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?”

 

Modest expectations Jiminy

In the Weekend NYT, there was a thought-provoking article saying we now have a great way in Instagram of recording aphorisms – the one-liners, deep philosophical verbal gestures. Jean Crispin writes:

“This should be the golden age of the aphorism. Constrained as we all are by time, attention and social media platform character limits, when we pull out our smartphones and stare into their illuminated fields, we can take in only so much. Shouldn’t those words be perfectly chosen to vibrate with hidden meanings?”

An aphorism has a way of bending you to its hidden truth, changing your way of thinking not with a 20-page document of well-reasoned arguments, but with just a sentence or two.”

I have two responses – one is that an Instagram is a vehicle for one line vanity press – “Look at me, aren’t I clever?” Mostly, the answer is no! In fact, given the weight of encouragement her opinion may give, I would introduce a Crispin Licence to Practise in her golden age.

The other is a question: “Have you ever read an anthology of aphorisms.” It is eye-glazingly boring unless you want to filch one and then pass it off as your own cleverness.

However Chris Brook, later in this blog, makes a very valid point, if obliquely. The name “blog” implies stodge as if we are working our way up a muddy hill. However, as Brook points out, the blog is a very good place to set up a conversation as long it remains coherent.

A blog is a modern cartouche. Not only does it name the author who is trying to explicate an eternal truth but also in itself it is self-contained. As I am writing, I glance up and see the front wall of our house; it is a variegated set of bricks that have been put together to cohere. Not exactly the wall of a Pharoah’s tomb, but the wall of brick cartouches is a sufficient metaphor for policy by cartouche aka blog. Thus, the blog can be used to build a policy wall, which Chris Brook is doing incrementally with his health policy contributions.

Napoleon Bonaparte, when he saw the ancient Egyptian way of hieroglyphic messaging, thought it looked like a gun cartridge, hence the name “cartouche”. I am sure he would have had a less viscous name for “blog”, perhaps “L’araignée boisée” abbreviated to “abois”.

A Memo to Me Mate the Minister for Minerals

Change is something that can take a long time. Therefore it is useful to live long enough to see change happen and then see the society change, especially when you yourself started on the wrong side of history.

By this I mean I started smoking when I found a half empty packet of brown Capstan in the train on the way home one night when I was 17 years old and from then on I smoked until I was 40, when I gave up. I have never had a cigarette since. But back then tobacco usage was pervasive. I owned several pipes so that tobacco could give me gravitas. They didn’t.

One of my memories is being in the emergency department during my internship. We used to light one cigarette from the butt of the last one. Many of the senior doctors smoked and we were corralled into the room at the end of the ward so that he, the senior doctor, could have a smoke (never “she” then) while he taught. The Medical Journal of Australia had until recently then been accepting advertisements from cigarette companies. My father, who was a doctor smoked cigarettes and more often Cuban cigars. He died in 1970 – he had a heart attack. It was Tobacco that helped get him.

It was Richard Doll who, with his colleagues in Oxford, identified the link between lung cancer and cigarettes from the late 1940s. He authored an article on doctors’ smoking habits in 1954. This whole public health investigation was not on the political radar, and even when it was there was a reluctance to interfere given how much cigarette money was sponsoring so many activities, including political parties.

Like many of my contemporaries in the health industry, I had one particularly uncomfortable moment on the way to weaning myself from cigarettes. I happened to be in the office of one of Jimmy Carter’s advisers. I asked whether he would mind me smoking, pulling out a packet of Gaulois. He looked at the packet and suggested that they were worst cigarette to smoke from a lung cancer point of view. Needless to say the rest of the conversation could have been better.

However, it was three years before I abruptly stopped. By that time I was working for the AMA, but there was no overt pressure for me to stop. I just decided one day it was a dirty habit. I just smelt. Cigarette ash like coal dust was a pollutant. So I went cold turkey. I surprised myself and never smoked again. And one of these days, we as nation will have to go cold turkey on coal, before it is too late.

