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19 July 2022

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Tāote – Cook Islands’ medical pioneers

Monday 28 March 2022 | Written by Rod Dixon | Published in Features, Weekend

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Tāote – Cook Islands’ medical pioneers
Cook Islands Health Department in 1965. SUPPLIED/22032515

With very few resources and little official encouragement, the Cook Islands first local doctors tackled epidemics and eliminated diseases, laying the foundations for the modern Cook Islands medical service.

A century ago, the Cook Islands Medical Service comprised two European doctors in Rarotonga supported by a handful of nurses. The outer islands were visited occasionally but between rare visits, were left without medical help.   

In 1926, Dr Sylvester Lambert, of the U.S. Rockefeller Foundation wrote – “With the best of intentions on the part of the (Cook Islands) Government, occasional visits from a European doctor are unsatisfactory for the dreadful emergencies that occasionally arise and for current severe sickness. Then, too, these (European doctors) do not understand the language nor the native mind.

Lambert’s solution was to train “Native Medical Practitioners (NMPs) … native doctors, well trained in Western medicine, and understanding the native mind”.

With Lambert’s encouragement and funding from the Rockefeller Foundation, a Central Medical School was established in Suva in 1929, to provide medical training for students from a range of Pacific countries, including the Cook Islands.

The School’s mission, according to its first Director Dr David Hoodless, was to “train natives to be better and still better natives and not to train natives to be even perfect imitations of Europeans”. This was in part a response to a widespread distrust of European doctors but also to ensure that graduating doctors would be willing to return to work in their villages, rather than clustering in European compounds in the main settlements.

As part of this policy, “Students were expected to wear standard ‘traditional’ lavalava; shirts were acceptable, but other overt indicators of ‘Europeanisation’ discouraged” (Stuart, 2006; 133).

Cook Islands medical students, however, were generally the sons of chiefs or of wealthy part-Europeans and having spent three years at Te Aute College for Maori Boys in Hawkes Bay they were, sartorially at least “almost completely Europeanised”, their trousers, shoes and other European clothing regarded with envy by fellow medical students restricted to the ‘short loin cloth and bare feet’” (Stuart, 2006; 133).

Instead of lavalavas and bare feet, Cook Islands students were usually to be found “at the Grand Pacific Hotel’s dances, in tail-coats and stiff shirts” (Lambert; 367).

Neither lavalava nor bare feet - Cook Islands medical students in Suva c. 1939. Front – (left) Dr James Rennie, (right) Dr Tere Williams with other unidentified people. (photo courtesy of the Rennie family). SUPPLIED/22032504

Three years at Te Aute and fluency in English also meant the Cook Islanders “knew so much already that they saw no necessity to work for what they got.”  None of this was conducive to the school’s efforts to build a collective islander ethos. But over time, the Cook Islanders made up for it with their prowess in the classroom and on the sporting field.

On their return to the Cook Islands as newly graduated NMPs, they found themselves “not trusted (by NZ colonial authorities) and given no real responsibility or incentive”. Their training and skills were devalued and under-paid. “Since the average salary of the practitioners was around one hundred and fifty pounds a year,” wrote Tom Davis, “they were obliged to supplement their earnings by farming …” In 1947, the salary of a New Zealand recruited papa’a Assistant Medical Officer was six times higher at £900.

The historian Annie Stuart believes the NMP concept was itself to blame for the subsequent demoralisation of the young doctors. Colonial administrations refused to train islanders to become fully qualified doctors, for fear they “desert their people and seek fortune abroad among the whites”. Accordingly, they settled on a scheme that produced local practitioners skilled enough to deliver unsupervised medical care but always subject to the overall guidance of fully qualified European medical officers.

 “(This) entrenched a hierarchical system of medical education and employment in which race (or at least whiteness or non-whiteness) determined options, career prospects and income. NMPs were only eligible for government employment, mostly in primary care, while European Medical Officers took on specialist clinical work at central hospitals” (Stuart, 132, 143).

To avoid such an outcome, Tom Davis undertook privately funded medical training at the Otago Medical School. In his autobiography, he writes that he wanted to avoid being “always at the beck and call of a fully qualified doctor from elsewhere” and believed an NMP qualification would be “a life sentence to the limited medical scene of the Pacific Islands” (Island Boy, 15).

