Prof Ngaire Kerse, Principal Investigator at Brain Research New Zealand (BRNZ), was named a Member of the New Zealand Order of Merit for “services to seniors and health” in the 2020 New Year Honours. Image taken from Brain Research New Zealand.
Professor Ngaire Kerse is the Joyce Cook Chair in Ageing Well and a Professor of General Practice and Primary Health Care at the University of Auckland. She is a practicing GP at the Auckland City Mission.
Since 2010 she has been co-principal investigator of a longitudinal study – Life and Living in Advanced Age: a Cohort Study in New Zealand (LiLACs NZ). She was listed in the New Year’s Honours as a Member of the New Zealand Order of Merit. After training in primary care in New Zealand, Australia, and the USA, completing a Geriatric Medicine Fellowship at the University of Pennsylvania, and a PhD at the University of Melbourne, she has built a programme of research promoting activity and function in residential care, residential care organisational culture and outcomes, promoting physical activity in community dwelling older people, activity for depression in the very old, staying upright (preventing falls and injury) in older people in all settings, improving prescribing in primary care, and a large cohort of Māori and non-Māori in advanced age.
Bruce Arroll is Professor of General Practice & Primary Healthcare, at the University of Auckland, New Zealand. He graduated in New Zealand, trained in Family Medicine at McMaster University in Hamilton, Ontario, and completed a Masters in Clinical Epidemiology in Vancouver, before returning to New Zealand in 1991. He now works at the Calder Clinic at the Auckland City Mission and is a director of the Goodfellow Unit which educates primary care clinicians.
” I wanted to stay in primary care because that’s where you have the whole person. You don’t just have a little slice of the person. And then with older people, which is so gorgeous and complex and challenging and I really enjoyed working with them.”
Bruce Arroll: Hello. My name in Bruce Arroll, I’m a Professor of General Practice in Auckland, New Zealand, and it’s my great pleasure today to be interviewing my friend and colleague of 30 years, Ngaire Kerse, who is Professor in the Department of General Practice and Primary Care at the Auckland University.
I’d like to start by asking, how come you ended up at medical school, and then maybe how you ended up in primary care, and then how you ended up with your gerontology focus. So maybe three questions…
Ngaire Kerse: I grew up on farms in the South Island, I was born in Gore, which is way down the south of the south Island. I was the number six of seven children. I had really bad asthma and was in and out of hospital until I was about five, and when I was seven they discovered Sodium Cromoglycate, which was the first sort of preventer. And that changed my life. That might have been one thing. And then when I was in high school, I was a nerd. I definitely could do stuff that the other kids couldn’t do. And in small country towns in New Zealand in those days, the 60s and 70s, everybody went to church. We had a lovely minister and he was great. And he said things like, “ you should fulfil the best roles that you can” And so I began to think, maybe I could go to medical school. What I really wanted to be was a rural land valuer, because I really liked the country, and I really liked climbing hills and the rural land valuer got to go and do all those things around the in the country. Anyway, I ended up applying to medical school because I had this this weird notion that if I didn’t do it, I’d be taking someone else’s job, which is not a really positive reason!
And then once you get into medical school, it’s very hard to change your mind and get out again. I kind of admire people who do that. As we went through, we did have a crisis. My mum got cancer and died during third year and I failed third year of medical school. That was when I was at Auckland Medical School, which is in the north, which is very unusual for my area. But then we were living in Geraldine in the middle of South Canterbury, just south of Christchurch, and so I transferred medical schools to Dunedin halfway through because of mum’s illness, to be closer to dad and all the rest of them. Those two things, had a pretty big impact on my life.
The decision to go to medical school was seriously influenced by my childhood illness, which now is fine. I’m got my gold card this year, and, and it doesn’t bother me at all because of the amazing advances in medical practice to do with asthma. I went to medical school but the choice of gerontology was really not made for quite some time. My grandmother seriously influenced that choice. Grandma was a lady who had supported my grandfather all her life. He was bipolar. And if you think back to the 1930s and 40s, there wasn’t really much treatment for people with bipolar disorders. So he would just go mad and end up in the asylum with all of those things that were associated with it. And then he died.
