Maki Maro Tuberculosis in the Cook Islands A social history 1896 - 1975 Debbie Futter-Puati A thesis submitted in fulfilment of the requirements of the degree of Master of Arts in History The University of Auckland March 2010 Abstract Between 1955 and 1975 the Cook Islands medical service launched an all out campaign against tuberculosis (TB). The purpose of this study was to explore the anti-TB campaign in the Cook Islands from the time the planning began for a ‘full frontal attack’ on TB, just prior to World War Two; concluding in 1975 when TB rates had dropped dramatically. It investigates the complexities of working with high TB infection rates within a colonial setting beset by problems relating to physical isolation, communication and travel, political and economic issues, alongside a lack of human resources. In addition to eleven interviews with medical personnel or patients historically involved with TB this study also included an examination of TB-related files from the Cook Islands administration, the New Zealand Department of Island Territories and the New Zealand Department of Health, held in the Cook Islands Archives and Archives New Zealand in Wellington. The thesis adopts a chronological approach. The history of the Cook Islands administration and medical services from 1896 until 1945 are investigated to provide understanding and important background information pertinent to the eventual anti-TB campaign. The years of Dr Tom Davis’ influence from 1945-51 provide an insight into the influence of a motivated individual on the medical service. From 1952 until 1975 the planning, implementation and ongoing difficulties and modification of the anti-TB campaign are examined. This thesis contributes to the history of TB and public health in the Cook Islands and internationally. It reveals the importance of the medical service developing constructive relationships with community, national and international organisations. The thesis highlights the influence of key motivated individuals and the need for a culturally appropriate and responsive multifaceted approach to public health that adapts to change. i Dedication I would like to dedicate this thesis to my grandmother Amy Aldridge who never had the opportunity to go to college but nevertheless was well educated by her life experiences. She taught me to work hard, to believe in myself and to never give up. She lived life to the full and never let an opportunity pass her by. Nana was an inspirational woman and an incredible role model who made me believe that I am special. The finest gift anyone can receive. ii Meitaki Maata This year I have had the honour and privilege of being part of a dynamic team and I have so many people to thank for the incredible academic, physical and emotional support I have received. My sincere thanks go to my supervisors Professor Linda Bryder and Dr Phyllis Herda. Their guidance, insight and friendship have supported my first foray into history and their wisdom and experience has supported me enormously. Many thanks also go to my co-supervisors Associate Professor Julie Park and Dr Judith Littleton. Both gave critical feedback, encouragement and advice on numerous occasions while also making me feel welcome as a newcomer to Auckland. Their friendly ‘pop-in to the office to see how I am going’ provided me with more support than they probably realise. Fellow Transnationalism in Pacific Health Through the Lens of Tuberculosis team members Dr Yvonne Underhill-Sem, Dr Ward Friesen, Dr Debbie Dunsford, Dr Pat Neuwelt, Dr Jennifer Hand, Professor Anne Chambers and Dr Keith Chambers, all supported me in varying ways and you always seemed to have perfect timing. I am indebted to the New Zealand Health Research Council for the sponsorship they granted me as part of the Transnationalism in Pacific Health Through the Lens of Tuberculosis project of which this study is part. Sincere thanks also goes to my employer, the Cook Islands Ministry of Health, for granting me a years leave, and especially to Ana File who has eased my work load considerably and more than capably filled my role. Also the Ministry of Health statistics department for the time and effort they went to uncover archival Cook Islands TB information, thank you. I also appreciated the helpful efforts and support of staff at the archives I visited in Wellington, Rarotonga and the Cook Islands Parliamentary Library. Special thanks also to Philip Abela at the University of Auckland library for answering my many questions. Briar Sefton for creating the maps in this study, thank you. Meitaki maata has to go to Jean Mason, from the Cook Islands Library and Museum, for her supply of photos. iii Philippa, you provided me with much needed laughter and friendship while also being completely amazing with excel and word. The work you completed for the CD, while being extremely useful for