September 2019 - The Best Mouse Tap

Modest Expectations – Julia

Looking at this young woman Greta Thunberg, her face contorted with rage, one has to ask what is the next step?

Rosa Luxemburg’s comment may be relevant and somewhat re-assuring:

The most revolutionary thing one can do is always to proclaim loudly what is happening.

Yet what happened to Rosa Luxemburg, who is one of my admired people, as is Dietrich Bonhoffer? She was killed by the Freicorps in 1919, as was Bonhoeffer – hanged by the sons of the Friekorps at Flossenburg in 1945. They both spoke their mind. They challenged the equivalent to today’s violent alt-right. Both had a form of courage, I wonder whether I could ever emulate; probably not.

But back to Thunberg. What is her next step? She has confronted her Armageddon in a unique way. Yet her following may yet be ephemeral. How many of those who demonstrated last week believe that when the Sun rises tomorrow it will incinerate our Planet in a cloud of carbon dioxide.

Greta Thunberg, in her speech, was full of venom. She is confronting a world that is full of hatred stirred up by the newly-minted demagogues. She is no longer a schoolgirl; to these demagogues she is a revolutionary – a dangerous person. Sweden has a history of assassination. Remember Olof Palme. His killer has never been caught. I do hope Greta has good security.

The Man of Coal gets a Shiny Coating

The Prime Minister has come out of his visit to the United States with a new moniker – a Man of Titanium.

Whether that sticks depends on whether the various spin doctors see any value in ridicule or defence emphasising the properties of titanium. Who knows? However, what else? Maybe some trivial contribution to Trump’s Mars Venture, a couple of speeches, opening a Pratt factory in Ohio in front of what looked liked a bikie convention. Wandering around the United States Morrison, despite all the flattery and pomp, presented a marginalised world figure.

Meanwhile, as well as the speech at the UN climate summit, Jacinda Ardern has given a headline speech at the UN Secretary General’s climate action summit private sector forum. She has been pushing her initiative, the Christchurch call to block extremism on the social media outlet; she has met with Sheryl Sandberg, COO of Facebook, Susan Wojcicki, CEO of YouTube and Brad Smith, president of Microsoft.

Her aim was to cement the Christchurch Call, during a roundtable with the tech companies including Microsoft, Google/Youtube, Amazon, Twitter and Facebook. Maybe the call will become an echo, but in our terms with the new crisis response protocol and the preparedness of Google to test it later this year, she’s giving it a red hot go – and what’s more, she is very relevant to what is occurring in the world.

She may not have been able to feast on Dover sole and apple charlotte with such luminaries as the Honorable Rudy Giuliani or the Honorable Katherine Henderson the other night, but Trump wanted to speak to her and it should be noted that Trump suddenly made time to drop by the Climate Summit – no show without Punch.

By contrast, our Prime Minister didn’t entrance everybody with his talk to the United Nations this week.

However, Morrison is not the tosser that some like to portray. I was thinking about what his next move with Ms Liu will be now that he has the Chinese well offside, and there seems to be some pushback by the Victorian Liberals.

Looking though the guest list for his dinner with Trump there was no Arthur Sinodinos – maybe a bit odd. But when the Niblick from North Shore who was at the dinner, comes home, he will be replaced by an envoy not tarnished by a Trump association; hopefully Sinodinos will be somebody who will be amenable to the Democrats. Just an errant thought chipped out of a cranial bunker.

Stop mucking about

One of the problems the health system faces is how to manage the aged person when their chronic condition develops into an impairment that requires varying levels of ongoing care, particularly institutional care. The health care system is faced with paying for custodial care – and preferably not in high-cost, state-managed acute hospital beds.

To the central Commonwealth agencies the imperative is to keep the aged brain and limbs working, for the forecast is that unless this is done there will not be enough people working to sustain the economy without extensive immigration.

This imperative to keep us working is an ironic outcome, given that the Commonwealth allowed the development of a superannuation scheme that required its own employees to retire on the eve of their 55^th birthday. Under the terms of the scheme it was not worth working beyond that age. Moreover, there were financial penalties if you did.

That scheme has been retired, along with a lot of 55 year old public servants, but it illustrates a shift in thinking. It is not that long ago that the futurist chatter was about an increase in leisure time and the expectation of retiring to a recreational middle age. Given the imminent workforce problems, that is not an option for government planners. Therefore the workforce has to be healthy if it is to prolong its usefulness. After all, healthy life expectation starts from intra-uterine life.

The fact is that we have the technology to prolong existence. Whether that existence translates into the kind of life a person would care to be encased is a matter of personal value judgment. To many, though, the primacy of the individual is a societal norm.

So what about this question of an aged care health benefit under Medicare? The Commonwealth already has the power to legislate for a sickness benefit. Also, the Constitution picks out, in addition to the doctors and dentists, benefits for hospital care and pharmaceuticals.

In all the discussions of the Commonwealth’s powers, it was only the passage of the 1946 amendment that enabled the Commonwealth to intervene directly in health financing.

It then created successively the Pharmaceutical Benefits Scheme (1950), the Pensioner Medical Service (1951), the Hospital Benefits Scheme (1952) and finally the Medical Benefits Scheme (1953).

It might be argued that the Pensioner Medical Service was an embryonic attempt at an Aged Health Benefits Scheme. But it was a very limited attempt, restricted to some services provided by general practitioners to eligible pensioners and their dependants.

