Modest Expectations – The meaning of Life

Stop Press: Premier Andrews will strive to lead Australia out of the charred wilderness at the next Federal election. He is a builder.

Anthony Norman Albanese will make a great Governor- General.

Yet it is reasonable to believe prophecy is just one step ahead of fake news.

Nevertheless, what is going is eerily reminiscent of the Liberal Party Coalition in 1972 when it entered a period of policy paralysis – Vietnam and China being two unresolvable problems. Despite the apparently huge wave of support generated for Whitlam, he did not win a huge majority in the 1972 election. Despite the narrow margin to Whitlam, the two unresolvable were immediately resolvable.

On the other hand Rudd did have a landslide, and in the process the man from which Morrison is seeking advice, John Howard, lost his seat. Australia was prosperous and yet the Prime Minister lost his seat. This had not occurred since 1929 when Australia was struggling economically; Prime Minister Stanley Melbourne Bruce was intent on confrontation. He lost his seat of Flinders.

Over the years the fickle nature of the electorate has come to resemble Queensland where there have been electoral landslides over the past 50 years. Queensland is unicameral and thus landslides are not complicated by a House of plush red seats. Rudd and Abbott both won large majorities, but the Senate – the house of the Red Plush – can muddy the policy waters and in between even in the lower house when there are slim margins and independents calling the shots, policy goes out the chamber in a gust of deals.

So bugger bushfire policy, sweetmeats for the privileged and the rent seekers is the go, with parliament a sandpit.

But underlying Dante’s Australia are the climate change denialists.

Young John Howard was a protégé of John Carrick and Bob Cotton, two guys out of Florentine casting, and he was their Chosen One, but it took from 1974 to 1996 for him to achieve his aim – Prime Minister Howard. To be so single-minded requires a certain sort of brain. But John you are 81 and I admire you for your tenacity. You actually made a much better Prime Minister than I thought possible, because you had principles. Many of my achievements were achieved under your watch, although I am not sure you would acknowledge that.

However climate change is reality, just like getting out of Vietnam and recognising China was a reality so long ago when we were both young. And I sure I know where you stood on these two issues, Young John, just like climate change.

Don’t get it wrong again otherwise Daniel Andrews is a real threat to your protégé, Scotty.

In the meantime, read on …

To market, to market, to buy a plum bun, Home again, home again, market is done.

Everybody is concentrating on Scott Morrison in these extraordinary times because politics Australia has never seen such a transparent calculating self-marketeer as its Prime Minister. In this season of the bushfire, his prime aim is that he must not let it consume his base – the Liberal Party of NSW.

He has been wrong-footed, and there is discontent within the ranks. Worse, the country is watching and listening to the ABC and not the Murdoch publications, and Alan Jones, the parrot on his shoulder, is also away. The belated announcement of the call up of reservists, the deployment of aircraft and ships are all good anchors on which to embed images of a forceful leader.

Undermining the NSW Premier is an essential strategy. She and her head of fire fighting have been criticised unsurprisingly with the Daily Telegraph implicated, especially in the plotting. Shane Fitzsimmons has the temerity to say nobody told him of the deployment of defence force staff. Then the blame is smudged in the need for all to come together. Nobody wins by personal spats at a time when the country is burning; but seeds are sowed for a time in the future when social media starts to be infected by stories about what could have been done better before the intervention of the Marketeer.

In marketing terms, the emphasis must be taken away from the States – the fire fighters, which are the Premier’s responsibility and thus the essential ingredient in halting the fires. The emphasis must be transferred to men and women in uniform, his responsibility. The fire fighters only have fire trucks and a few aerial helpers, but the real toys are held by the Defence forces. The Defence Forces can provide the imagery of might, even if they in the present circumstances providing a very public but, if analysed, marginal impact.

A good marketeer demands images and big ships and big aircraft with attendant servicemen and women helping the small child onto a helicopter conveys both concern and relevance. “Army heroes” – The Daily Telegraph shouts on the front page – is ferrying people away in helicopters heroic? Soldiers doing their job – but heroes? In these Telegraph front page images, there is not a firefighter in sight.

After all, the community wants good news stores of heroism and the Defence forces – a federal responsibility – coming to the rescue is the story.

Now the images are collected and the Murdoch Press assured, control of the ABC is the target. Reading the hostility towards Morrison on Twitter by prominent ABC employees will test how strong Ida Buttrose will be under the inevitable “ember attack” by the Murdoch claque. A strategy of inserting a number of friendly commentators repeating the Prime Ministerial mantra into the ABC reporting schedule is underway. I suggest one look at some of the commentators based in Canberra who show the first signs of this phenomenon – earnestly repeating without commentary the government’s media release. Once this is done to the ABC seen as untouchably “independent”, then media control is complete. The ABC becomes a loyal servant, and who cares about a journalist without an outlet.

Prince Valiant coming to save the damsels in distress with an audience of faithful knights and yeomen is a perfect marketing morality play. However, the Prime Minister has a long path to cement that role given the uncertainty of his out-of-town rehearsals, but there is always Jon Shier as producer.

However in deploying the defence Forces, Mr Fitzsimmons recognised the problems when a group untrained in fire fighting are dumped upon him, and he went public. I am sure if he had been informed he would have suggested an appropriate role, but normally outwardly calm, he was obviously irritated that he was not told prior to the Prime Minister’s announcement.

After all, the current Minister of Defence, Linda Reynolds should know. She has had an interesting career. She has had an astonishing rise to one of the major portfolios has this Senator from Western Australia. However, she had two parallel careers: one working as a employee of the Liberal Party and the other as a member of the Army reserve from the age of 19 years, rising to the rank of Brigadier and being awarded the Conspicuous Service Cross. This is a relatively recent award given for conspicuous “non-warlike activities”.

She was wrong footed in taking the Prime Minister’s lead by going to Bali with her family, while Australia burned over Christmas, and leaving her portfolio to Minister Littleproud.* Modest Expectations Joel 11/10/19

Having been in the Army Reserve for 29 years, she would know the capability of the reserve forces. Given the gravity of the present situation her first response was surprising in seeming to criticise Mr Fitzsimmons rather than indicating she wanted to cooperate.

However, she made a big deal of the deployment of reservists when the Prime Minister announced it as unprecedented. The obverse question is why the reservists have been left idle domestically for so many years; again, Minister Reynolds should know. Hence if she thought they could contribute why did she delay any recommendation given that she would be well aware that mobilisation of such resources takes time. Or did she recommend in a suitable time that they be deployed and her advice was initially rejected. I presume she is not a muppet, saying nothing when all these disasters were unfolding.

One of tasks foreshadowed for the reservists is burying dead stock; and I think it a bit harsh when my friend said when that is finished they may be asked to bury the Government.

Somebody who knows

Chris Brook PSM FRACP State Health and Medical Commander (Emergency Management) Victoria 2009

You don’t need an analysis of the response to the 2009 Victorian Fires or the 2010 Queensland Floods. It’s all on the public record and in people’s living memories. What you also already know is that the then PM Kevin Rudd was front and centre from the outset in both events and was praised for his initiative.

That’s not to say that his promises were prudent, nor even fulfilled in whole, but he was everywhere. 

In both cases there was a massive rebuilding and recovery effort, largely due to the important work of the States continuing long after Federal intervention had come and gone.

But this misses the real story of the here and now.

It looks to me as though Morrison is set to reinvent himself, as he must, to get through this. All of the anti-climate change rhetoric and anti-socialist left tirades do not change the fact that he has lost the respect of a good part of the community – although the hyper partisan Murdoch press remains staunchly supportive.

He must by now realise that his precious wafer-thin budget surplus is gone and that long term economic damage has been done.

For the fire affected coastal and alpine communities the damage to domestic tourism – their lifeblood – will last for years.

So he will pivot embarking on a huge rebuilding effort; a stimulus thus cunningly concealed. If he’s clever the cost will be described as a capital injection (from borrowings but no one will worry about that) and he can still claim that we are in surplus on the current account.

Gorse – an example of Government indifference

Janine Sargeant – Tasmanian ratepayer & regular blogger

Recently I wrote to the Premier of Tasmania because I was concerned about the rapid spread of gorse along the Zeehan to Strahan road on the west coast of Tasmania. Its spread is symptomatic of the disregard of the environment by all levels of Government, given that gorse as well as blackberry are two of the biggest invaders on the west coast.

If an example of where fuel reduction is needed, this is one hell of a big one.

Fuel reduction is but one element in what should be a comprehensive Statewide fire management plan; the lines of responsibility are clear, readily accessible and the expected results can be easily tallied against the actual achievement.

On Tasmania’s west coast, it rains – a lot. However, it is now clear from the NSW South Coast experience that temperate rain forest can burn. The only thing that prevents it occurring in Tasmania is the level of rainfall, which this year has been about two metres. By way of contrast, the NSW South Coast’s rainfall this year was about half the expected rainfall, between 40 and 60cm, as it was also last year. Much has been said about the desperate lack of rainfall across much of Australia in what is the driest and hottest year on record.

However, despite the rainfall, Tasmania is vulnerable and the gorse invasion is just one symptom of Government’s neglect of the fire risk.

I would hate to have to quote this next summer because nothing has been done and the West Coast has been burnt – with gorse being a prominent culprit.

DIPWE defines the spread of gorse on the west coast as “widespread infestation”. Gorse is a declared weed under the Tasmanian Weed Management Act 1999 and “a Weed of National Significance”. Government’s response is supposed to be to “prevent further spread”, a response in word only as there is not action. Gorse is a major issue in a region that is heavily dependent on “wilderness”, native forests, wild rivers, spectacular scenery and unique fauna – these define the reasons why tourists come to Tasmania.

However, apart from being a hugely damaging invasive weed environmentally, gorse is a major fire hazard, because of its oily content and tendency to shed its dead wood as it grows.

Some years ago there was a gorse eradication program in this area, which seemed to be keeping this weed in check, but there is no evidence of anything being done recently and as a result, the spread of the gorse has gone unchecked. There is no evidence that agricultural contractors, utility maintenance crews, road and earthmoving contractors and other people visiting the areas infested with gorse, are required to undertake basic hygiene measures to prevent spread of seed; this doesn’t happen. In fact it is reported that the roadside mowing that occurs from Zeehan south towards Strahan is actually spreading the infestation closer and closer to Strahan due to seed spread because the vehicles are not being cleaned.

There needs to be an integrated control approach with a combination of methods: herbicide, mechanical, burning and biological control, for maximum chances of long-term success.

Tasmania’s environment, wilderness and forests are an incredibly rich resource that must be protected and in the face of what has been happening across NSW and Victoria, the Tasmanian Government needs to sit up, take notice and act before Tasmania too is wiped out by fires. The gorse invasion is one element of a potential major fire problem that being ignored. My letter to the Premier is ‘being considered’; I hope the response is a little more enthusiastic.

Mouse Whisper

My marsupial relatives, the dunnarts on Kangaroo Island remember that during the 2007 fires there were over 800 people, seven fixed wing water bombers and an Elvis Skycrane Helitanker, all assisting in firefighting efforts.

Now dunnarts smell smoke; and run at the first whiff.

Thirteen years later I have asked on DunnartMail how are they and if the resources committed in 2007 are different from that committed today. The fire in 2007 was contained quickly and the Dunnarts replied to my query.

Unfortunately, this time I have had no response. Communication has been lost.

There may be 500 firefighters, with about 50 of the Reynolds reservists there as back up, and there is at least one 737 waterbomber. Maybe the response is comparable to the 2007 effort and has not slipped backwards. Probably not. Who would know. But what of my cousins?

Now they may be extinct – a terrible, terrible outcome.

I weep for them – they were such a close-knit community.

Modest Expectations – Qin Shi Huang

So Donald had gone to the Walter Reed Hospital, the betting given his track record is that he may have been stented and sent back to the White House where there is probably the equivalent of a coronary care unit on site; but not in sight. It was recorded that a year ago his coronary artery calcium had been rising and was indexed at 133, which puts him the range of risking a heart attack within 3-5 years. But with a man who is so addicted to the sunny side of his street, we can only speculate about this particular episode. But from afar he does not appear well, a point I mentioned in my blog on 17 May this year.

Ironic that this news would come in the same week that that the Kooyong Papillon has been fluttering about retraining us elderly to avoid the poubelle of old age.

More about that next week, but really are we surprised?

An Apologia of Academics

In response to my comment on the creation of exotic names for senior positions, a former academic drew my attention to another university, which has gone for the Latin dictionary.

