Dr Maxine Ronald: Treating cancer, fighting inequity

A high school careers advisor told a young Maxine Ronald that Māori didn’t do medicine — and that very nearly deprived the country of its only wahine Māori consultant breast cancer surgeon.

In this kōrero with Dale, Maxine talks about how a Mana magazine profile of another wahine Māori inspired her to take the leap into medicine, and how her own breast cancer diagnosis led her back to her Māori whānau.

 

Kia ora, Maxine. Do people call you Max? Do you call yourself Max?

Yeah, just Max — otherwise I think I’m in trouble.

All right then. I wonder if you’d be kind enough to talk with us about your name, your crew, the Ronald clan, and a little bit about your growing up days?

The Ronald part is actually my stepdad’s name, Tom Ronald. It’s a Scottish name. I grew up with my mum Pauline, who’s Pākehā, and she married my stepdad when I was about two or three. Her whānau name is Murray.

My Māori father was a Reti, from Waikare, but I didn’t know him when I was growing up. So I was quite disconnected from my Māori side. I grew up in a beautiful Pākehā family in Tāmaki Makaurau, in Kumeu. I was the only Māori in our whānau. I was very loved, and they celebrated my Māoriness, but I wasn’t connected to te ao Māori.

And it stayed that way when I was growing up. There was only one other Māori kid in our small primary school, and I experienced racism in that school. So by the time I hit high school, I didn’t want to be Māori, and wasn’t interested in that side of things.

I wanted to study French and German in high school, but my dad, Tom, wouldn’t let me. He said if I was going to learn a language, it had to be te reo, which I was quite angry about.

But by the time the next year came around and it was time to choose our options, I’d met more Māori kids in my high school, which was Massey High School, and I’d seen a little bit more of te ao Māori. So I was happy to start learning te reo.

I had a beautiful Māori kaiako, Awa Hudson. She was just so amazing at introducing us to te ao Māori. That’s where my connection with my Māoritanga started. And I have to acknowledge my dad for recognising how important that was and insisting that I learn te reo.

And my mum as well. Although she was never fluent, she learned te reo, I think mainly to help me to learn and to show me that it was something they valued. They both encouraged that side for me.

As I got older, I was curious about connecting with my Māori whānau, but it was quite difficult. Although my parents were supportive, it was hard to know how to make those connections. And there was a bit of trepidation about how I’d be received.

A few years ago, I was diagnosed with breast cancer (which is ironic for a breast cancer surgeon). But one of the good things to come out of that is that it gave me the space and time to be able to try to find out more about my whānau. I was able to connect with my brother, my sister and my cousin, and to go back to our marae, and take my kids back, too.

It’s been a beautiful part of my journey for the last few years.

I want to pay tribute to your mum and your stepdad, because this is something encouraging, isn’t it that? While not Māori themselves, they recognised that there’s a taonga here with our reo, with our cultural dimensions. Their attitude is one that might help guide us forward as a nation.

Absolutely. I was born in 1972, so it was the ‘80s when this was happening, and there just wasn’t the amount of Māori narratives or resources around that there are today.

And for my parents, growing up in the 1950s and ‘60s, it was such a normal part of New Zealand culture to absorb negative stereotypes about Māori. Somehow they rejected them or were able to learn and develop as well. So, yeah, I’m grateful to them for being that way and for allowing that to happen for me.

Tell us about reaching out to the whānau, and about that first time you were welcomed on to your home marae, and the feelings you had when that occurred for you and your kids.

I was always concerned about being rejected by my whānau, or of them being suspicious of me. I was quite āwangawanga (anxious) about that.

When I had my cancer diagnosis, I couldn’t work because I was doing chemotherapy. So I enrolled in te reo at Te Wānanga o Aotearoa, because I hadn’t done any te reo for a long time, and that was kind of my rongoā, my healing, for the cancer side of things.