The matter of Commonwealth powers is relation to health was one of the terms of reference in the first major review of the Constitution established in 1927.

In its report two years later the Royal Commission, which undertook the review, revealed a strong difference of opinion on where responsibility should lie. The majority view supported a “softly, softly” approach, which would have health as a Commonwealth power but well fettered by the states and even local government.

What emerged strongly in the report was a recognition of the strong sense of co-operation between the Commonwealth and the States. But here the discussion was about quarantine and the promotion of public health. The fact that co-operation had failed under the “stress of epidemics” of smallpox in 1913, influenza in 1919, and plague in 1921, was seen by the Royal Commission as the reason for even more co-operation between the various governments, not less!

In fact, the Commonwealth Department of Health was created as a result of the influenza epidemic and problems arising from the return of large numbers of troops from the First World War. From the national approach to episodes, such as Severe Acute Respiratory Syndrome (SARS) and the Swine Flu epidemic are evidence that co-operation in this area has continued to the present.

But health financing is another matter. It is interesting to note that when the Constitution was next comprehensively reviewed in 1959, health was not mentioned in the deliberations. The Constitutional amendments of 1946 had resulted in the changes welcomed when the world was experiencing the advent of the “wonder drug” era. The cost of the health system was not a political issue.

So what has happened since?

As the late John Deeble, one of the architects of first the Medibank scheme of universal care (1974) and then Medicare (1983), identified over 30 years ago, from 1972 onwards the average wage level of public hospital employees started to rise far faster than both average weekly earnings and medical practitioner incomes. The impetus for this was, in his words, “a compulsory arbitration system which takes almost no account of the ability to pay and was completely unaffected by financing arrangements”.

A number of strategies have been employed to try to contain the cost of the health system since this trend became very apparent in the early 1980s. But in the end, when the smoke clears from any round of Commonwealth-State conversations on health, the problems foreshadowed in tailoring a health care system to projected demographic changes will persist. Yet near the end of the Howard era, there was an explosion of Medicare benefits, expansion of the Medicare Safety Net and the reintroduction of the private health insurance rebate.

One wonders, then, whether it would be best if there were some consolidation of the power of the Commonwealth, such that it assumed complete control of aged health care and, by implication, total control of health. Alternatively, should the Commonwealth simply retire from health care? This debate has achieved currency periodically, although with the number of reviews, which have been entered into from Rudd to Morrison, the debate has become rather muted waiting for the deliberations of these committees. The time that the Robinson Review has been allowed to meander needs to be curtailed as I mentioned before; and who knows where the Royal Commission into Aged Care Quality and Safety, constituted at the beginning of the year and due to release an interim report at the end of October, will end up.

There remains a need to stimulate discussion on how best to address the issue of providing for an aged health care benefit.

At first blush, advocacy of such a benefit would appear to be for “health care” after age 65. Any person, whether in the guise of “patient”, “client” or just plain “consumer”, would have the discretion to use that government-funded benefit how he or she thinks fit.

Such a libertarian solution is immediately hedged with all the provisos that abound in that “dark and pessimistic world we inhabit” – a state of affairs we might expect if we listen to those who try to ensure that any freedom of action is hung on a line of conditional discretion for our own protection.

This is the dilemma: the tug-of-war between freedom to do what you want and the imposition of the fiat of “what is good for you”.

And so the level of knowledge about the various courses of action that are available becomes crucial when determining the outcome of this tug-of-war in relation to the individual complaint.

It is the power of asymmetric knowledge. The provider has knowledge, which the consumer generally does not.

Constitutionally, the Commonwealth may have the power to establish an aged care benefit which could, for instance, be just a redefinition of the power to set “sickness benefits” (which is mentioned in the 1946 amendment).

The fact that so few referenda are passed is testament to the conservatism of the electorate. But it also indicates that the same electorate takes change seriously.

There have been four referenda since the one in 1946. The consequences? Aboriginal people have been given the right to vote; price and income control has not been conceded to the Commonwealth Government; and the Republic has been denied. A number of constitutional anomalies were clarified in the 1977 referendum.

The financing of aged health care is another major issue.

The prospect of a referendum will draw out the vested interests, to be tested in the glow of debate. And that is the point! It is the vested interest who may feel that such a debate would not be fruitful because it is too hard to change the system. But in the end it would be academic. Referenda are expensive, and in the current economic climate seen as a luxury; nor would the cession of powers attract much interest.

But if one level of government does not at least have the unequivocal power for health care of the aged then the proposition of a consolidated benefit for aged care will never be tested. The optometric scheme was introduced in 1974, and the sleight of hand used to assure Constitutionality was to deem the optometrist service as “medical”. In any event, the Commonwealth was providing a fixed benefit for a limited range of services. The optometrist had to accept the benefit amount.

This is very different from the medical benefit, where the benefit is the Government’s contribution to the overall medical fee, which remains at the discretion of the doctor. The Commonwealth has progressively tried to cap the Medicare expenditures and at the same time maintain the gap payments at an accepted level; hence the expanded Medicare safety net and bulk billing provisions, which are increasingly working less well and there is a rising concern between benefit and actual fee proceduralists, in particular, charge. Given his craving for publicity maybe it could be called the Teo effect after the cavalier neurosurgeon of the same name.

The language of the majority opinion in the 1929 Royal Commission report still resonates as a challenge to this nation to consolidate the health power in that sense of co-operation, which has been apparent in public health matters since Federation.