This particular university has appointed scientia professors, presumably on the basis that scientia being the Latin word for knowledge, those without that appellation are sine scientia – or in the vulgate of the Quad, dumbo professors.

Earlier in the year, the Royal Australasian College of Physicians wasted everybody’s time with a series of motions put to an Extraordinary General Meeting to form a cohort of what were to be called ‘Respected Fellows”.

One young female Fellow stood up and asked whether passage of this motion to set up this exclusive group would mean that all those who did not gain entry to the RF club were not respected. Same logic as the above comment about “scientia”.

Although this was a unsubtle way of interfering with the democratic processes by setting up a junta, it was soundly defeated. At least the College gave its Fellows the choice of whether they wanted this nonsense.

What is it all about? Is it only vanity? As I indicated in my comment in the last blog, I think this title escalation is a ridiculous affectation, and affectation is always a perfect subject for satire.

At the heart of all this titular mumbo-jumbo, it is probably about privilege – and privilege in this world of ours is one getting somewhere because one has been inducted into such an elite. It is very seductive to be enticed onto a ladder of privilege where ultimately the reward is the laurel accolade of smugness. Probably in about 400 CE, one would have found that there were a number of laurel wreaths strewn among the ruins of Rome.

Impartiality – the silent partner in Democracy

I have never met the Speaker of the House of Representatives, Tony Smith. When you read his curriculum vitae, he has all the characteristics of the modern politician growing up through a variety of politicians’ offices before being rewarded with a safe seat, which he plodded through in his initial years. However, he became Speaker of the House of Representatives after the demise of the unfortunate Bronwyn Bishop.

I knew Bill Snedden very well and one of his wishes was that after his speakership, which lasted from 1976 to 1983, the speaker, once elected to the role, would be immune from challenge in the House and generally challenge at the election. Snedden was concerned that the Speaker role be seen as even-handed, and having witnessed one of Whitlam’s crueller acts – the public humiliation of Jim Cope, which led to his resignation as Speaker, Snedden was determined to advocate some protection for the position.

When he resigned after the defeat of Fraser Government in 1983, he regretted that he had not another term to pursue the reform, yet he followed his own dictum that the Speaker on resignation as Speaker should exit Parliament immediately. He said inter alia “…under the Westminster convention, when the Speaker leaves the chair he leaves the House. I think this is right. This Westminster practice has been firmly in place all this century and considerations of which I have spoken have led to its acceptance. I have weighed this principle against other considerations, both political and personal. I have concluded that the Westminster practice is correct and, pursuant to it, I intend to leave the Parliament and will resign forthwith.”

Needless to say his wish did not come to pass and the Speakers have come and gone until Tony Smith was elected in the wake of Bronwyn Bishop’s disastrous stewardship. The Speaker’s standing as an impartial chair was severely compromised by her antics, and only compounded by Gillard’s previous ill-advised manipulation to have Peter Slipper installed as Speaker.

The Speaker’s role needs a person with a firm grip on the rules, but also common sense and a sense of humour and above all a person who exhibits impartiality.

One of Whitlam’s less desirable acts was his lack of defence of the then Speaker, Jim Cope. Cope’s “crime” was naming a Minister, Clyde Cameron. Whitlam failed to support him and Cope immediately resigned, barely holding back his tears. Later Cameron realized the gravity of what he had instigated and apologised to Jim Cope.

However, although Cope was visibly distressed, when the time came to elect his replacement and Giles, a Liberal party member was selected by the Opposition to contest the ballot against Labor’s choice, Gordon Scholes, a voice was heard clearly calling out in the House “How do you spell Giles?” It was Jim Cope. His sense of humour never deserted him.

Jim Cope was a good Speaker with only a hint of partiality.

Moving onwards to Tony Smith, Smith’s conduct in the House has been so impeccable that at the last election, he was elected unopposed, and in fact his nomination was seconded by the Member for Caldwell, a Labor MP who glowed as she seconded his nomination.

That is an important first step, but although it would be impossible to know definitely, his performance as Speaker has kept control of the proceedings so that mostly the feet are out of the gutter and if not he has ensured that they are lifted back onto the pavement. That is his immense value to Australia at a time when there is much partisan hatred in the air.

He does not attend the Liberal Party Room, which even Snedden did on occasions. That is another step towards achieving what Snedden fervently wished. Smith is loathe to use his casting vote. I have not read whether he subscribes to Denison’s rule laid down by that Speaker of the House of Commons.

Then he does not seem to flaunt the not inconsiderable perks of office, and while Snedden was the last speaker to dress in full regalia, Smith’s gravitas proceeds without having to dress up to emphasise this.

The main drawback to an independent speaker underneath all the constitutional bluster is that, unlike the British situation where one seat more or less doesn’t matter generally, in Australia each seat is at a premium. However, having looked at Smith’s seat of Casey, it is buffered by two Liberal-held seats where the suburbs bordering on his electorate if redistributed into his electorate (as probably will happen eventually )would be unlikely to change it from being a Liberal seat. Therefore, Smith is in a safe seat and unlikely to be defeated any time soon, which buys time if the notion of an impartial Speaker immune from political challenge is seen as a necessity for Australian democracy to be maintained.

I fear that installing a partisan clown in the Chair may be one tipping point for civil unrest.

I may overstate the point, but one cannot underestimate Tony Smith’s role in sustaining our democracy.

Yet the resulting conundrum of the unchallenged member is that it would effectively disenfranchise the voters in his electorate. It would be interesting to ask them whether they would pay the price for having such a person as the Speaker as their Member.

The Media & Private Health Insurance 

Guest blogger:  Terry Stubberfield FRACP*

Sometimes you just have to say something and not just grumble into your breakfast cereal about the latest media commentary.

Thus this response was prompted by Ross Gittin’s recent article in the Sydney Morning Herald (30.10.19) – “Funds cling on for dear half-life” – complete with image of grasping skeletal X-ray hand. This article made a number of claims without any supporting data.  

Gittins stated that patients are experiencing “huge out of pocket costs that they were not expecting”. Yet at the same time it is interesting to note that in the June 2019 quarter report from the Australian Prudential Regulatory Agency (APRA) the average out of pocket cost per service/episode for private hospital care for the quarter was reported as $314.51, compared with the cost for the June 2018 quarter of $308.73.

For consultant physicians 86.8% of medical services in the Private Hospitals attracted no Private Health Insurance (PHI) payment; by comparison, if you look back three years to June 2016, it was 85.3%. In other words more patients are paying no gap.  Furthermore, that payment for a consultant physician/specialist service was no more than $25, irrespective of how funded. Consultant physicians indeed having the lowest gap payment, of any medical group, if calculated as a percentage of the service cost, i.e. 1%.

In discussing the cost of the private health insurance industry Ross Gittins has concentrated on medical services. Reviewing the June 2019 quarter data provided by APRA the total funds paid by PHI during that quarter for selected areas were:

  • Medical Services $603m  
  • Accommodation and Nursing $2,789m
  • Prosthesis $543m#
  • Dental $697m
  • Optical $204m 
  • Physiotherapy $112m 
  • Chiropractic $77m.

The summary of the June 2019 quarter data presented by APRA states: “medical benefits paid per service … does not mean medical services overall decreased or increased in cost”. 

So medical services are just one piece of the puzzle.

Ross Gittins’ article simply jumps on the populist wagon where over-paid specialist doctors are the cause of the PHI sector’s woes when the data above raises serious questions about escalating costs elsewhere in the health system.

Mr Gittins also falls victim to the common error of lumping all medical specialists under one umbrella when there are multiple specialist groups: consultant physicians and consultant paediatricians for instance are those medical specialists whose expertise is predominantly cognitive; they manage the most complex conditions often for the life of the patient – adult and paediatric – on referral from general practitioners and other specialists. This referral system is one of the strengths of Australia’s health care system.

The APRA report doesn’t comment on “medical specialists” as if they are homogenous group, but appropriately deals with the different medical specialties separately.

In a speech given by Peter Kolhagen, APRA’s Senior Manager, Policy Development, to the Health Insurance Summit 2019, he questioned the health insurance funds for their tardy response to the impact of a range of issues and changes the delivery of health care in Australia – including regulatory and health demands. APRA appears to not single out medical specialists as the root cause of all the problems for private health insurance in Australia.

Gittins however uses surgery as a proxy for all medical specialists, which reflects his basic lack of understanding. Hence his final thought bubble in the Sydney Morning Herald article claims medical specialists are promoting private over public hospital care in order to line their pockets and that if there was not a private hospital system, “…they’d (specialists) do far more of their operations in the public system, probably doing more operations in total than they did before (to counter the huge drop in their incomes)”.

This is disturbing, simplistic and displays little understanding of the delivery of hospital care in Australia. The resources required to provide additional inpatient services to replace the current private hospital services, would be considerable,

Just add the annual recurring expenditure currently provided to private hospital care, (according to PHI data, of around $15 billion),

Then add the cost of infrastructure required and additional nursing and hospital medical staff required to provide much of the day to day health assessment, organisation and implementation of care.

Analysis of health care in Australia is a useful exercise, given that health care represents a significant proportion of government expenditure. However, Australians should not be inflicted with simplistic commentary that can only result in misleading the readers who rely on commentators like Gittins to give them useful and accurate information.

# A real growth increase of >10% in the past decade and I thank Stephen Duckett from the Grattan Institute for this information – and a matter which is obviously concerning enough for the Government to launch a separate inquiry into this increase in the cost of prostheses.

*Dr Terry Stubberfield is a consultant paediatrician practising in a regional Victorian city. He is President-elect of the Australian Association of Consultant Physicians.

A Royal Wave through a Crack in the Door

The door ajar; the recognisable face; the smile; the object of the smile a young lady with long hair, her face concealed; the furtive but practised royal wave; the door shuts; the young lady gone. New York wakes for another day.

I wondered where Prince Andrew Albert Christian Edward had been. I cannot remember in fact seeing him on television, except during his matrimonial tussles and briefly as a Falkland War hero.

In discussing his relationship with the “unbecoming” Mr Epstein, HRH made mention of the fact that he does not sweat.

Of course, he does not, HRH perspire. Would anybody question that fact?

However that is trivialising the seriousness of the claim.

However, on that note, HRH has suggested he does not sweat because he got an overdose of adrenalin during the Falkland War. Nearly forty years later, he says that the after effects persist. Did I hear that learned gentleman at the back of the room clear his throat and was that clang another’s jaw drop? It is known that the use of other drugs such opioids can be a cause of reduced sweating, but for how long?

It is a rare condition and because of his claim it cannot be readily attributable to a congenital affliction, especially as Dad and Brother Charles are shown often perspiring freely after a chukka or two.

However his anhydrosis claim could be tested very readily, if there was enough interest in pursuing HRH.

Otherwise, Your RH, the RAF Salmon Boars are prepared to recognise your outstanding claim with a special flyover.

In fact, the interview may be the start of another crack in the house of Windsor; it recovered from the last crisis – but then the Queen was twenty-years younger – and the potential consequences are not just airbrushing away a case of serial adultery as was the case with the Diana tragedy.

Broken is the crown …

However, this not just one indulged ageing man, who disputes whether he sweats or not on the basis of a highly unlikely reason, a figure of derision, a butt for satire, but a serious challenge to the integrity of society. If guilty, then he is a high profile child trafficker. Exploitation of children is as unacceptable as slavery. That other Elizabeth queen was deeply involved in the slave trade, but there is no record of her ever regretting it. No; she did not among her many achievements invent Teflon.

Just different times; different climes, the apologists murmur. Just poor Andrew Albert Christian Edward. This episode is mere fluff on the shoulder of humankind. No it is not!

Slavery may have been the legacy of the First Elizabethan Age; it would be a pity if trafficking in children is the legacy of the Second.

Mouse Whisper

The derivation of the term for a member of the British Conservative Party comes from the Irish “tóraidhe”, (pronounced tawra) referring to a bandit. Ultimately the root verb for “tóraidhe” implies “pursuit”, hence outlaw or bandit.

In the late 17th century Whigs were those who did not want James, Duke of York, to succeed Charles II, as he was Catholic. The Duke’s sympathisers became known as Tories, and the Duke was briefly James 11, until the powers that be did a reverse brexit – more a bradit and invited the Dutch House of Orange to juice up the monarchy.

Brexit Boris the Brigand is a real alliterative tongue-roller – but Bradit Boris has a distinctive dissonance.

