Chapter Three: Medical education in Aotearoa New Zealand and Australia; efforts to address indigenous health inequities and contribute to indigenous health and wellbeing
This chapter will review the contributions that medical schools in Aotearoa New Zealand and Australia have made to the indigenous health agenda. It will then describe how these contributions help to position the present research. The potential contribution of medical schools to address indigenous health inequities in both Aotearoa New Zealand and Australia have been outlined in numerous documents (see: Phillips, 2004; Minniecon & Kong, 2005; Medical Deans Australia and New Zealand, 2007; 2012, Australian Medical Council, 2010). The AMC has proposed specific requirements for medical curricula in relation to indigenous health and advocated for medical school partnerships with indigenous communities (Australian Medical Council, 2010; 2012). Nevertheless, indigenous rights to health have yet to be placed at the forefront of the medical and medical educational agenda. Perhaps this is not surprising. In colonial and neo-colonial contexts, aspirations and solutions proposed and conducted by indigenous peoples themselves rarely find much traction with governments or the wider social contexts within which governments exist. Indigenous aims and aspirations for self-governed pathways to strengthen indigenous health and wellbeing regularly clash with the dominant paradigm of profit-oriented economic growth and rapid modernisation (Hodgson, 2002). Most forms of indigenous resistance to this dominant paradigm are accompanied by aspirations for a more diverse, pluralistic and egalitarian society. Not coincidentally however, this is exactly the context in which a socially accountable medicine would be most likely to flourish, and autonomous developments in health, education and social welfare would be most actively supported (Durie, 2004; 2008).
Indigenous pressure to reconfigure the unequal power distribution between coloniser and colonised in both Aotearoa New Zealand and Australia has been increasing over the past 40 years (Paradies, Harris & Anderson, 2008; Havemann, 1999). To cite just one example of this dynamic tension, it is useful to reflect on the United Nations Declaration on the Rights of Indigenous Peoples (UNDRIP, 2008). In 2007, only four nations voted against UNDRIP; these were the members of CANZUS (Canada, Australia, New Zealand and the United States), each of whom could be characterised as settler colonial societies with significant indigenous populations. In 2012, CANZUS reversed its position and voted for the UNDRIP. It is reported that what made this new stance possible were negotiations to soften the language of indigenous self-determination in the draft declaration (Davis, 2012). UNDRIP language reflects the current CANZUS position that allows for the promotion of indigenous cultures and languages, while still avoiding engagement with the more challenging political issues of indigenous rights to sovereignty and self-determination (Bellier & Preaud, 2011). This same stance can be found in colonial societies that embrace indigenous cultural symbols while ignoring the aspirations of indigenous peoples themselves (Sibley, Liu & Khan, 2008; Corntassel & Holder, 2008). Institutions such as universities are no exception to this rule. Far from being exempt from broader societal dynamics, educational institutions tend to replicate them (Parker, 2011).
Medical school commitments to indigenous health in Aotearoa New Zealand and Australia
In Aotearoa New Zealand and Australia, medical schools are required to meet the accreditation standards of the AMC. The purpose of accreditation is “to recognise medical programs that produce graduates competent to practise safely and effectively under supervision as interns in Australia and New Zealand, and with an appropriate foundation for lifelong learning and for further training in any branch of medicine” (Australian Medical Council, 2015, p.4). Having formally endorsed and embedded the Indigenous Health Curriculum Framework into their accreditation guidelines, the AMC put forward a proposal that medical schools undertake the teaching and learning of indigenous health (Paul, Allen & Edgill, 2011). Through their inclusion in the accreditation guidelines from 2007 forward, medical schools are required to report on progress towards the implementation of these guidelines. In 2002, the then Committee of Deans of Australian Medical Schools (CDAMS) – now known as Medical Deans Australia and New Zealand (MDANZ) – partnered with the Commonwealth Department of Health and Ageing to establish and implement the CDAMS Indigenous Health Curriculum Development Project. Hosted by the Onemda VicHealth Koori Health Unit at The University of Melbourne, the Project successfully carried out four key objectives, including: (1) an audit of existing indigenous health content in medical schools; the development of a national curriculum framework2; (3) the development of a network of medical educators to sustain implementation, and; (4) the inclusion of the curriculum framework in the Australian Medical Council’s (AMC) Guidelines for Accreditation (Phillips, 2004).