So let us play with the theme – directing the whole of our approach to health care, from conception onwards, towards conferring an aged care health benefit – but under a single power conferred by the Constitution. However, if the definition of “sickness benefit” is expanded then it may enable the benefit scheme to be extended to those health professionals that the current language of the Constitution excludes. There is for instance no provision for “a nursing fee for Medicare benefit”, unless you pursue the optometrist option – and I doubt whether either doctor or nurses would be happy that nursing services being deemed “medical” to attract a patient benefit

If that can be done without a referendum, there will be much saving of time and expense. But there is no doubt that referenda and the prospects thereof do focus the collective community mind.

Mouse Whisper

I love the story about an Australian bushranger called Charles Rutherford who was illiterate and lurked around the Lower Darling in the early nineteenth century. When he robbed a coach, he asked the passengers to read out the value of each cheque that he intended taking. Talk about honour among thieves. But there was more. He used to take his captives to a near-by hotel for drinks and lunch at which Rutherford, presided gun in hand.

Modest Expectations – Theodore R

I repeat what I said last week, eye gouging – or whatever euphemism is used in the charge – should result in the player being banned for life and the police called in.

Two weeks in a row – the one player. “Of no moment”, one cries, with a carefree flick of the polo stick. Is the AFL going to wait until a player is blinded?

At least despite pressure he has got a one week suspension. Hardly enough.

It is disappointing to say the least that the ophthalmologists of all people have not weighed in – at least it does not appear to be so on the web site.

They call it Molly

Back in the mists of time when the Neanderthals walked Australian soil I, as a male post-graduate researcher, had a regular task. I had to climb a ladder and, on the top of a long Sephadex column encased in lead bricks, had responsibility for the purification of two radioactive iodine isotopes – I¹²⁵ and I¹³¹.

The first of these isotopes had a half-life of about a month but the second isotope that of about ten days. Therefore for the research work, I¹³¹ had to be made frequently because as it decayed it lost both strength and purity for the work the laboratory was undertaking. Over the period, since we needed to be checked after each procedure, I labelled myself as well twice, which meant I had to take a dose of iodine to wash my thyroid out. Let me say that there are few worse punishments for laboratory carelessness than a dose of iodine. It sure defines bitterness.

So when I look at the latest problem that ANSTO is having with the supply of radioactive molybdenum (Mo⁹⁹) then I have great sympathy for when things go wrong.

For the community, nuclear reactors mean enriched uranium and the possibility of bombs and big power stations. But OPAL (Open-Pool Australian Lightwater Reactor) at Lucas Heights does none of those things. However, its role is equally important, as the low grade uranium fission in the reactor has been producing a significant supply of the world Mo⁹⁹which in turn generates technetium (Tc^99m). If you to identify the most important function of the reactor, this is it.

The ANSTO reactor has been having production problems with Mo⁹⁹ since June last year. First there was a problem with generation of the technetium, which meant Mo⁹⁹ had to be sent to Boston for Tc^99m generation, and given the half-life of the isotope and the turnaround time for the Tc^99m there needed to be spot-on timing to minimise the loss through decay of Mo⁹⁹in transit.

Now it is a more serious problem. A faulty valve in the dissolution cell means that while Mo⁹⁹ can be made, it cannot be extracted to produce the Tc^99m. There is already a huge shortage around the world as a number of reactors that did make the isotopes have closed down in recent years.

Before you all shrug your shoulders and say reducing radiation is good thing, everyone has to realise that this isotope Tc^99mis the mainstay of detection for cancer, bone disease and some cardiac conditions. Without it, this area is like a blank black TV screen. With the TV, you expect to be able to switch on, the screen to light up and you then settle in for a good night of relaxation. The same is true for the specialty of nuclear medicine and diagnostic imaging in general, you expect not have any interruption in the program.

Currently, the ANSTO boffins are scratching their heads about how best to proceed, given there is an great amount of highly radioactive material unable to be removed before the repairs can be started – the equivalent of how to stop Rome burning.

Elsewhere everybody in the industry and relevant parts of medical profession have got off their backsides to scour the world for any spare Mo⁹⁹ (there apparently isn’t much) and thus realistically searching for substitute tracer material which is generally more expensive. This substitute material has to be priced so as to ensure the industry does not go down because Medicare cannot adjust to pay the real cost of using the substitute radiopharmaceuticals.

The Government is very conscious about price and that is reflected in the precise definition of MBS item descriptors. It is an exercise in keeping the smallest number of moving parts operational – and when the crisis is passed then there can be what the dreamy educators would say – a time for reflection.

However, this whole period with ANSTO and its cascading troubles may need a great amount of investment to correct – and to many, nuclear reactor is equated to Chernobyl. Therefore, politicians get nervous, and if we could call it “fluffy duck” they may then be prepared to immediately stump up the money to fix the source of last year’s problem.

Having said that, this year’s problem has occurred in ANSTO’s newest world-class production facility. It might be a one in 10 or 15 years’ problem, but it is a major one and it has occurred very early in that 10 to 15 years.

The sector has responded as well as it can with emergency provisions being put in place very early on and a cooperative approach being taken. It will be a challenge to keep a smile on the face of the specialty if the shortage drags on.