Three decades earlier the doctor politician Sir Maui Pomare had foreseen the latter dilemma and, as Minister of Health, made provision for doctors serving in the Cook Islands to be on a rotation of three years, followed by four months furlough and a fourth year of practice in New Zealand. In 1948, Davis took advantage of both furlough and study leave to complete a year’s postgraduate training at Sydney University’s School of Tropical Medicine. In 1952, he was offered but declined an opportunity to study in London in preference to a scholarship awarded by Harvard. Both offers suggest that Pacific Islands’ tropical medicine was not a ‘limited scene’ or ‘life sentence’ after all.

Graduating from Otago, Davis returned to the Cook Islands in 1945, first as a medical officer, then as Chief Medical Officer (1948-52). In both roles, he developed a high regard for his Fiji trained colleagues. While the Administration considered NMPs in the outer islands ‘useful’, they regarded those working in Rarotonga as “not worth a damn” and treated them as ‘hospital chore men’.  “I could not quite see,” said Davis, “how they would be useful in one place and not in another” (Islands Boy. 36).

In this 1965 photo, Cook Island Medical Officer of Health, Dr. A. Guinea (right) seconded from the New Zealand Department of Health, and Health Inspector, Mr. Tuterua Arahu, draw tank water through filters which trap the bacteriological matter. 22032516

He first encountered the NMPs at morning surgery, “sitting on the (old Tupapa hospital) verandah-rail laughing and talking with the crowd (of patients) joking back and forth and roaring with laughter at some remark, as only Polynesians can. I smiled to myself at the thought that they had better laugh while they can, because I was planning to put them to full use” (Island Boy, 38).

He arranged for the NMPs to undertake post graduate training overseas in specialist areas such as TB, leprosy and filariasis. On their return Davis made full use of their skills and lobbied to improve their salaries. He supervised Dr Tere Williams in general medical practice and Dr Tekao Tinirau in surgery. NMP’s were also put to work tutoring Cook Islands student nurses studying for the NZ Trained Nurses Examination.

Dr Tinirau whom Davis encouraged into surgery was, with Tau Cowan, the first Cook Islander to graduate from the Central Medical School in 1931. He was the third son of William Parau Browne and Tuva’ine Elizabeth Tamarua and adopted by Makea Ariki-nui Tinirau. On graduating, he served as doctor to Penrhyn Island. In 1937, he married Noeline Titaua Brander of the Pomare family and the couple moved to practice in Mangaia. Tom Davis recalls that “When he met you, (Tinirau) bowed from the waist, clicked his heels together and shook hands. He seemed taller than he was, so straight did he carry himself; he was handsome, always courteous with a gentility I have found in no other …. He was the Prince Charming of our circle” (Doctor to the Islands, 85-6). After 16 years of official neglect, Tinirau’s abilities were finally recognised in 1947 when he was posted to Pukapuka, in the dual role of Resident Agent and medical practitioner (subsequently in 1953 to Manihiki/Rakahanga). As a Resident Agent his salary tripled.

Dr Tau Puruariki Cowan was the son of Charlie Cowan and Nuku Parapa Kainuku. The Central Medical School regarded him as “one of our outstanding graduates” (Lambert; 369). In 1937 he married the future Makea Nui Teremoana Ariki. The following year the couple moved to Atiu where, as local NMP, Cowan tackled an outbreak of typhoid that had killed 40 of the islanders (PIM, 25 May 1938). During the war, Dr Cowan, was responsible for the health of 2200 Aitutakians, benefitting from advice in surgical cases from American medical officers, stationed there. He served as a doctor for 40 years and was awarded the MBE in 1983.

In 1935, John Adam Numa became the third Cook Islander to graduate from the Central Medical School. John Numa was from the Numangatini and Parima families of Mangaia. “John’s purity of Polynesian ancestry,” wrote Tom Davis, was manifest in “classical features” and “gentleness in handling his patients” (Doctor to the Islands; 262). His bedside manner was so natural that “European mothers of young children … would usher him to the door after his examination of their child was complete, with perfect confidence that he had just worked a miracle”.

