A New Zealand-born surgeon – who spent most of his career overseas – shares the lessons he’s learnt from becoming an anatomy teacher for the country’s only kaupapa Māori nursing degree – and how he is now sharing that learning.

Key to the vision of Te Whare Wānanga o Awanuiārangi is to promote, grow and sustain Māori language, knowledge and culture in all its manifestations – including within its nursing degree.

Into this unique – yet culturally progressive educational environment in Whakatane – drop one surgeon; a product of a traditional western medical model.

Not only that, but someone educated in an era where New Zealand/ Māori history was largely written by white European settlers. Also a time when the Land Wars of the 1800s, were referred to as ‘the Māori Wars’, although they were more correctly ‘Colonial Wars’; as it was the soldiers who were attempting to suppress the indigenous/Māori peoples. Even though I grew up in the Bay of Plenty, the re-learning of history would be a major part of my immersion into the Wānanga (see more about Te Whare Wānanga o Awanuiārangi at end of this article).

Education has been something I have always really enjoyed – I lectured medical students at Adelaide’s Flinders University for nearly 15 years and undertook a teaching diploma. I also founded Specialists without Borders, a not-for-profit medical education organisation to take the highest level of medical education into developing countries, particularly Africa. The cultural learning from being involved in that work has been immense. One example being understanding how the cultural shyness of Rwandan’s impacted on their learning style, which lead to us developing Structured Clinical Instruction Modules (involving small group teaching) which are much more culturally sensitive.

The catalyst to me returning to the Bay of Plenty and teaching at the Wānanga was a badly fractured calcaneus (heel bone) and resulting complications that prevented me from standing and operating for extended periods. Being too young to retire, and with a feeling that I still had something to give, I accepted the offer of a teaching position in anatomy /physiology and clinical sciences within the Whakatane-based wānanga’s department of nursing.

The privilege of being immersed in things Māori

The total immersion meant my learning started almost immediately. Māori, despite being a fierce warrior group, have a cultural shyness, and a proclivity to visual and auditory learning. Lessons from Africa would possibly be of value; but immersion meant firstly the personal re-learning of history and understanding of the Māori health model. Particularly the understanding of tikanga, as it applies to Māori patients.

But first let me tell you how it started, so you will start to appreciate what a privilege and unique experience this is for a surgeon.

At my interview my academic background was naturally thoroughly reviewed, and then, after an hour, a last question: Did I know how to skin a possum?

As the question was asked with a smile, my reply was that “no I didn’t”, but I would prefer to vasectomise the creature being both a surgeon and environmentalist. I was appointed with much smiling, and then introduced into a nursing department with five strong, professional, culturally-sensitive women.

On my first day I was welcomed onto the campus with a powhiri. Standing at the gates I was called on to the campus by my female colleagues and sung to. Then I was welcomed by a kaumatua (elder) in te reo Māori, followed by a karakia in te reo. Reremoana, the kaumatua then greeted me with a traditional hongi while all the woman kissed me on the cheek. It did make me wonder whether most surgical departments would run better with this kind of introduction. But this was only the start.

I was escorted to my class of first year nursing students. There I was introduced in te reo and approximately 25 of them stood up and explained who they were in also in Māori, with each sharing their pepeha. Another rapid learning for me, pepeha describes many aspects of one’s historical background so culturally important to Māori. The mountain that you grew up with and associate with, your lake or river, your iwi (tribe) and the waka which brought you to the place where you are at.

When they had finished 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 and then came down 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 ten minutes. I knew then that I wanted to learn this beautiful language.

I was quickly assimilated into the Department of Nursing and immediately started teaching and learning.

The area surrounding the Wānanga, the Eastern Bay of Plenty, has a population 25% Māori, with 40% of the children under 16 years Māori. I discovered mortality across all cancers is 78% higher than the European population. Uterine cancer has an 84% difference in incidence versus the European population, and breast cancer a 38% higher rate. Leading causes of death in wahine (women) are ischaemic heart disease (IHD), lung cancer, chronic obstructive pulmonary disease (COPD), stroke and diabetes. Leading causes of death in tangata (men) are IHD, accidents, lung cancer, diabetes and suicide.

Many try to explain these statistics as lifestyle choice. The answer I am discovering however lies on many levels, not least an understanding of tikanga, how the Māori has traditionally seen medicine and healing, particularly as it relates to their tradition and spirituality.

