The Indigenous Health Agenda in Medical Education Anna Poutu Fay (Ngāti Porou) A joint PhD thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy in Community Health, the University of Auckland & in Population and Global Health, The University of Melbourne, 2017. Abstract This thesis describes the indigenous health agenda as a unique landscape located within the wider field of medical education. The indigenous health agenda offers medical educators the opportunity to contribute to indigenous health and wellbeing. The thesis reviews the commitments of medical schools in Aotearoa New Zealand and Australia to the indigenous health agenda and asks how these commitments are currently being enacted and can best be realised in future. The research identifies an indigenous rights to health approach as under- utilised and potentially beneficial. Using Kaupapa Māori methodology a research study consisting of thirty-two semi-structured interviews (28 individual, two joint, and two focus group interviews) was undertaken across two research phases. In Phase One, key informant interviews were conducted to gain insight into stakeholder perceptions of medical school commitments to the indigenous health agenda. In Phase Two, a case study was carried out at The University of Auckland Faculty of Medical and Health Sciences, in which key informants discussed the relevance and potential applications of Phase One findings. Thematic analysis was used to encode and order data. Study findings establish the viability of a rights approach, and bring into focus drivers of the indigenous health agenda, obstacles to the indigenous health agenda, and strategic pathways for the indigenous health agenda. The indigenous health agenda is redefined as building a strong indigenous presence in medical schools via four strategic pathways - indigenous knowledge and information, indigenous process and practice, indigenous personnel, and indigenous resource base - and transforming institutions to enable that presence to have impact. When the four strategic pathways are applied across the domains of clinical teaching and learning, cultural understanding and critical awareness, community relations, and indigenous leadership and organisational autonomy, a 4 X 4 table of the indigenous health agenda is developed. The indigenous health agenda is then understood to consist of ends, means, and motives. The ends are to reduce indigenous health inequities and contribute to indigenous health and wellbeing. The practical means are to develop indigenous presence within and across pathways and domains in medical education. The motives are human rights to health and more specifically and powerfully, indigenous rights to health. Developing each facet of the indigenous health agenda is a task still to be achieved, as is mastering the complex dynamics of equitable partnerships between medical schools and indigenous communities, and between indigenous leaders and their non-indigenous allies. Even so, the thesis predicts a iii bright future for better understanding and further practical developments of the indigenous health agenda in Aotearoa New Zealand and Australian medical schools. iv Acknowledgements Ehara tāku toa I te toa takitahi, engari he toa takitini I am extremely grateful to my supervisors for their generous support, their loyalty to this project and their faith in me. Ngā mihi nui Dr Pat Neuwelt, Dr Rhys Jones, Associate Professor Tim Tenbensel, Professor Shaun Ewen and Professor Geoff McColl. Many thanks to Health Systems, Te Kupenga Hauora Māori and The Nossal Institute for Global Health, in particular, Dr Rob McNeill and Dr Monique Jonas in Health Systems for their support. To all my informants and the LIME Network staff and reference group, ngā mihi for your contributions to this project and for all the important work that you do. I am grateful to the Health Research Council of New Zealand for the support provided through the Māori Health Research PhD scholarship fund and to the Educating for Equity initiative for their support. It was my pleasure and a true source of comfort to share in the PhD journey with Kimiora Raerino, Teah Carlson and Amanda Wood. Ngā mihi, wahine toa. To my dear friends for their unwavering confidence in me, their constant support and their exceptional love and care, in particular; Jay Jenkins, Morgana O’Reilly, Peter Salmon, Mythily Meher, Bonnie Stanway, Pax Zwannikken, Aria Jones, Jo Holsted, Jeremy Unkovich, Raukura Turei and the other Sister Womans – you know who you are. Thank you. Ngā mihi to Matua Haare Williams for your depth of wisdom. To Te Whanau o Papatipu for your steadfast aroha. To Bruce Arroll for your continued support of and belief in me. To Burke Hunter and Susan Hawthorne for your generousity of heart. My debt to my mother and father goes without saying, but to them, my brother Rush, sister Zoe, and I owe the motivation and means to contribute to a better world. Finally, to Hemi and our girl Ahi, who arrived three weeks after I submitted this thesis. I still would have still done this work without you both, but it wouldn’t have been nearly as fulfilling. Ngā mihi for making my life what it is. Ka nui toku aroha ki a korua. v vi Contents ABSTRACT .........................................................................................................................................................................III ACKNOWLEDGEMENTS .................................................................................................................................................. V CONTENTS ....................................................................................................................................................................... VII ABBREVIATIONS .............................................................................................................................................................. X GLOSSARY OF TERMS .................................................................................................................................................... XI PREFACE.......................................................................................................................................................................... XIII CHAPTER ONE: MEDICAL EDUCATION AND INDIGENOUS HEALTH INEQUITIES .......................................1 INTRODUCTION ...................................................................................................................................................................................... 1 RESEARCHER POSITION ....................................................................................................................................................................... 3 SETTING THE SCENE: INDIGENOUS HEALTH AND MEDICAL EDUCATION IN AOTEAROA NEW ZEALAND AND AUSTRALIA .. 6 THE STUDY: MEDICAL EDUCATION THAT CONTRIBUTES TO INDIGENOUS HEALTH AND WELLBEING AND SUPPORTS INDIGENOUS RIGHTS TO HEALTH ........................................................................................................................................................ 9 ORGANISING CONCEPTS USED IN THIS THESIS ............................................................................................................................... 