The Otago Medical School is such a part of Dunedin it seems hardly credible, even heretical, to suggest its future in the city might be at risk during the current debate over neurosurgical services.
When the Otago Daily Times put the question of the school's future to Health Minister Tony Ryall's office on July 19, the reply was: "An easy one - it's not on the agenda".
Reassuring, perhaps.
But, what did the National Government's Invercargill member of Parliament Eric Roy mean the week before when he told ODT health reporter Elspeth McLean that at some time in the future there would need to be a debate about where the best place was for a medical school?
The Roy comment will come as no surprise to Dame Dorothy Fraser when she reads it in here this morning.
She has already considered the worst-case scenario if Dunedin loses out to Christchurch in the debate over neurosurgical services.
"I suppose we could ask the question, I guess, as to whether or not Christchurch's determination to become the only centre for neurosurgery is also based on a growing desire for Christchurch to become a full medical school."
Dame Dorothy speaks with the authority of 29 years' service on the Otago Hospital Board and 12 years as chairwoman. She has also fought the same battle over neurosurgery - in the 1980s.
And, she is well aware of the pressure that has been applied by Christchurch and Wellington to have their own medical schools.
Each of those cities has had a "clinical school" of the Otago Medical School since the early 1970s.
The clinical schools were set up primarily to provide the Otago Medical School with access to more patients, enabling more students to get more clinical experience.
But a clinical school controlled from Dunedin is, obviously, somewhat less than a full medical school controlled by local Christchurch or Wellington interests.
Dame Dorothy: "I think sometimes we still see residues of the disappointment from when they became clinical schools rather than medical schools."
When making her comments to the ODT this week, Dame Dorothy pondered whether it was "advantageous" in "this particular climate" to suggest Christchurch's desire for a medical school was part of the current debate.
"But, in the background, watching the play, one suspects there may be an element of that in this neurosurgical thing. And, we've had similar things with cardiac surgery.
"If they can break down the clinical base here, it's putting more strength in their case to eventually become a full medical school."
When Mrs Fraser was first elected to the Otago Hospital Board in 1953, Dunedin had the only medical school in the country.
Auckland established its school in 1968 and Christchurch and Wellington have since gained their clinical schools. But, Dame Dorothy believes Dunedin's position over the retention of services has been weakened.
"I think the medical school approach, which I believe is still valid and still very important, can be challenged more easily by other areas of New Zealand."
University of Otago pro-vice chancellor of health sciences and dean of the faculty of medicine Prof Don Roberton, while concerned at the impact the lack of a neurosurgery unit would have on the Dunedin School of Medicine, does not share Dame Dorothy's view.
The faculty, he says, has three medical school campuses, including a large one in Christchurch, which is "linked in very much with the Canterbury District Health Board".
He does not expect that to change.
And University of Otago vice-chancellor Prof Sir David Skegg also does not consider the neurosurgery issue has "anything to do" with the medical school in Christchurch.
"There is already a school of medicine in Christchurch. It is part of the University of Otago ..."
However, he does believe that removing neurosurgeons from Dunedin would have "adverse effects" on the Dunedin School of Medicine.
But, he is "... confident that the medical school in Dunedin has a secure future".
Questions over the viability of the Otago Medical School, and attacks on Dunedin's specialist medical services, are not new - one battle fusing almost seamlessly into the next throughout the late 1960s, 1970s and 1980s in particular.
When, in 1980, for instance, Dunedin was denied government funding for its first CT body scanner - while Christchurch, Wellington, Hamilton and Auckland each got one - there was a "furore", according to Dunedin specialist physician Dr Tony Hocken, who wrote about it in an article in the British Medical Journal.
"The furore so aroused is probably unique since the abolition of the independence of Otago."
Dr Hocken wrote the "greatest dismay" was directed at the likely "deprivation" the lack of a CT scanner would impose on the neurosurgery centre.
"Dismay expanded into outrage when the Minister's stated intent to phase out neurosurgery from Dunedin and to place it in Christchurch was disclosed."
The ODT, he wrote, "went so far as to opine" that it was "deliberate government policy not only to phase out neurosurgery, but to undermine Otago Medical School at Dunedin, implying the intent to relocate the medical school in Christchurch".
On that occasion the public of Otago and Southland stepped up and raised $1.4 million for a CT scanner for Dunedin Hospital.
Even so, two years later the idea of a single neurosurgical unit in Christchurch was still on the Government's agenda.
Mrs Fraser and then medical school dean Emeritus Prof David Stewart made a direct approach to then health minister and loyal lieutenant of Sir Robert Muldoon, Frank Gill.
