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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.

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.

Modest expectations – Parrot

I want children growing up in Australia to feel positive about their future, and I think it is important we give them that confidence that they will not only have a wonderful country and pristine environment to live in, that they will also have an economy to live in as well. I don’t want our children to have anxieties about these issues.”

The antidote for such anxieties?

Religion is the opium of the People.

You get good Marx for that solution.

The safety valve

I never thought when I was challenged to write a blog, which I’m sure among the cacophonies of ideas and opinions may be read by one or two, looking for a murine apparatus and getting the spelling wrong. However, the blog is a safety valve. It allows one to shower cyberspace with words – and since cyberspace is self cleaning then you do not pollute but leave, in one’s own mind, priceless gems hanging like lanterns lighting humanity as they get swallowed by the uroboros.

However as the twilight glimmers, one of the only facilities left to me now is writing. Assuming that this is my skill, I am writing as if there is no tomorrow so that there is a legacy for what it is worth. I always listened to Alistair Cooke’s Letter from America every week when he was alive; there was always a reason for saying what he did. The book of his travel around America when he was a young man inspired me to see as much as I could, since that axiom that one is a long time dead rings so true – despite one’s affirmation of life everlasting in the Apostolic Creed. The problem is that these Creeds were hatched when 40 years was the life expectancy; thus before one realised the horror of old age and being cast into the Life Everlasting nursing home.

Rockchoppers revisited – A Weapon of Mass Destruction

I read Rockchoppers just after it was released in 1982. It was written by a Roman Catholic priest, Edmund Campion and in the wake of what I thought was the awakening of the Roman Catholic Church following Vatican II and with it the growth of the worker-priest movement. It was a brilliant book.

His description of Chartres cathedral – there is none better. To stand, kneel whatever your stance in Chartres Cathedral the cathedral is, the nearest I myself have ever felt of being in a divine presence. Edmund Campion put my inchoate thoughts in print elegantly, compellingly. He quotes those stirring words of Fulbert, one of the Bishops of Chartres.

We are as dwarfs on the shoulders of giants. We can see more and farther than they, not because we have keener eyesight or because we are taller than they, but because we are raised up and held aloft by their grandeur.

Yet as I clear my library of books accumulated over more than half a century, I wonder how Campion feels today about his Church beset by a tidal wave of child molestation, unacknowledged children of priests and the indefensible maintenance of the seal of confession in cases of child rape, the non recognition of woman as priests, the hurt and harm to so many of the flock over which these men in frocks and silly hats have presided. Shepherds they ain’t, although they do carry a crosier – representing the shape of a crook.

Corpus Christi College in Victoria, a seminary, has been revealed as a cesspool breeding pederasts. On re-reading his book, Campion is very chatty about his early life, except for the time he spent in the Manly seminary studying for the priesthood. He dismisses it in a few lines – “for years I would have nightmares that I was back inside those walls”. That is all, and his book then pursues the doctrinal-political pathway of a man whose beliefs are in line with those of the worker priest at a time when Santamaria was in ascendency. Yet he must have known about the increasing social dysfunctionality of the Church – he is too astute and sensitive not to have known.

However, this week watching these Roman Catholic apologists wheeled out for the courteous Lisa Millar and Geraldine Doogue to interview, there are the masks of geniality that are difficult to challenge, especially if you have been conditioned since childhood with a sense of guilt. You can never be rude to the Church. The Church would never send in the current Archbishop of Melbourne for interview as the public relations front – just get a good ol’ empathetic face of a Father Brown understudy with a purple vest to pour on the paternal charm.

This is the Roman Catholic Church in delay, delay and delay mode; the creed of Catholicism, as it is with many religions, is secrecy and rearguard. The description of church architecture to over the centuries as described by Campion designed to increasingly separate the congregation for the priest to enhance the impenetrable secrecy should be standard reading as should be his antidote in Chartres.

Personally I am pessimistic and the Campion book holds the clue of why that is. Within all religion there is a reactionary group fearful of change which intelligent unscrupulous populists like Santamaria can exploit, as he did through the DLP before it was effectively destroyed in the 1974 Federal election.

However, it is not only the conservative Roman Catholics, but also in Newt Gingrich’s cleverly exploitation in harnessing the political clout of the evangelical Christian movement in 1990s. There are two forces – fear and the authoritarian personality, which oppose the forces that Campion wanted unleashed to liberalise the Catholic church. Therefore, to protect the base the traditionalists are prepared – if not to condone the despicable behaviour outlined above – then to look the other way or throw a blanket of sophistry over it.

Richmond – A Reflected Glow

I am not a Richmond supporter. However, I easily could have been if the kids on the corner of the street where I lived when I was five had not been Essendon supporters. Deeply impressionable, I became a passionate Essendon supporter, a support that was transferred to my sons and their children.

However, my great grandfather, Michael Egan was Mayor of Richmond in the early 1870s and there is even a street named after him in Richmond. He distinguished himself by biffing another councillor who dared to disagree with him, but many of his other achievements as a councillor have been lost when at some time later the Council records were incinerated – some say suspiciously.

Michael Egan made a fortune with a wood yard, initially at the end of Rowena Parade and then transferred to Punt Road, where the Yarra River was convenient for transporting the wood. Anyway most of the wood ended up in the goldfield diggings, and when the great Crash of the 1890s came, I was always told that he survived because his money was in the Bank of NSW.

