Joanne Baxter: Seeing fairness differently

Professor Joanne (Jo) Baxter became the Dean of the Dunedin School of Medicine in July — and in doing so became the first Māori in that role. Jo is Ngāi Tahu and Ngāti Apa ki te Rā Tō.

Her mum is from South Westland and her dad from Hokitika. She lived up and down the West Coast as a young girl and spent her high school years in Picton. Then, 40 years ago, she started at medical school in Auckland. That move came about largely because of the help and encouragement from Monte Ohia, one of her Picton teachers.

And here early in this lightly edited interview with Jack Tame on Q + A, Jo starts by applauding Monte for the support he gave his Picton students.

 

Jo: Monte was a real champion for Māori education and, in his role as a Māori teacher in Picton, he engaged with all the people in his class, and he encouraged us to see that we could be thinking about more than just the pathways that were often set for us in Picton — the freezing works, the railways, the ferries.

And, as part of those conversations, medical school came up as a prospect for me, and he engaged with the Auckland medical school to get information and help me make my application.

Jack: I know it’s a cliché, but isn’t it amazing how a teacher’s influence can end up having a significant impact on your life?

Absolutely. And later on, in the university, as I’ve had roles in supporting pathways for Māori students and also students from low-decile schools, I’ve always had an understanding that it’s very easy for people to underestimate the potential in students, because they look at background factors and make an assumption about what your destiny is or ought to be.

And yet I see so many young people who have incredible potential, but who have similar stories. Someone really noticed their potential. Or they happened to have in their school an approach to working with the students. Unfortunately, it’s not consistent across our education system that students are all seen to have that kind of potential. 

I’ve been really interested in the debate about streaming in schools, and you may be aware that there’s been a lot of thinking around whether streaming in schools is contributing to inequity — and, in particular, to Māori inequity.

Some of this determining of people’s trajectories starts right from year nine, when the students come into high school, where they might be told: “You’re going to be in this class, where you get teachers that are going to push and extend you.”

Or they’re put in this other class where they might just get unit standards, and they’ll be trained to limp their way through school, and come out the other end, assuming that that’s their appropriate trajectory.

I think there’s still the tendency of the system to differentiate people on the basis of early assumptions about where they’re going to end up. And, of course, Māori often end up on the wrong end of that.

It’s interesting you bring this subject up, because over the last decade or so, the university has had a policy called Mirror on Society. I know the name has recently been changed and the policy has been adjusted a little bit, but, at times, it’s been a controversial policy because it is, essentially, looking at promoting pathways for under-represented communities into the health workforce in New Zealand, so proactively finding space for Māori, Pasifika and rural students. What have you made of the way the debate around that policy has been held? Have you learned anything from it?

Absolutely. It seemed to be a practical approach to ensuring that we were having a workforce that was closer to reflecting the people in our society, but also more likely to be able to meet those needs and influence the health sector.

Having a policy that looked at how we admit people into our programmes, and taking into account that we could do something different to shift some of that, seemed, to me, quite practical and important. It meant that we didn’t end up with a health workforce largely made out of people who’d only been to high-decile schools, who’d had the advantage of elite-level education — and who were then becoming our health professionals.

I learned in watching the reaction and some of the challenges that came up around the time of the Mirror on Society — that we can’t afford to be complacent. What I believed to be an understandable and appropriate policy for us as a society was not thought of in the same way by a number of people.

But I also learned that there was widespread support for the Mirror on Society approach — and that support wasn’t just from Māori. I saw that there was also backing from the Medical Council, the medical colleges, many of the health professions, the health sector, and all sorts of other groups.

And every year, I’ve been able to watch our Māori students graduating from all of their different programmes like pharmacy, physio, medicine and dentistry. Of course, we have to remember that few of our health professionals in New Zealand are Māori — and, of all our doctors, only just over 4 percent of doctors in New Zealand are Māori. So, even with increases to the point where about 20 percent of our students are Māori, and Auckland similar, we’re still not touching the sides.

What do you say, then, to people who still feel that it is fundamentally unfair? What do you say to people who say: “Jo, it is racist for a university to have an affirmative policy that prioritises one ethnic group over another.”

