Public health and Te Tiriti

The president of the PHA, Richard Egan, asks why – 35 years after the establishment of the Waitangi Tribunal – the country is not further along the road to bicultural concord?

The Treaty debates, race relations, bi and/or multi culturalism and national identity are issues that continue to nettle all New Zealanders. This is evidenced by such recent examples as Phil Goff's “nationhood” speech, Te Papa's Waitangi debates, the Auckland's super city Māori seat debacle and Hone Harawira's 'racist' email.

Why are such issues and attitudes still not resolved three decades after the establishment of the Waitangi Tribunal, when the then Minister of Health, Simon Upton, declared Te Tiriti to be the nation’s founding document? Are we taking too long to come to terms with the state of our historical and contemporary Treaty/bi-cultural dynamic?

Or does something as momentous as this take more than a generation?

Young people are learning more about Te Tiriti in schools, and Te Papa’s Treaty of Waitangi roadshow a few years ago did a good job with training and resources. But much work is still to be done and ground to be traversed.

Te Tiriti should be one of the cornerstones of health promotion practice in New Zealand. Yet there remains a great deal to be done to operationalise the Treaty in our day to day work.

In the next couple of issues the PHA News will be asking key people – Māori, Pakeha, Pacifica and Asian – to comment on these issues. We hope that this ongoing conversation will stimulate further understanding and debate.

Please do send your suggestions, comments and ideas to raeanna@pha.org.nz.

New School of Public Health launches at Massey University

In March the Minister of Health, Tony Ryall ,and Director-General of Health Stephen McKernan, joined leaders of the public health sector to launch Massey University’s new School of Public Health.

Professor Sir Mason Durie, a driving force behind the school, told guests two clear goals lay at the heart of its establishment.

It aimed to continue “world class research evident now for more than a decade nd to increase the health work force capability in New Zealand". Sir Mason described the launch of the school, held at the Museum of New Zealand Te Papa Tongarewa in Wellington, as a milestone in health teaching research for Massey.

For more information visit: http://sph.massey.ac.nz/.

And to learn what the Minister said, visit: www.beehive.govt.nz/speech/launch+massey+university+school+public+health+-+wellington.

The PHA and the French intern

Once upon a time in a far away country, there was a very intriguing PHA team. A French pharmacy student decided to fly there to see what was going on and to learn and understand Public Health on the other side of the world, by doing an internship.

At her arrival, she had been wonderfully received by PHA with weird accents and curious names: Keriata, Raeanna, Gay.

"I have never heard of these names before, were they really colonized by the British?" she thought to herself.

Thanks to their knowledge and passion, the French intern understood what Public Health was and the importance of Public Health advocacy. She discovered how research worked, the link between pharmacy and Public Health thanks to the submission about childhood immunisation. More than the work, PHA initiated the little intern to the New Zealand art of living and the power of Maori culture. So many discoveries and awarenesses, so many slangs and jokes.

Rae: "Sind mi a tixt"
Mousumi (thinking): "What? Quoi? Que?… What is she talking about?"
Rae: "A tixt !!! with your cill phone!!"
Mousumi (thinking): "What is a seal phone? There are seals at Red Rocks, I’d like to see them."
Mousumi: "Oh !! a text !! with my cell phone!!"

Thus days were passing calmly and less calmly, routine of surprises and rebounds.

"What is a seal phone? There are seals at Red Rocks, I’d like to see them."

One day, a misfortune happened! The intern’s visa was expiring! How would she finish her internship at PHA?

Quick quick! She needed to extend it. And thanks to PHA team's support and advice she could do it in one day without any problems.

She could then extend her stay in Wellington and go to the Select Committee to see her supervisors shining at parliament.

Enriched by this wonderful experience at the Public Health Association of New Zealand, with kiwi slang full in her head, the little intern is leaving for new adventures.

Thank you PHA for everything you taught me, your warm welcome, patience and for educating me about the values you defend.

Aroha nui,

Au revoir mes maitres, mes amies,

Your PHA intern, Mousumi

Download a specially formatted PDF version of this article created by Mousumi.

