Island Nurses

by Howie, Leonie; Robertson, Adele;

  He and Leonie talked it over. The problem was that neither local nor central government could be persuaded to take responsibility for providing facilities for what was, in effect, a private medical practice. Other remote areas in New Zealand had been made ‘Special Areas’ by the Ministry of Health, where the health service was free to the community. Great Barrier Island, unfortunately, remained the square peg that would not fit into the round holes of the funding models. The Great Barrier Island County Council with its small rateable base could not afford to build a facility like many other rural New Zealand local bodies had been able to do.

  ‘We could leave,’ Ivan suggested. ‘If we left, they would have to take responsibility.’

  ‘Where would we go?’

  Ivan considered it. ‘China, perhaps?’ he mused.

  He had been born to medical missionary parents in Yantai, in China’s north-eastern Shandong province. A few years before, he and his sister had returned there for a school reunion, and he told Leonie it was as though he had gone home. He could imagine them living and working there.

  But Leonie looked around their little house thoughtfully. It did not feel as though the Howies were finished with Aotea quite yet.

  It wasn’t just us who could see the value of a properly equipped medical clinic. The islanders had already reached the same conclusion. Fortunately, some of the locals were doing a bit of research of their own.

  One day in the late eighties, Ivan rushed through the front door, beaming.

  ‘Helen suggests I speak with the local council about a community health centre,’ he told Leonie. ‘She’s been looking at the district plan, and there’s a clause in there about the need for a medical centre. She is sure the islanders will find a creative solution!’

  Helen O’Shea was a former psychiatric nurse who had moved with her husband to the Awana Valley on the Barrier to become farmers. Although she once described herself as ‘the president of the newcomers’ club’, she had been on the island nearly twenty years by the time she was elected to the County Council. Her rural outlook typified most Barrierites—with twinkling eyes and smile set in a broad face beneath her curly auburn hair, she was unfailingly optimistic and possessed of apparently boundless, indomitable energy. Firmly believing that there had to be a better way to arrange things medical on Aotea, she had dug out the 42-year-old district plan and found, to her delight, that those drafting it had declared their intention ‘to investigate the possibility of establishing a medical centre in Claris’. A precedent had been set. If there had been a perceived need nearly half a century ago, Helen argued, how much more necessary was a medical centre now? She encouraged Ivan to attend a meeting of the County Council to put the case forward.

  So while Leonie ‘held the fort’—that is, stayed handy to their telephone in case an emergency call came—Ivan, Adele and Nancy met the county councillors. The fact that their predecessors had identified a need for a medical centre was news to the councillors, but with Helen fired up about the issue, they were relatively easily persuaded to agree in principle to find a solution for Aotea’s health infrastructure problems.

  While Ivan and Adele were buoyed by this development, Leonie wasn’t so sure. She could see the enormous amount of money that would be needed, and she wondered how a community so impecunious would ever find the funds necessary to construct a medical centre by itself.

  For a while, it seemed she was right. After the initial buzz from the meeting had worn off, hope dwindled and nothing happened. Ivan and Leonie went right back to kneeling in the caravan to examine their patients, and the need to get on with it swamped any such thoughts of a medical centre: they were busy, as before, just staying afloat.

  Helen was not to be deterred, however. She persuaded the County Council to create a committee comprising volunteers along with the health professionals: each of the geographical regions (north, central, south) were represented, as were the tangata whenua, and there was a broad range of opinion and expertise aboard as well. This ‘health committee’ met regularly, and at some point the notion of a Community Health Trust evolved—ensuring that the ownership of the health infrastructure would remain firmly with the community. Ivan and Leonie were particularly in favour of this: it meant that if death or disaster befell them or their practice, all that would be needed would be for new health practitioners to step in, future-proofing the service. The islanders need not notice any change in the health service. Besides, the community’s sense of identity being as it is, making the health system the islanders’ own would be far more than merely symbolic.

  David Palmer, a local with some experience with trusts, was duly enlisted to draft a Trust Deed, and in June 1988, the inaugural trustees of the Great Barrier Island Community Health Trust set their signatures to it. Helen O’Shea made short work of the bureaucratic difficulties that attend becoming a charitable organisation. We had the structure in place; now it was the not-so-simple matter of raising the funds to make the dream a reality.

  Ironically, the first donation the trust ever received came from a home-brew competition that was held in the Tryphena Hall directly after the Alcoholics Anonymous meeting had been ushered out. Everyone wanted to be involved—there were birdman competitions where locals dressed as birds and flung themselves off Tryphena wharf to cheers and jeers. There were Irish stews and raffles. A ratepayers’ grant of $10,000 from Great Barrier Island County Council consolidated the seeding fund; a bequest from an older, much-esteemed resident completed it. Over $30,000 would have been a tall order at any time for a community such as the Barrier’s, but to have amassed that total in just two years in the straitened economic climate that prevailed at the end of the 1980s was little short of miraculous.