In the absence of a photo of Boris the Brigand, here is Boris the pirate

Modest Expectations – The Spine

In an advertisement for the MD Anderson Cancer Center in a 2009 issue of Harper’s, a healthy triathlete smiles. His name is Bill Crews and under his name is the word “lymphoma” with a red line through the word. It is five years since he had been diagnosed and now following “an individual treatment plan”, he was in remission attested to which was completion of 14 triathlons at that point.

To celebrate his achievement a Bill Crews Remission Run was organised annually to provide funding for this Houston- based Cancer Center. Then there is a brief note in 2014 to say the website advertising the run is “inactive”. There is no record of Bill Crews dying – just that one word “inactive”.

It got me thinking, since my closest male friend also succumbed to lymphoma some years ago, although his course between diagnosis and death was far shorter. Once you get cancer, except for some skin cancers, you know your life will be limited. We all will die, but there is no need to face it until the doctor across the desk signals your mortality. You can of course avoid this confrontation by suiciding, being murdered, killed in an accident or sacrificed deliberately by those who would wage war.

What if I responded to the doctor after the sentencing: “I want you to tell me the exact day I am going to die.” What would be the response?

“Unfair question. Impossible to know.”

“OK, then will it be next week, week after… and this year, next year, sometime, never?”

We can be very precise with the input when we are provided with an individual treatment plan. Therefore, if you can give me such a plan, then it is reasonable to know the outcome, or what to expect. After all, infallibility is a power that some health professionals like to assume – well doctor, how long will I live? But then nobody writes on a funeral notice – he lasted x time longer than the doctors predicted or that the doctor got it so horribly wrong, he died well before the predicted date – perhaps in the middle of some surgical procedure, where the euphemism for “surgical vanity” is “heroic”.

The problem is that what I have written above is so foreign to how society is ordered. Most of us try and live in a predictable world. We expect that if we go to the gym in the morning it will be open at a certain hour. We know that lunch follows breakfast and we have a mid-morning coffee break.

Bill Crews probably had such a regimen. Cancer came; cancer went; but it never does. It marks time. How much of that time was consumed by unpleasant morbidity; how much did life become unbearable; and in the end, how much did he wish to live – all unanswerable now.

In fact, we live in a world of uncertainty. The flow of information from so many portals means that life is like traversing an Arabian souk. We never know what will happen next, but we always have the option of wanting or not wanting to know what we have bought – without it being varnished with fakery.

What does that all mean? Government, despite the various inputs, has to make the most cost effective allocation of resources in the face of all the individual treatment plans. There is no incentive for those manufacturing, distributing and prescribing the various medications to be less than optimistic. The cost of development of a drug is always stated as being so expensive so that the end product mirrors this expenditure. However, in the World of Optimism, who is going to undertake the rationing on behalf of community affordability. The plea, the crowd funding, the picture of the cancer sufferer, the hoped for remission mistaken for cure are all part of the emotional appeal. However, what price does one pay for a small addition to life of variable quality – what is an average of six months worth?

Policy should not be predicated on the outliers. Bill Crews had non-Hodgkins lymphoma. Through all the obfuscation surrounding survival rates, maybe his ten-year survival rate was about average when the last mention of Bill Crews was made.

Therefore, assessing the cost of Bill Crews’ treatment may be a useful indication of the individual cost for the condition. That statistic is just as important as knowing the relative success of the individual management plan and generalising from that one example.

But my whole case is predicated on two assumptions: the first is that the lack of mention of the poster boy by MC Anderson Cancer Center (now also with a red slash through the word “Cancer”) public relations, and the inactivity of the Remission Run from 2013 onwards means that Bill Crews is now cycling on a higher plane. In line with MD Anderson Center publications, I have not mentioned the word “death”.

The second is what Bill Crews’ individual management plan cost when everything was tallied, its figure would be useful enough to be used as a guide to cost – assuming that those costs could be found and adjusted for current prices.

Hopefully the responses, outraged or not by such reductionism, would be a welter of data trying to disprove my assumption. However, that could lead to a good controversy if the policy makers were listening, and cost could be determined with all the accompanying arguments laid out. Then tell the taxpayers!

The Senile Trail

Listening to the Health Minister, he talks about “self stigma” and that we should reach out for help. Well, may I tell you, if you bother to listen, Minister, self-stigma is a meaningless term, when you are crying spontaneously for no reason, when your body is at a point where you cannot undertake the activities you were once able to do; and you are alone. You reach out for what? The phone lines are always busy in the daytime. Trying reaching out at 3am in the morning wherever you are for help. About all that is left is the late night / early morning radio programs that provide an outlet to the old, the sick, the lonely who can’t sleep and who communicate with fellow callers from across the state or the country, through the radio: “How is Beryl from Cooma, we haven’t heard her on the show for quite a while, does anyone know?”

There is a great deal of breast-beating going on, because despite all the expense spent on input, nobody has a solution to care of the aged. I have been associated with nursing homes that work well, because there is a continuity in management and the constant positive is that those in charge worry and care for their nursing home community.

Being dependent implies that I have a carer, which fortunately I have “in spades”. I can no longer live independently unable to have shower, cook, dress and generally manage any housework efficiently – without help. It is frustrating knowing that when you are dependent, you have to wait – you have to learn patience without surrendering yourself to outright submission.

However, being in a wheelchair and then suddenly left facing a blank wall in an airport adds another dimension. The person responsible who leaves you without saying anything just adds that element of being ignored. It is no longer just waiting, you are being ignored and that adds a new reality. It is a sign that you a bit of garbage to be swept when the mood takes the handler. In the end, you lose your self-respect unless dementia beats you to that realisation.

Such are elements of growing old – such are the elements of being in care, where the rules are such that you – the resident – are governed by regulations engineered by government bureaucrats far away from your bedside. They call it compliance or accreditation – a meaningless term to indicate everything is under control. Unless you have a family, whether natural or manufactured, to act as the antidote, then every day is one day nearer to death, and increasingly you wish that day will come. Those words like “accreditation” have a meaning to those who love making paperwork look like an illuminated manuscript.

Are there any solutions beyond having a caring carer not an impersonal person – a shift worker with an inadequate handover when they come on duty, their measly remuneration ultimately dependent on some distant hedge fund?

All solutions are just a variation on that fact of individual care without the negative embellishment.

For instance, I mentioned in a previous blog the series shown on the ABC where four year olds visited an aged care facility over a seven-week period. Then the series finished, with an elaborate farewell antic. I wrote in my blog* at the time:

However, if the attempt of mixing the groups is just voyeuristic – “been there; done that”; then I believe the makers of this series have probably done a disservice to all involved if nothing further eventuates.

Old age is an increasing societal challenge. It should not be just a case of waste management. Yet I fear that is happening – and David Attenborough-like explorations of human foibles and cuteness should not replace serious consideration of what can be done.

The clue is in the series – get the elderly to tell their stories, whether they have a four year old audience or not. After all, it gives you a sense of relevance, even when you may be the only one listening. However even one child listening and responding with questions is a bonus. After all, I believe we are all storytellers.

My argument was not against the idea; my concern was it being generalised – the implication being that infant schools be co-located with nursing homes, so there is ongoing integration of experience – not just a one-off “gooey-eyed” curiosity but as part of a conscious government policy.

After all, each group’s experiences are transitory – the children grow up hopefully socialised to understand what it is to be old; and one of the aged care participants died between filming and release of the documentary. Such is life, as Mr Kelly is reported to have said.

It was ironic when the aged care report was released recently there was no mention of the documentary as one remedy – even seemingly by the ABC.

* Modest Expectations – Duckworth 30/8/19

Mount Augustus

 Uluru has been closed at last. To me, there has never been any question. The traditional owners should have the right to invite strangers to climb this extraordinary monolith. I have walked around the base which is measured at 10.6 kilometres and to me it felt ‘right”. Being a “whitefella” does not exclude you from being in touch with this extraordinary country. One of the things I have learnt from my association with the Aboriginal people is to know when the Land is accepting your presence.

The idea that climbing the Rock is akin to climbing a cathedral may satisfy some people as an excuse. However, the analogy does not hold. Tourists are like ants on the roofs and spires of famous cathedrals and churches; and prohibition to climb churches is more related to safety or privacy rather than it being a spiritual taboo.

The bogan chant of why can’t I go anywhere because this is Australia and I am Australian is OK if you are a self-absorbed narcissist who does not believe that any restrictions apply to yourself. There is a high-falutin’ word for this – “libertarian” and a more macho term – “individual”, its anthem: “I am what I am”.

Well, Mount Augustus may be just what you are looking for, to express your feeling and being what you are. Mount Augustus is technically a monocline but then for you guys, it is a “humongous Rock”. It is not red and bald like Uluru – it is covered by bush and it is still called by the “whitefella” name rather than its Wadjari name of Burringurrah.

Burringurrah / Mount Augustus

However, it is the largest rock in the world and I went there 20 years ago; so it exists and has not shifted. It is a bit inconvenient being 500 kilometres inland from Carnarvon. Uluru is tiny compared to Burringurrah. There is an eponymous Aboriginal settlement close to the monocline.

Rather than walking around the base, we were carted around the 43 kilometres in a minivan at a hair-raising speed by a male nurse then living in the outstation. The trip ended back near the settlement, when the van hit a large pothole and lost its wheel. Fortunately the sand provided a cushion and we were all uninjured and trudged back to the settlement. It just emphasised how huge this Rock is.

Currently, the local Wadjari people allow visitors to climb Burringurrah but unlike Uluru, there is scrub and a trail, which takes around five hours to climb and return.

Watch this space! I remember when Uluru was Ayers Rock and was hard to get there.

Burringurrah speedway

Sydney Ferries Fiasco – A form of naval gazing

Guest Blogger: Neil Baird#

It could be said that the only thing keeping the New South Wales Liberal/National Coalition state government in power is the even greater incompetence of the State Opposition. If the latest controversy over the renewal of the Sydney Ferries fleet is any indication, the Gladys Berejiklian led coalition is certainly not an exponent of open government. The Opposition has only now awakened to an announcement that was made nine months ago in February.

Unusually, the announcement about Sydney’s ferry renewal was made from Liberal Party headquarters and not from the Minister for Transport’s office. Sure, the party was in election mode but what were they doing issuing a press release announcing a $1.3 billion project in such an underhand way? What was the government trying to conceal? Why will just 13 comparatively simple and small ferries cost $ 1.3 billion? That figure appears grossly excessive. Or does that include running and maintenance costs for nine years as mentioned in one report? Why would the government not be more transparent?

Given their other shenanigans with the Northern Beaches and Mona Vale hospital projects, for example, taxpayers have every right to be suspicious. For the record, the three larger ferries are to be built in Indonesia, presumably by Penguin Marine; the 10 smaller ones are being built by Jianglong in Zhuhai, China. The local firms mentioned below Ross Roberts/Harwood Marine were never invited to tender. Nor was anyone else apparently.

It has since been fully revealed, in an 23 October 2019 press release from Opposition Leader, Jodi McKay, that the fleet replacement was a “done deal” by 27 February 2019 when the Liberal Party announcement was made.

The story goes that in early February this year a couple of Australia’s leading ferry builders had been approached with a vague invitation to tender for the ferries. Apparently they didn’t respond to the approach. So did at least one leading firm of naval architects. None could be bothered to respond as they had such bad previous experience in dealing with Sydney Ferries, apart from being very busy anyway.

The subject went quiet for a few months and has only now been revived by Ms McKay who seems to have confused the facts.

Simply put, after endless problems, mainly with the maritime union, the operations, but not the ownership, of Sydney Ferries has not officially been privatised. It is a public-private arrangement, which avoids the need to go out to tender. The French-owned transport conglomerate, Transdev have contracted to operate the ferries, and seem to have eliminated most of the problems when it was run by the NSW Government.

Yet the curious way the ferries were ordered remains, with virtual concealment of the nature and cost of project from the taxpayers of NSW.

While Ms McKay has revealed some of facts, other parts of the story are off-beam. While the Trade Unions have been one of the major reasons for the problems at Sydney Ferries, the relative absence of shipbuilders in NSW has not helped.

However, she is partly correct. The ferries could have been built locally, as she advocates, but the only company in the NSW with experience in building ferries of the size ordered is Harwood Marine of Yamba in Northern NSW.

Strangely, Harwood was not even approached or invited to tender. Indeed, the managing director of Harwood was unaware of the government’s intentions until very recently. Harwood has been busy with a major expansion of its company’s facilities including, ironically, a 60 metre shed in which large aluminium ferries could be built. Equally ironically, those who could have benefitted – the local youth workforce in a town where unemployment stands at 23 per cent – didn’t get a look in.