The only contribution I have made to policy in this area of tobacco happened one day in the early 1980s during my time at the AMA. I was rung up by a friend who was then on his way up the bureaucratic ladder, who asked what I thought about indexing the excise on tobacco products. I said great idea – and QED, it came to pass.

However, far more importantly, community behaviour has changed in Australia. The smoker is very much a pariah in public places – the array of butts on the windy corners of the city reinforce the image of the uncaring polluter.

One wonders how long it will be for those who hold up a lump of coal in Parliament proudly, to be like the young doctor in the emergency department lighting a cigarette amid an atmosphere of tobacco smoke, and change. Hopefully it will not take 17 years.

One cigarette executive once said of me that I was a hypocrite in my attitude to smoking. No, I said, as our coal-fired politicians and their minions hopefully may eventually recognise, they will eventually become as I did over the matter of cigarettes – a penitent.

Not to everyone’s Taste

When I went to the Baltic States a little time ago I visited many churches. I climbed the Hill of Crosses in Northern Lithuania. My visual cortex is an attic stacked with images of Christ the Child and Christ the Man. These are not my image of Christ nor indeed of my God the Father who dominates those below as if some Jovian presence as though Heaven is at the top of a religious escalator. As for the Holy Spirit as some wraith dodging in and out of my cerebral inglenooks … really?

Hill of Crosses

I therefore cannot conjure a visual image of the Trinity. I do not have the capacity to do so. They are not Three clustered on a Throne. I am thus left with my other known senses to provide me with some reference point by which I can relate to the Trinity.

I cannot touch Them, although in some worlds people seem to believe in the supernatural. Whether that is some kinaesthetic experience where God in various forms intrudes is again beyond my ability to fathom.

I cannot hear God. It is not that I am deaf, but I have not had the experience of having auditory communication, although I may have missed it – by not having paid enough attention, not being able to break the code or simply not knowing the language.

I thought that since frankincense and myrrh were so important in the Nativity that perhaps there would be a particular fragrance where I may be able to smell God. To me substances that emit a smell are important to my being. In particular I love herbs in all their differentiation. The Bible is full of references to herbs, and for a moment I toyed with the ability to distil these olfactory sensations as a means of conceiving God. But then the idea was too difficult and my brain inadequate to process – at least at this point in time.

Then there is taste, and in the early hours of one Thursday morning, I realised that when I have taken the Bread and the Wine at Communion it is somehow different. I cannot express that thought any further, but taste is a very complex physiological phenomenon. Taste is itself a trinity of cranial nerves – the facial, the glossopharyngeal and the vagus.   Surely that is a coincidence!

Perhaps, just maybe, that is how God is in my head. But I am still uneasy and unsure to presume even that. But it is the only way I can sense my God.

Chris Brook on Health

Whenever the future of the Australian health system in Australia is discussed, the discussants tend to focus on their own area of special interest and to adopt the “gap filler” approach. It is the basis of incrementalism.

It seems pragmatic and sensible to target perceived areas of deficiency. Examples of this currently are:

  • universal dental care (a costly initiative if ever adopted)
  • mental health care including youth suicide ( very deserving of consideration)
  • better public information to facilitate informed decision making
  • integrated care initiatives.
  • In fact the list is endless. It is a question of priority.

Filling gaps seems to assume that all is otherwise rosy in the health care system, when of course it is not. I listed above some of the schemes. Underlying the edifices we wish to build are the fault lines.

  • Think how far dental health schemes are from universality
  • Think lack of coordination between GP type primary care and specialists
  • Think of the gulf between hospital care and any form of community based care whether specialist, general practitioner or other
  • Think cost shifting between levels of government between care settings and funders including private insurance funds, a set of pernicious behaviours raised to an art form in some jurisdictions
  • Think out of pocket costs and deliberate privatisation of services
  • Think of the difficulty for the increasing number of people with chronic and often multiple morbidities in navigating the fragmented health system.