  Meanwhile, Ivan had been networking on the mainland. The real turning point in the trust’s fortunes came courtesy of Dame Cath Tizard, who at that time was the Mayor of Auckland City and was also on the ASB Community Trust. Dame Cath was very sympathetic to Ivan’s request for support. One day, she arrived on the island waving a huge cheque from the ASB Community Trust. She joyfully painted in the top of the red fundraising thermometer, indicating that our goal had been reached at last. The grant was enormous, and it was enough to build the long dreamed-of community health centre.

  As if that weren’t good enough news, the same meeting that was convened to formally accept the ASB Community Trust grant also heard that the Auckland Area Health Board had offered to donate a four-bedroom state house from the old Carrington Hospital to our cause. It took the trustees all of five minutes to decide to accept both.

  Hang on. Was it possible to accept both? Enquiries were made, and we were assured it most definitely was possible. The money from the ASB Community Trust could be used to redesign and outfit the Carrington building—expanding the original concept.

  Anyone standing on the white sands of Kaitoke Beach on the morning of 8 January 1990—and there was quite a crowd of us—would have found the sight of the little weatherboard house, painted cream and lemon with an orange tile roof, chugging around the point in the lee of the humped island just offshore quite surreal. The barge was manoeuvred into the surf where a bulldozer was waiting to attach a long yoke to the hydraulic trailer on which the building rested. The trailer, house and all, was dragged off and hauled up the beach. There was a pause while one of the locals, just to be sure, inspected the building to make sure nothing had stowed away inside. Good job he did: he found two possums hiding in the roof space. Because it is just far enough from the mainland, Great Barrier has always been free of possums. The beach was cleared of people. The policeman fetched his revolver, there were two sharp cracks and Aotea was possum free again. The border biosecurity formalities over, the bulldozer’s engine bellowed and the house was dragged up the sandy track through the dunes to the site close to the airfield, where it was to be transformed into the Great Barrier Island Community Health Trust’s new community health centre.

  Over the previous two years, while the funds were being r
aised, a lot of thought had gone into how the health centre should be configured. Gale Gibson, a trustee who worked for Barrier Building, had a great relationship with all of the local tradespeople and plenty more on the mainland, enabling him access to valuable information and ideas. The renovation and modification of the building was a truly collaborative effort: the local island architect did a superb job of the design, creating a multifunctional community health centre with the added funds; and the efforts of other skilled contractors, led by Lance Dixon—builders, plumbers, electrician, painters and cabinetmakers, all of them locals—soon saw it clad in new cedar and running on alternative energy, using thousands of dollars’ worth of donated materials. Up to 58 different mainland companies or persons supported the trust, too, to realise the islanders’ dream. Locals donated voluntary hours and expertise, an amazing stone sculpture depicting strength in unity and family, art pieces, crotchet rugs, linen and aroha nui. Helen and her team were there every step of the way.

  We already had modern equipment that had been donated lined up to install. We would no longer need to hang bags of intravenous fluid from a nail at the top of a mānuka pole while we waited in someone’s car for the plane to land; we could be in a warm, cosy, well-lit room right beside the airfield with the drip suspended from a stainless-steel IV stand with proper wheels. There was an overnight room with two comfortable beds where people could be cared for. There was a steriliser, a sterile area for minor surgery, an organised daily appointment system and, one day very soon, there would be an X-ray machine. It even had a brand-new automated telephone—the advent of the automated system coincided with the establishment of the health centre. Imagine that—being able to pick up the phone and talk to the hospital, any time of the day or night, without having to worry about confidentiality on the line or the need to drive anywhere to wake an operator!

  On Labour Weekend 1990, the Governor-General, Sir Paul Reeves, emerged from a Royal New Zealand Airforce Iroquois helicopter and was escorted across the airfield to where a crowd was waiting for the formal opening of our new community health centre.

  There were speeches, and lots of laughter and excitement. The community were justly proud of what they had achieved: there could be no doubt that this was progress.

  Adele spoke, and she spoke for island nurses past and present.

  ‘To me, this building epitomises the things that I find very special about Great Barrier Island—the sense of community spirit, resourcefulness and determination that its residents possess. Nursing has to do with caring for people, and it was with absolute amazement that I discovered in this community the reverse also applied, in that the nurses were also cared for and valued by the people. Thinking about the special affinity that the island has had with its nurses and looking up at this modern building demonstrates to me the importance the community places upon health.’

  Sir Paul spoke, and then cut the ribbon. Helen grabbed Ivan’s hand and shook it. ‘Congratulations!’ She beamed. ‘We did it! The islanders have prevailed!’

  The Great Barrier Island medical facilities had finally leaped towards the twenty-first century.

  With the health centre up and running, there was one last duty for the Howies to perform. Ivan and Leonie watched as the orange caravan was hauled away on flat tyres and in a cloud of dust. They hugged. It was the end of an era, and, while it had been a strange way to operate a medical practice, it was also somehow picturesque. Leonie was surprised at the sadness she felt.

  But on her very first day in the brand-new clinic her sadness is gone. It is as though she has been travelling towards her professional destination these last few years, and has only just arrived. The clinic feels right, and somehow validates her.

  The phone rings, and she answers. She hears the change in her voice, and so does the local on the other end. It is not the doctor’s wife answering. It is Leonie, the rural nurse.