Apart from Transdev, which is expected to correct Sydney Ferries’ inadequacies, one major local firm will benefit from the association with Transdev. That is the Port Macquarie-based company, Birdon, which moreover has been contracted to build ferries in China and Indonesia for Transdev.

Birdon is a highly reputable company, as is Transdev. This fiasco is no reflection on either. The government may well get a good deal in the end. However, the problem is the opaque process that the government followed. The State Opposition has been unaware of such a major project, until the belated statement from Ms McKay. It is also a major problem that Harwood, a significant employer and highly reputable local shipbuilder was not even asked to express interest in the project.

The taxpayers of New South Wales have not been well served by its politicians.

We have not heard the end of this.

# Neil Baird is non-executive Chairman of Baird Maritime, a global maritime trade publisher. Among his other positions, Neil is a long-serving director of the Australian Shipbuilders Association.

Mouse Whisper

Once I heard the confession of a poker-faced mouse whisperer despite it being difficult to squeeze into a murine confessional box.

In January 2004, I was in grade 12 of high school and about to graduate. I operated a profitable web design business as a part time job for some spending money. Seeing as my legal name is Mike Rowe, I created the domain MikeRoweSoft.com for my portfolio. The Canadian lawyers of Microsoft didn’t like this (I really don’t know how they found my site, I had 2 visitors a day. One was me (sic), one was my mom). They sent me a couple of emails and a large legal document telling me to give up my domain name. I asked for $10k. They said no. I went to the media. Hilarity ensued.

Since then I’ve been a full time professional poker player for the last 3 years. I’ve made enough to buy a condo and live very comfortably in that time. I have finished 5th in the PokerStars Sunday Million for $97,500 as well as 31st at the PokerStars Caribbean Adventure earlier this year for $40,000. So I guess you can ask about the poker stuff as well if anyone wants to.

And no, I didn’t sell out for an XBox.”

The site was still active in 2017, but not now.

Modest Expectations Skat

“The problem with the drought is that it is predominantly affecting National Party electorates and as the Prime Minister charges round these electorates all he succeeds in doing is emphasising the impotency of government, while making the National Party look like drongos. Then enter off right, the Belgian fixative who does a deal with Hansen who knows when to throw a tantrum. Obviously her colleague in Tasmania has viewed this Flemish reflex, which has been adapted from Pavlov’s observation on canine behaviour. Frankly, I am sick of Keating’s unrepresentative swill being given a disproportionate voice while I struggle to pay my mortgage and make ends meet, all because of the manipulation by a Flem.”

Unfair; of course. But that is one example of how Australia is perceived as being governed. Maximising the influence of a few to the detriment of the majority. Just the frustration of being a young urban graduate, and collectively primed to burst forth, when the articulate leader of reform – perhaps a numerate “Whitlam” would help – emerges in the next three years, a person who puts the interests of the country first. Or do we reach a Chilean tipping point where the rules become radically different.

Some weeks ago, I recounted briefly that I had just come back from Chile where I made a point of visiting the Museum of Memories and Human Rights. At the time I said that the museum was “the brainchild of President Michelle Bachelet, to ensure that one memory sticks in the mind of the Chilean people. On a wall on the first floor are myriad photographs of Chileans murdered by the Pinochet regime – 130,000, probably more.”

Recently, she has visited Australia in her role as the UN Commissioner on Human Rights to deliver the Whitlam Lecture, which was booked out by the time I got round to it. But from snippets, I got the gist.

I had also seen an enticing advertisement for a house nestled in a valley between Santiago and Valparaiso – separate terraced complex houses a sauna, Jacuzzi and hot tub, and two bathrooms. The property also includes a one-bedroom guesthouse, a covered parking area for four cars and organic orchards with 750 avocado trees and other fruit trees with “income-producing potential”; on 17 acres handy to both Santiago and Valparaiso. The price? About AUD2m. All this under the headline: “Following a tax hike and a steep drop in sales, prices are rebounding thanks to a stable economy and new infrastructure projects.”

Yes, when we had been in Santiago in late August, it had seemed very quiet; well run city, taxi driver even praised the cops as the only honest police force in South America. However, that contrasted with a comment in The Economist about the current President, Sebastián Piñera, which concerned the social conflicts with students that had bedevilled his first term. In order to reinforce the point, The Economist alleged police had tried to cover up their murder of a member of the Mapuche, an indigenous people.

The Economist added, “That followed a string of scandals – ranging from planting evidence to corruption – in the Carabineros, the once-revered police force. The army is no better. Some officers have been found to have stolen public money; others have sold arms to drug-traffickers.

Somewhat different perspective from that of our driver as we drove through quiet suburban streets to the Museum …

Sure, when we later went on the road to Valparaiso, the slums stretched along it for miles inducing a feeling of unease.

On the way, stopping for a wine tasting in the Casablanca Valley, it was just what you would expect from a wine tasting vineyard in Australia – impeccable surroundings both inside and out, a fire to warm this predominantly young stylish crowd from the winter cold. I was reassured there that Chile was an exemplar of middle class respectability.

Then off to Valparaiso, where the poor in barrios cling onto the sides of the steep hills, yet all with a stunning view of the ocean. Here the streets plunge down these steep slopes – a variation on the big dipper. Barrios did not exude stark poverty but the people in the doorways or struggling up the streets with their provisions did not look happy.

It’s not that long since Valparaiso was almost destroyed in a massive earthquake, and the city has a shabbiness that belies the fact that it is a tourist centre and the politicians meet here in the National Congress building. The city had a sullen feeling, despite it being one of those places where there is so much intrinsic beauty, at least to my eye, despite its vulnerability to earthquakes.

Now two months on, the cities are aflame, the streets are crowded with a rioting populace, the army has been called out. The 130,000 dead on Bachelet’s Memorial wall have had a few added.

The cause? A seemingly minor increase in subway fares has proved the tipping point. The people have had enough. The country’s prosperity revealed has been heavily weighted to a small fraction of the community who can afford to buy the property described earlier.

The currency is devaluing, the inequity in everything from wages to health care lies revealed. The hatred of politicians has boiled over; despite conciliatory gestures. People lie in the streets, dead or injured. Tear gas lingers; property estimated to be worth $2 billion Australian dollars has been destroyed in the rioting, and the number arrested harks back to Pinochet’s times. The military are on the streets, their punitive powers on show. Piñera has cancelled two international conferences presumably not to show the World his intention to return to a military dictatorship.

After all, he has an approval rating of 14 per cent, presumably by all those hiding within gated communities. Piñera is reputed to be the wealthiest man in Chile, having introduced credit cards into that country and, as a badge of his mercantilist mind, he has manipulated stock such that he faced court more than once. He is the sort of person, who fits in with the definition of “politician”. He is a man well versed in fraud who has tried to shuffle his Ministers, but the protests have increased. Shuffling or sleight of hand generally also means taking money from someone else’s pocket.

Those in the streets are not fooled. They can see what awaits them on the horizon. All they have to do is go in the Museum and see the filmed images the morning Chilean democracy last died on 11 September 1973.

Bubble Australia

The Congress in Valparaiso has been invaded, and while the major excuse given for the increasing development of Parliament House into an impregnable Bubble Australia, thought must have been given to a popular invasion to construct it in such a manner. Presumably Bubble Australia has food and cocktails in store to last for six months in the event of a siege.

When people hate politicians enough, the tipping point will be reached. We are not immune from a Chilean-like situation – the only difference is that Australia has yet to have experienced a Pinochet. Yet we have a number of very good would-be impersonators.

I think Chile needs you back, Michelle. As for Australia, the space is unfilled – as yet. But then one of the characteristics of these new movements, apart from their youth is the difficulty in finding the leader to be carted off to gaol, effectively decapitating the rebellion. The Extinction crowd is on the streets, but they do not have the same mentality as the police force in its armour plate; and one has to hope wearily not to have a rerun of Queensland brutality à la Springbok tour or ageing commentators of both genders mimicking Askin’s admonition to drive over curly-headed young Sri Lankans – metaphorically of course.

However, if a society is unequal in its rewards system, and in their Morrisonian Bubble the beneficiaries try to insulate themselves, eventually someone will prick the Bubble or let the air be exhausted from the Bubble. It may take time, but there will come a time if there is no remedial action, we could end up like Chile or, for that matter, Hong Kong or Beirut.

Another Play with Words

Guest Blogger – Chris Brook*

The NSW government has announced that it is moving away from activity based funding in health care, to an outcomes-based funding approach. More recently the Australian Treasurer has declared that he wants Australia to do likewise to a quality care approach and eliminate low value and unnecessary care.

Both reflect the adoption of a new approach to measurement of value.

This announcement presages the latest fashion in health care economics and organisational design in the United States, which is value-based health care.

It is growing into a huge industry reaping enormous fees for consultants. As with any scheme, it gains keen audiences for its promoters because of its purported benefits and simplicity.

Basically the theory is simple – along the lines of:

(a) value, never quite defined but clearly related to outcomes and

(b) value, again never quite defined but including elimination of low value or unnecessary care resulting in:

  • integrated care
  • improved efficiency at all levels
  • team based care
  • patient-focussed care
  • higher quality care
  • better outcomes
  • improved prevention of ill heath and
  • lower cost

How could anyone object to such a set of targets?

And this all happens, apparently, through tweaking of economic signals along with better IT, better data capture and use, incentives for provider re-organisation and a value focus by patients. No wonder funders love the idea, or at least the components they choose to understand. However, like all things that sound too good to be true, it is too good to be true.

Some of the issues emerging are:

  • it is a North American solution to a North American problem
  • it assumes complete market flexibility, both patient and provider
  • it does not define outcome (clinical, functional, meeting expectations – actual against expected) and
  • it does not define value (whose or which value particularly)

Nonetheless some very interesting tools are being developed, such as much better prediction software which may dramatically alter future risk rating down as far as the individual level (with all the accompanying risks that entails).

To give the topic due attention needs at least a podcast discussion, with more than one opinion to assess.

This is but a teaser – an opening shot.

It does remind me that the world thought it had the solution to health care back in the 1930s, with the establishment of health maintenance organisations with uncannily similar promises – and promise!

As a very smart man once said to me looking into the mirror: “Chris, health maintenance organisations are a great idea and always will be.”

*Chris Brook PSM FRACP is a medical practitioner with 30 years senior management experience in the Australian health system

Tiempo, damas y cabelleros por favor

I came across the 29 May 2009 issue of Time which listed the 100 most influential people in the World. These lists are just one form of vanity press, a filler where high profile people are paid to write about other perceived high profile people who, unlike the writers, have attained the “magic” hundred.

The first one listed was Teddy Kennedy, who promptly died before the end of the year – and his legacy was his work in advocating for still unfinished health care reform. The second one listed was Gordon Brown, his paean written sympathetically by J.K. Rowling. He is long gone from the influential hundred; although he is probably behind the scenes within the Scottish resistance to Brexit.

However, in the 100 influential figures listed, both Boris Johnson and Elizabeth Warren get prominent space. A young Boris Johnson with boyish face and laughing eyes is eulogised by Conrad Black. One might say that it takes one to know one, but Black, ten years on pardoned by Trump for his malfeasance, was right in saying that Boris was a man to watch.

For her part, Elizabeth Warren is there for her expert knowledge of bankruptcy through all its shades, and her take on the financial services industry; she is “characteristically unfazed by the criticism.”

Surprisingly Putin and unsurprisingly Trump are not listed, and Xi Jinping is reduced to a narrow column on page 28. After being described in his role then as the Chinese vice-premier as “best known to many Chinese for his singing wife”, the writer goes on to pen that Xi lost his patience at a meeting in Mexico. He is quoted as saying, “Some foreigners can’t seem to mind their own business and sit around complaining about China.” But as the writer went on “He carefully flavoured the complaint as a joke, which took some of the pressure out. The politician’s instinct, it seems, is always at the ready.”

And as the writer said earlier in his piece: “the running joke in Beijing is that anytime there is a potentially nasty task, Xi gets it.”

First, Xi may joke, but he is no joke, and secondly I am not sure how he would describe Trump, but he obviously has a great deal of experience in such matters.

As for the rest, well there are those in elected office, those blazing a trail as “influential” and in the end there is mostly a Warholian outcome – maybe a tick over 15 minutes.

All shook up …

Guest Blogger:  Janine Sargeant*

Hard to believe, but there apparently are “Elvis Loathers” – designated by areas of calm cobalt blue on a demographic map of the USA. The “Elvis Lovers” are bright red and shake up much of the eastern half of the US.

