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One Surgeon’s Indigenous Immersion

22 February 2018

Paul Anderson M.B.Ch.B. F.R.A.C.S/F.R.C.S (Edin) MA /PhD. Dip Tch
Upper Gastrointestinal Hepatobiliary and Bariatric surgeon
Specialist Review Clinic
Lecturer Health Sciences/Anatomy and Physiology

Providing a greater understanding and sensitivity for practitioners about Māori culture and health is critical in reducing alarming Māori health statistics in Aotearoa.

Te Whare Wānanga o Awanuiārangi is an Indigenous tertiary institution established in Whakatane in the Eastern Bay of Plenty, Aotearoa (New Zealand) in 1991 by Te Rānanga o Ngāti Awa. Awanuiārangi is one of only three institutions in New Zealand designated as a wānanga (Indigenous tertiary institution) under the Education Act 1989. Its establishment was an important step that recognised the role of education in providing positive pathways for Māori development.

Although Awanuiārangi has strong links to the people of Mātaatua, its doors of learning have always been open to all iwi (tribes) and all New Zealanders. The wānanga aims to be a quality provider of programmes in the tertiary education sector in Aotearoa. Its vision is to promote, grow and sustain Māori language, knowledge and culture in all its manifestations and especially with regard to tikanga (Māori practice). Programmes are designed to support and promote academic excellence, and are transferable nationally and internationally. One surgeon; a product of a traditional western medical model, is dropped into this unique, yet culturally progressive educational environment. Adding to the potential discourse the surgeon is educated in an era where Māori history was largely written by white European settlers. The re-learning of history would be de facto part of any immersion into this cultural environment. A lecturer at Flinders University/Medical School Adelaide for nearly 15 years, I had always been interested in medical education. I completed a teaching diploma and founded Specialists without Borders, a not-for-profit medical education organisation, to take the highest vlevel of medical education into developing countries. A badly fractured calcaneus preventing extended periods of standing and operating was my catalyst to consider full Indigenous educational immersion. I was too young to retire, and felt that I still had something to give, so I accepted the offer of a teaching position in anatomy/ physiology and clinical sciences in the Department of Nursing, Te Whare Wānanga o Awanuiārangi.

Total immersion meant I started learning almost immediately. Immersion also meant I needed to personally relearn history to better understand the Māori health model, particularly tikanga. But first let me tell you how it started so you can appreciate what a privilege and unique experience this is for a surgeon. At my interview my academic background was naturally thoroughly reviewed, and after an hour one last question was asked: did I know how to skin a possum (considered a pest in Aotearoa). As the question was asked with a smile, my reply was that no I didn’t, but then being a surgeon and environmentalist I would prefer to vasectomise the creature. I was appointed with much smiling, and then introduced into a nursing department. On my first day I was welcomed onto the campus with a powhiri (a traditional welcome). Then a Kaumatua (Māori elder) welcomed me in Te Reo Māori, the Indigenous language, followed by a karakia (prayer) in Te Reo Māori. Reremoana the Kaumatua then greeted me with a traditional hongi (a Māori greeting) while the woman kissed me on the cheek. I was then escorted to my class of first year students and introduced in Te Reo Māori. Approximately 25 of them stood up and explained who they were in their Māori language, undertaking their pepeha in Te Reo. Pepeha describes many aspects of one’s historical background and provides the potential for crucial relationships. At the end, they looked at me expectantly. With prompting from my colleagues, I explained my background in English, and that I would be teaching them anatomy/physiology and clinical sciences. They all clapped, came to the front of the lecture theatre and stood in a semicircle around me. Two guitars were produced, and they sang the most beautiful welcome waiata (song) for about 10 minutes. I was quickly assimilated into the Department of Nursing and immediately started teaching and learning. The Eastern Bay of Plenty has a 25 per cent Māori population, 40 per cent for children under 16 years. Sadly, the health statistics for Māori reflect inequity.

Mortality across all cancers is 78 per cent higher than the European population, a frightening fact. Uterine cancer has an 84 per cent higher incidence, and breast cancer a 38 per cent higher rate. Leading causes of death in wahine (Māori females) are ischaemic heart disease (IHD), lung cancer, Chronic Obstructive Pulmonary Disease, stroke and diabetes. Leading causes of death in tāne (Māori males) are IHD, accidents, lung cancer, diabetes and suicide.

Many try to explain these statistics as a product of poor lifestyle choice. The answer, I am discovering, lies on many levels, not least how Māori view medicine and healing, particularly as it relates to their traditions and spirituality. Approximately 65 per cent of Māori believe spirituality is a central concept in wairua (spiritual health). A health model which doesn’t recognise this or is devoid of this understanding creates a potential barrier to effective treatment. The Meihana model, initially published in 2007 (Pitama et al 2007) and updated in 2014 (Pitama et al, 2014) visualises the Māori concept of health as a double waka. In this model, the two hiwi (hulls) represent the patient on one side and their whānau (family) on the other. The patient and their whānau are strongly bound together via five crossbeams, each representing an aspect of total health: Wairua (spiritual health), Tinana (physical health), Hinengaro (mental health), Taiao (environmentalhealth) and Iwi katoa (ancestry). Each voyage is charted towards a destination; for this waka, the destination is the attainment Hauora (total health/wellbeing) helped by nga hau e wha (the four winds of Tawhiri-matea), and hindered by nga roma moana (ocean currents) when they work against the whakatere (navigation/direction). With this model in mind, I realised that speaking Te Reo Māori would allow me not only to fully understand the Māori concept of health but also better communicate with Māori patients. This was clearly demonstrated after I opened a free Specialist Review Clinic ( nz) to help the local community. New Zealand has one of the worst, across all race groups, colorectal cancer rates in the world.

During Colorectal Cancer Awareness Week I was asked to speak on prevention strategies on the local Māori radio station. By that stage I was able to introduce myself in Māori and discuss my pepeha. At the next clinic, I opened the consulting room door to find an elderly Māori gentleman standing with two women, each firmly holding an elbow. He looked reluctant to take a single step towards me or my office. I greeted him in Māori, stepped towards him, gave him a hongi and recited my pepeha. He looked at me, smiled, and said to me in English “so you played rugby” (which I had mentioned on the radio) and he walked into my office. The shortened version of this story is that we first had a discussion about his whānau traditions and his cousin who had bowel cancer, and then moved onto his rectal bleeding. He had a small dysplastic polyp at 23 cm, which was successfully removed. He then brought his three brothers to the clinic with similar presentations. He told me I was the first doctor who had spoken to him in Māori which made him feel comfortable and trusting. At that stage I felt my 15 years of experience as a gastrointestinal hepatobiliary and bariatric surgeon was finding another avenue of positive contribution. The thought was developing that the wider health community could help more with a greater understanding of Indigenous needs. The next step was to build a wider awareness. With our nursing students we created a short three act play, highlighting some of the barriers of the western medical health model for Māori patients and the importance for health practitioners to understand tikanga. Every four to six weeks we also now have eight to 10 students coming on to the campus as part of a Rural Immersion Programme. Students are exposed to the local Indigenous health issues and to the culturally sensitive methods of intervention and treatment.

The success of this programme now suggests that, in addition to expanding the free Specialist Review Clinic into a minor procedure centre, the next step is to provide educational immersion for foreign doctors coming to New Zealand. Providing a greater understanding and sensitivity for practitioners about the cultural and health needs of Māori is, I believe, a critical step in reducing the alarming Māori health statistics in Aotearoa. Who said only surgery provides the greatest excitement?

This complete version of this article was first published in "International Australasian Surgical News”.