Leak suppressed

I only came across this today, but it seems to me a bit of a News £td beat-up or stunt or something...

For cartoonist Bill Leak, the nanny state is real. It has just snuffed out his attempt to launch a new business aimed at poking fun at the government.

Leak had been planning to sell cardboard covers for packets of cigarettes that would have obscured and ridiculed the graphic images of gangrenous legs and cancerous mouths that have been mandated by federal legislation. ...

He made contact with manufacturers and developed the outlines of a business plan. But after he took advice from a Sydney silk about the impact of the government’s plain packaging laws, the project was dead.

The risk of being dragged through the courts was too great. ...

Leak said the law had stifled his ability to make a political point while developing a new business.

“It was an attempt to deploy satire as a weapon against the nanny state, but the nanny state has a bigger, nastier bite than I thought.”

Oh puh-lease!

It’s written by Chris Merritt, The Australian’s legal affairs editor who offers no insight whatever on Bill’s “advice from a Sydney silk.”

He features a quote from Nicola Roxon being all defensive about the government’s plain packaging legislation, presenting the A-G as creepily unhumorous while giving no context about what prompted her remarks.

Apparently one of Bill’s mock fag packets was ‘branded’ Roxon’s Nicolatinas. Gee, subversive yet classy. And hysterically funny at some level, I’m sure.

In keeping with the clubby News £td milieu, the story has been picked up by the likes of the IPA and Tim Blair as an example of the imminent threat to free speech by instinctively totalitarian nanny-statists, etc. etc. etc.

Tragic to think in what useful capacity these bods might ever be employable if their imaginary wicked nanny-statists were ever successful in ‘silencing’ them.

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Fingers crossed in place in WA

Piers Akerman is in full hand-wringing mode about the impasse over the National Disability Insurance Scheme.

Aside from declaring that “Gillard IS the national disability” (nudge, wink), he asserts

WA already has a more generous scheme in place.

Gosh, how very advanced of WA. So, one wonders, how “in place” is this western wonder?

The West Australian Government says it will trial a disability insurance scheme with or without the Federal Government. ...

WA’s Disability Services Minister, Helen Morton, says she has put forward four potential locations to her federal counterpart as the state would like to host a trial.

“We’re very keen, we’ve got our fingers crossed, we hope that we’ll be able to get one of those trial sites up and running,” she said.

One has to wonder about the gulf between Akerman’s conception of “in place” and Morton’s “fingers crossed”.

Oh, and how much “more generous”?

The State Government has not said how much money it will contribute to the NDIS.

In contrast with Akerman just making shit up as it suits him, Andrew Bolt at least has stated flat-out that “I don’t know enough,” but he’s “on high alert” anyway.

And so must we all be, with jokers like these ‘informing’ the national ‘debate’.

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No smoking gun

Peter van Onselen had a column in the Sunday Telegraph in which he contends that the aim of plain packaging of tobacco products is at odds with Wayne Swan’s budget forecast of excise revenue from tobacco.

Along the way he distances himself from the term “nanny-state” while suggesting that plain packaging is a nanny-state thing.  Go figure.

But I’m not so much concerned here with van Onselen’s strained polemics against nannyism as I am that he seems to have verballed Health Minister Tanya Plibersek in such a way as to bolster his argument. He wrote:

Just last month, Health Minister Tanya Plibersek said she was “confident that plain packaging will reduce the number of smokers”.

Whereas according to the transcript of the program in which van Onselen interviewed her, Plibersek in fact told him:

Well, we are confident that plain packaging will reduce the number of smokers in the future. [my emphasis]

Van Onselen, like so many who take issue with plain packaging, just does not get that the primary aim of plain packaging is to deter young people from ever taking up the deadly habit. It’s success therefore probably wouldn’t be evident in the shorter term, and therefore would probably have negligible budgetary impact for at least the first few years.

Yet, van Onselen plods on regardless...

It stands to reason that if the government seriously expects smoking rates to decline when plain packaging legislation comes into effect, there would also be an expected decline in tax revenue.

Yet according to the forward estimates in the budget, Treasurer Wayne Swan is relying for his much-anticipated return to surplus in 2012-13 on a largely unchanged windfall from smokers. It’s the same story in subsequent years.