Grandma was the most independent, kind, wonderful person you can imagine. My mum would arrive with these six kids. We were all pretty energetic and that relationship with her carried on right through university. I would then arrive at Grandma’s with a bunch of, maybe six people when we were tramping in the Cobb Valley. We’d come back from tramping and we’d find that Grandma had mended all of the shirts and sewed all the buttons on and done all the washing and had all this stuff ready. She got to be 95 and was independent very much until the end so I was always fascinated by that. After medical school I met my now husband and we went to Philadelphia for his PhD. I was a foreign non resident alien for all of the years we were in America. You could work in a training agency but you couldn’t work in private practice. So I did my family medicine training program, which was great. When I’d finished there, I thought we were going home but Simon hadn’t finished his PhD, so I had to choose something else.
I was fascinated by the questions that you could answer and how you could answer them. I also knew that from a population perspective, and from my experience growing up, that actually GP’s and primary care were really important.
“Improving the health behaviours of elderly people: randomised controlled trial of a general practice education programme” Published in the BMJ 1999. Cite this as: BMJ 1999;319:683
The choices were either hospital administration or geriatrics so that was an easy choice for me. Geriatrics was the thing. I keep thinking back about my grandma in that geriatric medicine fellowship and that two years provided research training. that’s when I got really interested in research. I was fascinated by the questions that you could answer and how you could answer them. I also knew that from a population perspective, and from my experience growing up, that actually GP’s and primary care were really important. I wanted to stay in primary care because that’s where you have the whole person. You don’t just have a little slice of the person. And then with older people, which is so gorgeous and complex and challenging and I really enjoyed working with them.
After that fellowship, I ended up coming back to New Zealand, which I thought would be forever. We stayed a couple of years, I did the GP training here, and then we went to Australia because my other half was head hunted to a postdoc position there. I then ended up in the University of Melbourne area and I did a Ph.D. there. When you’re a busy clinician, you have lots of questions, you don’t really have time to sit down and think about them. You don’t really have time to engage in research. I had this research training, I had written some papers, I got fascinated by the writing process and started applying for grants and I just got hooked on the academic pathway.
I did a PhD to try out the research lifestyle, to see whether I really liked doing research. I did a clinical trial with GP’s and older people about education, about health promotion, about trying to improve the health behaviours of older people and, by influencing the GPs I discovered that older people did respond, and I really enjoyed the research track. So then I chose an academic track in universities, always with general practice alongside and I’ve made that work. I came back to New Zealand in 1999, and I’ve been at the University of Auckland ever since.
BA: I’m curious to know what you found helpful from doing that PhD in terms of content or methodology or whatever. What did you have at the end that you didn’t have at the beginning?
NK: The PhD, of course, is a journey, and the journey is different for everyone. I was very fortunate to be in the University of Melbourne, and I had a group of people around me who were all doing PhDs. There must have been 6 or 8 of us. We pulled in other people and we formed the Pickles Club- William Pickles was a famous GP academic and primary care researcher. That was with Jane Gunn who is now the acting Provost of the University of Melbourne, and who has been the Dean of Medicine. We’d invite Paul Glasziou down from Brisbane and Chris del Mar to come and give talks. It was a very supportive environment and very exciting. And we had lots of discussions about methodology.
I was passionate about randomized trials. I still am. They have a place but they’re not everything. And so the research environment was very good. The Ph.D. emphasized that you need people around you while you’re doing your research to spark new ideas and also to give you the right kind of advice.
I’ve always had a biostatistician advisor in everything I’ve done because I don’t have that skill. I think I do, but I don’t really. I’ve always tried to put together the best teams. And so sometimes the teams for my research are really large, and that’s good and bad. I learned to focus attention on one topic. I think that’s the only time in my whole career I’ve been able to do that. It was a good clinical trial that was published in the BMJ. All of that was helpful in coming back to an academic position in New Zealand.
The PhD is an a very important training ground. I didn’t take any courses during the PhD, but that was because I felt that I’d had adequate research training in clinical epidemiology. I do think you need formal training in the methods of the PhD, irrespective of whatever the topic is. I felt like I’d had that during the clinical fellowships in the US. I do think that I learned a lot about analysis and how to make Stata work, and the ins and outs of data analysis, interpretation, and putting it in the bigger perspective. And I do think that people need to present their work and be in active discussions with other people about their work to understand where it fits in the wider view of health and research, and the area that you want to influence.
That made me realize that there are different ways of practicing medicine in different places, and you don’t really understand that unless you go somewhere else. So I think it’s actually very good for academics, general clinicians, specialists, specialist general practitioners, nurse practitioners, everybody to try out a different health system just to really understand the benefits of ours.
BA: Just looking back on your career, it marked a big sort of U-turn in the department because you were the first person who’d done a PhD in a primary care department. I’d done mine in a public health department. It was a big shift in perspective. You were the start of a modern primary care academic in New Zealand as we understand them now.