I met a beautiful lady there named Mere Taylor, who was from my marae. I always knew that I was from Waikare, but I didn’t  know how to connect with it. It took me a while to build up the courage to ask her about it. But as soon as I did, honestly, within 24 hours I had a phone call from a cousin, and she was immediately loving and welcoming. There was no sense of: “Who are you?” It was just: “We want to meet you. We have to meet you. We’re coming.” And it was just like this avalanche of love and craziness.

When I first went to the marae, I went with my cousin Naomi Reti and my sister Karen Harris, and it was part of a whānau tangi. But, again, it was a very welcoming experience, despite the sad occasion. Everybody was very accepting and open, and it was a really humbling experience.

I was overwhelmed to be able to go to my marae, because I’d started to worry that I might never be able to do that. And just to see all the photos of the old people, and to see our awa and maunga was very special.

Later, I was able to take my kids there for the marae school holiday programmes, and they were swimming in the awa and trying to catch eels with all their cousins — and it just blew my mind. I felt like I had come home. It wasn’t that I had completed a journey, but that I’d reached the start of the beginning of a new journey.

Did I hear you say your whānau name is Reti?

Yes.

Is that connected to Shane, or is that another line?

His grandfather and my grandfather were brothers, but I think his whānau moved south. Somewhere around Kāwhia, I think.

Has the reconnection with your whanaunga and your marae been a source of rongoā for you?

Totally. I had always felt a bit unsettled, and once I had kids, I was worried that they might never be connected to te ao Māori. But now I just feel this deep sense of being settled and tau, because I’ve been able to bring my kids back to their marae and they won’t ever be concerned about not knowing where they’re from.

It’s lovely because I live in Whangārei, so I’m not far from our marae. And I’m slowly getting more and more connected with activities that are associated with our marae and hapū.

Did you always want to get involved in medicine? What was the journey for you there?

I always wanted to do medicine. We had a lovely family GP, and he used to let me look at his medical books. I was always fascinated with how the body works. And my nan, Moira Murray, was just the most beautiful person, and she was always helping people. She was the chair of the Catholic Women’s Society in Gisborne, and she and my grandfather were part of the Labour Party. Service was a big part of what my whānau did, and I think that might be why I was attracted to medicine.

But when I was in high school, I was told by a careers advisor that Māori didn’t do medicine, and I stupidly took that on board. I did get some support from school to try and do well enough to get into medicine, but I never quite got there — I defaulted to what people expected of me, which was to not do well.

I thought that I’d never be able to do medicine. But I was able to get into physiotherapy, which was cool and a great profession, but it wasn’t what I’d wanted to do from the beginning which was medicine.

And all the things that I liked about physiotherapy training were the things that were at the medical school. So I finished physiotherapy, and I probably should’ve or could’ve gone to university and tried to get into medicine from there, but I had a student loan. So I worked as a physio for about four years to try and pay that loan off.

And then, do you remember Mana magazine? There was an article about Hinemoa Elder and she talked about how she had just got into medical school, and it was hugely inspiring to me. I couldn’t stop reading and rereading the article, because here was someone who’d started out doing something totally different, and then had gone into medicine later. I didn’t even know you could do that. It was such an influential article, and I’m so grateful to her for doing that.

So I stopped working as a physio and I went to university. I did some pure science subjects like chemistry, physics and biology, which I enjoyed, and I did some te reo papers and te ao Māori papers too. And then I applied to get into medicine, and was accepted.

By about year three or year four of the medicine degree, we could do an option paper, and I chose surgery, and spent some time with Jonathan Koea, who’s now Professor Jonathan Koea, a liver surgeon. He had just returned from a fellowship in New York, and he took me to theatre to assist with a liver resection. The whole experience blew my mind, and from then on, I was like: “I’m just doing surgery.”

I loved it so much, and he was an awesome role model. As I did more, I learned that it wasn’t just operating. It was seeing people in the clinic or on the ward or in the emergency department, and connecting with their whānau, and then working with lots of different team members. I enjoyed that side of things, too.