Like him or loathe him, Elvis is everywhere

This map appeared in the August 1993 issue of American Demographics. Prepared by a Texas market research firm, using demographic data and addresses of members of Elvis fan clubs, it purports to show the depth and breadth of Elvis fandom. The most “Elvis-friendly” places apparently are small towns dominated by mills, farms and main street retailers, but also the newer blue-collar baby boomer suburbs on the edges of cities like Atlanta, Miami, Austin, Kansas City and San Diego.

Bob Lunn, then president of Direct Image Concepts Inc., said he launched the Elvis survey for a client wanting to sell Elvis memorabilia. While the client went bankrupt, Lunn’s company enjoyed plenty of publicity by making the survey available to the media. The 7,000 responses to his questionnaires came from Elvis fan club members. He used the responses to develop a composite of the then typical Elvis fan: a conservative, blue-collar, white woman in her 40s or 50s who votes Republican, has a high school education or less, is married with children, watches sitcoms and the Home Shopping Network and reads Bride’s Magazine and the National Enquirer. The typical fan also drives American sedans or pickup trucks, swims in above-ground pools, smokes menthol cigarettes, drinks malt liquor, and eats white bread, canned meats and Velveeta – all of which probably had a place on Elvis’s pantry shelves.

The Elvis map showed the clear divides that commonly exist in the US between east and west and north and south, although in this instance the north eastern states (with the exception of New York and Boston) certainly carried the flag for Elvis.

However, the map demonstrates how data can mislead. Based on Lunn’s methodology Alaska, with the exception of Anchorage, apparently is full of Elvis Loathers. Problem is, not much population in Alaska to move that state into the red zone (or perhaps it is just that the moose prefered Little Richard). Look more closely at the blue zones (except perhaps Blue Hawaii) and to a large degree the problem is a lack of individuals to sign up with an Elvis fan club.

What would the map show if it were redone now? Probably a lot more of “Elvis Who?” in beige, although it would likely now be called “Elvis? Meh.”

Exercises like these are an amusing diversion, but perhaps not to be relied on, as Lunn’s client discovered.

Janine Sargeant runs a medical association in the not-for-profit sector.

Mouse Whisper

Funny coincidence but my mouse trainer’s thirty-second wedding anniversary has fallen in the week of the thirty-second Modest Expectation blog. A coincidence, but in the world of gifts even for such an anniversary, ebony is the go.

Ebony mouse whispering

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.

Titanium Man

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 55th 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?

John Deeble

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 – Mali

In my heyday

Young men wrote to me

Everybody seemed to have time to devote to me

Everyone I saw all swore they knew me

Once upon a song

Main attraction, couldn’t buy a seat

The celebrity, celebrities were dying to meet

I’ve had every accolade bestowed on me

And so you see

If I never sing another song

It wouldn’t bother me

I had my share of fame

You know my name

This was the last recorded song of Matt Monro when he was dying of cancer. Matt who? Frank Sinatra recognised him as his equal in voice and ability to connect with his audience. However, there is a plaintive quality – you know my name. Really, you, Mr Monro have been a long time dead – and there is limited space in a nation’s collective memory for anyone, even if a superb crooner such as yourself.

The problem is that you may know my name but the passage of time will dull and obliterate it.

That is unless you make sure that there is a memorial, where its message is relevant to an ongoing generation, and not just to remember “my name”.

For me, the muffled sound and grainy sight of Salvatore Allende crying out “Larga vida a Chile”, and the fact that his cousin, Isabel has been such a prominent author, has meant the name has stuck around, as a romantic standard bearer for the oppressed – something South America has in droves.

Museum of Memories and Human Rights, Chile

I have recently returned from Santiago where I made a point of visiting the Museum of Memories and Human Rights. This was the brainchild of President Michelle Bachelet, to ensure that one memory sticks in the mind of the Chilean people. On a wall on the first floor are myriad photographs of Chileans murdered by the Pinochet regime – 130,000, probably more.

People who are just an anonymous as Mr Monro may be now, but they exist, not by names but as a powerful dark photographic reminder of the cruelty of Chilean to Chilean; in other words, you may be nameless, but collectively you are not forgotten and that is due to the overarching forgiveness led by this remarkable woman. After all, her father was killed by Pinochet’s thugs and she and her mother tortured.

Perhaps this memorial will serve the people of Chile and remind them to never abandon democracy again. Never, never. Ask Chileans of the age what they were doing on the 11 September 1973, when the military forces were unleashed on the democratic institution and they know, as well as those of my age know what they were doing when we heard John Kennedy was assassinated.

On the surface, Chile is now a stable country with a reasonable economy, the most robust in South America. Some may say its economy is built on copper, but Chile is increasingly diversified. Santiago could even be a Spanish speaking Australia city if it was not for the appalling slums that litter its outskirts.

But what of the forces behind the public face of the Chilean coup and the lugubrious Augusto Pinochet on 11 September 1973, during which the legitimate President, Salvatore Allende, was probably assassinated? That ghastly horn-rimmed Kissinger and his President Nixon, who also gave us the Killing Fields of Cambodia; only worth remembering for the cold-blooded approach to their fellow humans.

Unlike Michelle Bachelet who has gone some way towards rectifying one of the injustices they perpetrated.

Pain 

Opium poppies, northern Tasmania

One of the most unexpected sights is driving around northern Tasmania in early summer is seeing field after field of opium poppies with their delicate pale mauve flowers giving such an innocent touch to the sinister drug industry which is dependent on its supply from this one of few legal areas for opium cultivation.

I am not one to unnecessarily applaud anyone, but I do applaud the Chief Medical Officer, Brendan Murphy, for sending out 5,000 letters to doctors who have a profile of high prescription of opioids. That letter elicited the usual aggrieved response, particularly as it was sent to so many doctors. The problem with many doctors, even in a climate of increasing peer review, is this natural reaction to being questioned on “infallibility”.

Even if the letters implicate those who have a legitimate excuse, it should flush out those who are just drug dealers with a medical degree. Let us get one matter straight, this letter relates to chronic usage – not acute usage. There are times when complaints have been made of the under usage of such drugs where the need is acute.

I well remember the country doctor who was well known to government for over-servicing which, among other misdemeanours, involved handing out opioid prescriptions. When this particular doctor died, his funeral procession through the town streets was lined by grateful dependent patients. It was an ironic way to end one’s days, with a town, which had become addicted to this one doctor.

I hope that the Murphy initiative ends with a marked decline in the chronic prescription of opioids – it is a strange state of affairs that doctors are reportedly suddenly afraid to prescribe opioids because of the letter rather than fearlessly continue to exert their clinical judgement as to whether opioid use in a patient are justified.

For my part I have an auto-immune disease in which pain has figured so prominently that I was taking the maximum dose of paracetamol each day and counting the hours until my next dose. However, I eschewed opioids because of the fact that I feared addiction, given how long I would gave to take them. Just hankering for my next paracetamol tablets was warning enough. I survived the time without resorting to opioid, and fortunately my need for analgesia has abated.

It was interesting to note that the recommended maximum dose of paracetamol in the USA is lower than in Australia. I wonder whether this had any effect on its use and the substitution to opioids.

The other problem is exemplified by the woman who claims to have been prescribed opioids for 25 years for pain and now her prescription base has dried up. I make no judgement on any individual case but it is not difficult to hypothesise that there is a cohort of people who have become addicted because of doctors, who act as drug dealers rather than as medical practitioners.

I do hope that Dr Murphy’s action will lead to this cohort of medical practitioners being exposed and appropriate action taken. The medical profession will be well rid of them.

In the USA, as usual with the vigilante approach long after the wrong has happened, they are lynching the drug companies without solving the problem. The drug addicts are there; the overdoses are there. Making the drug companies pay does not solve the problem. However, when combined with an initiative such as being prosecuted by Murphy, it just may work. Keep it up, Doctor so that its success will be celebrated as part of Murphy’s lore.

Where do we go from here?

The ABC has produced a four part series Old People’s Home for 4 Year Olds; it is modeled in some degree on a BBC series of the same name.

Lucy Mangan wrote in the Guardian about the BBC version (sic):  The show continues to tread the fine line between heart and sentimentality, between reporting on measures involving vulnerable groups without patronising them … and that at the very least the sociological gubbins should be let fade into the background instead of the makers trying to paint a scientific gloss on the commonsense appreciation that anyone’s mood, mobility and memory will improve if you throw activities, new experiences, a few highly supervised hours with some charming infants and the money to pay for it all at them.

I am somewhat uneasy at the sight of four year olds being led into an old people’s home to play with the residents. To me, the children could just as well be going to the zoo. These are strange creatures to the very young; and the carefully depicted interaction predictably elicited parental clucks by the commentariat at the wonder of it all. Annabel Crabbe is the ideal presenter.

However, where is it all leading after the cameras are turned off and the academics drift away to write their papers? The numbers participating are few and given that the camera cannot be a continuous record but one determined by the selectivity of the director, then the temptation is to have the cutest cuts and leave out the scenes that do not correspond to the producer’s definition of bliss.

There have been other experiments, such as the Seattle one where a preschool was placed in an old people’s home. It has been locally successful if one can believe the reports. However, it is just one example; but what does a policy maker do with such a project to make it generalisable? The other factor is the enthusiasm of those who initiated the transfer of concept to action. They have a vested interest in making it work, but times change, enthusiasm wanes. These sort of projects need a wider support base not only to be sustainable but more importantly generalisable.

The actual conduct of the operation probably requires a high level of supervision, because one is dealing with the interaction of two groups where there is both dependence and yet a high level of unpredictability. One group will soon move to another age group and perhaps will be left with a positive view, while the other group are about to die and leave their trace on a filmed archive only.

I remember when I was a small boy and following my father as he went around a ward full of war veterans. At one bed while my father saw other patients I got talking to a patient – a soldier. He was friendly and he talked so that I understood what his life had been, without any sense of self-pity. I remember saying I would see him next week. He smiled, called me “Blue” and patted my arm.

Later, (I cannot remember the time gap) I came back with my father and went straight to his bed. I don’t remember whether it was empty or if there was another person in the bed. However when I asked about “my friend”, the reply came back that he had died. I could not believe it. I think it was my first experience of loss. Whether this was experienced by any of the children in this “experiment”, coming back to see one of the old people only to find they have died. For me the memory has stayed tucked away for years.

Why do you tell stories as you get older? Nostalgia is the province of the elderly and the benefit of this type of interaction is that the elderly have an audience – admittedly a very fleeting, easily distracted audience to which to tell your tale. Perhaps in the end the ability of old people to tell a tale where the audience still has the flush of wonderment is a good thing. But loneliness is a 24-hour experience.

However, if the attempt of mixing the groups is just voyeuristic – “been there; done that”; then I believe the makers of this series have probably done a disservice to all involved if nothing further eventuates.

Old age is an increasing societal challenge. It should not be just a case of waste management. Yet I fear that is happening – and David Attenborough-like explorations of human foibles and cuteness should not replace serious consideration of what can be done.

The clue is in the series – get the elderly to tell their stories, whether they have a four year old audience or not. After all, it gives you a sense of relevance, even when you may be the only one listening. However even one child listening and responding with questions is a bonus. After all, I believe we are all storytellers.

Mouse whisper

I don’t know what I will be able to squeal and the Press to write once they silence Trump, but this quote from the New York Times has a degree of murine richness. And I thus thank Mr Krugman for the quote.

At that point you might expect an intervention from the grown ups in the room – but there aren’t any. In any other administration the Treasury Secretary Steven Mnuchin, a.k.a. the Lego Batman guy, would be considered a ridiculous figure; these days, however, he’s as close as we get to a voice of economic rationality. But whenever he tries to talk sense, as he apparently did over the issue of currency manipulation by the Chinese, he gets overruled.

Protectionism is bad; erratic protectionism, imposed by an unstable leader with an insecure ego, is worse. But that’s what we’ll have as long as Trump remains in office.

Modest Expectations – Hole

In the blog two weeks ago, Neil Baird, and in this week’s Chris Brook have indirectly or directly alluded to self-sufficiency. With the advance of globalisation the need for self-sufficiency seemed not to be so important. The supply chains were efficient, and it may be argued that they remain so. However, the rise of nationalism and the belligerent rhetoric accompanying this surge have made a number of those multi-national corporations worried if you believe The Economist. Apparently, so it goes, most multi-national corporations found that they did not know who supplies the supplier to their supplier; and so it is conceivable that on distant shores there is a vendor who cannot or will not fulfill its obligations. When the supply chain works, as Brook as shown with blood, the tendency is to take it for granted – nothing will change – let’s move on.