NK: I think that was the benefit of coming from the department in Melbourne which was, of course, a few years ahead of us because they had been a Department of General Practice and Public Health, and they’d split to be just general practice. And they had Doris Young who was a strong leader and other people coming up through, so I was quite comfortable with general practice being a thing in itself and primary care being the focus that didn’t need to be supported by other disciplines. And I was young and energetic and I wrote lots and lots of grants. Because you write lots of grants, you get better at writing grants and you start to get them. Other people see that success and I think that becomes a role model thing which was probably quite important throughout those the first ten years. I also got the opportunity to do a Harkness Fellowship, and that was interesting in itself. And that took me back to Seattle for a year. As you remember, we had all those years in Philadelphia but that was the East Coast, and now we were in Seattle on the West Coast. My experience with America is long and in-depth, but I still think it’s a real enigma. I do not understand it. It is so different and diverse in the different states that you’re in. The rules are different. The people are different. The ways and understandings of working, and delivering medicine in America, of course are different. During the Harkness I didn’t deliver medicine as such, but when I was training as a GP, a a family medicine resident and a geriatric fellow, the expectations of the population were quite different about their health and about the levels of investigations. That made me realize that there are different ways of practicing medicine in different places, and you don’t really understand that unless you go somewhere else. So I think it’s actually very good for academics, general clinicians, specialists, specialist general practitioners, nurse practitioners, everybody to try out a different health system just to really understand the benefits of ours. I think our health system is world leading. I think it’s fantastic. I don’t know why we get such criticism about why it doesn’t work. It’s so much better than a lot of other places. Practising in Australia and America gave me a perspective about what primary care is and could be.
In Australia, you’ve got Federal, Commonwealth and State funding to different bits of what happens to older people. In America, older people don’t get funded very well. In New Zealand, we do have a comprehensive health system and most things are available. It’s just clunky. I’ve also lived in Newcastle (UK) for six months, in Leiden in the Netherlands, and understand about those health system. And each health system has really intriguing, interesting things. Some are bitter, some are worse. I talked to Tim Tenbensel about the health systems area because he’s the health policy person in our university and we have good discussions about that. I guess, as I’ve gone through the different stages, the breadth of experiences has really helped me understand and potentially write better.
“I don’t want to change the world. I want to change the lives of our people here in New Zealand. And maybe the world will see here. I will obviously keep writing about it and maybe they’ll see that and realize that, actually, locally driven, designed, and developed solutions, have to be local.”
Professor Ngaire Kerse (Head of School of Population Health, University of Auckland. President of the New Zealand Association of Gerontology in 2019.
BA: All that international experience puts you on the international stage, and I often say to the young doctors working with me, that’s where you want to be. And by doing all that overseas stuff, you have done that automatically. Have you any comments on the importance of that internationalism.
NK: I was so fortunate in having that early exposure to overseas. I didn’t realize its value until now, and certainly when I went back on sabbatical. I think a sabbatical is really important for academics- to be able to go somewhere else and experience something else, and recharge. Remaking the connections that I had was so much easier because I understood the landscape and knew some people. It is very hard to get to know people unless you go. I don’t know what we’re going to do now because we have a climate crisis which means that travel shouldn’t really be done in the way that we did it in those days. I do think that it is possible to make overseas connections overseas but, without going, it’s much harder. Now I’m a senior academic, I’m much more interested in influencing what happens here in my neck of the woods than in being a world leading academic. My university won’t be happy with that but I think that is because I understand the investment that’s needed and the investment in time, energy, and thinking for our own populations.
We have a very complicated older population in New Zealand between, a growing body of Maori and Pacific elders and a burgeoning of the Asian older population who don’t engage in health services and who we don’t look at very well at all. I’d like to contribute to international stuff from doing good research at home. Another senior academic, Ian Reid, said that to me too- “you’ve got to be famous at home before you can be famous overseas”. But I got famous overseas before I was famous at home, so I was the other way around. Now I’m the ‘Joyce Cook Chair in Aging Well’ which is quite a prestigious appointment. It’s a philanthropic appointment. And I have a bit more time to focus on the lot of older people to make sure it improves through time rather than getting worse. For older people the impact of public health type things, like poverty which is coming to our older age groups. How are we going to stop that? These are the things that I’m struggling with at the moment.
BA: So that’s the next stage in your career – changing the world and putting what you’re doing into action. Would that be a reasonable reflection?