Well, E-Tangata is actually a descendant of Mana magazine.

Yeah, I thought it must be.

I remember that article with Hinemoa Elder, too. So it’s great that you’ve touched on that. You ended up in Fremantle. Was that your OE, or work?

When you finish surgical training, even though you’re qualified to be a surgeon, most people do a few years as a fellowship to specialise further. My partner is from Perth, and our daughter was about one-and-a-half when I finished my exams. So we thought we’d go back to Perth so he could have some time with his whānau and our daughter could be around his family.

So I looked for a fellowship in Perth, and worked there at Fremantle Hospital for a year and then at Royal Perth Hospital. And it was an awesome experience to work somewhere else and to see what things are done the same or done differently.

A lot of our people have spent some time in Australia. I did, too, and I think we feel a deep connection with the Aboriginal people. I can’t say that I knew too many, but I really felt for them. We have our problems in our own land, but I think theirs are multiplied many times over.

I hear you about your feelings for our First Nations whānau in Australia. I saw some of the racism and some of the prejudice that they experience within the healthcare system, and it was shocking. It was absolutely shocking.

I found it difficult to be there because of that that, actually. And it’s particularly hard for them in the big centres. I worked as a locum in Broome, way at the top of north-western Australia — and working with the mob up there was quite a different experience, because they are so connected to their land, connected to their culture.

In the cities, there was a lot of disconnection, or if people came off country, they were so far from their whānau, so far from their country, that it was a horrible experience for them.

I have a good friend, Kelvin Kong, who’s the first Aboriginal surgeon in Australia. I’ve learned a lot from him about the experience of their mob in the health system, and just in general, and it has really influenced my understanding of the similarities we experience in both countries as Indigenous people.

One thing I’ve noted — and your nana would be proud — is your willingness to talk about health inequities and raise the issues of intergenerational trauma and of disadvantage, injustice and racism. A lot of people just keep their heads down and don’t speak out about such matters. But you’ve been going to bat for a more level playing field.

Aww, kia ora. Thank you. Sometimes people question if there really is institutional racism and accuse us of making a mountain out of a molehill — they gaslight us when we talk about these things. But it’s real, and all Māori have experienced it in some way. When you listen to whānau voices, that’s what they say. That is their reality and lived experience. That’s proof enough for me, having experienced it myself. But then you look at how bad our health outcomes are compared to Pākehā, and it all becomes clear how racism contributes to the disparities in outcomes we see between Māori and Pākehā.

I think that, as health workers, we have a responsibility to advocate, but it’s an additional workload on top of our day jobs. Often my Māori and Pasifika friends will say how nice it would be to just be able to go to work and do our jobs and then come home. What a privilege that would be. But there’s this extra layer to our work because we can see that groups of people experience worse outcomes just because of who they are. It’s just not right.

As a celebrated breast cancer surgeon, was developing breast cancer yourself something of a reality check? How did that experience change your attitude to life?

It allowed me to slow down, and to reassess and think about the things that were important to me. It helped me to prioritise the stuff that I wanted to do, and to get rid of the things that weren’t bringing me value. It’s easy to get caught up in everything and say yes to 10 million things that actually take you away from the core of what you want to do. And it helped me to be grateful and to appreciate all the little things.

The thing with breast cancer is that most of the time it’s very treatable and curable. There’s a small group of people who are diagnosed with late-stage disease, or they have an aggressive cancer, but the majority of people will survive breast cancer. If you’re lucky enough to be in that group, then it’s important to make the most of it, because it’s a privilege to be able to have a second chance at things.

So you’re able to help some, but you’re not able to help all. How do you feel that, on one hand, you can be part of a journey that has a bright conclusion, and wāhine are cleared of the threat, and on the other hand, doing your best by people in whom the disease has gone too far and you lose them?