The CDAMS Indigenous Health Curriculum Project, alongside another initiative, which focused on the support and retention of indigenous medical students (Minniecon & Kong, 2005), represented a significant shift in medical education in Aotearoa New Zealand and Australia. For the first time, there was general agreement by the Deans of Medical Schools to an agreed curriculum framework; the first of its kind in any area of health care, as well as explicit requirements for medical schools in relation to indigenous health (Medical Deans Australia and New Zealand and Australian Indigenous Doctors Association, 2012; Australian Medical Council, 2007). The CDAMS Indigenous Health Curriculum Framework (hereafter referred to as the Indigenous Curriculum Framework) outlined curriculum development processes and resources, capacity and workforce development issues. The curriculum development processes included: suggested subject areas, key student attributes and outcomes, pedagogical principles and approaches, delivery and assessment and suggested process for curriculum development.
In 2005, the key objective of developing a network of medical educators was realised in the development of the Leaders in Indigenous Medical Education (LIME) network. The LIME network encourages and supports medical school collaboration within and between Australia and Aotearoa New Zealand, to “enhance the quality and effectiveness of Indigenous health curricula in medical education and to enable best practice in the recruitment and retention of Indigenous medical students.” (Haynes et al., 2013, p.65). The LIME network established a reference group with indigenous health leadership from each medical school across Aotearoa New Zealand and Australia, as well as secretariat, responsible for facilitating the core business of LIME, and a biennial LIME connection conference in which medical schools can share progress related to the Indigenous Curriculum Framework (Phillips, 2004; Haynes et al., 2013).
According to the Medical Deans Australia and New Zealand and Australian Indigenous Doctors Association (2012), effective implementation of the Indigenous Curriculum Framework could be greatly supported by a ‘whole of faculty’ approach. However, this approach would need to be a joint effort by Deans, indigenous health staff and domain or discipline heads (Medical Deans Australia and New Zealand and Australian Indigenous Doctors Association, 2012). The latest AMC standards (2012) include the expectation that medical schools to contribute to the development of the indigenous health workforce and have “effective partnerships with relevant local communities, organisations and individuals in the Indigenous health sector to promote the education and training of medical graduates. These partnerships recognise the unique challenges faced by this sector” (Australian Medical Council, 2012, p.6). Likewise, MDANZ articulates in their mission statement3 an objective to: “Promote improvements in Indigenous health through education and workforce development.”
It is clear from the statements above that medical schools are regarded by other medical professional bodies as having an obligation to address indigenous health inequities, and that they can play an important role in doing so, primarily through: (1) developing policies and pathways to increase the number of indigenous health practitioners, and; (2) training a workforce that has the knowledge and skills to effectively deliver healthcare services to indigenous communities. As noted by the AMC (Australian Medial Council, 2012), producing such a workforce entails partnership with indigenous communities, organisations and individuals. Likewise, success for indigenous health workforce development includes increasing community and family engagement, as well as the framing of initiatives within indigenous worldviews and a tangible demonstration of institutional commitment to equity (Curtis, Wikaire, Stokes & Reid, 2012). These individual and specific commitments are grounded in and anchored by a commitment to recognise and respect indigenous rights to health. They represent important steps in articulating what the application of that commitment might mean in practice. Naturally, upholding indigenous rights to health in practice is likely to be significantly more difficult than simply granting these rights formal recognition. As Hafferty and Franks (1994) have argued, the hidden curriculum of medical education includes a status quo of institutional self-interest and tendencies to preserve a long-established system of medical privilege and power (see Chapter Two). Despite this, medical schools in Aotearoa New Zealand and Australia have begun to action commitments to address indigenous rights to health. Recognition is slowly dawning that this means engaging more robustly with indigenous peoples’ aspirations to health self-determination and ensuring that they have a seat at the table wherever decisions are made with regard to issues that bear on indigenous health. As Phillips (2015) notes: “medical schools and faculties seemingly have a hard time comprehending and implementing this principle (of self-determination) in action, despite a clearly stated goal and accreditation standard articulating this as essential” (Phillips, 2015, p.264). As such, a number of key questions need to asked about how medical school commitments to indigenous rights can best be fulfilled. This thesis aims to address the practical implementation of this important political and ethical agenda for medical schools in Aotearoa New Zealand and Australia.