The Lucas Heights reactor is a vital cog in assuring the community’s health if for nothing more than the detection of the conditions named above. What happens if an unfriendly country corners the world market for Mo⁹⁹even by default because Australia can’t get Mo⁹⁹out of ANSTO?

Morrison – the Funambulist

Morrison is about to go and participate in one of those tawdry Trump events – called a State dinner with all the trappings of Mar-a-Casablanca chic. An Australian Prime Minister can hardly turn down what no other World leader except Macron has been afforded – Trump with full garnish. Morrison knows that as a middle order leader, he has to be able to genuflect to both the USA and China almost simultaneously without either getting the legs crossed or suffering from a case of morderte en el trasero.

To avoid the latter condition and given he has an electoral mandate until 2022, Morrison will be banking on either a Trump re-election or the aspiring Democrats not noticing or caring who is and what he has said. After all, “A gunboat short? No worries – just ring Australia.”

However, keeping sweet with the Chinese is a different matter. To counter any perception that he is a total American sycophant, Morrison has been very strong in the defense of the member for Chisholm, whose links to the Chinese government seem like a tapeworm – you can see the head but extracting the total worm is a tortuous, long drawn out task. An official Chinese publication has risen to the bait, by praising him, but there is a great deal of unraveling before the Prime Minister is invited to a banquet in Beijing.

At the same time the media are having a field day not just on the member for Chisholm, but also all the Chinese donations appearing in modern variations of the brown paper bags. What it tells me is that the Chinese never miss an opportunity. If they see a line of politicians and bureaucrats with their noses in the trough, why not feed them?

However the Chinese government cares not a jot about the media – they care about who is in government, and it is better to get your way without having to use brute force. As the Japanese found out, Australia was not the easy target to conquer that Malaya and the Dutch East Indies were. However, in the minds of some Australians there are still remnants of “White Australia” and the “Yellow Peril”; even now when over one million Australians have Chinese heritage. So for the Australian government, the Chinese government presents a problem, especially when you can hardly see the problem through a blizzard of bank notes.

However, one of the most interesting Morrison appointments which has not gone unnoticed is Graham Fletcher as the Ambassador to Beijing. As one of his predecessors noted, Fletcher is the most fluent Mandarin speaker sent in this role and has in fact lived for periods in China. Contrast him with the moustachioed Iowan Terry Bransted, the American Ambassador, lauded by Trump as a great friend of China because Bransted apparently casually met Xi Jinping many years ago when the latter was a minor official on an agricultural delegation to the Mid-west. Great credentials when placed against those of our new Ambassador. I think not.

However, whether the member for Chisholm is a Chinese Government operative or not, Morrison is showing a degree of solidarity with her that has not been lost on Beijing. It is hard to believe that the advice Turnbull received which made him shy away from the then candidate for Chisholm would differ from the advice received by Morrison about the member for Chisholm. And yet there is the Prime Minister unabashedly defending her.

The ALP missed their opportunity to send the Chisholm electorate result to the Court of Disputed returns, challenging the Liberal party’s advertising as scandalous and deceptive. Had they done so it is probable that this episode would have been played out in a more frosty, less emotionally charged atmosphere. However, the billy has been kept boiling by the maverick Oliver Yates, who has the member for Kooyong in his sights also in his appeal to the High Court.

Anyway, in amongst all the activity, the Prime Minister in his actions in relation to the member for Chisholm is addressing Beijing without appearing to genuflect. He has already a semaphore from the Chinese. It now depends on what he says in Washington – probably no “on the stump with Donald Trump” would be a good starter

As I said above I hope the Prime Minister will avoid treatment for a bad case of morderte en el trasero.

Jacques Miller

Very briefly: Congratulations to Jacques Miller on co-sharing the Lasker award this year with Max Cooper, although in its announcement, the NYT put the Yank’s name first. They really can’t help themselves, given that the research giant was Miller, then a 30 year old when he made his initial discovery about the role of the thymus, that gland in the neck which few of us have ever contemplated. His work was seminal to modern immunology. Miller is now 88.

For God’s sake, you Swedes, he has deserved the Nobel Prize for years. Gus Nossal’ s elegant panegyric written eight years ago says it all. How many of us have been touched by his work – his genius.

Let Professor Nossal’s succinctness remind you of the impact of the discovery:

Miller is the last person to discover the function of a human organ — the thymus — and not a single chapter of immunology has been untouched by the discovery.

T cells became even more prominent when it became clear that they were the chief target of the AIDS virus. Miller continued to make discoveries about the thymus and T cells for many decades, including gaining important insights into:

how the immune system discriminates between self and non-self;
how it goes wrong in autoimmune diseases; and
how the whole orchestra of the immune system is regulated.

Enough said.

Mouse Whisper

We all know about Shanghai Sam – he is the guy the Prime Minister did not name as such – 17 times.

Perhaps though, without reference to the black kettle, we can now call the Prime Minister “Chinese Morrison No 2.”

“Chinese Morrison No 1” was also famous in his time – an Australian born in Sydney. George Morrison was a journalist who, as a correspondent for the London Times in the then Peking, had an important role in the defense of the various legations during the 55-day siege of the Boxer Uprising in 1900, the year of the Rat. Then, as adviser to the fledgling Chinese Government, he was a pivotal figure in the fall of the last Emperor and the birth of the Chinese Republic.

“Chinese Morrison No 2” should remember that 2019 is the Year of Pig – to the Chinese a symbol of wealth not necessarily with its head in the trough.