I think it’s just trying to do the best for people wherever they are on that journey, or wherever you meet them. Even if it’s very advanced disease and there’s not much that we can offer medically, you can still try and make that as good a journey as possible. When you think about the stress and mamae that people experience in the later stages of cancer, quality care is huge for the person and for their whānau. For people to feel manaaki and to feel that somebody cares and is doing their best for them, I think is important. And powerful.

But it’s an important message that most cancers, if they’re detected early, are treatable, and that’s particularly true for breast cancer. It isn’t always doom and gloom, although it can definitely be scary. It might mean that people need treatment for a certain amount of time, and it might interfere with their life plans for a while, but overall, most people with breast cancer will do well if it’s detected early.

And even late stage breast cancer has some really sophisticated treatment available which can help extend people’s lives for a really long time. So it’s important to seek help early, enrol in the breast screen programme, and to complete treatment.

It’s interesting to me that a committed, experienced cancer surgeon wants to work in Whangārei rather than in one of our bigger hospitals.

I feel lucky to work in Whangārei. Whangārei Hospital has some of the best staff I’ve ever worked with. It provides a really high level of service — despite its failing buildings and facilities.

But working in Whangārei wasn’t part of my life plan. I assumed I’d end up in Auckland, and probably at Middlemore, because that’s where I did a lot of my training. I love the Middlemore community. I think it’s a great place to work, and I had some wonderful surgical mentors there as well.

But I just started to find Tāmaki Makaurau so busy and so hard to live in, and I didn’t want that for my kids. I grew up in Kumeu, and Muriwai was our beach. If I was living in Auckland, I’d want to live out there, but I couldn’t live there and work at any of the major hospitals. So, yeah, it just became too hard. And my partner felt the same.

When we were in Australia, one of my mentors, Pat Alley, rang me and told me that there was this job in Whangārei and that I should apply for it. I thought: “Oh my gosh, of course, that’s where I should be working!” Because it was a way for me to get closer to Waikare, to my marae. And my mum and dad were living in Dargaville at the time as well. So it all fitted.

And from there you’re able to advocate for improved access to treatment for people whose health needs are compounded by the fact that they live in Te Tai Tokerau. And you’d say the quality of care is as good in Whangārei Hospital as in our bigger hospitals?

Absolutely. I think that’s one of the misconceptions about the regional centres, that they don’t have the same quality of care or the same quality of clinicians. It’s just not true. We just may not have all the sub-speciality services available for certain conditions. But the clinical expertise and level of care is very high. I constantly hear patients and whānau saying how impressed they are with their care in Whangārei and Kaitaia hospitals.

In some ways, because we can provide care closer to home, and because the people who work in our hospitals up here understand what it’s like for our communities, they’re much more in tune with what’s happening locally — and that has an impact on the care that they provide.

Sure, there are certain things you can’t do in a small hospital that you can only do in a big hospital. But that’s just because that’s where the resources are, and not a reflection of the skills of the clinicians and staff who work there.

I also think working up here gives us more credibility to be able to talk about these issues, because we see it on a daily basis. And we understand what it’s like for someone from Te Hāpua, say, to come to Whangārei for a biopsy and an ultrasound and a scan, or whatever. Clinicians in bigger centres sometimes don’t understand that it can be a six-hour round trip, or more, for whānau to come to Whangārei for a 15-minute consult.

Most of the services in Whangārei Hospital will work really hard to coordinate appointments between different departments, to try and accommodate those travel issues for whānau, or to organise tests and clinics in the smaller centres. It’s not always perfect, but there is a general appreciation of how important that is for whānau.

And we also provide regional services. We do clinics in Kaitaia, for example. People really appreciate that, and it’s lovely to be able to provide care for people close to home.

