MCNZ Consultation Draft Statements
on Cultural Competence, Cultural Safety, and Hauora Maori
Introduction:
As a retired medical research scientist with nearly 30 years of experience working in close collaboration with consultant clinicians and teaching clinical training fellows, I wish to provide feedback on the Medical Council’s draft statements. While my career was spent overseas at the intersection of research and clinical practice (Queensland Institute of Medical Research, Queen’s Medical Centre, Queen’s Medical Research Institute) after graduating from Otago (Chemistry), I have observed first-hand the dedication of medics to patient-centred care based on medical need and evidence.
Let me start by stating I support the Council’s goal of promoting culturally responsive care and addressing health disparities. New Zealand’s healthcare system must evolve to meet the needs of our diverse population, and I acknowledge the well-documented inequities in health outcomes for Maori, such as lower life expectancy (7–8 years below non-Maori), higher rates of preventable deaths, and unmet primary care needs (44% for Maori). These gaps are real and demand action.
My core concern with the drafts, however, is their tendency to conflate socioeconomic status (SES) with systemic racism as a primary causal explanation for these disparities. While the draft documents do not explicitly state “systemic racism” it is evident from the use of terms like “systemic bias,” “unfair systems,” “institutional structures,” “power imbalances,” and “colonial histories”. This attribution of systemic racism remains unproven on rigorous scientific grounds and risks embedding socially and scientifically contested interpretations into professional standards, potentially at the expense of more practical, evidence-based solutions focused on prevention, education, and individual responsibility.
Acknowledging Disparities and Inequities:
The drafts rightly highlight inequities in access, treatment, and outcomes, but frames them as rooted in historical colonization and ongoing structural issues. For instance, the Hauora Maori draft states: “Historical and ongoing colonization means that Maori are prevented from accessing resources that promote good health and experience much higher exposure to health harms compared to non-Maori.” Similarly, the Cultural Competence draft notes: “The values and worldviews of settler traditions... continue to privilege or advantage people who align with the ‘norms’ of that time, and disadvantage others.”
I do not dispute the existence of these disparities. Data from the Ministry of Health and studies like the 2019 Waitangi Tribunal inquiry show Maori face higher burdens of chronic conditions (e.g., diabetes prevalence 8–10% for Maori vs. 5% for Europeans), respiratory illnesses, and barriers to care, often amplified by SES factors like poverty, housing overcrowding, and rural isolation which manifests in higher emergency department visits and lower preventive care uptake. I can also appreciate that cultural mismatches can also exacerbate distrust and reduce engagement with services but this issue is not unique to Maori, especially when we have a predominance of internationally trained and migrant medical doctors, nurses, midwives and allied health professionals.
However, the drafts’ mandatory requirements for medical doctors to “actively acknowledge and address your own power, privilege, biases” and “use your professional influence to work in partnership with Maori to identify and dismantle unfair systems and power imbalances” imply acceptance of “systemic racism” as a settled fact. This goes beyond encouraging respect and self-reflection; it mandates endorsement of a causal framework that conflates SES-driven problems with racism, without sufficient causal evidence.
The Conflation of SES with Systemic Racism: An Unproven Attribution:
From my reading of the epidemiological literature, the link between systemic racism and health disparities is suggestive at best, not proven. Studies like Steyn et al. (2021) in the New Zealand Medical Journal show residual ethnic differences in COVID-19 hospitalization odds (2.5x for Māori, 3x for Pacific peoples) after adjusting for age and comorbidities. However, these models often fail to fully account for unmeasured SES confounders, such as household crowding, occupational exposure, or nutritional factors like vitamin D deficiency [as explored in Robert Scragg’s work (UoAkl), which highlights lower levels in Maori and Pacific populations due to biological and environmental reasons].
Researchers like Michael Baker repeatedly attribute these residuals to “structural inequities and systemic racism,” but this is interpretive, presumptive and unproven. Self-reported racism (e.g., 13.8% of Maori citing ethnicity-based discrimination in healthcare) correlates with worse outcomes, but causation has not been established—correlations could reflect SES overlaps or recall bias. Critiques from sources like the New Zealand Initiative argue that SES explains 30–50% of disparities, with racism claims lacking robust empirical isolation. As a scientist, I expect causal proof through methods like mediation analysis or quasi-experimental designs; without it, labelling residuals expressed in increased odds as racism risks confirmation bias and ideological subjectivism in modelling and policy.