13 TERMS USED IN THIS THESIS ............................................................................................................................................................ 19 SUMMARY OF CHAPTERS ................................................................................................................................................................... 21 CHAPTER TWO: MEDICAL EDUCATION RESPONSES TO THE CHALLENGE OF HEALTH INEQUITIES .............................................................................................................................................................................................. 23 INTRODUCTION ................................................................................................................................................................................... 23 SOCIAL ACCOUNTABILITY IN MEDICAL EDUCATION ...................................................................................................................... 24 COMMUNITY-ENGAGED MEDICAL EDUCATION: NOTIONS OF PARTNERSHIP AND ACCOUNTABILITY TO HEALTHCARE STAKEHOLDERS................................................................................................................................................................................... 34 CULTURAL COMPETENCE, CULTURAL HUMILITY, AND CULTURAL SAFETY ................................................................................ 40 CRITIQUE OF MEDICAL EDUCATION RESPONSES TO ADDRESSING INDIGENOUS HEALTH INEQUITIES ................................... 42 SUMMARY ............................................................................................................................................................................................ 49 CHAPTER THREE: MEDICAL EDUCATION IN AOTEAROA NEW ZEALAND AND AUSTRALIA; EFFORTS TO ADDRESS INDIGENOUS HEALTH INEQUITIES AND CONTRIBUTE TO INDIGENOUS HEALTH AND WELLBEING ...................................................................................................................................................................... 51 INTRODUCTION ................................................................................................................................................................................... 51 MEDICAL SCHOOL COMMITMENTS TO INDIGENOUS HEALTH IN AOTEAROA NEW ZEALAND AND AUSTRALIA ................... 52 ADVANCING THE INDIGENOUS HEALTH AGENDA IN MEDICAL EDUCATION IN AOTEAROA NEW ZEALAND AND AUSTRALIA ............................................................................................................................................................................................................... 55 MEDICAL SCHOOLS AS SITES OF STRUGGLE .................................................................................................................................... 56 THE CASE FOR AN INDIGENOUS RIGHTS TO HEALTH FRAMEWORK IN MEDICAL EDUCATION ................................................. 58 vii LINKING A RIGHTS FRAMEWORK TO THE RESEARCH QUESTIONS OF THIS STUDY .................................................................... 62 SUMMARY ............................................................................................................................................................................................ 63 CHAPTER FOUR: KAUPAPA MĀORI METHODOLOGY ....................................................................................... 65 INTRODUCTION ................................................................................................................................................................................... 65 KAUPAPA MĀORI: RESEARCH, THEORY AND METHODOLOGY ................................................................................................... 68 A KAUPAPA MĀORI METHODOLOGICAL FRAMEWORK ................................................................................................................ 71 SUMMARY ............................................................................................................................................................................................ 78 CHAPTER FIVE: RESEARCH METHODS .................................................................................................................. 79 OVERVIEW OF METHODS .................................................................................................................................................................. 79 PHASE ONE ......................................................................................................................................................................................... 85 PHASE TWO ........................................................................................................................................................................................ 92 SUMMARY ............................................................................................................................................................................................ 98 CHAPTER SIX: DRIVERS OF AND OBSTACLES TO THE INDIGENOUS HEALTH AGENDA ...................... 99 INTRODUCTION ................................................................................................................................................................................... 99 BUILDING INDIGENOUS PRESENCE IN MEDICAL EDUCATION: DRIVERS, OBSTACLES AND STRATEGIC PATHWAYS ............ 100 DRIVERS FOR THE INDIGENOUS HEALTH AGENDA ...................................................................................................................... 101 OBSTACLES TO THE INDIGENOUS HEALTH AGENDA .................................................................................................................... 118 SUMMARY .......................................................................................................................................................................................... 132 CHAPTER SEVEN: STRATEGIC PATHWAYS TO BUILDING A STRONG INDIGENOUS PRESENCE WITHIN MEDICAL EDUCATION .............................................................................................................................. 133 INTRODUCTION ................................................................................................................................................................................. 133 STRATEGIC PATHWAYS: INDIGENOUS KNOWLEDGE AND INFORMATION, PROCESS AND PRACTICE, PERSONNEL, AND RESOURCE BASE ................................................................................................................................................................................ 133 SUMMARY .......................................................................................................................................................................................... 163 CHAPTER EIGHT: REALISING COMMITMENTS TO INDIGENOUS RIGHTS TO HEALTH; HELPING MEDICAL EDUCATION ‘WALK ITS TALK.’ ........................................................................................................... 