I think that van Onselen might be being somewhat like a dog with a bone on this.  Or maybe I haven’t properly followed his diabolically clever argument? At any rate, I tweeted him a query last night regarding his omission of Plibersek’s qualifier... but no reply thus far.

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Webber and the Medicare Safety Net

There’s been some sloppy reporting in the press recently regarding criticisms by the former head of Medicare’s Professional Services Review board, Dr Tony Webber, of rorts and abuses in Australia’s public health system. Dr Webber has estimated that $2-3 billion are “spent inappropriately” annually.

A claim given particularly lurid prominence in most media reports is that the Medicare Safety Net had been used “to subsidise cosmetic procedures, including surgery for ‘designer vaginas’ at $5000-$6000 each.”

Really? As in, subsidised directly under the benefits schedule?

Well, no, actually...

Here’s Dr Webber quoted in The Australian:

Denouncing the system he helped oversee, Tony Webber claims Medicare is “riddled with misdirected incentives” for doctors, that payments worth up to $140 to GPs for writing care plans have created “opportunities for a bonanza” and that the safety net has been used to “subsidise cosmetic procedures such as surgery for ‘designer vaginas’ at $5000-$6000 each”.

Now Webber quoted in The Age:

He says he is aware of instances where the Medicare Safety Net had been used “to subsidise cosmetic procedures, including surgery for ‘designer vaginas’ at $5000-$6000 each”.

Now here’s Webber writing in the primary source, his article in the Medical Journal of Australia:

During my time as Director of Professional Services Review, the Safety Net was used in effect to subsidise cosmetic procedures such as surgery for “designer vaginas” at $5000–$6000 each.

Attentive readers will notice both The Australian and The Age omitted to quote two rather important words; i.e., those cosmetic procedures were “in effect” subsidised under the Medicare Safety Net.

The import, I believe, of what Dr Webber actually wrote is that the “open-ended nature of the Safety Net” permitted opaque arrangements under which such cosmetic procedures could be effectively, albeit indirectly, subsidised without administrative detection. (See paragraph 9 here.)

But the sloppy quoting, by both the above papers, promotes the impression that such cosmetic procedures have been somehow directly subsidised, as if under the MBS.

Note, however, that The Australian at least made reference to Webber’s “open-ended” criticism of the Safety Net, albeit several paragraphs down from the ‘designer vaginas’ quote; whereas The Age omitted that “open-ended” bit entirely.

Webber’s article is worth the read. Note also, he doesn’t “denounce the system he helped oversee,” as hysterically reported in The Australian; he actually quite seems to like it but wants it fixed.

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Public health facility now unencumbered with patients

Yes Minister, this could be one of the best run facilities in the public health system.

With all residents now gone from the nursing home a new staff structure has been put in place.

Some administration staff have been retained to oversee the closing off the facility and to explore options for its future use. Maintenance staff also remain in place with two house keepers and caretakers appointed to ensure the building is kept up to a high standard as future uses are sought out.

Koroit Health Services Acting CEO and Director of Nursing Michelle Finnigan said the appointment of the housekeepers and caretakers were important ones... “This will ensure the building is safe and secure and it will be keep fresh and vibrant to help get ready for future opportunities.”

Meanwhile, even the former staff never had it so good.

“And the nursing, kitchen and cleaning staff have also found some wonderful new opportunities and they are now free to move onto the next stage of their careers.”

Everyone’s a winner!

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Elsewhere: Lancet assessment of mixed outcomes in Afghan health

The Lancet reports the release of the first national comprehensive mortality survey of Afghanistan as providing cause for both hope and concern.

To improve rebuilding efforts as well as gauging development initiatives and years of multisectoral investment by the international community, the Afghan Public Health Institute of the Ministry of Public Health and the Central Statistics Organisation undertook the Afghanistan Mortality Survey (AMS) 2010. AMS 2010 is the first national comprehensive mortality survey of 222,351 households, 47 848 women aged 12—49 years, and verbal autopsies of 3157 deaths in the 3 years preceding the survey, and covers 87% of the population in 34 provinces in the country. ...