However, this quote from The Economist is salutary: “In the wake of the Japanese tsunami in 2011 a global semiconductor giant tried to map its vulnerabilities to third and fourth tier vendors; it took a team of 100 executives more than a year to work out which firms were in its extended supplier networks.” Presumably this would not happen now if Silicon Valley were hit with a massive earthquake – or Seattle for that matter.

Apart from natural disaster, borders are going up everywhere yet we still depend on the integrity of the supply chains.

Meanwhile back at Parliamentary St Andrews, they chortle over their wonderful use of the wedge, the bluntness of the mashie and the judicious use of the constitutional niblick, while along the course the clouds are gathering. 

Blood

 Brook recounts his Success Story

I first got involved in the organisation and management of blood (and then blood products) in 1988 when I was appointed as Victoria’s youngest Chief Medical Officer.

Then every State has its own separate blood service which, although under the umbrella of the Red Cross, could and did have differences in approach, even donor deferral. This could create problems and these were not resolved until the early 2000s. 

Most of the big concerns at that time were about fresh cellular products, including adequacy of supply, in a system where only a tiny minority of the population are donors, predominantly white and “Anglo”. This has not changed. There are many cultural and even religious reasons for this, but it remains a big problem.

In my early stewardship, I was confronted by the HIV scourge and subsequently the rise of Hepatitis C infection in the blood supply.

Preventing their transmission through transfusion was urgently needed and for people with haemophilia the risks were multiplied due to pooling of plasma used to fractionate into products like haemostatic factors and fractionated plasma products like Immunoglobulin. The number of deaths of those with haemophilia due to contaminated products resulted in a drive to eliminate this spectre. 

It is difficult for people who were not there to understand the horrors of the HIV / AIDS era in the 1980s, before adequate testing and treatment. Australia’s response is regarded as a world leader, thanks to Neal Blewett, then Commonwealth Health Minister, whose government funding provided a systemic health response, community programs and research.

The Hepatitis C virus was not even identified at the time – it was suspected to be a new virus, but was known only as “Non A – Non B” hepatitis. Its subsequent devastating long-term effects were then unknown.

Universal testing for HIV was introduced and Hepatitis C antibody testing came later. There were also stringent rules for a person to be accepted as a blood donor thus assuring safety of the supply.

Problems in product supply and clinical usage became evident in the early 1990s. Australia’s blood and plasma product supply was considered to be largely self sufficient, in reality markedly sub-optimal plasma product use was masked, and overuse and wastage of red cells needed to be addressed.

The States and the Commonwealth jointly funded state-based Blood Transfusion Services on a 60:40 basis and the Commonwealth government at that time funded the Commonwealth Serum Laboratories (CSL). CSL did not fractionate some products from Australian plasma due to low volumes and large cost; and while there was funding for some imported products, like purified Factor VIII, the arrangements are best described as chaotic which led to perverse outcomes.

For example, haemophilia was treated only “on demand”, only at the time of a bleeding (often into a joint); and even then the treatment might comprise cryoprecipitate (a form of clotting factor soup)  or even fresh frozen plasma , as these products were “free” being available from CSL, whereas purified  Factor VIII was not and was thus a significant cost to the hospital.

So not only did a generation of young people with haemophilia suffer HIV and Hepatitis C, those who survived grew into adulthood with not only often severely damaged joints but also with repeated painful hospitalisations.

In 1994 CSL was privatised and as a successful case study in the benefits of privatisation when properly enacted CSL Pty Ltd has gone on to become the largest plasma fractionator in the world – a stunning achievement.

In the same year, with support of the then Victorian Premier, Jeff Kennett, I chaired a Working Party to look at Factor VIII in young people with haemophilia. Best practice meant prophylactic daily treatment with purified Factor VIII to prevent bleeding. 

This prophylactic treatment actually reduced hospitalisations, far better adult functional outcomes were achieved, and lives transformed from one of disability to one of approaching normality.

Then imported recombinant Factor VIII became widely available for the treatment for Haemophilia A and other bleeding disorders.

In 1996, I participated in the Red Cross amalgamation of all of the State blood transfusion services into a single national Australian Red Cross Blood Service (ARCBS).

In 1999, the then Commonwealth Minister for Health, Dr Michael Wooldridge, commissioned an enquiry into blood and blood product arrangements in Australia, chaired by Sir Ninian Stephen. Its 2001 report still reads well.

The most important recommendation was to create a National Blood Authority (NBA) to assume all supply planning and purchasing on behalf of all Jurisdictions (including the Commonwealth), using common pricing, and clear jurisdictional agreements.

The design of the NBA included the influential Jurisdictional Blood Committee (JBC), which reflected my belief that overcoming some of the problems of Federation can only be achieved by well functioning cross jurisdictional bodies, a lesson I learned as Chair of the Intergovernmental Committee on AIDS when the initial HIV / AIDS Strategy was devised and which incidentally informed the structure of the Australian Commission on Safety and Quality Health Care. 

During this time I was also the Chair of the AHMAC Blood and Blood Products Committee and remained so until the National Blood Authority creation in 2003.

In 2004 all recombinant clotting factors were funded by the Commonwealth government.

The NBA has performed to above expectations. It is a small agency with around 50 staff and I remain on its Advisory Board.

The NBA has contracts with CSL and with suppliers of imported haemostatic factors. ARCBS is funded by NBA on a product pricing basis for each State and reconciled annually. All products are funded jointly by the Commonwealth and States on an agreed 63:37 split with annual supply plan for each jurisdiction agreed by COAG Health Council.

There are excellent information systems allowing NBA to track fresh product issues and usage, plasma products, and haemostatic factors.

There are guidelines for usage of Immunoglobulin (Ig) and haemostatic factors, and a major blood usage (Blood Matters) program with all jurisdictions having vigilance programs to identify appropriate use and risk. 

In conclusion, Australia is well organised and managed in relation to the availability and supply of blood products.

Red cells are no longer the demand driver. Red cell use is declining as better education and usage monitoring occurs , along with reduction in waste.

Haemostatic products are now predominantly synthetic recombinants. This a great advance, given the tragedies with plasma-derived products in the past as occurred with both boys and men with haemophilia. 

Having said this, demand is now driven by the Ig requirement, which has ever-wider uses but is currently unable to be synthesised. This is not a insurmountable problem, but I also believe some of its uses will be replaced by specific antibody drugs in the future.  

Australia is one of the highest users of Ig, along with the US and Canada, but have long since needed to import Ig. Now imported, Ig is the majority source and costing much less than domestic supply.

Ig usage in Australia, whilst high, is not inappropriate and countries currently with lower usage rates will rapidly catch up – with all kinds of global consequences for its supply. 

Australia can boost domestic supply, but currently at relatively high cost, yet a cost-effective local supply should be pursued given the uncertainty of the global supply.

However, there are three matters that should form the basis of any ongoing review – just because, “it ain’t broke”, does not mean that it could still be improved. 

First, Australia is committed to at least try to achieve self-sufficiency, with minimal waste. We are self sufficient in cellular products, but arguably this should apply also to plasma products, which should this country aim to be?

Second, blood and domestic plasma collection is a totally conducted by ARCBS. The Blood Service is not a charity funded by the Red Cross, but a multi hundred million dollar government funded business, as it should be to assure the community of its efficacy. Should the community know this? 

Third, the ARCBS is trying to increase plasma-only donations but even so, our model has a higher cost structure. As a result Australia uses products from the USA and Germany, which generate the majority of global plasma products. These countries remunerate the donors. Australia is legally committed to a voluntary donation model, and the government would be loath to change. But should it at least be looked at?

Blood is too important a part of the health system not to always be in the forefront of policy considerations, especially when biosecurity and self-sufficiency are on the agenda.

Beware the unintended consequences, my friend

We returned to Australia through Darwin and as always, it is difficult to resist the two-bottle duty free concession. However bottles become heavier as we, not the bottles, age – or else seem to! I am disabled because of an intercurrent autoimmune disease, requiring a wheelchair at the airport. We had to board a flight to Sydney. My companion had recently had a heart attack, and though well enough to travel needs some assistance with luggage.

Thus we have the curious experience of the commissionaire, the name for the wheelchair pusher, being able to place my small bag and two of the four bottles in the overhead luggage compartment.

My companion had gone on ahead, and I was presented with the unedifying spectacle of a young female flight attendant standing by while my elderly companion, who had a recent heart attack, struggled to place her items in the overhead locker.

This spectacle was further compounded by the fact that we had been allocated business seats in row one. In the front row, all bags –including handbags and toiletry bags with necessary medication –must be off the floor. In other words at some time in the flight, bags must be taken down and in a full flight this means moving bags around in the overhead locker often, a strenuous manoeuvre if the passenger is disabled.

Apparently there is some recent ruling that prevents the flight attendant helping with placing luggage in a overhead container. We had not brought on portmanteaux, which for some reason the airline allows people to do. Rather the airline insists that the flight attendants stand back and not help. When I protested, I was put firmly back in my box, old man … them’s the rules.

The problem with rules is that there are those flight attendants with common sense and those without. A rule does not have a brain to distinguish one from another. I would suggest to the airline to stop people bringing on huge cases, and that when people are placed in bulkhead or exit rows, which require all baggage to be off the floor, to exert a bit of common sense. And if they cannot, defer to somebody who can.

Finally, I would say I have been disabled for six years and the problem with airport terminals is they are getting larger, and the demands on disabled services is not getting any less. I have been able to observe many cases where there has been no obvious reason for a wheelchair except it seems culturally important to have your mother when she gets to late middle-aged to be wheeled around the airport. So the task is not getting any easier when you also have to deal with a sense of entitlement as well as disability.

Mouse Whisper

What did you mean by “He met her in abasement” or should it have read “He met her in a basement”? Might be the same. Nevertheless, it put me in mind of the time when I was the MP (mouse parliamentarian) for Mousehole. I sent a stern letter to a PS (parliamentary skunk) where I meant to write that his action was “imprudent” but somewhere along the way, the “r” was dropped. Created quite a stink!

Mousehole

Modest expectations – Pale Waves

One thing I seem to have missed as I have aged is the music revolution. Last week in Melbourne there were all these people in red dancing around in a park – something to do with Kate Bush, in red, outside a window singing about “Wuthering Heights”. My appreciation of music is limited by the fact that in its creation, playing and singing I am completely talentless. However, I understand that there is a very popular band called Pale Waves, an Indie-band with a lead singer called Heather who has one of the voices that would divide a mosh pit like the Red Sea. They sing:

I was eighteen when I met you

Poured my heart out, spilt all my truth

I finally felt like I could feel for the first time

When I met you.

The video is dark and moody with more than a hint of sex but with all the “on the road” clichés pasted along its way.

Now my era danced to Chuck Berry’s “Sweet little Sixteen” – bit of poetic licence in the age difference, but it is all about being young, which is the root of nostalgia. The Beach Boys pinched the tune for “Surfin’ USA”.

Sweet Little Sixteen

She’s just got to have

About half a million

Framed autographs

Her wallet’s filled with pictures

She gets ’em one by one

She gets so excited

Watch her look at her run

Berry was a genius. The singer from Indie Pop group, Pale Waves may turn out to be one as well. I saw Chuck Berry perform in the twilight of his career in a basement in St Louis. We were the ageing mosh pit; it was one of our most memorable experiences.

Chuck Berry

I missed the Pale Waves when they were here in 2018, but perhaps they will roll in again.

Fanfare for the Common Man

I am not an American citizen, however for what it is worth, I have an alternative view of the USA to that of its President.

I have friends in Lubec, on the Canadian border in Maine. Across the water in Canada is Campobello Island, which is synonymous with Franklin Delano Roosevelt. Roosevelt smiled; he exuded optimism. He was also a cripple, struck down by the poliovirus one morning on this most beautiful of islands. Yet he strove for his own independence and courage.

I come from a country where to bare arms is to get down to work with my fellow citizens. I have never seen a gun except sleeping in a rack. Maybe I am careful, but the myths of the NRA are powerful, like those of Washington Irving. The story goes … it’s the guns that kill, not people. Guns must therefore awake, get off the rack, stretch their barrels, and discharge a thousand bullets before breakfast. People are killed but guns remain the same.

I live a country where there is no gun culture comparable to that of the United States and yet our major commemoration is a World War One disaster at Gallipoli and our national day is called by some “Invasion Day,” when Great Britain dumped a bunch of their unwanted – convicts and marines – in a desolate place called Botany Bay in 1788. Despite its apparent vigour, this is a country rooted in pessimism.

