As many of you know, back in the late 80 and early 90s, I worked with Professor Pete Joyce (who is now Dean of the Christchurch School of Medicine) to build the eating disorders program in the South Island of New Zealand (see photo of the Princess Margaret Hospital). It is now known as the South Island Eating Disorders Service and serves as the regional service for the entire South Island of New Zealand. I recently had the pleasure of conducting a review of the service and wanted to briefly share some thoughts. I will start with some pride by saying how wonderful it was to see so many of the people whom I trained years ago still richly engaged in eating disorders treatment and research. Those of you who work with me here, these are functionally your academic and clinical “cousins” and I am sure if you ever find yourself in New Zealand, you will be greeted with an open door (although there are other wonderful things to do in New Zealand aside from visiting eating disorders programs! (see photo of view from the Anaconda Trail).
Many of the challenges faced by their service parallel those we experience in North Carolina. Three struck me as particularly relevant. The first is how we each deal with patients “from the regions.” Both programs serve as tertiary referral centers, and are often then in the position of transitioning patients back to remote regions, often with limited or no specialist services. In NC, we are constantly developing our referral networks, we organize a conference each year to help upskill clinicians from around the State, and we engage in numerous AHEC-sponsored and other trainings. In NZ, they have a kernel of a regional team that coordinates their services to the various districts around the South Island. Through frequent travel, teleconferences, and videoconferences, they provide supervision and guidance to the clinicians around the island who care for patients after their return home. The remote clinicians have nothing but praise for this arrangement as they report that there is always someone on the other end of the phone line who can help them problem solve and treatment plan. It also seems like an idea set-up for some of our internet-based interventions, which I of course suggested!
A second shared challenge is dealing with eating disorders in minority populations. A recent survey of mental health in the Māori population (native New Zealand population) indicated that they may have a higher prevalence of eating disorders than New Zealand whites (Pakehas). Yet they are vastly underrepresented in treatment settings. One of the most amazing honors I had while in New Zealand was to meet with around 15 Māori health workers and representatives Pukenga Atawhai to begin the discussion about needs of the community. Many important themes emerged including the fact that Māori has not words to describe the core behaviors associated with eating disorders (e.g. binge eating) and, that there may be considerable shame (whakama) associated with revealing that you suffer from an eating disorder in the Māori population, especially given the fundamental and essential relationship between the Māori people and the land and the food that it produces and the perception that it is a “white-girls’ disease.” The relation between eating disorders and the serious problem of obesity in the Māori and Pacific Island populations also emerged. Most importantly, any solution that arises in terms of eating disorders in Māori individuals must be a solution that emerges from within the Māori community and is appropriately culturally tailored. NZ is also dealing with an upsurge in cases of anorexia nervosa in Asian immigrants and is facing similar challenges with outreach and service provision for these families, many of whom are unable to speak English fluently and find themselves in a foreign healthcare system. Needless to say, these challenges reminded me of the issue that we face in detecting and treating eating disorders in people of African-American, Latino, Asian and other descents in NC. Dr. Reyes has been working with the Latino community to understand barriers to treatment seeking and to develop culturally-appropriate interventions. Although many of the cultural issues differ between NZ Māori and minority populations in NC, many fundamental principles and challenges are shared.
Another challenge is a public health one. The NZ Ministry of Health declared binge eating disorder (BED) to be a “public health” rather than a “mental health” problem. This means that there are no budgeted funds in the mental health budget for the treatment of BED. Sound familiar? Although we acknowledge that BED is an eating disorder (at least unofficially), we still fall far behind anorexia nervosa and bulimia nervosa in terms of treatment availability. BED is the underdog both in NZ and in NC.
Then there are clear differences between the programs. Patients can stay on the inpatient unit in Christchurch for long periods of time without getting bumped out by insurance limitations. With socialized medicine, these stays are covered financially. In the final stages of treatment, patients can go home on weekends, have extended passes, and even travel back to the regions to have more “out of hospital” experience before discharge. Intriguingly, they aim to keep people in hospital until they reach a BMI of 20-22 and they find that this is associated with much better prognosis after discharge and fewer re-hospitalizations. Of course we all know this, but we are unable to attain these healthy BMIs except on rare occasions. A second difference is that families from the regions whose loved ones are hospitalized in Christchurch are able to apply regularly for travel assistance from the government in order to travel to the center for treatment and visit their child. Clearly a kinder gentler system when compared with the countless families who deplete their savings in order to obtain treatment for their family members here.
Overall, the opportunity to spend time with the members of the Christchurch team was an amazing experience. I continue to marvel at the fact that anorexia nervosa, bulimia nervosa, and BED “look and feel” the same across cultures. No matter where I go in the world, I can step onto and eating disorders service and feel “at home.” Yes, that’s a strange way to put it, but after working in the field this long, it becomes part of who you are.