Advancing the indigenous health agenda in medical education in Aotearoa New Zealand and Australia
In Aotearoa New Zealand & Australia (and elsewhere, notably Canada) recognition of the urgent need to address indigenous health disparities has led to the development of indigenous health curricula and other indigenous initiatives in medical education. Indigenous health has now established itself as an emerging part of medical education and may be regarded as its own specialty area (Pitama, 2012). As a specialty area, indigenous health is distinct from social accountability and other approaches with a strong social mission in medical education (see: Boelen & Heck, 1995; Boelen & Woollard, 2009; 2011). As outlined in Chapter One, the indigenous health agenda in medical education is medical schools’ commitment to address indigenous rights to health by developing indigenous contributions and providing institutional support for those contributions to have impact. This includes all medical school activities that can contribute to indigenous health and wellbeing, from the indigenous health curriculum and indigenous student recruitment and retention, to resourcing and workforce infrastructure, to institutional governance and leadership.
In contrast to the social accountability literature’s emphasis on health needs as the basic referent for the allocation of health care resources (see: Boelen & Woollard, 2009; 2011), indigenous health initiatives developed by indigenous peoples themselves tend to adopt what can be described as a rights-based framework of understanding, in which indigenous leadership and self-determination are essential (Phillips, 2004; Pitama, 2012). As such, indigenous peoples themselves are positioned at the centre of attempts to reduce health inequities, employing strengths-based approaches with clear understandings of sovereignty (Phillips, 2015). This is crucial because even where institutional backing for an indigenous agenda does exist, indigenous leadership is still necessary to ensure that indigenous agency is strengthened rather than undermined. As Hunter (2006) notes: “The undermining of Indigenous agency in terms of ‘getting involved’ may thus reflect a range of historical, developmental, contextual and circumstantial factors. However, whatever the causal mix, it has been powerfully influenced by non-Indigenous policies, processes and protagonists – by the role of governments in Aboriginal and Torres Strait Islander lives that “despite banners such as self-determination and self-management have often further compromised real agency and control of destiny” (Hunter, 2006, p. 29). This same problem can be found not only at government level, but within medical education itself. As previously discussed, approaches that focus on racial/ethnic disparities from a mainstream perspective, such as the provision of cultural competency training to mainstream practitioners, may be well-intended efforts to intervene on behalf of indigenous peoples that have the unintended effect of disempowering them (see: Paul, Hill & Ewen, 2012; Ewen, 2012).
Medical schools as sites of struggle
Many medical schools across Aotearoa New Zealand and Australia already demonstrate some level of commitment to indigenous-led initiatives that seek to increase the number of indigenous health practitioners and produce a culturally safe workforce. Examples of these initiatives include indigenous workforce development schemes (see Curtis, Reid & Jones, 2014), as well as academic indigenous-specific health domains within the medical curricula (see: Ewen et al., 2016; Medical Deans Australia and New Zealand and Australian Indigenous Doctors Association, 2012). For the success of such initiatives, institutional change is often required to ensure that indigenous leadership is maintained and that there are shared understandings as well as a coordinated, long-term approach to the support of these initiatives (Curtis, Reid & Jones, 2014). As outlined above, colonial norms may still compromise indigenous agency at government, university and medical school levels, hence the need for substantive institutional change. As Phillips (2015) points out, an essential part of addressing indigenous rights to health by medical schools includes “decolonisation practices of ensuring Indigenous leadership, and shared decision-making and resourcing in partnering with other academics and stakeholders” (Phillips, 2015, p. 128).
Both the Indigenous Curriculum Framework and the development of the LIME Network mark important advances made towards addressing indigenous health disparities in medical education contexts across Aotearoa New Zealand and Australia. The CDAMS Indigenous Health Curriculum Project has sought to make the health curriculum more responsive to the realities of indigenous health inequities. These efforts have typically centred on framing curricula responses around the Indigenous Curriculum Framework (Phillips, 2005; Ewen, 2011). As acknowledged in the Indigenous Curriculum Framework itself, the implementation of indigenous health into the medical curriculum is primarily an organisational reform task, inclusive of curriculum development as well as resources, capacity and workforce development (Phillips, 2004, Mackean et al., 2007). The development of the Critical Reflection Tool (CRT) marks another advance where assisted reflection on institutional structures and norms helps to ensure support for the inclusion of indigenous health content in the formal curriculum as well as indigenous student recruitment and retention strategies (Ewen, Mazel & Knoche, 2012).
