Navigating culture, public health service and leadership: E iloa le lima lelei o le tufuga i le soofau

Tui Atua Tupua Tamasese Ta’isi Efi

Head of State of Samoa

Keynote Address, Auckland Regional 

Public Health Service Conference 

11 July 2016, Auckland, New Zealand

There is nothing better than a story – and for busy people preferably a short one – to make a point. This morning I wish to tell five short stories. From these stories I will draw out and examine what I consider key areas for reflection on the exercise of navigating culture, public service and leadership in health. 

I have raised these stories elsewhere but I bring them together again today to underline my point about public service and leadership, a point captured in the Samoan saying: e iloa le lima lelei o le tufuga i le soofau (the mark of good statecraft or leadership is shown in blending idiosyncrasy). I shall come back to this saying later, suffice to say for now that this saying also serves as the title for my talk.

I told my first two anecdotes in an address to the Pasifika Medical Association in Auckland quite a few years ago now. The points they make are still salient.

My first anecdote goes as follows:

When visiting family in New Zealand I would often come away feeling dreadful. This was because I would watch and listen to them with angst. Parents would insist that their children follow the Samoan protocols they were accustomed to when they lived in Samoa. The following commands or statements would be issued, often sternly and with that tone that says if you don’t do it you will get it. I would hear:

 “Sit on the floor!” (Nofo i lalo!)

“Do not walk in front of our guest!” (Vaai tagata! Aua le soli le tatou malo!) – “Say tulou (excuse me)!” (Fai le upu ‘tulou’)

“What foolish children!” (Matuā tou valelea tele)

“Serve the tea in a tea pot with a tray and bring a side table!” (Aumai se laulau! Faaaoga le tipoti lelei ma aumai i luga o se laulau lelei!) 

“Be silent!” (Aua le pisa!)

If I become too uncomfortable I would then intervene and say:

 “Please if you continue I will leave and not come back. You are turning me into a bogeyman. Every time I come your children will say: “here comes the bogeyman”. I am not a bogeyman. I am the matai of our family and I want to talk with you, to you the parents and to your children. I know that your household is not schooled in the ways of our people. But our ways, our faasamoa, is founded on alofa. The message of our faasamoa should be framed in language and in a tone that bespeaks alofa. Harsh words and unjustified reprimand will alienate and antagonise them unnecessarily. And we can’t afford that.” 

My second anecdote goes:

There is always a special bond between grandchildren and grandparents. I remember the bond between Fau’olo and Kise Fuifatu and their handicapped grandson, Ieti. Ieti lived with his grandparents on the island of Savaii. His parents lived on Upolu. One day upon seeing how fragile their parents were getting and witnessing the deterioration in Ieti’s physical condition, Ieti’s parents proposed to take Ieti back to Upolu to live with them. Before they could finish their sentence they saw tears welling up in their parents’ eyes. Fau’olo and Kise were devoted to Ieti. He had become their life; their heart and soul. They said: “We would rather die than part with Ieti”. Ieti remained with Fau’olo and Kise till he died. He lived to 21 years of age. Shortly after Ieti died Fau’olo died. It is believed  that Fau’olo died from the grief of losing Ieti. 

My next anecdote is of an experience I shared when Filia and I went to visit Germany in 2006 and were able to have lunch with Hans Kung. Hans Kung is a world renowned Christian theologian. We had been corresponding and in September 2006 we were able to share a meal in his home. The anecdote goes as follows:

When we arrived at Hans Kung’s place where we were to have lunch we were escorted up to the second floor where he was. Hans Kung resides in a four storey building which serves as office cum home. As we were going up I noticed that on one of the walls was a reproduction of a portrait that seemed familiar. I asked whose it was and the gentleman who was escorting us said, “It is that English saint”. I said, “Thomas More?” He said, “Yes!” What was noticeable about the portrait was that he was the only non-family member portrait in the house. Intrigued I asked Hans Kung, “Is Thomas More your favourite saint?” He said, “Yes”. Then he asked, “Who is yours?” I replied, “Augustine of Hippo”. He said, “Ah, you’re one of Ratzinger’s gang”! I smiled. 