America’s national day celebrates something more than putting a British foot on a distant shore.

Australia has a dirge for a national anthem. America’s anthem was forged as the smoke from the British bombardment of Fort McHenry cleared in 1814 and the American flag was still flying. Francis Scott Key was inspired to write the words of “The Star-Spangled Banner.” Today Fort McHenry is one of only two places in the United States where the 1814 fifteen-star flag still flies. The other is at the end of the Oregon Trail.

I love my country. I have travelled all over my own country.

But then I have also been privileged to roam the United States too. I have sponsored musk oxen called Amethyst and Pixie Stix in that Folly, Alaska. I have sat in the San Franciscan courtyard and then written about the early days and aspirations of Genentech before Silicon Valley arrived to crush the city. I have eaten king salmon in Salem, Oregon, and crab in Sabine Pass, Texas – both sublime experiences. I have stood at the doors of that miracle of Minnesota, the Mayo Clinic. I have gazed at Mount Rushmore and know now why those four presidents were carved. I have wept at Shiloh. I have stood in the wheel ruts of the Oregon Trail in Douglas, Wyoming. I have joined in a march to the Tenderloin on January 15. And so on … identifying something extraordinary in all the 50 States I have visited, not to mention Puerto Rico.

However, I am white and while there was a certain exhilaration of being part of a January 15 homage to the life of Martin Luther King, I have had another far different experience of turning a corner in the national capital from a gentrified brown stone street, to find that I seemed to be the only white person in the street. Not even an Officer Krupke. I did not turn; I walked briskly making no eye contact yet experienced the tension of being alone in a very foreign country, well outside my comfort zone. I walked the block, before turning into another zone of brownstone gentrification.

I have money; I do not have to panhandle; I have a bed to go to every night. I do not have a child in a cage on the Mexican border. I know where my children and, for that matter, my grand children are.

Now, my luggage did vanish forever at Los Angeles Airport. I still had money and passport, but trying to find a suit of clothes in downtown Washington was a challenge. In the end a modified “zoot suit” made me feel very foreign.

Only once have I had to use the American health system. I quarantine myself by taking out very expensive travel insurance. I am able to do so. My actual experience with the health system came one day after I had run in the Annual Bay to Breakers fun run in San Francisco, a novel way to see that city. I developed a dental abscess, but as I had to fly to Orlando taking a day to get there with only aspirin and bicillin which did nothing. Hence when I arrived late into Orlando, I experienced probably my worst night in pain. I sat up all night watching the wrestling on TV and in the morning the organiser of the conference, seeing that I had a face the shape of an angry balloon, took me to an endodontist who immediately drained the abscess without requiring me losing any teeth. I had immediate relief from the pain.

The United States in all its diversity, both good and bad, has been my energiser from the first time I went there. But I am and have been a privileged observer able to see the sights and yet travelling around its less well-known parts without a gun being poked in my face.

Even in adversity, America has always exuded optimism, and on my latest visit it was no different. But that was almost two years ago.

Make America great again!

What crap!

America remains Great despite all its warts. The only problem is that the USA has a President who wants to make America Hate.

He wants Americans to lose their Smile, to lose their Optimism; to lose the meaning of the fourth of July.

Such a pity!

Twenty years has passed

Let me start with a quote:

“… there is no substitute for a careful and painstaking history and a meticulous physical examination. This is the cornerstone of medical practice…”

This came from a 1977 article by Lou Ariotti – it is clear; it is not infested with jargon. It says it all. It is applicable across all health practice.

Lou Ariotti was the real deal in Charleville for many years and some of what he did with limited resources was remarkable. Initially, there were no beds in the hospital. So he taught the families how to look after the sick in the home, taught them simple procedures. There were inadequate facilities at the hospital; so he set up the forerunner of the day surgery in his premises.

However, very tellingly he stated that he got his inspiration from the Mayo Brothers who trekked out from Chicago as young medical graduates into the Minnesota wilderness – and today we have the Mayo Clinic.

Charles and William Mayo

What the Mayos demonstrated was that you can move intellectual capital to remote areas, but you have to have succession planning. As I have said many times, the doctor in the bush faces inter alia social dislocation and professional isolation.

Yet that world of the Mayo Brothers and Lou Ariotti was the world of the individual. The difference between the Mayos and Lou was that the Mayos left a legacy and Lou Ariotti a memory. Lou made sure the Queensland Premier provided him with a large hospital, but as you know monuments are just that. He may have admired the Mayo Brothers, and while he left an adequate health service – his legacy was the memory of himself, the man rather than memory of Charleville itself being a centre of medical excellence.

After all, we are still digging up parts of the ruins of ancient Roman monuments, but the Vatican on the same site as Ancient Rome has learned the trick about matching monument retention to succession planning.

This was written last year for the commemoration of the first 20 years of the Mount Isa University Department of Rural Health, part of the successful endeavour to move the education of medical and other allied professionals to universities of rural health and rural clinical schools. In my last blog, I questioned the glacial progress of the review of the MBS. Having been closely involved in the introduction of the rural clinical schools, it is disappointing to read that the Rural Health Commissioner, in a recent article, can only conclude by saying “a nationalist rural generalist pathway is good for rural communities” Appointed two years ago in 2017, it has taken him two years to say that! Oh, I forget, there are the inevitable diagrams. 

But at least he will have a huge number of happy snaps to remember where he went over the past two years as the rural Bill Peach. 

Seriously are these reviews going anywhere? Now there is talk of the Health Minister ordering a heath of private health insurance review. Hopefully, Minister, the deadline will be somewhat tighter than the ongoing ones. Show the community how they are influencing health policy or are they just an elaborate way of doing nothing while re-arranging the flowerpots on the window sill?

Mouse Whisper

I remember when the song “Diana” was released in 1957, and the sensational fact at the time was that Paul Anka was the 15 year old song writer as well as the singer.

The story goes that Diana was an older kid who used to look after Paul when he was a child. Paul had a kiddy-crush on her with less than enthusiastic response on her part. There was about a three-year difference. Years later, after the song went to Numero Uno on the charts and he was a star, she suddenly showed up saying, “Take me! I’m yours!” to which he gently replied, “Sorry, our time is past.”

But she still had Diana!

Modest expectations – Tennessee Ernie Ford

We were having lunch at the weekend and were discussing the penalty of age and what happens when you grow old. “Yes”, he reflected. “You may have a point. Once, my phone calls were returned immediately; now it may take four days or longer.”

I immediately thought of a time I was at a function in Dubbo and a number of politicians mentioned my name in glowing terms. One guy came up to me and said he had not heard of me, but I must be influential because of the things being said about me. “No, I replied, “Influence is ephemeral – it can disappear as quickly as it appears.’’

Not that some people do not retain influence for a long time – but there is a price to pay. You have to mix with a crowd of the same types grasping at the ephemera until, like Citizen Kane, they have only “rosebud” to murmur; some don’t even have that.

The comment that summarises much of what occurs was from the defeated member of parliament who said what he noticed most was that the telephones stopped ringing. Obviously that image needs to be updated in social media terms, but it summarises the ephemeral nature of influence and the intellectual laziness that surrounds it and which is epitomised by the growth in each politician’s office of the number of consigliere.

Traditionally, the more senior the ex-pollie the more important the government sinecure away from Canberra; some ex-Ministers have became chancellors of universities all the way down the ephemeral rungs to that of teaching politics part-time. Using their retirement or ousting, some are able to undertake pro bono or voluntary work, underpinned by their generous pensions and their contacts.

The problem is that politicians over the past 40 years have become outrageously well paid, with generous perks that seem to be never-ending. However, the stories of excess are not met any more by community outrage when reported but by clamours for more of the gravy train tickets.

“Jobs for the boys” have been replaced by the scourge of “rent seeking” – essentially jobs for doing nothing while wrapped in the gossamer of influence.

The hoary excuse for such greed is “I have sacrificed so much.” To which is added the lachrymose sacrifice my family has made for my increased prancing around in the Ephemera.

To put it bluntly, a rent-seeker is just a metastasis. A cancerous excrescence away from the main tumour, but still reflecting the nature of the tumour as it destroys the framework of the body. Doing no good but draining the life from the body for a price.

Yes, a metaphor, but the metaphor is obvious. And the metastases, male and female, let’s mention no names but they know who they are.

Mr Unaipon – My modest acknowledgement of NAIDOC week

Of all the Aboriginal people, I would have most liked to have met David Unaipon.

He died when I was in my mid-twenties. I had never heard of him then.

But what had been my exposure at that time to Aboriginal people? Virtually none. I had been to the Hermansburg mission as a child and seen Albert Namatjira and Rex Batterbee, the white fella associated with encouraging Namatjira’s talent in watercolours and that of the Western Arrernte people.

I was a rabid Essendon supporter from a young age. Norm McDonald played on the half back flank for Essendon. I never thought of him being Aboriginal, a Dhauwurd Wurrung man from around Lake Condah; just a magical footballer – boy was he fast!

Then, if an Aboriginal person was mentioned with the word “footballer” it seemed always to be Doug Nicholls.

It was a world where I could have met David Unaipon but there was no $50 note to tell me he even existed.

David Unaipon died in 1967, and the closest I have got to him is his grave overlooking Lake Alexandrina, Victoria’s name before she became queen.

One of my fondest memories of when I used to go around the bush was seeing the Ngarrindjeri land near the mouth of the Murray river at Raukkan. Its Lutheran church is pictured on the $50 note. For some reason, it has some of my best memories.

One of my clearest memories of Raukkan was going into the Aboriginal office and seeing the number of portraits of their late elders lining the wall – mug shots as you would see in a whitefella boardroom. There was no concern about showing the faces or mention of the dead among the Ngarrindjeri, so I was told.

I happen to have a wonderfully annotated copy of David Unaipon’s slim volume “Native Legends” which he wrote in 1929. It is said to be the first volume actually written by an Aboriginal person. He is succinct.

For instance, Pah Kowie – The Creature cell of Life and Intelligence is just one page and concludes:

Thus many of the ideas formulated by my ancient fathers may seem absurd to an enlightened age fantastic and absurd, but to us these ideas are the foundation of a structure and edifice of knowledge under whose shadow we live today.”

I wonder what Mr Unaipon would have said today.

However, I am a bit surprised that this early work has not been reprinted, at least as far as I know, given that most of us are reminded of him everyday.

The Bruce Robinson New World Odyssey

I remember the Independent Enquiry into the Repatriation System under the wonderfully named Justice Paul Toose. It was set up in 1971 and did not report until February 1976 – three elections and three Prime Ministers later. As people in government joked, this “plodding” inquiry lasted longer than the First World War and ran to 800 pages and 300 recommendations, one of which seems to have been changing the name of the repatriation department to the department of veteran affairs.

Not that I would like to see the Review of the Medicare Benefits Schedule break the Toose record, but Professor Robinson is giving it a red hot go. The review has been going for four years – for what? Any review that takes that amount of time becomes problematical.

As a comparison, while this Robinson Review with its 30 committees has been meandering along, the Review into Australian banking practices under Mr Justice Haynes has been [2017-2019] and reported in 1,137 pages ; in the USA the Mueller investigation has also been [2017-2019], and reported in 472 pages.

They were somewhat significant inquiries.

Yet here we have Bruce Robinson and his crew backed by McKinsey just like the Mississippi River, “it just keeps rollin’ along”. I have heard the time 2023 mentioned as the new end point. Well, that would break the record – a formidable feat. Probably we could have a plaque to celebrate the finish of this Homeric epic.

Perhaps getting a sharper Shadow Minister for Health in Chris Bowen will see if we can dam the Robinson and his multiple tributaries.

The subsidiary question is how much has McKinsey cost the Government for no noticeable impact – you know McKinsey, the firm that is in a running feud with the NYT about its methods and clients. It is an unedifying backdrop.

It is interesting that the latest round of Ministerial adjustments to the Medicare Benefits Schedule by Minister Hunt did not seem to mention the Review. As one senior politician said to me once, governments use these inquiries as a means of maintaining a freeze on patient benefits. I wonder if the patients themselves know of this stratagem.

Unlike the original Nimmo Inquiry which reported in 1969, which had the knowledgeable advice and expertise of John Deeble and Bruce Scotton, subsequent reviews since the breakdown of the periodic Enquiries conducted by Government and the AMA have not achieved very much – but at a great cost in time and the employment of outside consultants.

I should know. Medibank and Medicare have been central to the life of most doctors, including myself and it should not be left to slowly decay, because of an interminable uncertainty, which is the other side effect of an unending wander through the Medicare Benefits Schedule.