Whānau weight loss challenge inspires Auckland Māori

Florence Hoeta of Waiuku says it was a stern lecture from her doctor that motivated her to begin her weight loss journey.

She is pictured here with the prize-winning cheque for most weight lost by an individual.

Obesity is one of the most serious health risks to Māori, and Mana Whenua i Tamaki Makaurau have come up with a unique way to encourage Māori living in their area to lose weight.

Mana Whenua i Tamaki Makaurau is a consortium of iwi who encompass the same geographical territory as the Counties Manukau District Health Board. Their Project Manager, Tahuna Minhinnick, came up with the idea of a weight loss challenge that would focus on whānau – rather than individual – weight loss.

Whānau teams of between 10 and 12 members were invited to enter the competition with the biggest prize being awarded to the most weight lost by a whānau. At stake were cash prizes amounting to $21,000.

Mr Minhinnick expected around six teams to enter but the numbers soon swelled to 40 teams, which meant that almost 500 Māori from around South Auckland and Counties Manukau were competing.

The 12-Week Whānau Weight Loss ran from the beginning of August until the end of November.

“We need to claim our mauri and keep going. You have to stay positive and at
the end of the day you have to want to maintain it.”

Florence Hoeta of Waiuku took the prize for most weight lost by an individual. Florence has weighed close to 200kgs and at the beginning of the challenge clocked the scales at 159.8kgs. Over the course of the competition she lost an impressive 31.8kgs – and she says it was a stern lecture from her doctor that motivated her to begin her weight loss journey.

“I was on the borderline of so many diseases it wasn’t funny. It’s about life and death. If I’d kept going the way I was I may not be here today,” she said.

She liked the focus on whānau at the centre of the challenge. According to Florence whānau can be the biggest supporter or worst enemy when you are trying to lose weight.

“We need to claim our mauri and keep going. You have to stay positive and at the end of the day you have to want to maintain it.”

The winning team was the 12 Disciples who represented Raukura Hauora o Tainui. Their overall weight loss was 133.5kgs. Speaking on behalf of the team, Vance McPhee says they all set a goal to lose 10 kilograms each.

“Eighty percent is about diet, and we had to resist the normal temptation of food. Our biggest learning was seeing something through to the end. We all aim to keep the weight off for good,” he said.

The competition concluded with a celebration at the TelstraClear Event Centre in Manukau on 30 November attended by around 1000 people. Tahuna Minhinnick is already planning this year’s challenge, which will see many of the same people entering along with a host of newcomers.

We shed health jobs at our peril

The Ministry of Health has shed 200 jobs and is planning to cut another 150 by mid-2011. Health Minister Tony Ryall says cutting administrative jobs allows more doctors and nurses to be employed at the front line.

However, Public Health Association National Executive Officer Dr Gay Keating questions the value of that when those same doctors and nurses are increasingly burdened with people becoming unnecessarily ill.

We absolutely need the doctors and nurses, physios and psychotherapists, dialysis technicians and radiotherapists. But we also need the computer staff, the pay clerks and the hospital cleaners. Having adequate support staff allows clinical staff to get on with their jobs. Otherwise, it’s the doctors and nurses who end up having to order equipment and fill out paperwork.

So called ‘back-room bureaucrats’ play a vital role in keeping us safe and healthy. They set food handling standards and inspect cafes so customers don’t get food poisoning. They check that people’s immunisations are up-to-date, that women are having their breast screening and cervical smears, that middle-aged men are getting their blood pressure checked, that people with diabetes are having their eyes checked, that older people are getting their flu shots.

Every year we need bureaucrats and lab technicians to make sure the flu jab has the right mix of virus strains. And for every vaccine, it’s bureaucrats who make sure the products are transported and stored safely.

Reducing the 'back room' workers who help prevent sickness will inevitably
lead to more demand for hospital beds.

It's bureaucrats who require ingredients be listed on processed food. Not a big issue to many of us perhaps, but ask the parent of a child with a peanut allergy what they think about ‘bureaucratic labelling’.

Then there’s the team on the phones at Quitline. And the enforcement officers who make sure tobacco isn’t sold to children, and that those responsible are prosecuted if they do.