Above all, think “systems”! Then ask why don’t we actually have one! For historic reasons we have a set of arrangements based largely on fee for service, whether Medicare, Hospital casemix funding, or Pharmaceutical Benefits scheme.

Multiple costly government attempts to engage general practitioners, with the latest being primary health care networks (PCHN), but also with practice incentives, IT incentives and without anything similar for specialists. They just have not been sensibly considered.

There are many questions about the Australian health system. For example, why is Australia’s rate of hospital admissions some two and a half times greater than virtually all other OECD countries? The answer lies solely in what Australia counts as an admission where it includes day treatments and day procedures as admissions when no actual overnight stay is involved. Once this is taken into account the Australian apparent admission rate plummets to the normal international level. Australia does this for accounting and payment purposes and it may be said that it works reasonably; but could it be better if done differently?

Many countries are far more advanced in consideration and implementation of capitation-based funding for large parts of health care, adjusted for risk using some really very good predictive tools, such as DxCG predictive for risk.

The appeal of capitation since the 1930s has grown with the birth of Health Maintenance Organisations like Kaiser Permanente. Offering an annual payment for all care should allow flexibility in the “what and where” of care including, most importantly, preventive services. It should allow tailored care for individuals and greatly facilitate navigation.

The theory may not always translate because the bogey of managed care is that it is rationing in disguise – and rationing has caused many problems notably in the USA, in particular knowing where to draw the line.

Nevertheless, capitation has its advantages, especially for the funder.

Fee for service at the extreme is a free-for-all encouraging providers to offer as many services as possible to as many people as possible, whereas capitation encourages providers to offer as few services as possible to the least number of people.

So measurement of adequacy of patient benefit must be part of any approach, being preferably outcome based, incorporating the triad of: clinical assessment, whether periodic or after a specific care; patient reported health outcome measurement, including some measure of satisfaction; and periodic functional assessment. Here elective surgery is the easiest one to reference – post-joint surgery or post spinal surgery; one functionality, the other more relief of pain.

Barriers are pervasive. The structure of the Australian Constitution originally only accorded one Federal health power – that of quarantine – and has made the Australian health system a patchwork, which is increasingly fraying around the stitches.

One blog is too short a space to go much further, so take this as just a start. Serious policy is always work-in-progress. However serial blogging over time will help, as now is a very appropriate time to take this whole policy area much further.

The rise of the zinger

I remember when the late Senator John Button, in a mischievous moment in the Senate, once asked the Minister of Science a question without notice: how many centimetres there was in an inch? The Minister did not know. Button achieved his point; he made the Minister look like an idiot. Although amusing at the time, it has not improved the quality of the politicians who have been given the science portfolio – that is when the portfolio hasn’t been abolished.

Alan Jones uses the same ploy but slightly differently. Ask a relevant question when confronting someone ideologically at odds, but unlike Jones who does his homework, the other person has not done so.

So when Jones asks one of these adversaries what is the current level of CO2 in the atmosphere, and that person doesn’t know, Jones goes on his victory tirade. It doesn’t matter if that person knows the answer, reality is not based on some human dot not knowing the answer.

Oh please … the zinger. Smart, but it doesn’t help when we are seriously discussing the future of Planet Earth.

The reality is that the level of CO2 in the atmosphere is straight lining upwards like the trajectory of a bullet into the sky. We have passed the 400 ppm mark.

If fossil-fuel burning continues at a business-as-usual rate, such that humanity exhausts the reserves over the next few centuries, CO2 will continue to rise to levels of order of 1500 ppm. Then forget about the human race. Think Venus with billowing clouds of CO2 disguising the uninhabitable planet surface below.

But Alan, you will not be around, nor shall I – but unlike you, I have descendants for whom I feel responsible.

Mouse Whisper

Three years too soon? Or don’t talk about the Polls? It was not only Newspoll. Some weeks before the election …

“Labor is comfortably ahead of the Coalition in the latest Guardian Essential Poll, and just over half of the voters in this fortnight’s sample, particularly voters under 34, worry Australia is not doing enough to address climate change.”