Until she trained in public health, Vanessa Selak saw no reason to challenge the prevailing view of many in the medical profession about why Māori suffer worse health outcomes.
When I graduated as a doctor in 1998, I didn’t understand why Māori experienced barriers accessing the health system and were dying younger than other groups in New Zealand.
At medical school, I learned about the contribution of behavioural risk factors, such as smoking, to the health outcomes of Māori. I was presented with a narrative that implied that Māori were at fault for their own ill health.
I considered myself to be a fair, scientific, and competent doctor in accepting this narrative. I had no reason to challenge it, especially as my own family’s experience seemed to bear it out.
I was born into a hard-working and loving family in West Auckland. My parents and maternal grandparents had emigrated from Croatia in the late 1960s, early 1970s. After a few years, they bought land and established a successful market gardening business.
Despite being immigrants, my family had quickly worked out how to access healthcare. They felt reasonably comfortable with the doctors and nurses (once their English improved), and were mostly well treated. To them, the New Zealand health system was much better than the one they’d left behind because healthcare was available and they didn’t have to bribe anyone to get it.
I didn’t learn English until I went to primary school, but while I felt a bit different from my classmates, I blended in easily because I looked like the other white kids. It wasn’t long before I was fluent in English, Kiwi accent and all.
I did well at school with relatively little effort — the education system was clearly able to meet my needs. And although my parents couldn’t help me with school work because of their limited English and long work hours, they were determined to ensure that I had, and made the most of, all of the educational opportunities available to me in New Zealand. Opportunities they’d missed out on in Croatia.
My parents chose to send me to a private high school. I was an awkward, overweight and mostly miserable teenager, but I continued to succeed academically and felt that academically-based pursuits would be my key to success.
I also cared deeply about doing the “right thing” by other people and was awarded the school citizenship award in my final year. I was unsure about what to do at university, but the expectation that I should attend university was clear.
In the last months of my final year of high school, I decided to apply for medicine. After all, I had good grades, I wanted to be challenged academically, and I wanted to “help people”.
If I’m honest, though, I think the things that were driving me towards medicine were my desire to make my parents proud and to have a high status job. My understanding of being a doctor was predominantly based on what I’d seen on TV. I hadn’t spoken with a doctor about doing medicine before deciding to apply. But I thought I’d quite like to be one.
Despite feeling lukewarm about doing medicine in the first place, I was crushed when, at 17, I found out that I hadn’t been offered a place at the Auckland University School of Medicine. This was the first time in my life I’d really wanted something that I couldn’t get.
I can see in retrospect that this was an over-reaction, but, even now, it doesn’t take much to bring back the intense feelings of failure, humiliation, self-loathing and shame.
I was devastated and my family were devastated for me. This distress would have been even greater if medicine had been my lifelong dream and if I believed that I’d unfairly missed out on a place because of preferential entry for other applicants.
Instead of triumphantly striding into Auckland Medical School, I slunk down to Dunedin with my tail between my legs and embarked on my Plan B: the intermediate health sciences year at Otago University — the gateway to Otago Medical School.
Not with a burning desire for knowledge. Not with a burning desire to help other people. But with a burning desire to get into medical school.
My first year at Otago University wasn’t easy. I was sad and lonely, but I was able to focus solely on getting good grades. I had a warm, dry, quiet place to study in my hall of residence, I didn’t have to manage a household or children, and I was a short walk away from campus. My parents paid for my expenses, so I didn’t have any financial worries.
I had excellent literacy and numeracy skills and knew how to prepare for assignments, tests and exams. I’d been able to acquire, practise, and excel at all of these skills at school. I didn’t have to worry about family responsibilities. Instead, I received regular care packages and phone calls.
In the end, I got straight A-pluses and easily secured a place at Otago Medical School. I felt that, because I’d worked hard, I deserved those marks and that place at medical school.
I felt very proud to be a medical student, as were my family. Not only was I the first person in my extended family to go to university, but I wasn’t doing any old degree. I was doing medicine and I was going to be a doctor. I was now part of an elite group of people, highly esteemed by society. And I would have a job for life and decent pay to boot.
I knew that the medical profession wasn’t perfect, but I felt confident that I would be able to thrive and find a way of working within it to make it better.
Medical school was difficult and intense in terms of the volume of contact time, work and assessments. The first two years, unsurprisingly, involved a lot of learning about the human body and how it works. In parallel with this explicit curriculum, I was apprenticed into the medical profession through a hidden curriculum.
It became clear to me that, if I wanted to succeed in medicine, the most valid sources of information were doctors. Not researchers. Not people from other disciplines. Not patients. I understood that my career prospects were dependent on not ruffling feathers or undermining the prevailing power structure. Challenging and critical thinking were not skills that appeared to be highly valued in those of us learning the ropes.