There are the food safety workers who ensure melamine contamination doesn’t happen here. There are the emergency management workers, the ones we rely on to plan for The Big One.

Not one of them ‘front line’, but all of them needed.

In a recession, the health of a population is less robust than in good economic times. Reducing the ‘back room’ workers who help prevent sickness will inevitably lead to more demand for hospital beds.

Efficiency and value for taxpayers’ money are extremely important in health. But any economist will tell you it’s a false economy to save money letting people get sick so they need more expensive hospitalisation further down the line.

This piece appeared in The Dominion Post, 31 March 2010.

How the New Zealand health system compares with other countries

This is an abridged version of an address by Don Matheson, Professor at the Centre for Public Health Research at Massey University and a former Deputy Director-General of Health, and Director of the PHA to the 21st Annual Conference of the Association of Salaried Medical Specialists, on 3 December 2009.

Comparisons

There is much that the rest of the world envies in the New Zealand health system and it is not the basket case that some like to present it as. The Horn Report¹ says:

New Zealand spends a high proportion of its national income on health. It is higher than the OECD average and, with the exception of the US, Switzerland, France and Germany, it is not materially different from the highest in the world... Sustainability of our public health and disability systems is under serious threat.

But 2009 OECD data shows New Zealand has, in fact, the lowest level of spending of comparable countries, despite increases between 2003 and 2007.

New Zealand is among the most efficient of OECD nations in terms of money spent on health and associated life expectancy; we spend the least per capita on drugs, and GPs’ use of technology leads the world, as does their satisfaction with practising medicine.

In health equity between Māori and non-Māori the country is showing improvement and New Zealand is ahead of other OECD members in its ability to track this, so up-to-date data is always available.

The most comprehensive analysis of the performance of the New Zealand health system in relation to similar countries comes from the Commonwealth Fund. In 2007 it found that while New Zealand had the lowest expenditure, in terms of quality, access, efficiency and life expectancy, the country (together with Australia and the UK) “continue(s) to demonstrate superior performance”².

Prevention

In 2009, the New Zealand economist Gareth Morgan wrote: I accept that we need to treat obesity as we have smoking. This may mean being a bit of a nanny state, in order to avoid becoming a nursery state.³

"New Zealand's relatively strong commitment to prevention and public health has
helped improve life expectancy."

Five years earlier, a United Kingdom Treasury-sponsored report⁴ asserted that the only effective way to tackle the ever-rising cost of healthcare is for the whole of society to ‘fully engage’ with prevention.

But in its scepticism of the role of prevention, the Horn Report is unique amongst economists and bankers who have reviewed health systems. While it begrudgingly notes:

New Zealand's relatively strong commitment to prevention and public health has helped improve life expectancy, delayed the onset of disability associated chronic disease, and reduced inequalities;

It goes on to say:

Opinion is divided however on the much narrower question of the extent to which further spending in this area at the expense of more immediate health needs might help reduce future health costs or improve the country’s economic performance.

This breaks new ground in defining prevention and public health almost solely in terms of their impact on the economy. In fact improving life expectancy, delaying the onset of chronic disease and reducing inequalities all improve economic performance. ^{5, 6, 7} But Horn suggests that the princely sum of 4 percent of health expenditure currently spent on public health may be better diverted to curative care.⁸

"We should not repeat the mistake of the 90s where we elevated efficiency to a goal in itself,
instead of seeing efficiency as an ingredient to achieving real health sector
goals such as equity and quality."

Challenges

Equity and caring for our young remain major challenges in this country. We know that six percent of New Zealanders are unable to access primary health care when they need it due to the level of fees charged, alongside other access issues.⁹ So how do we find ourselves in 2009 with a review “Meeting the Challenge” that fails to emphasise that addressing health equity is a core purpose of our health system? Have we had enough “equity” for now?

We should not repeat the mistake of the 90s where we elevated efficiency to a goal in itself, instead of seeing efficiency as an ingredient to achieving real health sector goals such as equity and quality.