Wherever there has been recognition of indigenous rights to health in medical education settings, there has been evidence of indigenous leadership and support for that leadership, as for example in the CDAMS Indigenous Health Project. However, support for this leadership often wanes at the very point at which implementation of such initiatives is imminent. This can be seen in the case of the CDAMS Indigenous Health Project, where support from Deans for indigenous-leadership in the project appears to have been offered, yet there was little follow-through in terms of the implementation of specific indigenous-led initiatives within medical schools (Phillips, 2015). In 2011, the Indigenous Curriculum Framework was evaluated by MDANZ and the Australian Indigenous Doctors Association (AIDA). The major findings from this review found that while the indigenous health curriculum content in medical schools had increased since 2003, there had been no increase in resources or mechanisms to assess curriculum quality and graduate learning outcomes. Furthermore, in the Australian context, although indigenous medical enrolments had increased, the rate of indigenous medical graduates had not increased (Medical Deans Australia and New Zealand and Australian Indigenous Doctors Association, 2012). These findings suggest that indigenous leadership requires more institutional support to become sustainable, effective and capable of autonomous decision-making within medical education settings.
The case for an indigenous rights to health framework in medical education
Indigenous rights to health include basic human rights to health equity, i.e. equality in diversity, and health equality underpinned by principles of justice and fairness. This chapter has suggested that an indigenous rights to health framework in medical education may be able to offer an important missing link between medical school commitments to address health inequities in general (see Chapter Two), and commitments to address indigenous health inequities in Aotearoa New Zealand and Australia. As indicated in Chapter One, indigenous rights are additional to and distinct from human rights in general. The collective rights of indigenous peoples consist of the right to autonomy and independence, sovereignty, and self-determination in relation to a history of colonisation. Decolonisation requires not only the acknowledgement of historical injustices, but the recognition of ongoing and oppressive social practices in the present. This thesis proposes that the social agenda of decolonisation can and should be actively pursued through partnership with indigenous peoples and affirmative action designed to promote indigenous interests. At a fundamental level, reducing indigenous health inequities requires indigenous expertise. Indigenous peoples need to be consulted with, recognised and respected in determining their own healthcare needs and priorities. It can be argued that understanding and addressing indigenous health inequities requires an analysis of power as well. Health equity and affirmative action in healthcare can be understood as the remediation of systemic and systematic disadvantages historically imposed by colonisation and maintained in the present via the status quo assumption of a level playing field. This would explain the need for indigenous health independence, that is, all the many creative aspirations and solutions proposed and conducted by indigenous peoples themselves to address indigenous health inequities and strengthen indigenous health and wellbeing. Equally, however, it appears that indigenous health interdependence or partnership requires an equitable allocation and sharing of mainstream, non-indigenous resources and expertise. An example of this would be ensuring that there are adequate numbers of indigenous doctors and places made available in medical schools for indigenous medical students, with the aim of producing adequate numbers of indigenous doctors.
As discussed in the previous chapter, ‘person-centred’ care implies understanding people as social and cultural beings; not simply as health care consumers who have “social, cultural and consumer expectations” (Boelen, 2009, p. 2; Abdalla, 2012). For many indigenous people, daily experiences of being ‘othered,’ and living in relationship to a collective history of colonisation and systemic discrimination, impacts health needs and the experience of health care in a variety of ways. To cite one example, proposals for the development of cultural competency, along with other culturally related teaching in medicine such as cultural awareness and cultural reflexivity, promotes the positive aspiration of equipping future practitioners with the necessary skills to effectively treat indigenous patients. However, cultural competence programmes typically neglect the need to recognise, challenge or address inherent power imbalances that are due to the persistence of colonisation at both the individual and institutional level (Paul, Hill & Ewen, 2012). Equally importantly, such approaches tend to be narrowly focused on assessing student learning, rather than widening the scope of inquiry to assess staff competence, institutional compliance, and the longer-term effects of such learning on the culture of medicine itself. It is the combination of attending to the learning needs of staff as well as students and active collaboration at institutional levels as well as workforce development that could reasonably be expected to impact and improve indigenous health outcomes (Paul, Hill & Ewen, 2012). Metzl & Hansen (2013) suggest redefining cultural competency in structural terms. This would require a shift from “an exclusive focus on the individual encounter to include the organization of institutions and policies, as well as of neighborhoods and cities, if clinicians are to impact stigma-related health inequalities” (Metzl & Hansen, p. 127).