During the 1970s I frequented the Vaucluse Hotel in Richmond where we had monthly meetings, and this was time when the licensee, Graeme Richmond, was one of the geniuses behind that golden period when Richmond was last a powerhouse football team; and mine wasn’t. However, despite the horror of the period I did not change my colour from red sash to yellow.

Then Kevin Sheedy came along, a Richmond champion footballer as coach of Essendon in 1981. I thought Sheedy a dirty player and remembered him breaking Des Tuddenham’s leg, another ferocious footballer of that era, who had gone to Essendon as playing coach from Collingwood.

Now this Sheedy had come to Essendon as coach, and there was a perverse satisfaction in him losing five out of the first six games as coach such that he contemplated putting on the boots and coming back as a playing coach.

Then the Sheedy era blossomed. Essendon won 15 games in succession until it lost the very last game of the season to Geelong to Geelong and subsequently the 1981 elimination final. In three years though, Sheedy achieved his first premiership with my team – the first since 1965 – and during this time it turned out that Sheedy had been an Essendon supporter as a kid.

The tide was turning. Sheedy in my eyes now had been a fearless, uncompromising player, who brought the best out of his players instilling that intense fearlessness, of which the current Richmond coach, Damien Hardwick, as one of his protégés was a beneficiary.

One day Sheedy had also stopped to play cricket with my sons who were practising on one of those malthoid wickets in Yarra Park close to the Richmond Cricket Ground. How good was that for two teenage boys forever devoted to the Essendon red and black! Richmond and Essendon were thus forever closely intertwined.

However, even before Sheedy was appointed, I did make amends in relation to the yellow and black when in 1979 I moved to Balmain – Richmond on the Parramatta River as I called it – and became a very strong rugby league supporter of the then Balmain Tigers.

Balmain colours were orange and black. But what is there in a different shade of colour?

But then that is another story.

Trudeau or Scheer. Scheer who?

It’s colder; they play ice hockey more; their bacon is really ham; and their obsession with maple syrup products borders on unhealthy. So penned a BBC reporter in an introduction to an article about the Canadian versus American political system.

The Canadians go to the polls on 21 October with 338 ridings up for grabs. Next week, the leaders of the various parties face the media in a Quebec venue – one in English –the other in French before audiences presumably who can understand “pollyspeak” in two languages.

There seem to be six parties in the electoral campaign, although two of the parties have two and one member each – the Greens, two on the Vancouver islands and a one-man party led by a LePen-like character who holds a Quebec seat. This leaves the left-of-centre New Democratic Party under its leader, Jagmeet Singh, struggling to repeat its 2015 successes. The Bloc Québécois Leader, Yves-François Blanchet, seems more secure and concentrates on the francophone areas, and it is the loyalty of his constituency that will probably determine whether Trudeau can wrest seats and be re-elected.

Trudeau thus will have to win seats in Quebec, an aim helped by the fact that the Conservative leader, Andrew Scheer, who represents a riding in Saskatchewan, does not speak French well.

However, the end result of the election should be interesting. We Australians pay scant attention to Canadian politics, only mentioning briefly Justin Trudeau’s travails, when he had been embarrassed by his appearance in blackface on several occasions when young, well before politics beckoned. These antics have been portrayed by the right-wing media as though they were a mortal sin. However, given the rise of social media and the tendency apparently to trade intimate and potentially embarrassing images, maybe this minor transgression by Trudeau will be magnified in future elections for aspiring politicians as the “sins of the past” are paraded as “weapons of mass destruction”.

What is important about our future relations with Canada is that both countries for their size and GDP have substantial pension/superannuation funds, with the potential for investment. An example of this is the joint arrangement announced in August between Australian Super, Australia’s largest industry superannuation fund, and Ontario Teachers’ Pension Plan, Canada’s largest single-profession pension plan, to invest $1 billion each in the National Investment and Infrastructure Fund (NIIF) of India’s Master Fund.

Then this week, Webster Ltd, Australia’s monopoly grower of walnuts, signed a deal for an AUD854 million takeover, yet to be ratified, by PSP Investments, Canada’s huge public service pension fund. The same fund has funded the Hewitt Cattle Company to expand its holdings in the Northern Territory. PSP Investments also owns 25 per cent of the NorthConnex tunnel, 25 per cent of the Westlink M7 toll road, 33 per cent of the rail freight company, Pacific National and a large slice of BAI Communications – in political terms all highly strategic.

The problem with the two countries is that in addition to being far away from one another, they traditionally excel in different sports (unlike other countries in the British Commonwealth). So the two countries exist in parallel. Any communication between Morrison and Trudeau one can guess has been minimal; perhaps if Scheer becomes Prime Minister there will be more evidence of shared vision in a common adulation of Trump, given the way their political careers have slid forward.

Politicians are great followers and perhaps the investment profiles of the large superannuation/pension funds of each country may guide them to pool their common interests so there is a potential third force in this increasingly polarised world.

And one great advantage Canada has over Australia is the lack of the Murdoch shadow. It should be noted that James Murdoch has purchased a property in a remote part of British Columbia, but then does he count? After all, he has been caught providing funding for democratic aspirants for the U.S. Presidency.

Mouse whisper

Mentioning “Boof”. It may have been 2010 … with apologies to A.A. Milne.

Scott Scott Morrison Morrison whether a matter for glee,

Took great care of his bear, though he was forty-three.

Scott Scott said to the Rupert: “Rupert, ” he said, said he.

“Don’t ever go up to the top of the town if you don’t go up with me …

and look what happened – Scott² Morrison² has another bear called Lachlan.

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 19^th 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 – Whistling Dixie

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?

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.”