One area that is a complete embarrassment is that our material support for children and young people is so low compared to other industrialised countries. There has been some improvement but New Zealand continues to have the highest rate of youth suicide of OECD countries – at 15.9 suicides per 100,000 15-19 year olds, compared with the average of 6.9. Our spending on young New Zealanders 0-17 years of age is consistently less than the OECD average and is less than half the group’s average for children up to the age of five.

The prevalence among adults of obesity and the number of years of life lost because of diabetes is second only to the United States and, despite improvements, New Zealand is just 14th out of 19 OECD member states for premature mortality from conditions amenable to health care.

Our practising physician workforce is lean – only Canada is below New Zealand in the number of doctors it has per 1000 people. The Scandinavian countries have the most at almost five, the OECD average is slightly higher than three and New Zealand has just over two.

So the New Zealand health system certainly has its challenges – I suggest health equity and the welfare of our children and young people, and chronic diseases such as diabetes would be a better focus for our activities rather than  theoretical health expenditure levels in 2030 alone.

Read Professor Matheson's address online here. The speech is fifth in the list.

____________________________

1. Ministry of Health, July 2009, Meeting the Challenge: Enhancing Sustainability and the Patient and Consumer Experience within the Current Legislative Framework for Health and Disability Services in New Zealand, Report of the Ministerial Review Group (This is also known as The Horn Report).

2. Karen Davis, Cathy Schoen,et al. Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care The Commonwealth Fund, May 15, 2007, Vol 59

3. Morgan, G and Simmons, G, 2009, Health Cheque, published by The Public Interest Publishing Co Ltd

4. Wanless, Derek, 2004, Securing Good Health for the Whole Population, HM Treasury

5. Investing in Health for. Economic Development. Report of the Commission on Macroeconomics and Health. Chaired by Jeffrey D. Sachs http://whqlibdoc.who.int/publications/2001/924154550x.pdf

6. Chronic disease: an economic perspective', Marc Suhrcke, Rachel A. Nugent, David Stuckler and Lorenzo Rocco for Oxford health Alliance, 2009. www.oxha.org > Initiatives > Economics

7. Economic theory predicts, and econometric evidence finds, that inequality increases crime and political corruption and, in certain circumstances, constrains growth. Ref: Economic Costs of Inequality (November 2007). McAdams, Richard H., U of Chicago Law and Economics, Olin Working Paper No. 370; U of Chicago, Public Law Working Paper No. 189. Available at SSRN: http://ssrn.com/abstract=1028874

8. Health Sector – Information Supporting the Estimates of Appropriations for the Government of New Zealand for the Year Ending 30 June 2010, New Zealand Treasury

9. Ministry of Health, 2008, A Portrait of Health – The 2006/07 New Zealand Health Survey

Ora Taiao says New Zealand must commit to limit greenhouse gas emissions

“The consequences of runaway climate change are truly frightening,” says Ora Taiao spokesperson Professor John McCall.

A recently-formed New Zealand grouping of health professionals concerned by climate change is very disappointed at the lack of progress made at the recent Copenhagen summit.

Ora Taiao: New Zealand Climate and Health believes a legally binding United Nations accord between the countries to limit the increase of temperature to 2 degrees by 2100 was a vital step toward avoiding the worst effects of climate change.

“What was achieved fell way short of that,” says John McCall.

“A non-binding agreement and no real goal to aim for is a disappointing result.”

“The problem in New Zealand right now, as in many other countries, is that the
number one priority for the government is the economy, and protecting the
environment comes a very poor second."

The group, which formed in August 2009 but already boasts 150 health practitioner members, is lobbying for more government action on climate change, and made submissions on changes to the Emissions Trading Scheme last year.

“The problem in New Zealand right now, as in many other countries, is that the number one priority for the Government is the economy, and protecting the environment comes a very poor second. We would like to see the climate change debate reframed so it is not just seen as an economic and environmental issue but a public health issue,” Professor McCall says.

“The consequences of out of control climate change are truly frightening and the cost of not mitigating its worst effects are enormous in both population and personal health terms.”

He says the health effects of runaway climate change include:

• mass starvation
• infectious disease due to lack of access to clean water and altered patterns of insect borne disease transmission
• conflict over increasingly squeezed resources
• mass displacement of populations due to the rising sea levels
• the direct consequences of increasingly frequent and severe weather events.