Fast forward a few moments to the scene where we are now sitting at the lunch table. We are full of conversation and food was starting to appear onto the table. In mid-conversation I saw a bread roll and without thinking I picked it up, broke it, put it into my mouth and started to munch. Suddenly there was silence. Hans Kung said in a slow and measured way, almost incantation-like: “In our household whether you are atheist, agnostic, believer or non-believer, we say prayers before meals”. Although I was clearly being rapped on the knuckles, in a strange way I felt reassured that despite doubt over whether Kung was a ‘believer’, I knew right then and there that whatever else he would say prayers before he ate. 

My fourth anecdote comes from Socrates via my dear friend Brother Stephen Filipo, when he was based in Samoa as principal of St Joseph’s College. The story goes:

In ancient Greece Socrates was someone lauded for his wisdom. One day the great philosopher came upon an acquaintance who ran up to him excitedly and said, “Socrates, do you know what I just heard about one of your students?” Socrates replied, “Wait a moment, before you tell me I’d like you to pass a little test. It’s called the Triple Filter Test”. “Tripe Filter?”, came the reply. 

“That’s right”, Socrates continued, “Before you talk to me about my student, let’s take a moment to filter what you are going to say. The first filter is Truth. Have you made absolutely sure that what you are about to tell is true?” “No”, the man said, “Actually, I just heard about it and…”. “Alright”, said Socrates. “So you don’t really know if it’s true or not. 

Now let’s try the second filter, the filter of goodness. Is what you are about to tell me about my student something good?” “No, on the contrary…”, the man started. “So”, Socrates continued, “you want to tell me something bad about him, even though you’re not certain it’s true?” The man shrugged, a little embarrassed. Socrates continued, “You may still pass the test, because there is a third filter – the filter of usefulness. Is what you want to tell me about my student going to be useful to me?” “No, not really…”, the man replied again. “Well”, concluded Socrates, “if what you want to tell me is neither true, nor good, nor even useful, why tell it to me at all?” 

My final anecdote comes from Emeritus Professor Charlotte Paul. I got to know Charlotte a little when she came to Samoa in 2009/2010 to assist with a joint National University of Samoa and University of Otago summer school course on health research methods. As I got to know her I was struck by how much we shared in common, especially in terms of a love of great English poets. When I came across the story she shared in the New Zealand Listener about compassion and ethics, I was extremely touched. It was about her reflections on the moral resources needed to care for someone, in this case her dying husband. It was also her response to the debate in New Zealand at the time on the suggestion to codify compassion as part of a health practitioner’s duty to care, which many of you will be familiar with. I take no particular stance on the debate; I merely offer her view because her story identifies some of the tensions and challenges of providing good public health care. She says:  

 “It is not easy to feel compassion for someone who is hard to care about. The demanding task is to nurture the capacity to go on feeling compassionate, in order to go on caring. In this difficult situation, moral sources need to be discovered. What follows is a personal list; others may draw on different traditions.  

First the old idea of reciprocity: that we are somehow given to each other. Caring requires a double vision. Alongside dependence and the need for care, the free agency of the person cared for must be imagined and respected. Such respect is possible even when very little capacity for autonomy can be exercised. 

I realised that my almost helpless husband was comforting me when he knew his death was near. Reciprocity happened through shared jokes that undermined the sentimental stance to the sick: “in-valid”, “culpable sclerosis”, “de-habilitation”. 

Shared experience of sustaining words also matters. … I read aloud selections from John Donne’s Songs and Sonnets, and poems of George Herbert. After each poem Kevin sighed. His sighs were sociable and included me; and they were composed of sadness and contentment and appreciation – sheer wonder that human beings could grace the world with such phrasings and such perceptions. 