Modest Expectations – Klinefelters

Robert Mugabe, that unpleasant man from Zimbabwe, died recently at 95. I remember one of those Rhodesian types, I could see him elegant in a safari suit sipping a Pimms in a Bulawayo club in the days when Cecil was a remembered name. This guy voiced what I had wondered about for some time. He said that it was an open secret that Mugabe suffered from tertiary syphilis – or in more specific terms that variation known as general paralysis of the insane.

For some years after he assumed power in the new Zimbabwe carved out of the old Southern Rhodesia, Mugabe was viewed as a being a reasonable ruler of an emerging country but slowly over the years he was transformed into a tyrannical paranoid despot prone to grandiose ideas – and it was also noticeable that he was increasingly having difficulty with his balance.

The problem is that dementia has many manifestations, as does syphilis, which in its clinical manifestations is the great chameleon. While primary syphilis is relatively easy to diagnose, as the causative spirochete agent then wanders away from its genital base through the body and across the blood-brain barrier, syphilis can manifest itself clinically in many ways.

In a post-graduate examination may years ago, I was presented with a specimen of a large aortic aneurysm, which fortunately in my discussion I said could be a tertiary manifestation of syphilis – not the paretic but the luetic form. My examiners then launched into a thorough menu to find out how much I knew about syphilis. The specimen was just the amuse-bouche.

Syphilis is very well treated by penicillin if diagnosed, as the spirochaete does not or cannot conjure up any defence against the drug. However, the disease can disguise itself well, once the primary focus is healed. One of my recollections is that of a guy bought into the emergency department comatose and with these strange lumps over his body. One was biopsied and showed masses of plasma cells and then when stained appropriately, there was coil upon coil of spirochete. Syphilis unmasked and I believe once penicillin was administered he lost his lumps and became alert. Syphilis cured. However, it showed how deceptive syphilis can be.

However, penicillin availability has not cured the disease. Syphilis still prowls the community often strand in strand with the HIV virus.

Once upon time in the 1950s and 1960s, if Australians wanted a US visa, they needed to have a Wasserman test to show they were free of the spirochete; and before World War 11 some of states of the US, at the urging of the then Surgeon General, instituted mandatory testing for syphilis before a marriage license could be issued. How that was enforced is an area of speculation, but data did show that those about to marry was not necessarily the area where the Surgeon General should have been looking.

Now the Amazon behemoth is moving into heath care data collection with Alexa chirruping from the Bezos hip pocket. So what happens now if the data find the deceptive spirochete coiled up the policy maker brain? What of this person? Increasingly irrational you say – maybe we should wait till the person in question starts to fall over – literally. Then Mr Bezos may have the answer for us.

Not on my Kisser

I have always preferred shaking hands when greeting anybody, but I was taught as a boy to shake hands with a person of the opposite sex only when she proffered her hand. Relatives were different. As a small boy they would come at one at different angles to kiss me. Apparently, that was an acceptable trespass.

I agree very strongly with Leigh Sales about the unwanted kiss, especially when it lands on the lips whether dry or oozing with saliva. However, it applies for both sexes. As presumably Leigh Sales does, I like to control my personal space – those that come into it are only licensed to do so. Personal space varies; you know roughly how much you have. For me, it varies with the mount of grog I have drunk; and thus when one drinks too much that space is more easily invaded and vice versa.

I not only dislike being kissed by someone where the feeling is not reciprocated, but I also avoid the hug as much as possible. The hug makes me feel very uncomfortable, and here again personal space is violated unless it is consensual. In one TV chat program I watched, someone proudly said she was a hugger as though that gave her a complete license to do so.

Personal space I found out long ago is variable. Having tested it, if someone comes up to me, and wants to shake my hand, I have no problem with distance of the outstretched hand. I have been known to grasp the arm to regulate the greeting distance. If someone comes up to me aggressively, I generally do not back away.

People coming up behind me whether putting their hand on my shoulder or not do not worry me, but this is one area of personal space where many people feel most vulnerable and hate the person coming up behind them and touching them.

And of course it depends on the venue – a back lane at 3.00 am or an office at 10.00 am are somewhat different. Therefore, context is always important.

Being male gives one an advantage in maintaining personal space integrity. You develop strategies, but I would imagine a high profile person as Leigh Sales is, has many, but the ambush is difficult to manage especially if the assailant is someone you believe should have known better.

Eye Gouging

The National Rugby League recently inflicted an eight-week penalty for eye gouging on a Canberra Raider, but the Australian Football League slapped the wrist of a GWS player with a fine. Irrespective of the history of this player on the field, I found the defence by his captain ironic. He is alleged to have said, in reference to his colleague: “sometimes that means people look at stuff that he’s involved in in a light that’s probably not neutral”.

I agree if the eye gouging had resulted in blindness his victim would be in a light that was probably not neutral. He would be blind.

I am not an ophthalmologist but perhaps such a specialist could more eloquently tell the community of eye gouging leading to retinal tears, dislocation of the lens, vitreous haemorrhage, globe rupture, traumatic optic neuropathy or fracture of the orbital floor – and of course blindness is always an option.

I have a simple remedy. Ban eye gougers for life from the sport and call in the police.

After all, look at the penalty meted out for sandpapering a cricket ball. A cricket ball versus an eye!