The most encouraging progress is in maternal health, with an overall increase in coverage of antenatal care, skilled birth attendance, and births in health facilities to 63%, 34%, and 32%, respectively. Despite these achievements, fewer than 16% of women reported having at least four antenatal visits (the minimum necessary to provide adequate screening for pregnancy complications), while 71.5% women had not received postnatal check-ups for their last birth, which is vital for monitoring delivery complications.

This is in a context where...

According to a UNICEF fact sheet released last month, Afghanistan is one of the most dangerous places for a pregnant woman or a child to be born. Afghanistan has the highest rate of maternal mortality in the world, with 1400 women out of every 100 000 livebirths dying of a complication related to pregnancy or childbirth, while its mortality rate for children younger than 5 years is ranked second in the world, with 199 deaths per 1000 livebirths. Even if a child is lucky enough to survive birth, he or she could only expect to live 44 years, while the life expectancy at birth of the world overall is 67.2 years for 2005—10.

However,

this report is not without limitations. First, 9% of the total populations in Afghanistan, who live in the rural areas of Helmand, Kandahar, and Zabul provinces in the south zone, are not represented in the survey owing to security reasons, which seriously limits the report’s usefulness for planning. Second, although the survey has suggested much lower maternal, infant, and child mortality rates than previous estimates, given the geographically limited samples and use of verbal autopsy data, the numbers should be treated with caution. ... Finally, anthropometric indicators such as stunting or wasting rates, which can help evaluate malnutrition—the biggest contributor to child mortality by far, are missing. According to UNICEF’s Afghanistan Country programme document 2010—2013, around 1.2 million children younger than 5 years and 550,000 pregnant or lactating mothers are at high risk of severe malnutrition in Afghanistan.

The Lancet concludes, ominously:

To safeguard what has been gained with so much difficulty, sufficient and consistent assistance must be ensured from the international community.

Hear hear! And let’s be reminded again of Tony Blair’s 2001 pledge that we will not abandon Afghanistan.

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O brave new climate!

For his final TV show of the year, Andrew Bolt had tantalisingly promised his followers “a mention of Tim Flannery.”

So naturally I had to tune in, hoping for his sake he wasn’t going to run with Bunyip’s failed gotcha on Flannery, to which he’d given such prominence on his blog. In the event, he took a somewhat different angle. Phew!

Bolt sought to ease our Flannery-inflamed anxieties by emphasising three points. (See youtube video. Note: creepy presenter warning.)

First,

• With the expected increase in Australia’s population this century, you’ve got to expect some increase in the number of “weather-related deaths” anyway.

True enough so far as it goes, and we eagerly await the release of Doctor Easychair’s study into what the actual real numbers will be.

Second,

• The “death estimate” presupposes the world warming by “an incredible four and a half degrees this century, when it hasn’t actually warmed for the last decade.”

The supposed absence of warming over the last decade to which he refers is, of course, a recurring fancy of climate change ‘sceptics’ everywhere.

Also noteworthy is that the study he refers to, published in 2008^* (way before Flannery was appointed to the Climate Commission), actually considers various public health outcomes, aside from ‘death estimates’, across a range of scenarios.

For his third point, Bolt quoted a snippet from that study:

This assessment does not quantify the extent to which future adaptation to climate change will modify the levels of death...

The document itself continues,

..., injury and ill-health for each health outcome. It will be difficult to make confident quantitative assumptions about the potential adaptive consequences...

“Difficult”? Not for our Doctor Easychair, who confidently gushes his third point:

• “This death estimate comes from researchers who admit they didn't allow for us getting richer and smarter, so much better able to adapt to the new climate. You know, being able to afford better cures, better disease prevention. Cheaper air conditioning!”

Yay, we’re saved!

While we eagerly await the details of Doctor Easychair’s confident quantitative assumptions about our adaptation to this “new climate” — which he may or may not believe in anyway, who can say? — still the prospect of unspecified cures and cheaper air conditioning is welcome relief after all that scary stuff.

And it’s not unreasonable to expect Doctor Easychair will next solve other problems such as war, famine, and... oh, let’s throw in cold fusion and teleportation.