Second, religious traditions can be drawn on. The idea of a suffering God and the love of God for humans, through which humans love themselves and one another, is part of the Christian tradition. It is central to Donne’s and Herbert’s poems. Our modern ideas of benevolence can be traced back to this source. It is not easy to love people for their attributes when they are disintegrating. But love can be powered by a deep attention to the person who is suffering. 

Third, there is the experience of failure and of trying to prevent failure turning into giving up on oneself. Failure is almost inevitable. It is too tiring to do all the caring when it goes on for years. Eventually, you may abandon your relative to hospital level care. If this is accompanied by giving up on one’s own capacity to love, then it might really be abandonment. As Yeats’ poem Easter 1916 says: “Too long a sacrifice can make a stone of the heart”. 

Moral sources that recognise human frailty offer the possibility of self-forgiveness and of continuing to care and/or attend. It is possible to make a room in a geriatric hospital an extension of the rooms at home. … By focusing on rights and obligations, we are neglecting the other side of morality. Perhaps we should focus [instead] on nourishing the capacity for compassion. …Compassion is a great ideal, but it brings with it difficult or even impossible demands on the heart that shouldn’t be underestimated. It needs to be actively sustained within the healthcare professions. It is not the stuff of a code of rights.”  

Each of these five anecdotes touch on experiences and issues relevant to Samoans and other Pacific peoples living and working in the modern age. I offer them because they make a statement about the world we navigate today. They offer suggestions about the moral codes we live by and affect our behaviours. 

Although I do not have direct experience as a health practitioner, I am currently patron of two community health organisations in Samoa: Faataua le Ola (a suicide prevention group) and Goshen Trust (a mental health group).  

I also served on the Wellington Family Centre Board in the mid-1990s. During my time with them I was involved in a qualitative research project on Samoan perspectives on mental health and culturally appropriate services. I recall the lengthy discussions I had with the researchers at the time about what mental health might mean to a Samoan or within a Samoan frame. We talked about a range of issues but for today I will focus on two in particular. First, the importance of understanding the Samoan person’s sense of belonging.  Second, the importance of developing an appropriate vocabulary for talking sensitively and meaningfully about mental illness. 

As I have said elsewhere, as a Samoan I am not an individual; I am an integral part of the cosmos. I share my divinity with my ancestors, the land, the seas and the skies. I am not an individual, because I share a ‘tofi’ (an inheritance) with my family, my village and my nation. I belong to my family and my family belongs to me. I belong to my village and my village belongs to me. I belong to my nation and my nation belongs to me. This is the essence of my sense of belonging. 

This is what frames or informs my sense of right and wrong, my morality; my sense of rights and responsibilities, my ethics and capacity for compassion and caring. It is within this intricately woven sense of reciprocal, collectively-based, belonging that I draw meaning and substance about who I am, and who I am accountable to, and who is accountable to me. It is within this frame of reference that I expect my carer – whether a doctor, a nurse, a friend, or a family caregiver – to operate. 

Working closely with aiga, villages and communities has for some time been a central part of the approach adopted by Samoa’s mental health service. Matamua Iokapeta Enoka and the team at the Mental Health Unit have published in the journal Asia-Pacific Psychiatry (2012) about their ‘Aiga model’, which includes understanding cultural protocols, the power of storytelling and the need for active aiga (or family) engagement in the caring process. This model prioritises the aiga in the care of their mentally unwell person or consumer. It suggests that this care is best undertaken in the home environment by people who know the consumer, people who he or she feels a sense of belonging to. 

The role of healthcare worker, Matamua and her colleagues say, is “to allow the family to take the lead in determining what could be the problem and what to do about it”. The family or aiga, they say, “can identify and help look for treatment that they think is appropriate or they can refer them to the Mental Health Unit for further assessment”. Matamua and her colleagues go on to talk about making sure that institutional care is the last not first resort for families. If the aiga is unable, for whatever reason, to take care of their mentally unwell family member, community-based mental health care is then recommended. Goshen Mental Health Trust is currently Samoa’s only community-based mental health service. It offers respite residential services, and engages in aiga and community support projects. Savea Tutogi, the founder of the service, believes firmly in the aiga model of the Mental Health Unit and in the need for Goshen to work closely with the Unit and with consumers and their aiga. Both organisations have highlighted in their respective work the significant challenges the mental health sector faces in delivering effective services. 