Caribbean storm

This time it is the Bahamas; last time Puerto Rico. These are high profile remnants of hurricane fury. Battered by hurricanes of increasing intensity, the Caribbean is increasing liable to become a tropical rubbish dump.

The funny thing is that these events seem to be increasing in intensity while the climate changer Canutes are clustered on the shores of their indoor swimming pools sipping their strawberry daiquiris and watching the clouds roll by.

This troubling development is not going away, as these micro-nations, which are exploited either as reservoirs for the black economy whether money laundering or drug trafficking or for the tourist playground. There is a huge discrepancy between the living standards of the tourists and the ordinary citizens with many living as little more than subsistence farmers.

Climate change is real, and in countries which are as vulnerable as most of those in the Caribbean, these events of Nature, whether they be hurricanes or volcanic eruption like the one which destroyed most of Montserrat, have not the financial capacity to do much.

Then Haiti is the classic failed State. Ruthlessly exploited by the Duvalier regime, classically described by Graham Greene in The Comedians, Haiti was subject to a massive earthquake in 2010 which killed 300,000; followed by a cholera epidemic; followed by two hurricanes. What chance has that country got to be anything but a pile of impoverished rubble. In my recent visit to Chile, I noted a number of black people roaming the streets obviously in low paid work. They were Haitian refugees. There are over 150,000 of them in Chile alone, about 10 per cent of the immigrant population.

However, only in one Caribbean country can you detect any systematic response to what will become a regular summer hazard – and unsurprisingly that is Cuba. In an article after hurricane Irma in 2017 devastated a 300 kilometres swathe across the island, affecting 90 per cent of the population, Jon Anderson noted in an article in the NYT:

Taking part in preparations for the defense of the island from the vicissitudes of hurricane season may have a practical imperative, but this, too, is framed as a revolutionary duty. For decades, beginning under Raúl’s late brother Fidel, Cubans have conducted annual drills to prepare for hurricanes, resulting in a national disaster-response system that has saved many lives during past storms.

As another source noted about Cuba: These attributes are: (1) actively learning and incorporating lessons from past disaster events, (2) integrating healthcare and public health professionals on the frontlines of disaster response, (3) proactively engaging the public in disaster preparedness, (4) incorporating technology into disaster risk reduction, and (5) infusing science into risk planning.

None of the other countries have invested the way Cuba has in guarding against Nature’s invasion. There is no doubt that in disaster planning centralised control has its advantages as long as the people are part of that control. Cuba has had to live within constricted means because of the United States’ embargo. Although, like a growing number of people, I have visited Cuba, but for my part as a “working tourist” on an American delegation flying out of Miami in an unmarked Delta jet. I have sampled Cuban tourism, but it is not the mainstay as it is in the legitimate economy of other Caribbean nations.

Granted that Cuba is the biggest island but only 25 per cent more in land mass than Hispaniola which is shared by Haiti and the Dominican Republic. So size does not necessarily equate to economic stability.

Tourism is a fickle contributor to the economic health of the community. You can see the consequences of damaged resorts left to rot after experiencing a weather catastrophe. Nearer to home, just wander up the Queensland Coast. In the case of the Caribbean countries, which country of the G20, say, is prepared to go guarantor to rebuild after Nature has had her way? Certainly not the United States, the nearest and wealthiest neighbour. One just has to see the continuing plight of Puerto Rico, which has been left as a wreck by Trump – despite the fact that it is part of the United States, with even one non-voting resident commissioner in the US Congress.

In other words, the Caribbean is very much going to be the bellweather of climate as small nation after small nation is knocked over until even those of us reaching for a third daiquiri may be concerned that the increasing pile of rubble is blocking the view – and then there is that stench from a decayed economy!

But then it will be too late to do anything, and we, the generation who have caused it, have gone on our way out of earshot from the curses of the future generations for the legacy that we have left.

Mouse Whisper

The Modest Reflector loves conundra, and the title is Klinefelters – you know, the syndrome where people who can look a bit like women because they have XX sex chromosome, in fact have the attributes of men through their “Y” chromosome. And one Y trumps XX when it comes to sex.

Klinefelter’s syndrome has caused all sorts of problems in working out in which gender a sporting person with the XXY chromosome should compete. There is some suggestion before chromosomal testing was available, that a number may have competed as females in various Olympic Games, despite having the male sex chromosome.

Well, why is modest reflections Klinefelters? 25 is XXV in Roman numerals. Now take the stalk off the Y … not even original and he promises not to do it again.

“Babe” Didrikson Zaharias – “The Texas Tomboy”

Modest expectation – Hourglass

The member for Dickson, that doyen of child care ownership, is showing all the compassion that we have come to expect, and for which the good burghers of Dickson rewarded him with an increased majority at the last election. However, it was not all high fives out at Mount Nebo, where 75 per cent of the votes cast there were for the Labor candidate.

Overlooking the promised land, from Mount Nebo

It is not that the member for Dickson is not without compassion. He has a daughter born out of wedlock, whom he seems proud to have as part of his family with his second wife. Therefore I find it difficult to know why he is rejecting these two Australian children who are part of the growing multicultural nation family, because they happen to have Tamil parents.

Perhaps some of that affection he has extended to his daughter should rub off in a decision to enable these two little Australian citizens to remain.

But he won’t. He was trained as a Queensland copper to be tough, unrelenting, a man very much into leather. After all, any criticism in his home state is strangled by the Murdoch Press. He cannot stand loss of face. He has had so much of that over the past year. Yet his electorate apparently love him – the May election would have been a good ego stroke for his basic insecurities.

