to them and whether they will look to the future or the past (or both) to determine what will sustain them in their role as parents and nurture their newborn to adulthood. This sifting process involves parents interpreting and accepting or rejecting the values, beliefs, and practices from both their heritage culture and their current community.

Migrant Indian mothers play a pivotal role in such negotiations. This chapter presents research findings from a study on the maternity experiences of Indian migrant women living in Auckland, New Zealand in late 20062. It begins with a brief discussion of the literature around the process of acculturation and its influence on Indian health and maternal health in particular. It then looks at the inherited beliefs and practices that shape the maternity experiences of Indian mothers, especially the centrality of motherhood to identity, and the idealisation and rewards of self-denial and good behaviour. Finally, the chapter discusses the study’s findings. These exemplify how motherhood is idealised and viewed as a socially powerful role among immigrant Indian mothers, and that these mothers have also taken on the messages of New Zealand models of motherhood (and parenting in general) where self-monitoring is required in order to be ‘a good mother’.

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Power relations

Hot off the press! I’ve just had this chapter on power relations published in S. Shaw, A. Haxell & T. Weblemoe (Eds.), Communication and lifespan development. Melbourne: Oxford University Press

Many practitioners see themselves as apolitical and powerless, particularly with regard to their relationships with the structures of medicine and management. However, in reality practitioners are powerful both as individuals and as members of the groups with which they identify. The structures and cultures within which most health and disability practitioners exist and work are based on beliefs and practices that constrain autonomy. These constraints are at work through a number of mechanisms, such as the market, the infusion of targets and performance measures and quality programmes (Newman & Vidler, 2006). In addition, the changing role of consumers or service users from passive recipients of care in the past to people who may be informed, empowered, articulate and ‘demanding’ poses a threat to the ‘knowledge–power knot’ on which professional power rests.

When practitioners view themselves as people who are doing good, they tend to lack awareness of their complicity and embeddedness in relations of power that structure inequality. Yet, power is embedded in everyday practices and interactions (Bradbury Jones, Sambrook & Irvine, 2008). Practitioners within the wider health and disability sectors contribute to social regulation through their roles as employees of the state. They enact government policies for the benefit of the health of the citizens of the state; so they are both governed and governing. Members of recognised professional groups are provided with a moral authority by their capacity to define problems and pose solutions, and their role in defining and evaluating good or normal behaviour and health practices through surveillance of the population and the criteria for interventions on behalf of the state (Gilbert, 2001, p. 201).

These ambivalent relationships with power that are evident among health professionals require exploration. This can be done by considering the various ways in which power is conceptualised and the micro and macro definitions of empowerment. Some shifts in power have occurred in the last few decades, largely influenced by various social movements. Maternity and mental health are two particular examples of professional practice and service delivery in which power can be recognised and ideas of empowerment can be translated meaningful engagement between service delivery and those who engage with the service.

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