"Everyone will be affected but the young, the old, the poor and people living in vulnerable geographic regions will be hardest hit. We have to hope we can avoid the worst of these consequences but hope alone is not enough, we need to agitate for the politicians to take meaningful action whilst meaningful action is still possible.

“On the other hand there are immediate and substantial health co-benefits to be gained from converting to a low emissions economy, such as more active transport, clean air and water, healthy diets and better insulated houses.

"New Zealand must work on a firm commitment to limit temperature increase to 2 degrees."

“Reducing emissions is not only about avoiding future catastrophe, it also provides an opportunity for improving public health.”

New Zealand submitted its intended reduction in greenhouse gas emissions, as per the Copenhagen agreement, on 1 February. Professor McCall says the targets are the same the government proposed last year: 10 to 20 percent reduction on 1990 levels by 2020.

“This is too modest. According to the best available scientific evidence if every other country was to aim for this, it would not be enough to limit temperature rises to 2 degrees.”

Ora Taiao says New Zealand must work on a firm commitment to limit temperature increase to 2 degrees. Professor McCall says the government should drop the many conditions it has attached to its non binding goal.

“We would especially like to see dropped the government’s desire to preserve the ability to continue buying carbon credits overseas, rather than making real reductions at home.”

Professor McCall, who is Professor of Surgery at Otago University, says one of the best, up-to-date, and reader friendly documents on the health effects of climate change is the World Health Organization’s Protecting Health from Climate Change, which is available here.

Learn more about Ora Taiao here.

Conference 2010 preparations underway

We are honoured to be able to hold the 2010 conference at the historic Turangawaewae Marae, which was the home of Princess Te Puea, one of New Zealand’s most famous women.

Preparations for PHA Conference 2010 are afoot with the call for abstracts closing 28 April.

"Tomorrow for tomorrow's people – He ao mō ngā whakatupuranga o āpōpō", has three main themes:

• Health and environment: for projects or work in social and physical environments that link to wellbeing
• Sustainable development: for projects or activities that involve community development OR those that look to a sustainable future
• Making the connection: focusing on linking health to other sectors OR working in collaborative partnerships.

Abstracts are invited for:

• workshops (1 hour)
• oral presentations (15 minutes + 5 minutes for questions)
• posters.

More than one abstract may be submitted.

A change of government leads to policy and funding changes; throw in matters like global warming, and we can say the winds of change are certainly upon us.

It is important for us working in public health/community development to come together to share and inform one another about public health directions and what we can offer all the people of New Zealand.

This year’s PHA conference is about encouraging those who work with communities to share their stories of today to help build a healthy future for tomorrow.

We are honoured to be able to hold the 2010 conference at the historic Turangawaewae Marae, which was the home of Princess Te Puea, one of New Zealand's most famous women.

For those who have never visited Turangawaewae this is a great opportunity to come and experience the marae’s manaakitanga. What greater place is there for a marae experience and to be guided through the protocols?

So, come join us at the official royal residence of the Māori King, Tuheitia Paki, where we will explore the conference themes of health and environment, sustainable development, and making the connection.

Mark 22-24 September in your diary and book your tickets to join us for spring in the Waikato!

Round the branches

Te Tai Tokerau had a busy year in 2009, making several submissions on public health issues.

The committee’s submission to the Law Commission on its review of alcohol law emphasised the need to strengthen regulation of the advertising of alcohol and changing the way people market, supply and sell it.

The committee also made a submission to Statistics New Zealand that it strongly supported the removal of “New Zealander” as a category in future census. The committee submitted that for efficient planning and decision-making in health, it was vital to have good information about different ethnicities.

Te Tai Tokerau also made submissions to Far North, Whangarei and Kaipara District Councils, as well as the Northland Regional Council, on public health issues within their Long-term Council Community Plans, such as housing.

The committee has also been working with Alison Blaiklock from the Health Promotion Forum to develop a training schedule that meets the workforce development needs of kaimahi in Te Tai Tokerau.