Knock before Entering

My wife loves photographing doors. Front doors, that is. Front doors opening on streets; front doors not hidden by a pathway, a garden, a porch or verandah and a flyscreen.

In it simplest form she believes the front door defines the place, the thoroughfare, the relationship of one place to another, the people behind the door in the space, working and living there.

I am not so sure. I see the front door as an identifier of the place but not necessarily those behind the door. Many of us merely inherit our front doors. Many front doors do not identify anything. There may be nothing behind that door but an empty space.

The doorway is Ianua in Latin, named for the god with two faces and from where the word “January” is derived – and janitor as well. January is the doorway to the year. We cannot prevent anybody from passing through the doorway. February always comes.

We, however, may have a janitor to maintain the upkeep of door and passageways. That person may have many names and interpretations in many languages.

We invented the door and then locks to keep people away from the space behind the door, for whatever reason. The door becomes the vehicle for the lock and for maintaining permission to use that space. The door can become a massive contraption to secure that space or as occurs in rural areas in my country just a way of keeping the dust and the animals out. The houses meanwhile are left unlocked. The unlocked door can be a measure of trust, but also a measure of carelessness.

Once I could turn the handle on any church door in any out of the way place, and I could enter and stand in this church with all its furnishings and stained glass intact. This is not carelessness, but an act of trust by those who have the key to the door.

The front door as an inanimate piece of wood or metal is an obstruction to that passage, and so may be an identifier. My wife may be right. How we regard the front door in fact may define the civilisation in which we tread.

Mouse Whisper

I decided to try my hand at shrew taming. I sent for an application form and received the following questions. Well, not actually.

I have inserted the word “shrew taming” to protect the names of the drongos who manufactured these questions. My reflection is the same as it has always been, except my fur is bit greyer and the lines on my faces are deeper than when I was a pinkie.

But see if you can interpret this set of Parts into English. Good Luck!

Part 1: Tell us about yourself and your role 

Objective: Understand the individual’s overall role and interactions with shrew taming

Part 2: Tell me about your experience with shrew tamers

Objective: to understand individuals touch points with shrew tamers and their overall end to end experience

Part 3: What is your overall reflection based on these experiences? 

Objective: to understand shrew tamer’s strengths and pain points to identify future areas of focus for the end to end experience 

Part 4: What would you like to see more of in future? 

Objective: focus on the future experience and how we can orchestrate touch points in the future to ensure a seamless experience.”

Modest Expectations – Union

One can hardly believe that in a country with so many challenges there is so much concern over some footballer who made a list of people he wished to be assigned to Hell.

Echoing what I wrote in an earlier blog, Peter Singer, the bioethicist, is reported as having written:

“Folau is a born-again Christian, and his post was an expression of his religious beliefs. To prevent misunderstanding, I should say that I do not share those beliefs. As an unrepentant atheist, I am among those for whom, Folau believes, hell awaits. But that does not trouble me, because there is, in my view, no god, no afterlife, and no hell. Nor do I differentiate, ethically, between homosexual and heterosexual relationships.”

Singer picks up the “hell awaits”. It is not as though Folau is advocating violence or even earthly sanctions. Nevertheless, the sheer arrogance of such a list should not have goaded the Rugby Union establishment into a response, which in turn has started a chain reaction. It has enabled the fundamentalist Christian groups to start braying about religious freedom, using Folau as a martyr strung up on a goal post.

In the course of this saga the community is being suckered into a situation where a silly statement is now being adopted by those who want to use the cloak of the Christian Church to run extreme agendas; where dominance of women is one of, if not the main objective.

Symptomatic is the resurfacing of the anti-abortion crew, who have never gone away – the matter has become a surrogate for maintaining the subservient role of women. Christian churches out of the mainstream are very good at keeping women as handmaidens, where the violence is not necessarily physical. And it is not limited to Christianity.

I have a visceral dislike for abortion, but it is not my business – not my choice. It should be a woman’s choice.

There was one occasion when I was faced with a friend who wanted an abortion, and the potential father had disappeared. It was at a time before the Menhennitt ruling changed the secrecy and enabled abortions to occur openly, and the words “criminal abortions” rendered obsolete. (In Victoria, a landmark Supreme Court ruling in 1969 (‘Menhennitt ruling’) established that an abortion will be lawful if the accused held an honest belief on reasonable grounds that the abortion was both ‘necessary’ and ‘proportionate’.)

The whole episode made me so disgusted that we, in an ostensibly Christian society, were allowing women to be exposed to emotional and – on those occasions when the “backyard” procedure went wrong – physical trauma on women. Here a degrading scene was being played out, because men – predominantly men, and celibate men at that – thought it sinful.

Fortunately, my friend survived the ordeal. She recounted what had happened, I was appalled but we never talked about it again.

That is the worry if this whole Folau imbroglio, with the forthcoming legal action, is allowed to energise this group of anti-abortionist misogynists over what is, in the end, a belief lodged somewhere inside Folau’s head that should have nothing to do with anything but his contract with RU.

Nearly 20 years ago, Susan Ryan, the former senator, reminded us it had not been that long ago that the House of Representatives’ vote against abortion – four years after the Menhennitt ruling – was 98 to 23.

“The debate was conducted in an all male chamber, the women were outside rallying, organising, shouting through loud hailers, preparing for disappointment. I decided that next time we should be in there making the laws.”

It is not often that I agree with Susan Ryan, but I do on this matter – wholeheartedly. The whole of the Coalition voted against the decriminalisation of abortion although one young Liberal party member who stood up with a flourish as though he was going to break ranks and cross the floor to vote for decriminalisation, looked around and seeing he would be on his own, sat down.

As for Folau, it may have been easier to tell him to get lost. Of course he would not have, but I do hope that when some other sportsman near the end of his career and with enough notoriety to be noticed, says something as stupid as Folau has, that the situation is better handled, including not to renew the contract at some astronomical figure.

For instance, select him in an Australian team and he can then work out who is the adversary, given that he likes to compile lists.

Somewhat more important than Israel Folau

Opera is watched by an estimated a total audience of 300,000. It is a form of artistic licence that belongs to a different age. In that age women were treated dreadfully, composers had various forms of pathology. Who knows how many operas were written under the creative phase of syphilis so rife then. But now, to try and change the opera so as to satisfy a fad is as crass as the efforts of the Bowdler family in the 19th century to change Shakespeare to remove the “dirty bits”.

It is ironic that a report in the SMH of the opera “deisembowdlerising” itself, is perched alongside a report about the number of hate and violent items appearing on Twitter, Facebook/Instagram and YouTube. Here those indulging in such unspeakable behaviour are totalled in the millions.

So while token behaviour to cauterise opera plots may make those involved feel appropriately righteous, the problem is not solved by tokenism towards women’s rights.

However there is, as reported, a public health emergency in the way social media has become diseased.

Humans coming in contact with one another harbour the means of infecting one another with both the good and the bad. Globalisation is the jazzy word that we have for the removal of barriers to the spread of a vector, be it conventional trade, disease or whatever.

As the globalisation of Christianity occurred so did the spread of European disease against which the Pacific islanders and Australian aboriginals among others had no defence.

Similarly the globalisation of those who went to the New World of the Americas took a cornucopia of transmissible diseases as the contribution of Europe in this “free trade of infection”. In return Columbus is reputed to have brought back larges doses of syphilis. So it was a form of bilateral trade.

In those days when there was no idea what caused disease: perhaps the miasma, which was great for the perfume trade; or some dark unknown medium, which provided the excuse to torch women – and the ersatz cure – the miracle sustained by intercession via prayer or veneration of some osseous part of a saint.

Perhaps it is encryption that is the best analogy, especially as the means it has to deceive is akin to microbial mutation.

However, it is always the word “plague” which focuses the mind. And while we do not have the spectre of bodies loaded on carts being wheeled to mass graves, the world is entering into a time of cyberdisease, and “cyberplague” is convenient shorthand, although it has been used in generic terms before.

We now know the bacteria Yersinia pestis causes plague. Fleas and lice carry the bacteria. They can also lodge directly on humans if sanitation is bad – otherwise rats, dogs and cats inter alia are convenient intermediate hosts.

These abbreviated instructions from the Centers for Disease Control (CDC) in Atlanta on how to prevent plague provide clues:

* Reduce rodent numbers. Make your home and outbuildings rodent-proof.

* Wear gloves if you are handling or skinning potentially infected animals to prevent contact between your skin and the plague bacteria.

* Use repellent if you think you could be exposed to fleas or lice.

* Keep fleas off your pets by applying flea control products. Do not allow dogs or cats that roam free in endemic areas to sleep on your bed.

So it should not be too difficult to assign the appropriate language to deal with Cyberplague. One thing is for sure: it is the role of Government to supervise. The private sector does not do this well.

This darkening cloud over social media is the scourge. It is a public health emergency. And Donald Trump seems able to call a National Emergency, at a drop of a red cap… if he understands.

Where did all the Money Go?

I received an email this week from John Kitzhaber, once the Governor of Oregon and the man who received international attention when he devised the Oregon Health Plan. In part he wrote:

The cost of health care in this country is utterly out of control.  Mind-boggling. Approaching $3.8 trillion a year. This amount of money has attracted a whole host of private equity funds (that are) simply milking the system to feed shareholder profits. We had big national for-profit insurance companies that are likewise using public funds to increase shareholder value instead of reinvesting in the community.

John Kitzhaber – painting by Henk Pander

That problem is now also occurring here. When the Medibank model was established here in Australia, the expectation was that the patient would receive a medical benefit when they consulted a medical practitioner to assisting in paying for that medical service.

Doctors were considered to be in solo or group practice, and in fact when the first benefits were struck for procedural items, it was assumed that the benefit reflected what the government was prepared to pay to the patient for the perceived skill of the doctor.

Therefore when the array of medical benefits was struck for a surgical procedure, it was assumed the patient benefit recognised the skill of the doctor. The cost of the attendant scrub nurses, the surgical materials, the operating theatre were all absorbed into hospital costs, covered either by the public or private hospitals. In other words, the Medibank the scheme was constructed on a guild model – a hangover from the time when doctors sent accounts in guineas to patients who could afford to pay.

However, the medical professional entrepreneurs recognised that with the advance in technology, particularly in pathology but followed by diagnostic imaging with the arrival of the CT scans, there was a “pot of gold” awaiting. Radiotherapy and general practice have followed, and now other specialties such as cardiology are the target.

Technology improvements emphasised two of the problems with an open-ended floor price scheme as Medibank and subsequently Medicare demonstrated. The first one was the entrepreneurial manipulation of throughput against capacity for a particular procedure. This was lucrative when the Medicare benefit was set at a low throughput and not scrupulously adjusted over time as throughput increased with technological improvements. The second was the tiresome ‘pass-the-parcel’ game between the state and federal governments, otherwise known as ‘cost-shifting’. Private sector entrepreneurs have been able to utilise this for their financial gain but state governments have equally become adept at the cost shift and at the same time burying the real costs of health care.

As can be seen, health financing was drifting away from the original intention of enabling the patient to get a fair and reasonable subsidy for their medical care

The problem with the business model, which may have been devised first by economic rationally doctors in the Edelstein mould, is that it has been transformed into a business model not unlike the one described by Kitzhaber.

Here the doctors may be listed as the providers but in reality it is a company which employs them in some form which is harvesting the profits and shovelling Medicare money who knows where into tax havens around the world. Medicare money has acted as seeding finance for the eventual acquisition of overseas health companies.

It is difficult to watch the Federal government being so compliant. The problem is compounded by these companies giving a fraction of their Medicare-seeded profits to political parties for them to enable to run election campaigns saying they are looking after “all Australians” and thus these private firms to have a firm foothold into the political process.

The central governmental agencies know this but at present their political masters are impervious to this flow of taxpayer’s money off shore – after all we have a taxpayer Medicare levy so some firm profiting from such taxpayer funding can buy a health service in the USA or a pathology company in Germany – in effect using Australian taxpayers’ money to fund their business and not only that, but funding where there is a guaranteed floor price for each of services. So risk is negligible once the investment model is settled.

Kitzhaber’s comments are more than timely.

And for us in Australia, it gives us gives another meaning among others for a sonic boom.

Mouse Whisper

Heard between Nobby and Cambooya driving through that magnificent black soil country of the Darling Downs.

“Mate, the soil is so good out here you can plant nails and they come up crowbars.”

Yes, appropriately it is Steele Rudd country out here. But as my young mouse cousin asked “Who is Steele Rudd?”