This conflation concerns me because it diverts focus from actionable SES interventions. For example, access barriers where practices are often “maxed out” which stem from workforce shortages and capacity issues, not selective turning away based on race. Framing them as “prevented from accessing resources” due to colonization implies racism where logistics and deprivation may dominate. Similarly, obesity and smoking—major risk factors disproportionately affecting Maori and Pacific peoples—are often targeted by clinicians as modifiable behaviours, not ethnic traits. In my experience, any expressed frustration from medical colleagues was directed at these risks, not ethnicity, though critics might call this de facto racism due to demographic patterns. I argue otherwise: it is evidence-based risk stratification.
I would also add that despite historic and targeted preferential entry pathways for Maori students at both Otago and Auckland medical schools (~15-20% of recent intakes) the proportion of practising Maori doctors remains at ~5.5% of the workforce (Medical Council of New Zealand, 2025). This suggests that even with equity mechanisms in training, broader SES, educational, and distributional challenges continue to limit the impact on community service, rather than a lack of opportunity rooted solely in “systemic racism.”
The Role of Individual Responsibility and Education in Prevention:
The drafts emphasize treatment equity (e.g., “equitable outcomes” and “different approaches and resources to get equitable health outcomes”), but underplay prevention. A recent casual observation in nearby Hastings—a city with high Maori and Pacific populations—illustrates this: a McDonald’s packed with Maori/Pacific families and schoolchildren mid-afternoon, with fast food as an affordable social hub. This scene underscores how SES (time poverty, food insecurity) drives dietary patterns contributing to obesity (47% for Maori, 63% for Pacific vs. 32% for Europeans) and related conditions, yet the narrative often defaults to colonial legacies rather than immediate prevention strategies (see post-script).
At what point does individual responsibility enter? Prevention requires education on nutrition, exercise, and health-seeking behaviours, but discussing this risks accusations of victim-blaming, especially from non-Maori voices. Maori-led programs like Whanau Ora show promise in culturally tailored education, yet the drafts focus more on doctors challenging “systemic bias” than advocating upstream interventions. The Ministry of Health’s Equity Adjustor for elective surgeries—prioritizing Maori and Pacific peoples via points systems—addresses treatment gaps but feels like “reverse discrimination” to some, conflating race with need when SES targeting might suffice. Are disparities truly race-based, or SES proxies? The drafts’ language supports the former, potentially embedding it into standards without proof, and that I find unacceptable and unprofessional.
Recommendations and Conclusion:
To strengthen the statements, I would recommend:
Emphasizing universal respect, bias self-reflection, and evidence-based equity actions without mandating acceptance of systemic racism as causal.
Focusing on SES-driven prevention: Encourage doctors to advocate for education, nutrition programs, and community-led initiatives over treatment prioritization alone.
Tying requirements to proven evidence: Require ongoing research to disentangle SES from racism, ensuring standards evolve with data.
Avoiding compelled belief: Reflection on privilege and power should be voluntary tools for improvement, not threats to re-certification.
The Medical Council’s role is to ensure clinical competence and patient safety, not to enforce interpretive frameworks on causation. By conflating SES with racism, the drafts risk dividing the profession and distracting from holistic solutions. I urge the Council to refine these statements to prioritize evidence, prevention, and individual agency alongside equity. I believe this balanced approach is better suited and will better serve all New Zealanders.
Yours faithfully, Simon B Brown (PhD)
PS: Why fast food can look affordable when households are food-insecure:
Food insecurity is not about having literally no food or not knowing when the next meal will arrive. The MoH defines food insecurity as “limited or uncertain availability of nutritionally adequate and safe foods” or “limited ability to acquire acceptable foods in a socially acceptable way.” This often means families can eat regularly but must compromise on quality, variety, or nutrition because of money, time, or access constraints.
Fast food (e.g., McDonald’s) can appear inconsistent with poverty, yet it frequently fits the pattern because:
It delivers immediate calories and satiety at a low upfront cost per meal (high fat/sugar/salt makes it filling quickly).
Healthy home-cooked meals often require more cash at once (buying multiple ingredients), more time (shopping, preparation, clean-up), and reliable access to a kitchen and fresh produce that doesn’t spoil.
In deprived areas, fast-food outlets are denser and more convenient than supermarkets; transport or time to reach better options may not be available.
For exhausted parents juggling shift work or large families, “quick and filling now” often trumps “healthy but effortful.”
This creates a structural trap: fast food solves short-term hunger and time pressure but compounds long-term health problems (obesity, diabetes). It’s not an excuse for poor choices, but it helps explain why the pattern persists despite food insecurity. Prevention—through better education, affordable fresh-food access, and community support—needs far more emphasis than it currently receives.
Ministry of Health. New Zealand Health Survey: Annual Data Explorer (2022/23). https://minhealthnz.shinyapps.io/nz-health-survey-2022-23-annual-data-explorer/
Carter et al. (2010). Aust N Z J Public Health. DOI: https://doi.org/10.1111/j.1753-6405.2010.00615.x