Politically, we’ve just seen the demise of Te Aka Whai Ora (the Māori Health Authority), which was seen as a vehicle to try to change the intergenerational disadvantage facing our people in the health system. It was a lost chance, but we still have to keep barracking to get positive change. And that’s something we can all be involved in, yeah?

Absolutely. Māori communities know what Māori need, and we’ve seen the evidence of that. Let me talk about Te Kaha, on the East Coast. I think 90 per cent of the population is Māori, and they only had 45 percent coverage for breast screening in the community, which is very low.

They have a single health provider there, and one GP, Rachel Thompson. And they basically went to the community and asked them why their breast screening rates were so low. The community told them what the issues were, and they made a number of changes to the way breast screening was delivered down there. And they were able to get their screening rate up to 98 per cent, which is huge.

That’s powerful, because we know that if Māori women are diagnosed with breast cancer through the breast screening programme, they have the same survival outcomes as non-Māori. Breast screening is vital for early detection.

If we can do more of that, harness the knowledge that sits in communities, that’s an important factor in addressing health inequities.

But we also need transformative change, which is what Te Aka Whai Ora was all about. It was doing things differently in order to have the same outcomes as non-Māori. And unfortunately, that always gets conflated as Māori receiving special treatment. But it’s not. It’s implementing treatment in a way that’s aligned with the Māori worldview. And it’s not exclusive to Māori either. Everyone is welcomed. It’s just that the treatment is done in a Māori way.

We have to understand that our health system, like all of our western systems, wasn’t designed for us, and even with the best intentions, things will always default back to the status quo. So we do need substantial transformative ways of doing things. Like prioritising Māori and Pasifika people for surgical waiting lists, or making sure clinical wait times mitigate against the impact of delays at all points on the treatment pathway.

Because we have less access to GPs, we have delayed referrals, delayed presentation, and even slower journeys through the treatment pathway once we’re on it. And doing something substantial that would accelerate that pathway is one thing that might contribute to addressing inequities.

Tēnā koe. Finally, what do you do to keep yourself fresh and emotionally strong?

It’s pretty simple. I either go for walks in the ngahere or head out to the beach with my family. I’m still on my reo journey, and though it sounds geeky, sitting down with my reo Māori books and having some space with my mates to practise what we’ve been doing in our te reo class, or reading Scotty and Stacey Morrison’s books, or listening to a Māori podcast like Indigenous 100 and getting inspired — that’s a real happy place for me.

You can take the girl from Muriwai but you can’t take Muriwai from the girl, āe?

I do love those black sand beaches!

Tēnā koe, Max, what an interesting kōrero it’s been. I salute you for all the mahi you’ve been doing over the years and your commitment to helping others. Thanks so much.

(This interview has been edited for length and clarity.)

See also, Maxine Ronald: Why do we have to keep explaining the ethnicity gap?

 

Dr Maxine Ronald is Te Kapotai ki Ngā Puhi, Ngāti Wai, Ngāti Hine and Ngāti Rangi. She is a general and oncoplastic breast surgeon working in Northland. Last month, she was named the inaugural Māori Breast Cancer Research Leadership Fellow by Breast Cancer Cure and Breast Cancer Foundation NZ. The fellowship aims to address the disparities faced by wāhine Māori and Pasifika women affected by breast cancer in Aotearoa New Zealand.  

Dr Ronald is the first Indigenous councillor at the Royal Australasian College of Surgeons (RACS), a member of the Aotearoa New Zealand National Committee Surgery and past chair of RACS Indigenous Health Committee. She was a clinical advisor to the Māori Health Authority, a member of the Planned Care Task Force, member of the Steering Committee for Medical Workforce, the National Māori Pandemic Group, and Hei Āhuru Mowai (Māori Cancer Leadership Group.) She was recently appointed to Te Pae Whakatere — Breast Screen Aotearoa Review Committee. She is an advocate for Māori health equity and increasing the Indigenous surgical workforce in Aotearoa New Zealand and Australia.

E-Tangata, 2024