By Donald Mackie, M.D.
More than two years ago, my family and I left our many friends in Ann Arbor and returned to New Zealand. The editor thought that a description of what we have been doing since then would add an international flavour to The Michigan Airway, so here goes.
New Zealand lies in the southwest Pacific, approximately 1,200 miles east of Australia. Three and a half million people live in an area equal to that of the United Kingdom or Japan. Since there are a million people living in Auckland, you will appreciate that the rest of the country is thinly populated. There are, of course, plenty of sheep here. For years the country’s economy rode on the sheep’s back, with a little help from dairy cattle. When Britain, the main market for these products, joined the European Community, New Zealand farming entered a period of diversification. The opening of new markets has put the rural economy back on its feet. Kiwifruit (kiwi in the U.S.) are one success story. Nashi pears and stonefruit are exported to Japan. Fish and crustaceans are major exports, along with more exotic meats such as venison and emu. Kangaroos live in Australia, but in the spirit of the rivalry between our two countries we eat ‘roo meat whenever we can (it is lean and makes a very good curry). The national emblem is the Kiwi, a small, brown, nocturnal, flightless bird. Perhaps it lacks the majesty and power of the American eagle, but its image crops up all over the place.
Auckland is New Zealand’s largest city. It sprawls around the isthmus between two harbors, the Manukau and the Waitemata. The Waitemata, Maori for sparkling waters, lives up to its name. The Manukau has a different kind of appeal—being muddy and home to the airport, a cement works and a sewage treatment plant. To the west of the city lie the bush-clad Waitakere hills and the rugged beaches of the Tasman Sea. To the east lies the Hauraki Gulf, a marvelous area for messing about in boats. Auckland is rightly called, “The City of Sails.”
The Auckland plain is dotted with the cones of volcanoes that have erupted over the last 30,000 years. The youngest, Rangitoto, erupted 800 years ago. Its near-symmetrical cone is one of the city’s most distinctive features. Glimpses of it appear and disappear as one travels around the city. There are active volcanoes in New Zealand and some areas of the country are regularly shaken by earth tremors. Wellington, at the southern tip of the North Island, is the country’s capital but Auckland is the commercial centre. There is a friendly rivalry between the two cities. Wellington is an earthquake-prone area. Whereas we Aucklanders prefer to live with the remote possibility of a catastrophic volcanic eruption. Wellingtonians find regular, gentle jolts more relaxing.
Those of you with Internet access might care to point your web browser to http://nz.com/guide/ to find out more about the country and its people. Alternatively, you might like to follow the news group soc.culture.new-zealand.
Middlemore, where Bernadette and I work, is a 900-bed public hospital located in South Auckland. This is a predominantly working class area with a large Maori and Pacific Island population. Auckland is not only the country’s commercial centre but a Polynesian city. The Maori are New Zealand’s indigenous human inhabitants. They arrived here during the great Polynesian migration throughout the Pacific some 1,000 years ago. In South Auckland there are large Cambodian, Fijian, Indian, Samoan, Tongan and other island communities. The cultural breadth of Auckland is remarkable, from the Dalmatian wine makers in the west to the recent arrivals from Hong Kong and Korea in the eastern suburbs.
Middlemore Hospital was originally built by the U.S. military during World War II. In those days (1943) it was out in the country, Auckland has since grown to envelop it. We keep a bit of the country around us in the form of two golf courses. There is a fine view of the 14th green from our day stay theatre—very distracting on a fine day during a tedious knee reconstruction. The hospital was built by a railway line. Casualties from the Pacific battlefields came to the hospital by train from the docks as soon as their ships docked. Some of the original buildings are still in use, we keep our administrators in them.
The hospital provides both secondary and tertiary services. The internal medicine department includes special renal and diabetic units. We are a tertiary centre for plastic surgery (including burns), maxillofacial, specialized orthopaedics and spinal surgery. Regular general surgery, obstetrics, gynecology and some vascular work fill up the rest of the time. We serve the top half on the North Island in these areas, a population of around 1.2 million. One important feature of our workload is the high incidence of acute cases. So far this year 68 percent of surgical cases have been acute (or emergent). This adds a special kind of pressure to running the floor. Heart valve disease, secondary to rheumatic fever, is relatively common in our patient population. This presents particular challenges in obstetrics. The valve lesions may be diagnosed for the fist time in pregnancy—sometimes when a patient presents in labour with pulmonary edema!
Regional anesthesia is a house specialty. The steady stream of acute hand cases ensures that our trainees soon develop facility with brachial plexus blocks. We are still looking for an agent that will last as long as our surgeons take to repair nerves and tendons. Catheter techniques allow for top-up doses of local, the patient’s sense of humour is harder to top-up.
We have 11 ORs, one dedicated to obstetrics and one in the day-stay unit. The department consists of 18 attendings, 14 residents, 8 technicians and an indispensable secretary. We run over 1,400 cases every month. The Australia and New Zealand College of Anaesthetists oversee training, much as the ABA does. The training period is five years. Senior residents work with limited direct supervision, thus gaining experience in working alone (with help available by phone) as they make the transition to specialist status. We have a close relationship with the intensive care unit. This is staffed by five specialist intensivists with four residents. Intensive care and anesthesia training overlap in New Zealand. Intensivists are required to spend time in anesthesia in training, and vice-versa. This makes it a lot easier to get patients admitted to an allegedly full ICU. One merely has to remind the ICU resident that they will shortly be an anesthesia resident and that one has considerable influence with the roster-master.
Medical practice here is remarkably free from civil litigation. The Accident Compensation Corporation (ACC), a tax-funded, central system of no-fault compensation provides compensation to victims of medical misadventure. The system has been overhauled, greatly to its detriment, by recent governments. No doubt civil litigation will gather momentum in the wake of these changes. There is a worrying tendency by the police, in some areas, to pursue manslaughter charges against medical practitioners. The reasons for this are complex, some police officers appear to have particular zeal in this area. There has been a handful of convictions, none of them resulting in a jail sentence. It is hoped that lobbying to change the law under which these cases are prosecuted will bear fruit soon.
New Zealand’s health system, like every other, has been undergoing reform. There are two sectors, public and private. Primary care is provided by general practitioners who bill patients directly. Many of their services (children’s care for example) are subsidized by the government. Secondary care may be in a public or private hospital. Public hospitals are now called Crown Health Enterprises (CHE), essentially free standing businesses with the government as the major (currently the only) shareholder. CHEs are able to contract with the government or insurance companies (or anyone else) for their services. The same applies to private hospitals.
The intent of this set up is that public and private hospitals can compete on a relatively level playing field. It is not yet certain that this has happened. The reforms have only been in place for two years. None of the CHEs have gone out of business yet, but it is possible that some will. This will be the test of the economically driven rationalization of services that was intended. Some large CHEs believe that the government will not let them go broke so they continue to overspend, confident that they will be bailed out of any crisis. They are probably right. There have been some resignations from outspoken CEOs. Change is the only constant.
Publicly funded health care is still rationed, by waiting lists for elective procedures and by the deliberations of the Core Services Committee. This group’s goal is defining which health services should be available to all from public money—a little like the Oregon initiative. They have made some progress but it has been slow. As soon as they reach a consensus the media spotlight an anomalous case that reopens the debate. Much of this will be familiar to North American readers.
Enough of medical politics. You will have heard that the World Congress of Anesthesiologists (WCA) is in Sydney next April. You may not know that the International Society for Regional Anaesthesia (ISRA) is holding a satellite meeting in Auckland before the WCA. Why not come down under and visit us? The ISRA meeting has a full and interesting program, both scientific and social. You can be sure of a warm welcome.