One challenge is the challenge of employing the right vocabulary when speaking about mental illness. Is there a vocabulary that one should use when speaking to aiga or nuu? And is that different to what ought to be used when speaking to policy makers and the general public? Should we keep the English medical terms for mental illness diagnoses and treatments or should we translate them into Samoan? How should we translate them? Where should we begin? I find the vocabulary issue fascinating and frustrating. It is complicated enough in one language, let alone trying to negotiate a bi-lingual rendering. Language shifts with time and new contexts and we, as individuals and as advocates of mental health, do not hold a premium over these shifts. Therefore gaining consensus on meaning and nuance is always going to be subject to the biases and persuasions of different disciplines – academic, professional, cultural, or otherwise. 

To make my point I refer you to shifts in meaning in the following words: firstly, the term for war (especially between nations) is today just “taua”, but in the past it was also referred to in oratory as “ma’i o malo” or “gasegase o malo”. Here we find the interesting suggestion that war was an “illness” (ma’i), at least metaphorically so. 

Moreover, the term for hospital is generally accepted today to be “falema’i”, but more recently there has been suggestion to call it “maota o le soifua maloloina”. I am told that the shift away from illness to wellness models in policy rhetoric is the basis for this shift in naming. And finally, it may be of interest to engage in discussion on the use of the word ‘vale’ (which as you all know is a derogatory term often used to describe the mentally unwell). How might we understand the term when used in words such as “valevale matua”, “valetuulima”, and “agavale”? I leave it to you Samoans to discern the significance of such shifts in vocabulary and what they represent in terms of societal changes or author biases. 

The point remains, with such huge stigma associated with mental health in Samoa, getting key words right, making sure that they say what they’re meant to say, that when you say them that the people you are targeting know exactly what you’re talking about, and even more to the point, feel compelled to help in positive ways. This is what ought to drive the discussion on the vocabulary issue not only in mental health but any health are. Indeed in any profession or discipline. 

Of course, this is easier said than done and requires openness and patience. But throwing one’s hands up in despair and walking away from the debate will not make the issue go away. It’s an issue that is here to stay. We have to find ways to develop and agree on a lexicon that has good solid scholarly support and can be adapted as our Pacific societies change. And, if that wasn’t enough, I am also told that there is a major issue with access to sound population based information or prevalence data. I was surprised to read that there is no base-line information on the prevalence of mental health disorders in Samoa. 

Perhaps there is some small comfort in knowing that Samoa is not alone in this, that many other Pacific island countries suffer the same lack. I agree with our policymakers that this is cause for concern.

 We are told that all policy and practice decisions must be evidence-based, but if there’s no evidence then what is the basis for our current practices? 

The Samoa Bureau of Statistics in 2011 counted the number of people in Samoa who identified as having suffered or is suffering from an emotional and mental disability to be approximately 8.5% of the total population (i.e. almost 16,000 people). Dr Ian Parkin, our current on-island psychiatrist, who works part-time, estimates that it is more like 20% of Samoa’s population (which at the time of his statement in 2007 was @36, 000 people). The Mental Health Unit is reported in the 2007 MOH annual report to have cared for 145 regular consumers in 2005, and most of these were diagnosed with schizophrenia or other psychotic disorders (MOH, 2006, p.6). More recent figures provided by MHU suggest the total numbers have increased to 195 this year, with approximately 415 since 2011. When considering the size of the mental health workforce against both the actual and potential figures of our Samoa mental health consumer population the picture painted is disconcerting to say the least. There is an obvious need for the country to rally together to figure out how best to address these challenges. 

Whenever I watch people who care truly for the mentally unwell I am filled with admiration for their patience and commitment. 