Approximately 65% of Māori believe spirituality (wairua) is a central concept in health. A health model which doesn’t recognise this or is devoid of this understanding, creates a potential barrier to effective treatment. A model that incorporates this blending of spirituality and tradition is the Meihana model of the waka hourua (double-hulled canoe – see below).

The two hulls represent the patient and their whānau (family) attached and bonded through the five aku or crossbeams of wairua (spiritual), tinana (physical), hinengaro (psychological), taiao (environment) and iwi katoa (services and support) that each have a role in the patient’s health. Each voyage is ‘charted’ towards a destination, the patient attaining hauora (health/wellbeing). But the voyage can influenced by nga hau e wha (the four winds that include racism), nga roma moana (ocean currents including the patient’s relationship with their whānau) and whakatere (navigation/direction). (*See more about Meihana model below).

Te reo and tikanga – making a real difference to people’s health

Personal learning was starting to break down some of my indigenous misunderstandings.
It was, however, apparent that to fully understand the differences, speaking some te reo Māori would be of benefit. In addition, it would importantly allow me to begin to communicate to patients.

No better demonstration of this followed me opening a free Specialist Review Clinic (see more at www.eaFund.org.nz), with a view to helping the local community.

It is well known New Zealand has one of the worst rates, across all ethnic groups, of colorectal cancer in the world; and I was asked to speak on prevention on the local Māori radio station.

By this stage I was able to introduce myself in Māori and discuss my background. I talked about the need, particularly for men, to be aware of the significance of rectal bleeding.

At the next clinic, I opened the consulting room door to find an elderly Māori gentleman standing with two wahine, each woman firmly holding an elbow. He looked like he was not going 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” as he walked into my office.

The shortened version of this story is that we first had a discussion about his whānau traditions, then about his cousin who had bowel cancer, and then moved onto his rectal bleeding. He had a small dysplastic polyp at 23cm, which was successfully removed. He later brought three brothers to the clinic with similar presentations.

At this stage I felt another avenue was opening up for my 15 years’ experience as a gastrointestinal hepatobiliary and bariatric surgeon to make a positive contribution. Another thought – that more could be done if there was a greater understanding of indigenous needs by the wider health community – was also developing. The first step would be to create more awareness.

With our nursing students’ we created a short three act play, highlighting some of the barriers of the western medical health model for indigenous Māori patients, while also highlighting the importance for health practitioners to understand tikanga.

Every four to six weeks we now have eight to ten health professional students from across the country coming on to the Wānanga campus as part of a Rural Immersion Programme. Students are exposed to the local indigenous health issues (including presenting the play) and are also exposed to culturally sensitive methods of intervention and treatment. History’s contribution to today’s Māori health statistics (i.e. forced urbanisation) and modern diet are also featured.

The success of this programme is prompting the thought that the next step for me – apart from expanding the free Specialist Review Clinic into a minor procedure centre – is to also provide educational immersion for foreign doctors coming to New Zealand. Thereby providing a greater understanding and sensitivity to the cultural and health needs of Māori by doctors new to New Zealand.

Who said only surgery provides the greatest excitement.

Paul Anderson, MBChB FRACS/FRCS (Edin) MA, PhD Dip Tch is an Upper Gastrointestinal Hepatobiliary and Bariatric surgeon. He is a lecturer at Te Whare Wānanga o Awanuiārangi’s nursing school, offers the free Specialist Review Clinic to the Eastern Bay of Plenty – www.eaFund.org.nz – and is the founding Chairman of Specialists without Borders (http://www.specialistswithoutborders.org/).


*The Meihana model was initially published in 2007 – using Mason Durie’s well-known Te Whare Tapa Wha model as its foundation – and re-published in 2014.

Pitama S, Huria T and Lacy C (2014). Improving Māori health through clinical assessment: Waikare o te Waka o Meihana, New Zealand Medical Journal, 127 (1393).

Background:
Te Whare Wānanga o Awanuiārangi is an indigenous tertiary institution which was established in Whakatane in the Eastern Bay of Plenty, New Zealand in 1991 by Te Rūnanga o Ngāti Awa. Awanuiārangi is one of only three Wānanga under the Education Act of 1989.
The name Awanuiārangi is linked to the genealogy (whakapapa) of the Mātaatua canoe, which landed at Whakatāne. 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 institution aims to be a quality provider of programmes within the tertiary education sector in Aotearoa (New Zealand).

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