Prof Stewart believes the case they put then differs little from that being put now in the face of the current threat.
"They are related first of all to the provision of acute emergency services, secondly as a back-up for other tertiary services and thirdly for both teaching and training ... of specialists."
Back then, Mr Gill listened to the Dunedin case, considered the options and granted the city's neurosurgical services a reprieve that has lasted 25 years.
No-one who knew Dame Dorothy in full chairwomanly regalia would be in the least bit surprised that Mr Gill succumbed.
The question is: Can today's defenders of Otago's health services deal similarly with Health Minister Tony Ryall?
A seasoned health warrior is in the background, watching the play ...
• Schools defined
The Otago Medical School refers to the University of Otago's entire Faculty of Medicine. It has schools of medicine in Dunedin, Christchurch and Wellington, as well as the School of Medical Sciences in Dunedin.
~ TIME LINE ~
The current arrangement for neurosurgery in the South Island is for two neurosurgeons to be resident in Dunedin and four in Christchurch.
It has been suggested in future all six be resident in Christchurch with none in Dunedin - an arrangement referred to as the "one-site model".
THE STORY SO FAR:
• Jan 2009: Dunedin neurosurgeon Suzanne Jackson resigns, leaving both Otago positions vacant.
• Mid-2009: A report by Prof Spencer Beasley to South Island health boards recommends the one-site model. The boards cannot agree. Otago and Southland health leaders prefer the option of two neurosurgeons resident in Dunedin and four in Christchurch.
• Late 2009: Independent Nelson consultant Dr Ian Brown is appointed by the boards to lead a review.
• April 2010: Dr Brown recommends the one-site model.
• May 27: The boards advise director general of health Stephen McKernan they cannot reach agreement and ask him to appoint an arbitrator.
• June 21: Mr McKernan announces he is convening an expert panel to advise him on the impasse and asks boards not to make permanent appointments.
• July 10: Health Minister Tony Ryall tells nurses' conference in Dunedin he hopes a decision on neurosurgery services in the South can be made within two months.
• July 13: The eight mayors within the Southern District Health Board region express their concerns about the future of neurosurgery in the region.
• July 19: Mr McKernan announces a panel consisting of Auckland paediatric surgeon and head of the clinical school at Auckland University, Anne Kolbe (chairwoman), Adelaide neurosurgeon Glenn McCulloch and consumer rights advocate David Russell.
• July 23: Dunedin Hospital's clinical leader of intensive care, Mike Hunter, says transporting Otago and Southland emergency neurosurgery cases to Christchurch is unacceptable.
• July 24: The Otago Daily Times reveals Southern District Health Board chief executive Brian Rousseau has engaged two European neurosurgeons to fill the long-standing Dunedin vacancies. They are expected to start work in January.
• July 27, 2010: The New Zealand Nurses' Organisation supports retaining neurosurgery in Dunedin, saying the implications of a Christchurch-only service for acute patients from the southern area are grim.
• July 27, 2010: Retired Dunedin neurosurgeon Samir Bishara says losing the service would put lives at risk and be the beginning of a downgrade of the hospital, the University of Otago and its medical school.
• July 30, 2010: Dunedin Hospital intensive care specialist Mike Hunter challenges the impartiality of advisory panel neurosurgeon Glenn McCulloch, following comments he is said to have made at a medical conference.
EARLY NEUROSURGICAL DAYS
Former dean of the Otago Medical School Emeritus Prof David Stewart says prior to the 1930s, surgeons would operate on any part of the body.
"But, gradually, surgery has developed what's called sub-specialities which have allowed more surgeons to concentrate on one particular range of operations."
The great pioneer of brain surgery was American Harvey Williams Cushing, described as the "father of modern neurosurgery".
Dunedin's first specialist neurosurgeon, Prof Murray Falconer, also became known as a "giant" in the field during a distinguished career that began with his graduation from the Otago Medical School in 1934.
Prof Falconer trained in neurosurgery at Oxford and returned to Dunedin to form New Zealand's first formal neurosurgical unit.
His particular interest was in providing a surgical solution to epilepsy and his obituary in the British Medical Journal in 1977 noted he had carried out more than 300 "temporal lobectomies" - the removal of part of the brain.
The operation is still the most common type of epilepsy surgery, with as many as 85% of patients gaining some benefit.
Prof Falconer left Dunedin for London where he set up a neurosurgical unit at the Maudsley Hospital.
A ward at King's College Teaching Hospital is named after him.