It can be argued that indigenous peoples themselves need to contextualise and re-frame definitions of adequate care as it pertains to them, as well as co-author the standards by which Boelen & Woollard’s (2009) definitions of quality, equity, relevance and effectiveness are measured. Recognition of the enduring legacies of colonisation reveal the inadequacies of an equality paradigm that assumes a level playing field. An equity-based medicine and medical training would require recognition of the role of colonisation in creating indigenous health disparities in the first place and continuing to maintain them today. Boelen & Woollard’s (2009, p. 889) definition of equity as trying to “ensure that every citizen has full access to health care services and does not face any form of discrimination” puts a strong focus on equality of opportunity, but leaves out the even more important focus on equality of outcome.
From an indigenous frame of reference, then, institutional decolonisation needs to be part of the picture, and white-settler relations with indigenous peoples must be considered in their historical context. In the context of indigenous rights, the parameters of group to group relations between indigenous peoples worldwide and the largely white and western world of medicine become much more visible and clear. Partnership cannot be based on western perceptions of indigenous need alone; these will continue to operate in a deficit model that undermines the sovereignty and dignity of one of the partners. Indigenous rights and the indigenous responsibilities attendant upon these rights, offers another, more promising path to authentic partnership. Here partnership is a contract between two parties with equal dignity and equal rights that also explicitly acknowledges an asymmetry based on evident disparities in power, privilege, resources and cultural validity. This asymmetry is the result of colonial history and colonising dynamics between white-settler and indigenous peoples in the past that continues into the present. It is therefore incumbent that the medical establishment, in this context, medical schools, as the party with greater power and privilege, recognise an obligation to uphold indigenous rights and seek to promote a partnership in which equality in diversity becomes possible. Meanwhile, indigenous rights to health equity and equality bring with them the responsibility for indigenous peoples to adopt an approach to self-care and self-determination that will play to indigenous strengths as well as indigenous needs and assist indigenous peoples to uplift themselves. For the immediate future, health independence for indigenous people requires health interdependence; skilled assistance from medical partners, and the provision of resources, training and expertise will allow indigenous partners to develop the capacity to take full responsibility for their own health and healthcare.
GLOSSARY OF TERMS
CHAPTER ONE: MEDICAL EDUCATION AND INDIGENOUS HEALTH INEQUITIES
SETTING THE SCENE: INDIGENOUS HEALTH AND MEDICAL EDUCATION IN AOTEAROA NEW ZEALAND AND AUSTRALIA