me, I am sure, will be useful to other scholars. Sagaa, your quiet support was always appreciated as was Laura’s skill at proofreading. Fellow students Setapu and Evelyn, thanks for the support and occasional moan bonding session, and to summer students Lara, Kaea, and Rosanna, thank you for uncovering more gems in the archives. The Transnational TB project reading group provided invaluable insights into the different perspectives of differing disciplines and extended my thinking to interpret one piece of work in many different ways. I really enjoyed spending time with former TB health professionals and patients whom I interviewed for this project. You gave generously of your time, and memories, and I thank you for your contributions, they have provided a different essence to this study, as your stories brought the Administration files alive. To those friends who provided me with a bed, a bike, a car, furniture or any of the other myriad of things one needs when living away from home, I cannot thank you all enough. My dear friends Helene, Gaylene, and Guida, who read numerous chapters, provided me with coffee, food, or wine, and listened to me through days that were up, and sometimes down; thank you. To Dad (Bryan), for being so painstakingly thorough and providing editing skills, and Mum (Jeanette) who is always there for me; thank you. Sam, thanks for the enormous pleasure of having you alongside me as a fellow student and for including ‘Mama Deb’ in your student life! To my extremely precious family who have managed without me for the last year; James, Jordan and Samantha , I am eternally grateful and I thank you for believing in me, for providing me with emotional support, and for giving me the incentive to persevere. James you are my rock. Jordan and Sam, as you start on your university journey; I hope I have been a good role model - hopefully you realise, that if I can do it, you can too! Meitaki maata e kia manuia. iv Table of Contents ABSTRACT I DEDICATION II MEITAKI MAATA III TABLE OF CONTENTS V LIST OF FIGURES VII LIST OF TABLES IX LIST OF ABBREVIATIONS X MAORI XI MAPS XII INTRODUCTION 1 Early TB 3 First Surveys 3 Sources 5 Oral 5 Written 6 Difficulties with Sources 7 Themes 9 Reasons for my Involvement 12 CHAPTER ONE: TUBERCULOSIS: THE DISEASE AND RESPONSES 15 CHAPTER TWO: THE COOK ISLANDS ADMINISTRATION AND MEDICAL SERVICES RELATING TO TB, 1896 – 1945 25 Medical Services 27 TB in the Cook Islands 31 Training 36 Health Services 41 Conclusion 49 CHAPTER THREE: DR TOM AND TB 1945 – 1952 51 Introduction 51 Dr Tom’s Early Impressions of the Medical Services 52 Dr Tom and the Sanatorium 55 Dr Tom and the General Health Administration 58 v Dr Tom and TB Control 60 Dr Tom as CMO 1948 – 1951 65 Dr Tom and Medical Research 67 Developing Issues at the Sanatorium 72 MMR 74 Dr Manea Tamarua and Pari Tamarua 75 Full-scale Anti-TB Campaign and Dr Tom’s Departure 79 Conclusion 81 CHAPTER FOUR: ‘FRONTAL ATTACK ON TUBERCULOSIS’ 1952 – 1960. 83 Introduction 83 Mobility and Migration 87 Medical Services Relating to TB 94 Drug Treatment 96 The Sanatorium 98 The Training Debate - New Zealand or Fiji? 107 The Magic of Mass Miniature Radiography 109 The Campaign Begins – Ready, Set, Go! 115 Improvements in Housing and Living Conditions 131 South Pacific Commission Tuberculosis Conference 1958 136 The TB Association 138 Conclusion 140 CHAPTER FIVE: BECOMING SELF GOVERNING 143 Introduction 143 Self government 145 Mobility and Migration 147 The Sanatorium and Domiciliary Treatment 151 Drug Treatment 157 Surveys, Surveillance and Services 159 International Airport 167 Development of a Laboratory 168 Mass Miniature Radiography 171 Developing a Public Health Strategy 175 Conclusion 178 CONCLUSION 181 APPENDICES 190 List of Senior Officials and Ministers of the Cook Islands 190 Thesis Timeline 193 See CD inside back cover for ancillary data related to TB in the Cook Islands. 198 BIBLIOGRAPHY 199 Archives New Zealand, Wellington (ANZ) 199 Cook Islands Archives, Rarotonga (CIA) 199 Cook Islands Library and Museum Society Incorporated 199 Cook Islands Ministry of Health, Rarotonga 200 Cook Islands Parliament (Rarotonga) 200 Interviews conducted by Debbie Futter-Puati 200 Official Publications 200 Newspapers 200 Books, Chapters in books, Articles, Theses, Websites 201 vi List of Figures Figure 1. The Cook Islands in relation to New Zealand Figure 2. Cook Islands Figure 3. Aitutaki Figure 4. Rarotonga Figure 5. TB Rates, Selected Countries, Western Pacific region, 2006. Auckland Regional Public Health Service, Tuvalu TB Awareness Programme Handbook, 2009. Figure 6. Number of Cases of Pulmonary TB 1964 - 75 Table 22, Legislative Assembly of the Cook Islands, 1974, Vol. 1, Legislative Assembly Paper No. 7, Report on the Health Department, Cook Islands Parliament, Rarotonga.; Table 22, Legislative Assembly of the Cook Islands, 1975, Vol.