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* Garnaut Climate Change Review, June 2008, “The impacts of climate change on three health outcomes: temperature-related mortality and hospitalisations, salmonellosis and other bacterial gastroenteritis, and population at risk from dengue.” Available as PDF document from the Garnaut Review website.

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UPDATE

Yep. Andrew Bolt really does believe it’s all about him. On a video of a discussion between Robert Manne and Tim Flannery, he observes:

I’m mentioned so often by the two alarmists that I wonder why they didn’t simply invite me along to have the debate they’d promised.

Promised debate?

Latrobe University, which hosted the event on August 12 this year, billed it as “A Conversation between Tim Flannery and Robert Manne.”

It’s the youtube hosted version (posted, it says, 1 day ago) that for some reason titles it as “Robert Manne vs. Tim Flannery,” with the description, “Robert Manne debates Tim Flannery.”

Anyway, I had to wait 17 minutes for the first mention of Bolt (17:27), then 23 min (40:10) during which Greg Sheridan came up (33:58). Then he was mentioned once during the Q/A where Manne imagined a hypothetical debate between Bolt and Phillip Adams (1:07:55).

So that’s three very brief mentions in over 80 minutes. None of those mentions related to any particular point of science because the focus of the conversation was on Flannery’s role in communicating his brief as Climate Commissioner.

Manne and Flannery did have a number of points of difference, but they maintained the discussion in a spirit of civility (so often missing in political discourse, so Bolt is always saying).

It’s a pity our Doctor Easychair only has ears for himself, because he’d seem to have missed out on hearing a thoughtful, wide-ranging discussion.

Why wasn’t he invited? I guess because it was intended as a thoughtful, wide-ranging discussion.

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Bunyip’s failed Flannery gotcha

The Australian government’s Climate Commission this week released a controversial report projecting “impacts of climate change on the health of Australians.”

The report was launched by Chief Commissioner Tim Flannery, which was duly reported in The Australian. From among the report’s projections, the paper reported:

Without international action on climate change to limit temperature rises to [2 degrees celsius], the number of predicted temperature related deaths in Australia is predicted to rise from just over 6000 in 2020 to about 10,000 in 2070.

Admirably taking this statement with a sceptical grain of salt, blogger Professor Bunyip armed himself with “a pocket calculator and a copy of some recent Bureau of Statics [sic] projections” to set about testing the Climate Commission’s predictions.

In 2020, according to the ABS, Australia will be home to some 30 million people, of which Flannery insists roughly 6000 will be carried off by dengue fever and other curses that thrive in the heat. By 2070, the same ABS projection posits a likely population of between 46 million and 54 million, depending on which curve you choose to track.

So let’s see how that works out: 6000 deaths per 30 million means a 1-in-5000 chance of being done in by nasty weather as of 2020.

And 10,000 deaths in a 2070 population of 54 million? Well that comes in at 1-in-5400 climate casualties.

So the warmer it is, at least by Flannery’s reckoning, the safer and healthier we will be.

Neat... except Bunyip has made a couple of erroneous assumptions — one trivial, and one that’s somewhat more serious.

Trivially, he attributes the “reckoning” to Tim Flannery, when in fact the report’s authors are Lesley Hughes and Tony McMichael. (Hughes is a commissioner with the Climate Commission, and head of the Department of Biological Sciences at Macquarie University. McMichael is professor of population health at Australian National University.) True, Flannery as Chief Commissioner did launch the report, but the centrality attributed to Flannery by Bunyip and his fellow travellers is about an agenda.

More serious, however, is Bunyip’s simplistic (albeit pocket calculator-friendly) assumption that the health-related effects of hotter temperatures will be linearly uniform across Australia.

Whereas the modelling from Hughes & McMichael is somewhat more complex:

Under a worst-case scenario, unmitigated climate change may modestly reduce temperature-related deaths in Victoria, Tasmania, South Australia and NSW . . . but deaths could increase markedly in Queensland and the Northern Territory.

That’s an actual quote from the report that was in the article Bunyip relied upon for the above, so he has no excuse other than agenda-driven zeal.

So, Bunyip will need to factor into his calculations some sort of inverse differential between Qld/NT and the other states and territories, based on population projections for each, factoring in some assumptions about relative risk in each, etc. etc. etc.