Why can’t these politicians stand loss of face? They are pitiable, but as I said, 53,000 of Dicksers love him.

However, I pity the children far more – and if they want to come back to Australia, they should be given passports like anybody else born in this country, including the Member for Dickson – notwithstanding any change in the Australian Citizenship Act 33 years ago.

Rhiannan Iffland. Who?

I always think I know generally what goes on the sports pages. So it was somewhat surprising when television surfing in a non-English speaking country far from Australia, to come upon Red Bull-sponsored cliff diving. There are seven events this year where the contestants dive off cliffs mostly with temporary platforms jutting out over the sea. I have always associated this daredevil idiocy with the young Mexican divers at Acapulco.

However, now it is an organised sport which allegedly attracts 60,000 to 80,000 spectators, and the Australian, Rhiannan Iffland, who has combined her diving and trampolining into an extraordinary skill, is far and away the best female cliff diver in the world. At her last appearance – diving from the famous restored bridge at Mostar in Bosnia Herzegovina – she achieved straight tens.

The last competition for 2019 is at Bilbao on 14^th September where the competitors dive from the La Salve Bridge, 24 metres down into the River Nervion, in full sight of the Guggenheim museum. Majestic daredevilry. The sight of this young woman twisting and somersaulting, slicing into the water feet first is indeed breath-taking. The danger of this diving is underscored by the number of frogmen swimming around in the water waiting for the mishap.

I do not know if anybody can be bothered showing it to an Australian audience, but we are strangely unknowing about this woman’s extraordinary talent, given the fact that women’s sport overall is attracting more and more interest. Perhaps it is because she is so good, that even we Australians get bored with those who win all the time. We just expect it. Do we remember Heather Mackay who won the British open squash title for 16 years in a row before winning the inaugural world championship and then retiring? We certainly remember Winx, quite a female performer.

Rural Health

One of the repeated catchcries is the lack of rural health services in Australia. My response has always been that one has to actively transfer intellectual capital to the “regional, rural and remote areas” to encourage a positive outcome. In this blog, “rural” will be used to encompass all.

One of the most important developments in the medical system, amid all the jeremiads over the past two decades, has been the new medical schools with a rural emphasis, the rural clinical schools and the university departments of rural health.

These teaching institutions have facilitated transfer of intellectual capital to rural areas. Medical teaching has been shown to occur more than adequately outside the metropolitan teaching hospitals; and significant intellectual capital exists already in both the larger and the smaller rural hospitals.

Without this innovation, the health education system would have had great difficulty in handling the increase in medical students that occurred in the decade following the introduction of these new rural facilities.

However, this rural dispersal needs good medical management, and especially with the Government’s obsession with Regional Training Hubs, as though the basic structure does not already exist.

One inspiration underpinning the recommendations of my Rural Stocktake in 1999, which led to Government funding for the establishment of rural clinical schools and university departments of rural health, was the story of the Mayo Clinic and visits made to both to the Rochester Minnesota and Scottsdale Arizona campuses some years before I did the Stocktake.

The Mayo Clinic was formed by the Mayos – father and sons – in Rochester in the 19^th century and to me has always exemplified that excellence is not confined to the largest conurbations. The Mayos proved to be very good managers and developed intellectual capital involving a wide range of skills, in the “wilds of Minnesota”.

Then one also remembers the story of a gifted doctor named Samuel Fitzpatrick, who was based in Hamilton in Western Victoria. He was a world authority on the surgery of hydatid disease, then a major affliction – particularly in Western Victoria where sheep farming was a major component of the local economy. The disease was of such importance that the then Royal Australian College of Surgeons established a national hydatid registry in 1926 that, until its cessation in 1950, identified over 2,000 cases. Such attention helped in the campaigns to reduce the incidence of hydatid infection in humans – the intersection of Fitzpatrick the surgeon and Fitzpatrick the public health doctor.

At the height of his practice Dr Fitzpatrick dreamt that this niche disease could propel Hamilton into having its own Australian version of the Mayo Clinic. However hydatid disease lessened as a major disease and, unlike that of his Mayo exemplar, Fitzpatrick’s dream faded. While Hamilton doctors have maintained a high reputation for medical care and procedural competence, this remained a country practice in Victoria.

The surgical virtuosos of the bush, like Fitzpatrick – the doctor who was that generalist with an equal ability to treat any disease or condition – increasingly disappeared. The intellectual capital that they possessed was not translated into major teaching and research facilities in rural Australia, let alone centres for public health as had occurred with the Mayos and their stake in rural America.

The rise of specialist medicine and then sub-specialist medicine, together with their resultant perceived skills and knowledge, concentrated teaching and learning in metropolitan teaching hospitals, and in so doing emphasised the importance of the individual at the expense of the total population denominator.

Public health was dismissed in some quarters as surveillance of “tips and drains” Yet public health training for many years was concentrated in the School of Public Health in the University of Sydney. Public health education as a medical specialty was invigorated by a consultant physician, Sue Morey, and a number of like-minded people following the Kerr White report. Dr Morey headed the resultant Faculty of Public Health Medicine, which ended up within the Royal Australasian College of Physicians.