Well, it’s really tricky, because often, it’s about the frame within which people understand an issue. Some people may only see the issue as about Person X having a 95 percent average over seven science-based papers and therefore having more  right to a place in medical school than someone who’s had a very different set of opportunities through their education and a different set of experiences in coming to university, and then getting a different outcome, which may not quite be the upper-90 percent averages.

But when they see that as a fairness issue, they’re not looking at the wider issues of fairness within society. Is it fair that, in order to be best prepared, and to be able to get those kind of marks in health science first year, you probably need to have gone to a very high-decile school? You need to have done all the sciences to a very high level? You need to be able to afford to live in a hostel or a college when you come to university so that you’re being supported and getting those extra tutes?

If you have all those advantages, you’re likely to end up at the top of the pile. And some people don’t see those as fairness issues.

I wonder if the policy also says something about the purpose of the school itself, and the school exists through this policy to serve New Zealand rather than to serve individual students?

Yep, absolutely. And if we think about education and health and the interface of education and health, we have an amazing opportunity to have wins in both. If we engage with equitable educational outcomes that will support equitable health outcomes — then we’re dealing with a societal good that is much broader than an individual focus.

Do you have experience of non-Māori coming to med school and going through a personal transformation when they’re exposed to some of the inequities in our society for the first time?

I’ve been really impressed with the level of engagement and support that the non-Māori students have for hauora Māori as a subject, but also as something that they want to aspire to get right as clinicians.

Our goal for our graduates is that they come out being awesome as clinicians or doctors or in whatever profession they’re doing. And, in order to be a good doctor, they also have to be a good doctor for Māori.

I think some of the students who have “a-ha!” moments are ones who’ve had backgrounds where the family discourse about things Māori has often been very narrowly framed and very deficit.

So they may come to medical school having been raised in a family where there’s a view of Māori as being: “Well, if they don’t work hard enough, they shouldn’t be here.” Those kinds of things. Then they come into the medical school space where about 20 percent of the students in their class will be Māori and about 10 percent Pacific.

So that’s a real challenge for them. It may be that there, in their own med school class, it’s the most Māori people they’ve ever been exposed to. Then, in the teaching, they learn that there are things they’re going to need to know and do that will stand them in good stead when they graduate. And they start dropping some of their preconceived prejudices as they start to engage.

Do you have any views on the extent to which we should be relying on a foreign workforce?

Our health workforce space is a big landscape that includes migrant workers coming in, with some of them coming through from our educational facilities. Some of our workforce is through growing our own — and another element is protecting our workers. I think, in medicine, about half of our current medical workforce are  internationally-trained, and about half are New Zealand-trained.

That’s very high.

It is. And we‘ve been running like that forever. Then there’s the need to ensure that all our workforce, no matter where they’ve been trained, have a really high level of understanding of the environment they’re working in. A lot more can be done in that space as well. I don’t think we’re very good at doing meaningful orientation. They come in and might have a few days max orientation.

Then they’re on the wards?

Then they’re on the wards. And I’ve had conversations with some of our internationally-trained colleagues, who have been hanging out for a much more in-depth and meaningful understanding of the cultural context within which we work.

Can we just double the number of students we teach?

Well, because we teach programmes that interface with the health sector, there’s a whole lot of contextual issues that you’d need to sort out to make that work.

We couldn’t just double the roll overnight? It’s not quite that simple?

Yeah, not quite that simple. Some of it is because it’s such experiential learning. You don’t learn to be a doctor by theory. You’re actually out there. And then you’ve got to have enough of the right kinds of learning experiences to learn that. So you have to navigate where and how that would all happen.

Yeah. What has to happen with the health reforms for us to achieve the aspirations?

We have to be optimistic. And we’ve needed to do something differently. We’ve had 20 DHBs, all trying their absolute best to meet the needs of their communities.

But, in order to do that, they had to connect — and one DHB would have an initiative that was making a difference, but it was never shared.

Probably the issue which concerns me most, is the possibility of a change of government because we have different political parties saying: “Well, we wouldn’t do that.” Or: “We would get rid of the Māori Health Authority.”

And I think: “Gosh, it’s assuming that the Māori Health Authority only exists as a political thing, when, in fact, for Māori and for Māori health providers, it sits there as a pragmatic, potential approach to developing and delivering services that will get us the outcomes that we want.”

This edited interview was screened on TVNZ’s Q + A on August 28, 2022.