The take-home message of Bunyip’s foolishness is that modelling of complex systems is ... well, complex ... and requires somewhat more than a pocket calculator and an agenda.

Oh, and beware when someone like fact-averse Andrew Bolt thinks well of you.

UPDATE 06/12

Bunyip has rebutted my remarks here in an update to his post, in which I’ve been soundly bitch-slapped, had my arse ass handed to me on a plate, whilst simultaneously having it kicked, on my way out the door. That’s fixed my little red wagon, yessah, and I won’t be dragging my arse ass back in a sling for more, nossah!

Kidding. He called me some names and had a little whine about standards.

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Longevity not so affordable in long-term

From a discussion of various models for reform of the residential aged care sector in New Zealand:

Enhanced integration of aged care and other health services could improve older people’s outcomes and lower direct costs. It is, however, a complex structural change and international experience suggests that it may, in fact, not reduce total costs, primarily because initial savings are often offset by increased longevity.

• Aged Residential Care Service Review: Summary of Findings (PDF)
  Grant Thornton New Zealand

Always a catch, but then it stands to reason. Increased budgetary and other imposts due to increasing longevity is in fact a recurring theme in the Grant Thornton report above, as indeed it is in the Australian Productivity Commission’s Caring for Older Australians draft report.

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Fertile and fresh fields for tobacco in China

This op-ed in The Lancet again highlights that China, while streets ahead of most western countries on some important indicators, has a long way to catch up in other respects, here particularly with regard to the scourge of tobacco.

It sounds like a public health nightmare: a country where smoking is socially acceptable, people can smoke in public places, cigarettes are cheap, cigarette packets are devoid of effective health warnings, government officials use public funds to buy expensive cigarettes as gifts, and the tobacco industry sits on public bodies charged with tobacco control. But this is, in fact, the reality in China today, as detailed in a new report by the Chinese Centre for Disease Control and Prevention.

Given this situation, the statistics contained in the report are, perhaps, unsurprising. China has 300 million smokers and around 740 million non-smokers who are exposed to secondhand smoke: tobacco is the country's biggest killer.

China did ratify WHO's Framework Convention on Tobacco Control (FCTC) in 2005. But the signing of the FCTC seems largely symbolic. The report finds that the country is doing poorly with implementation, with a performance score of only 37 points of 100 possible points. Underpinning this poor performance is lack of political will to tackle tobacco control and the tobacco industry.

According to the report, the tobacco industry in China has a Counterproposal and Countermeasure Scheme against the FCTC, it has distorted the Chinese version of the framework, denied the scientific evidence on the health hazards of smoking, abused public powers of government to counteract tobacco control, and encouraged tobacco consumption through covert advertising and sponsorship.

China's Government has allowed this situation to prevail because the country's tobacco industry is seen as a major taxpayer and employer. Although this is true, the report states that an integrated benefit analysis shows the net benefit generated by the tobacco industry is already below zero. In other words, the rapidly growing medical expenditures and loss of productivity from tobacco-related illnesses outweigh the economic benefits of the industry.

China has shown it can address health threats such as avian influenza and the HIV/AIDS epidemic. It is now time China tackles tobacco—its biggest health hazard and a serious economic threat.

For the Chinese Centre for Disease Control and Prevention report see http://www.chinacdc.cn/n272562/index.html

It will be interesting to see how China fares in its struggle against the blood-sucking pushers of tobacco, whose resilience against public health measures in the west has been legendary.

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Skewed priorities

“Understand the extraordinary power of various Federal and State Government departments and agencies and be under no misapprehension that their focus is on the provision of appropriate care and their only interest in respect of the viability of an individual facility is as it impacts on the quality of care being provided.”

• Residential aged care – dealing with a business in crisis. KordaMentha, May 2010, p. 11. (PDF)

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Whittington spends your taxes on ‘amiss’ women

Well, that might have been Andrew Bolt’s headline for this... but the following may in fact be the first recorded instance of special needs targeting in the provision of health services:

In the 15th century 8 beds were added [at St Thomas’s Hospital, Southwark] at the behest of the Lord Mayor, the famous Dick Whittington. They were ... “for young women that had done amiss.”