In Suva, he had been given specialist leprosy training including attachment to the Makogai Leprosarium.

Native Medical Practitioners in the medical dispensary, Mangaia c.1940 (photo; Hugh Hickling)/ 22032508

From 1937 – 1940, as NMP at Penrhyn, he was responsible for the Leper isolation station at Te Sauma motu. Leprosy cases from other islands in the group were concentrated there for later transport to Makogai.

In mid-1937, Dr Numa made the first of many surveys on the prevalence of leprosy in the Cook Islands. Lambert, who had intended to carry out the survey himself, described it as “outstanding” (Lange, 238). Dick Scott tells the story of “a world expert brought in by the South Pacific Commission to conduct a leprosy survey (who) found 42 new cases on Aitutaki, only one more than John Numa had already diagnosed”. Dr Numa’s ability to identify and diagnose early cases, meant Cook Islanders spent much shorter treatment times at the Fiji leprosarium.

In 1952, he completed a further six months of post-graduate work in leprosy and medicine in Suva and Makogai. The senior doctor with whom he worked reported that Numa “revealed a splendid practical knowledge of leprosy. This was expected of him, for the Cook Islands patients sent by him to Makogai are always early cases, in better condition than those from any other of the Pacific Territories”. He was an “outstanding” practitioner, “possessed of initiative, clinical judgement and reliability far beyond most of his fellows” (Lange, 244).

Numa was also author of an article on leprosy in the Cook Islands, published in the International Journal of Leprosy, 1953 – making him the first Cook Islander to be published in an international medical  journal.

In a second co-authored article for the New Zealand Medical Journal (61:77-85) in 1962, he was able to announce that leprosy in the Cook Islands was “no longer a major problem” “It may well be that leprosy in the group will soon be a matter of history”, he wrote.  The last new case of leprosy was diagnosed in 1995 and in 2005, leprosy was declared eliminated from the Cook Islands by WHO (Lange, 247). Described as a man with “an insatiable thirst for knowledge”, John Numa was twice denied official support to further his medical studies at Otago. He continued in medical service until his death in 1967 at the young age of 54.  In addition to medicine, he was an accomplished pianist, historian, dictionary maker and writer.

Dr Tuariki Nia Rua who graduated as NMP in 1938 took over from Dr Numa at Penrhyn, as physician in charge of the Te Sauma facility from 1940.

Dr Terenuku Williams also graduated in 1938. Tom Davis recounts how, in 1946, he and Dr Williams endured three days and nights at sea on the towing launch Takuvaine to reach Atiu where an outbreak of cerebro-spinal meningitis had killed 18 children. The launch had been hastily converted to a sailing craft by Ron Powell using sails borrowed from the Muri Sailing Club.

Dr James Rennie was the sixth Cook Islander to graduate from CSM having distinguished himself both academically and in rugby, tennis and cricket, playing against the touring Maori All Blacks in August 1938. At his graduation in Suva in 1939, the British Governor Sir Harry Luke presented him with the British Medical Association’s gold medal in surgery, the Dr A. H. B. Pearce gold medal in Obstetrics and the Sydney Pacific Islands Club prize for the School’s most advanced medical work.

Tuberculosis was once a major health problem in the Cook Islands. On the lower slopes of Rarotonga, the principal island of the group, this small sanatorium was run and staffed by the Cook Islands Health Department in 1965. SUPPLIED/22032515

At the outbreak of the Second World War, Dr Rennie, enlisted as a founding member of the 28th Maori Battalion, later transferring to the 2nd NZ General Hospital (2NZGH) corps serving in North Africa, as a medic on numerous battlefields including El Alamein. Dr Rennie was awarded the United Kingdom’s 1939-45 Star, the UK’s Africa Star with 8th Army Clasp, the UK War Medal 1939 – 45 and the NZ War Service Medal. 

In 1943 Dr Rennie was granted a war concession bursary for medical studies at Otago Medical School and in May 1949, travelled to Dublin, Ireland for further studies, graduating in 1952 as Licentiate of the Royal College of Physicians and Licentiate of the Royal College of Surgeons in Ireland. He was chronologically the second fully licensed Cook Islands doctor after Tom Davis.