I wonder how it is that they always seem to have the requisite capacity for compassion. And I think about how much of that capacity comes from our own cultural resources, our faasamoa. While I am forever mindful of the fact that our faasamoa has evolved and that what was before may have little meaning or relevance to what is now, as suggested by my first anecdote, I am encouraged by the continuing level interest in our indigenous values. 

It is to this end that I wish to conclude my talk with some reflections on the philosophical underpinnings of our traditional breadfruit culture and how this part of our faasamoa could offer a valuable cultural and moral resource for navigating the concerns of public health service today. 

The breadfruit tree and its fruits played a significant role in our Samoan hospitality customs and agriculture. Before the introduction of supermarkets, the fruiting seasons of the breadfruit tree would guide traditional Samoan horticulture. The planting of other food crops such as yams, taro and bananas, was organised around the breadfruit seasons to ensure they would be ready for harvest in between the breadfruit seasons. This ensured that food was available for the village all year round. In Samoa’s serving culture the traditional way of making the breadfruit delicacy called taufolo was to cook mature aveloloa breadfruit on top of rocks that are heating in an open fire to be used for the umu. Once cooked, the breadfruit is taken off the burning rocks and the burnt skin is removed. The steaming hot flesh is then placed into a bowl. An unripe breadfruit, with a stick pushed through it to act as a handle, is then used to pound the hot flesh into a soft dough. The still hot dough is then piped using one’s hand through a small hole formed by the index finger and thumb. The dough coming out the other end is broken into pieces by the index finger and thumb closing the hole and effectively cutting the dough. 

The pieces of dough, which should still be hot, are then shaped by hand into round dumplings. A sauce of caramelised coconut cream or sea water is then added to the dumplings and the dish is presented ready for eating. 

In traditional times a server’s ability to show discipline and artistic flair in his service was measured by his ability to make good taufolo and to serve it with panache. These breadfruit traditions reflected a spiritual culture that emphasised the importance of being in tune with and appreciating the blessings of God as our provider (faamanuiaga), of knowing ourselves and our boundaries with nature (tuā’oi), and of knowing the significance of having humble and grateful hearts in the sharing of our providence. What does all this mean for public health and health care? 

Our traditional faasamoa emphasised the importance of knowing one’s environment, of taking time to prepare well, of fully utilising our God-given talents and strengths, of acknowledging the source of our providence, and of taking collective responsibility for caring for the wellbeing of all in the village, the community, and aiga. Knowing the significance of the breadfruit is to know the significance of all this. Much like knowing the significance of prayers in the Kung household, of knowing the significance of poetry to Kevin Paul, of knowing the value of deference and respect for elders and guests in a Samoan household, of knowing the value of compassionate and loving care, and of knowing good, truthful, and useful information.  

In our Samoan culture there is a saying “Lou muamua le ‘ulu taumamao” (Pick the breadfruits on the far-off branches first). For those who have undertaken the arduous task of collecting breadfruit for a large family get-together, you will know that the most prudent thing to do is to first attend to those breadfruits most difficult to get. And to remember that as another saying goes, “o le fuata ma lona lou”, each new breadfruit season will require a new stick. 

Navigating the challenges of public health care delivery requires understanding who your hard to reach patients are and how or which stick or lou you will use to be able to reach them. This is no different to navigating the challenges of public office – in both there is a need to know how to blend good state craftsmanship or leadership and idiosyncrasy. The saying that frames this talk – e iloa le lima lelei o le tufuga i le soofau – is all about this. A tufuga is a master craftsman. Soofau refers to the weaving of fau or sinnet in the process of Samoan house building. 

E iloa le lima lelei o le tufuga i le soofau is a saying that uses the metaphor of house building to make the point that leadership is a craft that takes time and talent; love, sacrifice and care.  The best of our house builders drew not only on their own knowledge but also on the knowledge of those who supported them, those who would tapua’i, both physically and spiritually. This is what is idiosyncratic of our kind of public service and what underlines our care. 

I wish you well in your deliberations and pray that you will build a house that can withstand the tests of usefulness, goodness, and truth. God bless. Soifua.

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