We are currently trying to organise a date so as many people as possible can attend our 2010 AGM – not easy with so many busy committee members!

Callie Corrigan
PHA Council Representative
Te Tai Tokerau

National Office roundup

The PHA’s national office has started the year with some changes.

Gay Keating is back as National Executive Officer after (ironically) a period of poor health. She’s well into planning for the next financial year. Gay’s return also means Keriata Stuart returns to her usual role as Senior Policy Analyst, Māori public health. Gay, Keriata and Office Manager Raeanna Thomas are looking forward to a cracker of a year in 2010.

We also have a return visit from Mousumi Rahman, a French pharmacy student who spent three months with us as an intern last year. Seeing public health in New Zealand helped Mousumi decide that this was her career path, and she has now been accepted for post-graduate study at the London School of Hygiene and Tropical Medicine.

Mousumi loves New Zealand and New Zealanders, and is really enjoying having contact with Māori culture. While she’s back in Wellington, she has been helping develop our submission on increasing immunisation rates. She’s also seeing other parts of the public health sector, working on a project with Regional Public Health.

On the downside, Liz Price, the PHA’s Communications Manager for five years, is leaving her role. Liz has been the integral link in the PHA’s interface with the rest of the public health community and the wider New Zealand public.

She has been at each of our annual conferences during her PHA “career” liaising skilfully between presenters and reporters to make sure the PHA got as much media coverage as possible. She project managed our new branding, led our communications when we supported the repeal of Section 59 and conducted many successful media training sessions for other NGOs as well as for PHA personnel.

Liz was a great help to branches when they needed to get a “message out” and she also managed media coverage of Wellington branch’s annual post-budget breakfast.

Liz will be very much missed although she assures us she will be around and seeing everyone from time to time. Rob Zorn, who has worked with Liz for many years, has made a seamless transition into the role of PHA Communications Manager.

Our busy year so far has included:

• a submission to the Māori Affairs Select Committee inquiry into Māori and tobacco use
• a submission to the Health Select Committee inquiry on improving immunisation rates
• contributing to the development of a qualification framework for generic public health competencies – the framework is close to being ready to go out for consultation
• supporting the development of the new public health leadership course, which is calling for applications for 2010
• contributing to a new project on multi-disciplinary approaches to public health.

Mason Durie – a new knight for Aotearoa

Professor Mason Durie, Public Health Champion for 2003, was made a Knight Companion of the New Zealand Order of Merit for services to public health and Māori health in the 2010 New Year’s Honours.

Sir Mason (Rangitane, Ngati Kauwhata, Ngati Raukawa) says he accepted the knighthood on behalf of the many Māori health providers in NGOs, PHOs and DHBs.

“To me it recognises the significance of Māori health as an integral and distinctive part of New Zealand’s public health sector. It is only in the past 25 years that Māori health has been embraced as a significant dimension of the New Zealand health system. It means that the work of many people has been recognised.”

He says he is particularly mindful of the people, many of whom have since passed on, who he had the good fortune to work with and who inspired him: Rina Moore, Nitama Paewai, Doug Sinclair, Henry Bennett, Eru Pomare, Paratene Ngata and Les Ding.

Asked if the knighthood is one of the most exciting things to have happened to him, he replies, diplomatically, that the most exciting thing for him has been to witness the rapid growth of the Māori health workforce.

“And the ways in which their contributions have been embraced by our health services, as clinicians, community workers, researchers, managers, policy makers and at governance levels.”

Sir Mason says despite the honour, things seem pretty much “business as usual” which is what he would expect. He says official mail now tends to bear his new title, but mostly he remains “just Mason”.

Read a biography of our new knight at www.pha.org.nz/phchampmdurie.html.

Media roundup

The November 2009 to February 2010 period has seen much “behind the scenes” work with media training and activity on an extended communications strategy based on avoidable hospital admissions. Media work was limited by the absence of our major spokesperson Gay, and Keriata working exceedingly hard in different directions for the PHA.