One of the important outcomes of the growth of rural medical education has been the opportunity to be both director of medical service and director of clinical training. I was able test this association personally and found it fruitful, being involved in the establishment of a medical intern program that requires the interns to undertake 20 weeks in rural general practice, plus the mandatory hospital terms. Health education (rather than medical education per se) has been attached to a group of academics primarily in traditional teaching hospitals. I was lucky with having forward thinking CEOs in a number of rural health care services.

They realised that what I called small teaching services, where the general practitioners have provided a variety of services, are rich teaching environments. I term these health services as “teaching services”. My argument is that by having a series of interns each year, you give the local doctors the opportunity to teach without the layered bureaucracy of the medical colleges telling you what to do.

Hence the 20 weeks in general practice as an intern and the concept of rotating interns ‘in’ to the regional or teaching hospital, not “out “ from those same hospitals. In other words, the small teaching service are allocated the interns; not having to depend on the big hospitals.

That was the core of the M2M program which has been rolled out in across Victoria and, to conform to the commonwealth funding provisions rather than the intent of the program, then called “Rural Medical Generalist Program”. The Rural medical Generalist program is an Queensland concoction of the ACRRM.

It aims to provide a training program for that College and really a reason for that College to exist. Simply put it aims to skill general practitioners to work in the country. A very good thing, but for it to work well it has to have a defined connection with the rural clinical schools – and that was the aim of the intern training program.

Nevertheless, there is this major barrier to this program – the attitude of some senior members of the university hierarchy and their teaching hospitals – not all I would emphasis – who could not care a jot about rural Australia – the major universities are there to perpetuate elitism. You measure that by research dollars not by the benefit you may provide to rural Australia.

Medical education is one of those areas that, in the undergraduate field, have been attached to universities and the post-graduate qualifications left to the various Colleges. As I found out this leaves a gap in the first two post-graduate hospital years as intern and resident medical officer when there is often a high level of angst. There is a need for expertise and experience to assist the doctor in those first two years.

I realised this need for pastoral help with the interns – surely an accompaniment of an empathetic educational environment . Taken seriously medical education without forgetting the importance of public health should be a major concern of any university, which considers itself to have a pastoral role rather than a treasury for the fees of international students. If the university adopt that pastoral challenge just as the Mayos and Samuel Fitzpatrick did, then this whole exercise of having rural clinical schools, defined educational programs in the first two years of post-graduate life as a doctor is still relevant despite being in a different era

As one famous person once said: “Before you capture the citadels, secure the fields first!” Therefore, for the young doctor think of gaining experience in a rural post before tackling, rather than being absorbed into, the “citadel culture” of the urban teaching hospitals.

The Brethren

Back in the 1970s while fresh from his exploits in hastening the departure of Richard Nixon, Woodward wrote a book with Scott Armstrong about the United States Supreme Court from the 1969 term to 1975 term. This was the time when the Court was moving from the liberal court of Earl Warren to the more conservative court of Warren Burger. Earl Warren had resigned in the belief that he would be succeeded by somebody cut from his legislative cloth.

This did not occur, and instead the court became the plaything for Nixon appointees. Not only did Nixon appoint the new Chief Justice in Burger but also three other justices, only one of which – William Rehnquist – fitted what Nixon hoped the court would become – a bastion of conservatism. As with the current Chief Justice French, Burger was elevated directly to Chief Justice with all the administrative load that entailed, without any experience as a Justice of the Supreme Court.

What is fascinating about the book when read against the churning turmoil of the Trump presidency is how complicated are the politics of the Supreme Court. Not for nothing is the book named The Brethren for all the religious overtones that the name implies.

It deals with all the machinations of Roe vs Wade, which is where Trump supporters and the Roman Catholic Church want repealed. It should be realised that seven out of the nine judges concurred with the proposition that including three of the Nixon appointees including Chief Justice Burger voted for the proposition that the United States Constitution protects the rights of a pregnant woman to have an abortion.

Only the newly appointed William Rehnquist, later to become Chief Justice and Byron White, the only Kennedy nominee dissented. So despite the howls of the anti-abortioners, this decision represented a very diverse cross-section of men of different political persuasion.

However, the most chilling aspect of the book was its conclusion when it summarises four cases which hinged on the court’s interpretation of the Fourth Amendment to the United States Constitution. The Fourth Amendment states: The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized.

In each case the decided that day in July 1975, the court ruled in favour of government rather then for the individual citizen. The final line says: “the center had won”, which can be roughly translated into “the right were gaining ascendency”.

It had been a short time between 1973 when the Roe vs Wade decision and July 1975 – the so-called Black Tuesday. When The Brethren was published in 1979, the composition of the court remained the same as it was in 1975.

However, changes were afoot with the very intelligent but ideologically driven Rhenquist in the wings awaiting his ascension into the Chief Justice role. In 1981, with the retirement of Burger the die was cast; the die which contains the court ruling in favour of Bush over Gore; the deviousness of McConnell in denying an Obama nominee, and the sad sight of Ruth Bader Ginsberg hoping her pancreatic cancer does not kill her before the next Presidential election -in other words outlasting Trump. Such is the state of American democracy.

Mouse Whisper

An interesting comment overheard in the back streets of Whroo.

Every year, there is a change in the education curriculum in Hong Kong, so eventually the education program between the children of China and Hong Kong will be indistinguishable. The level of information manipulation will be the same.

By the time, the total absorption of Hong Kong into China occurs in 2047, who among those of the “one country, two systems” will have heard of the riots of 2019.

Talk about the long game …