NK: After 25 years of generating original research, 300 papers, and I feel like nothing’s changed. So now it’s time to just focus on changing things. That’s what I’m going to try to do- do you know how to do that? How do you change things?
BA: That takes a whole different focus, I think. But a lot of us in the second half of life want to leave a mark on the planet, and help change the world.
NK: I don’t want to change the world. I want to change the lives of our people here in New Zealand. And maybe the world will see here. I will obviously keep writing about it and maybe they’ll see that and realize that, actually, locally driven, designed, and developed solutions, have to be local. You can’t impose things from overseas on people because often it doesn’t work, because the understandings in the health system and the drivers and all of that are different.
“I learned that your expectations from one cultural group can’t be transposed upon another cultural group. You really have to understand that cultural group from the bottom up.”
BA: Along those lines, what are the two or three things that, you now know that you didn’t know when you started out….I remember you talking about the elderly Maori, that they didn’t know what depression was when you asked them. I thought that was amazing. They didn’t really have a concept of it. It wasn’t a thing for them
NK: That’s right. The Lilac Study. Te Puāwaitanga O Ngā Tapuwae Kia Ora Tonu/ Life and Living in Advanced Age, a Cohort Study in New Zealand:
“The unexpected lessons for ageing well” A talk at the University of Auckland in 2025
The flourishing of older people is an 85plus study. There are a group of 85plus studies around the world. We started by looking to those who were exactly 85 years old in one regional area. We wanted to do the right thing and our Tunuwaki lead said, you have to have equal numbers so that you can do analysis for Maori that are good and have integrity for Maori. So we had two cohorts actually.
There were enough Pākehā at age 85 but for Maori there was a small percentage of the population- at that time it was about 6.5% of the population over 65. So we broadened the age band from 80 to 90. We had about 400 Maori and 500 non-Maori. And then we did a cohort study. We measured lots of things, interviews, assessing blood pressures, grip strength, followed up every year for five years and then a ten year final follow up. In every analysis that we did, what predicted the outcomes was, as expected, for Pākehā but there were different drivers amongst Maori. The qualitative aspect varied. We had a wonderful PhD student Marama McDonald, who interviewed older Maori. She started out wanting to interview about depression, but that just had no resonance for Maori so it turned into an interview about happiness. It did uncover a framework of aspects which influence wellbeing or psychological well-being or happiness. But the concept of depression just wasn’t relevant, actually. And that came through in several other analyses as well. And of course, the measures that we used were Western developed measures. The cognition measure was the Modified Mini-Mental State (3MS), the depression measure was the Geriatric Depression Scale (GDS), the physical activity measure was the PACE measure. And of course, those things worked for Pākehā because that’s where they were generated from. But there were different from those things influencing Maori. So from that study, Makarena Dudley, a fabulous Maori neuropsychologist, went ahead and developed a Maori cognitive assessment tool, the Maori Assessment of Neuropsychological Abilities (MANA) tool, which is much more accessible and does describe dementia very well for Maori. And, there’s been lots of other aspects like that. I llearned that your expectations from one cultural group can’t be transposed upon another cultural group. You really have to understand that cultural group from the bottom up. We have wonderful Maori researchers who are doing that. They need more resources and more time. And I was also so respectful and so admiring of the older Maori in that project because they were resilient, they were welcoming, they were generous. From the questions we did ask them, the Maori were much more likely to be contributing financially and, of course, in language and culture to the mokopuna, the grandchildren, than the non-Maori. And yet the Maori were much more economically disadvantaged, had lower incomes, had less savings etc so they had a different view of material wealth because it was not as relevant to their wellbeing and to the societal success as it is for Pākehā. I don’t want to denigrate Pākehā at all but I’m just saying that we understand now that things operate, and that risk factors and influences, operate differently in different cultural groups.
BA: And the word Pākehā in New Zealand is Maori for European.
NK: Pākehā means that you are a person of European descent in New Zealand. I think it’s different from somebody who has just moved from Scotland or England, because they haven’t got the New Zealand influence. Growing up as a European in New Zealand changes you very differently from growing up in the UK. I don’t know if you’ve had that experience when you went to Canada.
BA: Yes, it takes a while to become part of the of the backdrop. Perhaps we’ll finish with that thought. It’s been fabulous having you as a friend and colleague for this past 30 years. And I look forward to the next 30 years
NK: Probably 30 years Bruce, we are in for it. We are successfully aging, that for sure!