I have regretfully resigned from my PHA communications role. I have really enjoyed my time at PHA, and in particular working with such committed and caring people, who put wellbeing before profits every time. It is a rare thing to be able to work with such people. I particularly want to thank Gay, Keriata, and Rae for the support they gave me. I wish everyone at the PHA my very best for an exciting and satisfying future!

Liz Price
March 2010

Media activity

PHA media releases are archived online at www.pha.org.nz/keydocs.html#mediareleases.

Heroes of public health

This is our second instalment in a series of profiles of pioneers whom present day public health folk regard as heroes of public health practice. Unfortunately we were not able to secure suitable permission to publish photos so links to photos have been provided instead.

Professor Sir Mason Durie pays tribute to some of his champions.

Nitama Paewai

Nitama Paewai was a talented rugby player who achieved national honours but he was also a highly innovative general practitioner. For many years he practised in Kaikohe where he quickly came to appreciate the close links between health, social environments, and economic circumstances.

Among his several community projects, in the 1960s he established a budgeting agency designed to help struggling whānau. Through his efforts many families were financed into healthy homes and many students were able to continue secondary education.

Nitama had abundant energy, was an advocate for healthy lifestyles, and a staunch supporter of the Church of Jesus Christ of the Latter Day Saints. His religious beliefs sometimes led him into conflict with colleagues but he never swerved from acknowledging spirituality as an element of good health.

Nitama Paewai was a public health practitioner who tackled the wider determinants of health in a practical manner within his own community.

View a photo of Nitama Paewai at http://teaohou.natlib.govt.nz/journals/teaohou/image/Mao52TeA/Mao52TeA005.html.

Sonny Waru

Sonny Waru was neither a health practitioner nor a university graduate. But his example in the 1980s paved the way for subsequent programmes that would enable Māori youngsters to regain more balanced lifestyles and a sense of identity.

As a member of the Māori Health Standing Committee (of the then New Zealand Board of Health) he strongly advocated that marae authorities should take more active roles in public health and provide much needed leadership. His influence as a tribal leader himself was an important ingredient.

But probably his greatest contribution to public health was his work among solvent abusing street kids in Auckland. With minimal funds and no technical knowledge, he transported groups of alienated youth back to Taranaki where he exposed them to marae living and immersion in Māori language, culture and tradition. He never lectured them about glue sniffing or other health hazards but guided them through a series of encounters that more often than not transformed their lives and unleashed positive attributes.

He died before his work could be widely appreciated but as a champion of youth he recognised that good health was founded on a secure identity and the internalisation of positive lifestyle values. In later years, those understandings would form the basis of public mental health programmes.

View a photo of Sonny Waru at http://collection.aucklandartgallery.govt.nz/collection/results.do?view=detail&db=object&id=8497.

Eru Pomare

Professor Eru Pomare was both a scholar and a healer. Before his death at the age of 52 in 1995, he was Dean of the Wellington Clinical School and Professor of Medicine.

But his enduring legacy lies with his contributions to Māori health. In that respect he followed a family tradition. His grandfather, Sir Maui Pomare, was the first Māori medical practitioner who, in 1901, had become the Medical Officer of Health to Māori in the newly formed Department of Public Health.

Sir Maui established a team of Māori health inspectors, all leaders within their own communities and instructed them in the importance of drainage, sewerage, water supplies, the causes and management of tuberculosis, healthy eating and child care. At a time when the average Māori life expectancy was 31 years, he travelled the country urging iwi to adapt to new lifestyles and to embrace the best of western health practices.

His efforts, and those of his colleague Sir Peter Buck (Te Rangihiroa) were instrumental in turning the tide of Māori depopulation.

Like his grandfather, Eru Pomare devoted his professional life to Māori health. He published a series of reports that compared Māori and non-Māori life mortality and morbidity and drew attention to both biological and environmental risk factors.

The research centre he established (renamed the Eru Pomare Centre for Māori Health Research after his death) undertook much needed research into environmental stressors, including unemployment, asthma and access to services, but Eru will be remembered in many Māori communities for his tireless efforts to bring health knowledge and health promotion to the marae.

View a photo of Eru Pomare at http://teaohou.natlib.govt.nz/journals/teaohou/image/Mao58TeA/Mao58TeA029.html.