165 INTRODUCTION ................................................................................................................................................................................. 165 DEFINING THE INDIGENOUS HEALTH AGENDA IN MEDICAL EDUCATION .............................................................................. 166 DISCUSSION OF DRIVERS................................................................................................................................................................. 166 DISCUSSION OF OBSTACLES ............................................................................................................................................................ 169 DISCUSSION OF STRATEGIC PATHWAYS: DEVELOPING INDIGENOUS PRESENCE IN MEDICAL EDUCATION ...................... 171 DOMAINS OF MEDICAL SCHOOL ACTIVITY................................................................................................................................... 173 THE COMPLEX UNITY OF INDIGENOUS HEALTH AGENDA ........................................................................................................... 178 INDIGENOUS PRESENCE: COMBINING DRIVERS, OBSTACLES, AND PATHWAYS..................................................................... 179 SUPPORT FOR INDIGENOUS PRESENCE WITHIN DOMAINS OF MEDICAL SCHOOL ACTIVITY .............................................. 181 viii DISCUSSION OF INDIGENOUS IMPACT: SUPPORT FOR INTEGRATION AND ALIGNMENT OF THE INDIGENOUS HEALTH AGENDA ............................................................................................................................................................................................. 182 EXPLORING KEY DYNAMICS AND TENSIONS IN THE DEVELOPMENT OF THE INDIGENOUS HEALTH AGENDA ................. 184 INDIGENOUS RIGHTS TO HEALTH AND (BICULTURAL) PARTNERSHIP: CONTRIBUTIONS TO THE INDIGENOUS HEALTH AGENDA ............................................................................................................................................................................................. 191 TE TIRITI O WAITANGI AND THE INDIGENOUS HEALTH AGENDA ............................................................................................. 192 SUMMARY .......................................................................................................................................................................................... 194 CHAPTER NINE: CONCLUSIONS AND FUTURE DIRECTIONS ........................................................................ 197 INTRODUCTION ................................................................................................................................................................................. 197 WHAT ARE AOTEAROA NEW ZEALAND AND AUSTRALIAN MEDICAL SCHOOL COMMITMENTS TO THE INDIGENOUS HEALTH AGENDA? ............................................................................................................................................................................ 198 HOW ARE THESE COMMITMENTS CURRENTLY ENACTED IN MEDICAL SCHOOLS IN AOTEAROA NEW ZEALAND AND AUSTRALIA? ...................................................................................................................................................................................... 200 HOW CAN THESE COMMITMENTS BEST BE REALISED IN FUTURE IN MEDICAL SCHOOLS IN AOTEAROA NEW ZEALAND AND AUSTRALIA? ...................................................................................................................................................................................... 200 STUDY LIMITATIONS ........................................................................................................................................................................ 201 RESEARCHER REFLECTIONS ............................................................................................................................................................ 202 FUTURE RESEARCH .......................................................................................................................................................................... 203 IN CONCLUSION ................................................................................................................................................................................ 204 REFERENCES ................................................................................................................................................................. 209 APPENDIX A .................................................................................................................................................................. 231 APPENDIX B .................................................................................................................................................................. 232 LIST OF FIGURES Figure 1: The intersection of indigenous rights to health and medical education ................................................... 9 Figure 2: Developing Indigenous Presence in Medical Schools ................................................................................... 101 Figure 3: Indigenous presence to indigenous impact in medical education .......................................................... 180 LIST OF TABLES Table 1: Boelen & Woollard's (2011) Social Obligation Scale ........................................................................................ 27 Table 2: Kaupapa Māori methodology: the integration of critical theory, social constructivism, and indigenous worldviews ........................................................................................................................................................ 71 Table 3: Phase One participant sample .................................................................................................................................... 89 Table 4: Phase Two participant sample ................................................................................................................................... 95 Table 5: A map of the indigenous health agenda ................................................................................................................ 175 ix Abbreviations AIDA – Australian Indigenous Doctors Association AMC – Australian Medical Council ATSIC – Aboriginal and Torres Strait Islander Commission CANZUS – Canada, Australia, New Zealand and Australia CDAMS – Committee of Deans of Australian Medical Schools (former name of MDANZ) CRT – Critical Reflection Tool HRC – Health Research Council of New Zealand ICIHRP – International Collaborative Indigenous Health Research Partnership KMT – Kaupapa Māori Theory KMM – Kaupapa Māori Methodology KMR – Kaupapa Māori Research LIME – Leaders in Indigenous Medical Education MAPAS – Māori and Pasifika Admissions Scheme MDANZ – Medical Deans of Australia and New Zealand MOUs - Memoranda of Understandings MOAs – Memoranda of Agreements NHMRC – National Health and Medical Research Council of Australia THENet – Training for Health Equity Network WGIP – United Nations Working Group on Indigenous Populations x