During my time at medical school, I had the occasional lecture on Māori health and te Tiriti o Waitangi. I remember how out of place and at odds with the rest of the curriculum these lectures felt. They seemed tagged-on and, frankly, irrelevant.
None of the content from those lectures was reflected by any of my other lecturers, in anything else I was learning about, and didn’t seem necessary to being a good doctor. After all, I was going to treat all of my patients the same, because I was “colour-blind”.
This was largely my thinking throughout medical school and while working as a junior doctor. It wasn’t until I started specialising in public health that I realised how ill-informed and ignorant I’d been.
I learned that just focusing on health services isn’t enough. This is because our chances of living a longer and healthier life increase the better our education, income, and housing.
I can illustrate this using the example of heart attacks and strokes.
We know that, on average, the less we earn, the more likely we are to have an unhealthy diet and to smoke. An unhealthy diet increases the chance that we’ll have high blood pressure, high cholesterol and diabetes, each of which, in addition to smoking, increases the chance of having a heart attack or stroke.
I also learned that our chances of living a longer and healthier life vary according to our ethnicity. Going back to the example of heart attack and stroke, if we’re Māori or Pacific, even after taking into account things like our income, blood pressure and cholesterol, as well as whether or not we smoke or have diabetes, we’re still more likely to have a heart attack or stroke than if we’re Pākehā.
I learned that this difference in the risk of heart attack and stroke between Māori, Pacific, and Pākehā people isn’t primarily driven by biological differences. It’s driven by the differences in our society and health system that advantage Pākehā at the expense of Māori and Pacific people.
The scales didn’t come off my eyes immediately and it was very confronting when I began to realise that many of my core beliefs were simply wrong. I accept some responsibility for that. But I can’t accept all of the responsibility. I am, after all, a product of the New Zealand medical school system.
I appreciate that the curricula within our medical schools are much improved and that Māori health and public health are much better covered and integrated within those curricula now.
But I also know that there’s a limit to what we can do within medical schools to ensure that Pākehā doctors are capable of fully embracing, understanding, and thereby adequately addressing the needs of Māori and other underserved populations in New Zealand.
I think this is for two main reasons.
Firstly, however much training we as Pākehā receive, we’ll never be a substitute for Māori and Pacific doctors. We are not the same, we don’t have the same lived experience. So however much we might want to, it’s impossible for us to be able to relate to our Māori and Pacific patients in the same way as our Māori and Pacific colleagues.
Emma Espiner’s fabulous podcast provides a powerful insight into the perspective of Māori on healthcare. This is important because Māori and Pacific patients simultaneously experience greater health needs and worse health access for most conditions compared with Pākehā. If we want to deliver on equity for Māori and Pacific people in New Zealand, it’s crucial that we have more Māori and Pacific people across our health workforce, including in medicine.
Secondly, the hierarchical nature of medicine means that it’s going to require a lot of momentum over many years to significantly change the overall attitudes within the medical profession towards recognising the importance of supporting equitable health outcomes for Māori and Pacific people and the part the medical profession has to play to make that happen. I’ve seen some shifts in attitudes over the course of my career, but we still have a long way to go.
Because we’re apprenticed into medicine, medical students and doctors are most strongly influenced by more senior doctors in their specialty of interest. This means that even if medical students are taught about, understand, and accept the need to focus on Māori and Pacific health at medical school, this influence is easily undermined through their subsequent training.
Pākehā doctors, myself included, can help, but we can’t provide the whole solution. We urgently need to increase, not create further barriers to, the entry of Māori and Pacific students into our medical programmes. Professor Peter Crampton and Associate Professor Elana Curtis provide a compelling and thorough rationale for preferential entry programmes into medicine here.
Even with these in place in their current formats, it will take decades before the proportion of Māori and Pacific doctors (let alone specialists and doctors in senior positions) is similar to the proportion of Māori and Pacific people in our population. Other health workers are also essential to the delivery of high quality health services, and we also urgently need greater numbers of Māori and Pacific people across all of those roles too.
To aspiring doctors who’ve been unable to secure a place at medical school, I commiserate with you, but urge you to honestly reflect on what you really want out of a career and to focus your energy on considering the many other pathways that will enable you to achieve your aspirations.
To current and future Pākehā health workers, know that our contributions to healthcare remain important and valuable. We can contribute even more by recognising the importance of strengthening our Māori and Pacific health workforce, and supporting and elevating the voices of our Māori and Pacific colleagues and patients.
Vanessa Selak is a public health physician and senior lecturer at the Department of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland.
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