  We had seen a kind of tidal ebb and flow in the former days of the Department of Health. Sometimes the people in decision-making positions understood the demands and requirements of rural nursing. Sometimes they seemed to think that it was little different to working in a well-stocked clinic in a leafy suburb with straightforward access to all main transport modes and all medical mod cons.

  The vehicles that Adele and Nancy were finally supplied with reflected the degree to which the urban managers misunderstood what it meant to try to supply health services to the sparse population on a mountainous island with a very poor roading system. Adele’s first Health Board vehicle was a Toyota Land Cruiser (Nancy had a four-wheel-drive Suzuki). But when the time came to replace them, there had been a change in personnel in the vehicle procurement department. It was decided that Nancy should have a station wagon and they sent Adele a boxy little two-door four-wheel-drive Lada. Nancy did what she could with the station wagon, but island conditions took their toll upon it. When it went back to Auckland full of dust and with all the doors rattling, Nancy was accused of not caring for it.

  Adele’s Lada stood up to the rigours of the roading rather better, but she couldn’t fit her patients in it, and it was so poorly designed that she developed a repetitive strain injury in her left shoulder from the difficult gear changes. She grew to loathe the vehicle. But the day was at hand when she could get shot of it, and ensure that its replacement was much more fit for purpose.

  In 1992, Adele and Shannon attended a one-week intensive small-business course that was run on the island by the Auckland New Venture Trust. They had finally got their mussel-farming venture off the ground, and the course introduced them to some of the processes needed to operate a small business—such as wrangling taxes like PAYE and GST, and how to write a business plan. Ivan and Leonie were there too, as their medical practice was growing fast. Little did we all know that we would be using the skills we acquired to take Great Barrier’s health services another quantum leap forward.

  In July 1993, New Zealand’s health system was radically reformed. Funding and procurement was shifted from the Department of Health, which was renamed the Ministry of Health, to newly formed Regional Health Authorities (RHAs). The management of the Northern RHA (North Health) was largely in the hands of people who wished to improve health-service delivery and reduce costs, and, consequently, they were far more receptive to suggestions for new and better ways of providing services. We all immediately saw the opportunity that the brave new funding model presented. It might mean that we could finally set up a comprehensive health service tailored specifically to meet the needs of the people of Aotea.

  So together we wrote a business plan, describing the community’s health needs—rated as ‘remote rural’ in the official classification system—and proposed a new organisation to cater efficiently to these needs and to accommodate the unique demands that the island imposed. The new enterprise would pool the public and private revenue streams, and we would combine the expertise of the private practitioners with that of the public health nurses and engage additional professionals to provide a comprehensive health service. Our proposal was supported by Dr John McLeod (CEO of the Auckland RHA) and his deputy, Dr Colin Tukuitonga. John had been Medical Officer of Health and in this role had made regular visits to the island and had met with Adele, as public health nurse, and with Ivan and Leonie. John saw for himself the extent of Ivan’s dedication to the island. He had also watched with interest the formation and achievements of the Great Barrier Island Community Health Trust, and he could see that our proposal was the logical next step.

  Aotea Health Limited was duly incorporated on 2 August 1994. Ivan designed the company logo—an elegant motif that at once resembles a Māori design and also a stylised map of Aotea itself. We are the directors. We have ended up working to our strengths, with Adele doing the finances and Leonie island-proofing the policies, and both of us sharing everything else along with full-time clinical work. For his part, Ivan liked the idea of being a doctor free from the burden of running the business and getting mixed up in the fine details
of contracts. Within days of launching the company, Adele had resigned from her position as public health nurse. She took great pleasure in sending the Lada back to the mainland. She has often joked since that it was the Lada that convinced her to enter private enterprise.

  The first task ahead of our new venture was negotiating with the service funders. On the one hand, it was a refreshing change to deal directly with those holding the purse strings, instead of having to go through an intermediary. On the other hand, it turned out that it came with its own unique range of frustrations and was never plain sailing.

  Adele sat on the floor surrounded by paper—the draft of a contract that we had agreed with the RHA and a newer, final version that had just spooled from the fax machine. They were more or less the same—apart from the sum the RHA was now offering to pay for our services, which was mysteriously $20,000 less than the agreed figure.

  What? Adele wondered. Did they think we wouldn’t notice?

  She phoned the funding manager, but his receptionist told her he would not take her call. Adele felt close to tears. She checked her watch. Ivan and Leonie were on their way off-island for a two-week holiday. Here she was, unemployed and confronted with a contract that would doom the fledgling new enterprise to failure.

  Adele phoned the airport. The airline agreed to hold the plane and to fetch Ivan off it. After a delay, Ivan came on the line. She explained the situation.

  ‘But that’s not what we agreed,’ Ivan said. ‘I will try to ring as well.’

  Adele waited on tenterhooks. The phone rang.

  ‘He agreed to change the figure back,’ Ivan said. ‘He will fax us a guarantee that we’ll get the missing funds.’

  Adele heaved a sigh of relief mixed with irony that Ivan had managed to get through.