THE STUDY: MEDICAL EDUCATION THAT CONTRIBUTES TO INDIGENOUS HEALTH AND WELLBEING AND SUPPORTS INDIGENOUS RIGHTS TO HEALTH
ORGANISING CONCEPTS USED IN THIS THESIS
TERMS USED IN THIS THESIS
SUMMARY OF CHAPTERS
CHAPTER TWO: MEDICAL EDUCATION RESPONSES TO THE CHALLENGE OF HEALTH INEQUITIES
SOCIAL ACCOUNTABILITY IN MEDICAL EDUCATION
COMMUNITY-ENGAGED MEDICAL EDUCATION: NOTIONS OF PARTNERSHIP AND ACCOUNTABILITY TO HEALTHCARE STAKEHOLDERS
CULTURAL COMPETENCE, CULTURAL HUMILITY, AND CULTURAL SAFETY
CRITIQUE OF MEDICAL EDUCATION RESPONSES TO ADDRESSING INDIGENOUS HEALTH INEQUITIES
CHAPTER THREE: MEDICAL EDUCATION IN AOTEAROA NEW ZEALAND AND AUSTRALIA; EFFORTS TO ADDRESS INDIGENOUS HEALTH INEQUITIES AND CONTRIBUTE TO INDIGENOUS HEALTH AND WELLBEING
MEDICAL SCHOOL COMMITMENTS TO INDIGENOUS HEALTH IN AOTEAROA NEW ZEALAND AND AUSTRALIA
ADVANCING THE INDIGENOUS HEALTH AGENDA IN MEDICAL EDUCATION IN AOTEAROA NEW ZEALAND AND AUSTRALIA
MEDICAL SCHOOLS AS SITES OF STRUGGLE
THE CASE FOR AN INDIGENOUS RIGHTS TO HEALTH FRAMEWORK IN MEDICAL EDUCATION
LINKING A RIGHTS FRAMEWORK TO THE RESEARCH QUESTIONS OF THIS STUDY
CHAPTER FOUR: KAUPAPA MĀORI METHODOLOGY
KAUPAPA MĀORI: RESEARCH, THEORY AND METHODOLOGY
A KAUPAPA MĀORI METHODOLOGICAL FRAMEWORK
CHAPTER FIVE: RESEARCH METHODS
OVERVIEW OF METHODS
CHAPTER SIX: DRIVERS OF AND OBSTACLES TO THE INDIGENOUS HEALTH AGENDA
BUILDING INDIGENOUS PRESENCE IN MEDICAL EDUCATION: DRIVERS, OBSTACLES AND STRATEGIC PATHWAYS
DRIVERS FOR THE INDIGENOUS HEALTH AGENDA
OBSTACLES TO THE INDIGENOUS HEALTH AGENDA
CHAPTER SEVEN: STRATEGIC PATHWAYS TO BUILDING A STRONG INDIGENOUS PRESENCE WITHIN MEDICAL EDUCATION
STRATEGIC PATHWAYS: INDIGENOUS KNOWLEDGE AND INFORMATION, PROCESS AND PRACTICE, PERSONNEL, AND RESOURCE BASE
CHAPTER EIGHT: REALISING COMMITMENTS TO INDIGENOUS RIGHTS TO HEALTH; HELPING MEDICAL EDUCATION ‘WALK ITS TALK.’
DEFINING THE INDIGENOUS HEALTH AGENDA IN MEDICAL EDUCATION
DISCUSSION OF DRIVERS
DISCUSSION OF OBSTACLES
DISCUSSION OF STRATEGIC PATHWAYS: DEVELOPING INDIGENOUS PRESENCE IN MEDICAL EDUCATION
DOMAINS OF MEDICAL SCHOOL ACTIVITY
THE COMPLEX UNITY OF INDIGENOUS HEALTH AGENDA
INDIGENOUS PRESENCE: COMBINING DRIVERS, OBSTACLES, AND PATHWAYS
SUPPORT FOR INDIGENOUS PRESENCE WITHIN DOMAINS OF MEDICAL SCHOOL ACTIVITY
DISCUSSION OF INDIGENOUS IMPACT: SUPPORT FOR INTEGRATION AND ALIGNMENT OF THE INDIGENOUS HEALTH AGENDA
EXPLORING KEY DYNAMICS AND TENSIONS IN THE DEVELOPMENT OF THE INDIGENOUS HEALTH AGENDA
INDIGENOUS RIGHTS TO HEALTH AND (BICULTURAL) PARTNERSHIP: CONTRIBUTIONS TO THE INDIGENOUS HEALTH AGENDA
TE TIRITI O WAITANGI AND THE INDIGENOUS HEALTH AGENDA
CHAPTER NINE: CONCLUSIONS AND FUTURE DIRECTIONS
WHAT ARE AOTEAROA NEW ZEALAND AND AUSTRALIAN MEDICAL SCHOOL COMMITMENTS TO THE INDIGENOUS HEALTH AGENDA?
HOW ARE THESE COMMITMENTS CURRENTLY ENACTED IN MEDICAL SCHOOLS IN AOTEAROA NEW ZEALAND AND AUSTRALIA?
HOW CAN THESE COMMITMENTS BEST BE REALISED IN FUTURE IN MEDICAL SCHOOLS IN AOTEAROA NEW ZEALAND AND AUSTRALIA?
GET THE COMPLETE PROJECT
The Indigenous Health Agenda in Medical Education