Dr Rennie was formally registered as a New Zealand medical practitioner in November, 1952. He continued in general practice in New Zealand for the rest of his working life, further distinguishing himself as first responder to New Zealand’s worst bus crash in February, 1963, saving many lives. 

Dr Ngaeikura Tou graduated as a NMP in 1942. During the war he served at Penrhyn and, like Dr Cowan on Aitutaki, benefitted from medical and surgical advice provided by US Army doctors stationed on the atoll. He later specialised in obstetrics, gaining a positive reputation among the “most conservative of New Zealand ladies” (the wives of the NZ colonial administrators).  Dr Tou served as a doctor for 37 years, becoming Deputy Director, then Secretary, of the Department of Health. He died in 1980 aged 63.

Dr Tou graduated in the same year as Dr Manea Tamarua. Dr Tamarua spent the first four years of medical practice, 1942-5, on Mangaia with responsibility for the health of 1600 people. There, under radio direction, he was one of the first NMPs to successfully undertake remote surgery on an outer island, in this case for a strangulated hernia. 

He subsequently undertook post-graduate specialisation in tuberculosis in Fiji. On his return in 1951 he took charge of the TB sanitorium on Hospital Hill and helped lead the country’s fight against the disease. Against objections from colonial administrators, his wife Pari Taniera, a Rarotonga trained nurse, replaced the European qualified sister-in-charge at the sanitorium. Together, they are credited with a leading role in the ultimate elimination of TB from the Cook Islands.

The late Sir Terepai Maoate and his wife Lady Marito, pictured at Buckingham Palace, London, after he was awarded the title of Knight Commander of the Most Excellent Order of the British Empire (KBE) in 2007. The title recognised his contribution to health and the public sector in the Cook Islands. SUPPLIED/18072437

Later, with a fellow CSM graduate, Dr Pupuke Robati, Dr Tamarua became one of the many Cook Islands doctor/politicians, and first Deputy Premier of the Cook Islands. His medical partner and wife, Charge Nurse Pari Tamarua was awarded the British Empire Medal in 1985 for services to medicine.

In 1946 it was estimated that these eight men and the teams they led, had collectively saved hundreds of Cook Islands lives (Otago Daily Times, 22 January 1946). They had also contributed significantly to the eventual elimination of the islands’ more serious diseases – leprosy, TB, yaws and filariasis; fought measles, typhoid and other epidemics; made perilous boat journeys to save lives and attended the birth of a new generation of Cook Islanders.

When Tom Davis left Rarotonga in 1952, he reported that there were a further 25 Cook Islanders in training at the Fiji CMS as doctors, pharmacists, technicians, etc. These included three future prime ministers, Dr Sir Pupuke Robati, Dr Robert Woonton, Dr Sir Terepai Maoate and a cabinet Minister, Dr Teariki Matenga. 

By the late 1950s, with 16 NMPs (now called Assistant Medical Officers), four public health inspectors, 24 trained nurses, 23 trainee nurses, six male nurses, 20 mosquito inspectors, 12 dressers and nurse aides, seven technicians and seven district nurses, and a complement of dentists and dental assistants, the Cook Islands had a full-scale national health service with doctors rotating on fixed-terms around the northern and southern group islands.

Every island in the Cooks could boast its own local doctor (with two on Aitutaki) except Mitiaro, Rakahanga and Palmerston, which had resident male nurses. 

Today, only one outer island can make this claim.

REFERENCES

Thomas and Lydia Davis, 1955, Doctor to the Islands, Michael Joseph, London

Thomas Davis, 1992, Island Boy, IPS, USP, Suva.

S.M.Lambert, 1941, A Yankee Doctor in Paradise, Little Brown, Boston

Raebum Lange, 2013,  Exile And Compassion: The Management of Leprosy in the Cook Islands, 1925-95 Pacific Studies, Vol. 36, No. 3, December

Annie Stuart, 2006, Contradictions and Complexities in an Indigenous Medical Service, JPH, Vol. 41, No.2, September