That would be unmarried mothers; and it was even proposed to take a culturally sensitive approach in regard to those special needs cohorts:

The transgressions of these so-called “unfortunates” were to be kept secret as “it might cause hindrance to their marriage.”

Nice! What a cuddly bunch of medievalists.

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The Lancet gets it right yet again

At this stage in the wash-up of the UK general election, it looks like The Lancet got it right. Yes, yet again!

In its editorial of 1 May (which it grandly called its “general election manifesto”), The Lancet oraculated:

Health will be only one of many issues influencing your vote on May 6. And, to be fair, all three main political parties have important and interesting ideas to offer. A fact that leads us to look forward to an era of cooperation and collaboration in a hung parliament.

UPDATE

The Lancet now has rightly lauded the Rudd Government’s bold initiative to force Big Tobacco to sell its deadly products in plain packaging.

Australia, a world leader in the battle against smoking, stays in pole position with the government there announcing plans, from July, 2012, to force cigarette manufacturers to remove all branding colours and logos from cigarette packs. ... Australia's new anti-tobacco initiative is an historic event, and other countries now need to follow suit.

This historic event is one that a well-known rupertblogger derided as “a trivial campaign on smoking.” Happily the Bolt politburo is powerless to stop it.

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Andrew Bolt trivialises killer drug

Andrew Bolt’s blog is of course Rudd Hate Central and, as such, part of the rich tapestry of Australian political life, providing a relatively harmless outlet for those who have nothing else with which to fill their days.

Among other threats to civilisation as we know it, Bolt is currently excoriating Rudd for his “lack of courage” in shelving the Emissions Trading Scheme — the evil “tax on everything” Bolt previously excoriated Rudd for wanting to promote.

But it’s not just Rudd’s “cowardice” and “ineffectiveness” with which Bolt takes issue. It’s that Rudd wants to “distract you” from his failings with the announcement of a proposal to only allow tobacco products to be sold in generic packaging.

Rudd has downscaled his gandiose [sic] ambitions from saving the entire planet to saving just a few smokers... Rudd is treating voters with complete contempt. The very next day after his humiliating backdown on his emissions trading scheme he announces a trivial campaign on smoking, banking that it’s enough to change the topic from his deceit and cowardice, and talk instead of hios [sic] being “tough” and “bold”.

Truly, if there’s an anti-Rudd angle to anything, Bolt will nail it and package it for ready consumption by his boltoids. Not that he’s a pioneer in that kind of thing, just as the Rudd Government is no pioneer in “distracting you.” Of course, it’s all just part of the rich tapestry of Australian political life.

But I must take issue with and excoriate Bolt for his careless throwaway line about “a trivial campaign on smoking.” The proposals announced are not about “saving just a few smokers.” Potentially, the measures could save hundreds or even thousands of people (particularly, the young) from ever taking up the deadly addiction.

If Bolt wasn’t so blinded by Rudd Hate, he might see that potential is underscored by the threat of a major legal challenge from the tobacco industry. And if he wasn’t so addicted to attention, cash and power, he’d alert his readers to the merits of the proposal.

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Swine-flu-gate: Andrew Bolt wants to kill your Grandma

The World Health Organisation has “admitted that they may have overreacted” to the threat posed by H1N1 swine flu.

One can only agree that, with the death toll approaching a mere 18 thousand worldwide, the H1N1 swine flu ‘pandemic’ has been a bit of a fizzer.

This will probably be cause for relief or even celebration for most of us, but for people like Andrew Bolt it merely provides more confirmation, if any were needed, that nobody other than Andrew Bolt can be trusted about anything.

According to Bolt,

their “overreaction” wasn’t a mere mistake, but an utterly predictable bid for more attention, cash and power of the kind we expect from UN bodies.

Not being paranoid myself about Werld Guvment, I’m quite prepared to give the WHO the benefit of the doubt. Mistakes will unfortunately happen, but when making a decision that may affect many lives, most of us may prefer to err on the side of caution.

Quite likely, moreover, heightened public awareness of the threat will have contributed to saving many lives. The downside, of course, is that next time people might figure they can afford to be more complacent about such threats.

Especially so when people like Bolt actively undermine public confidence in health authorities for grubby political purposes, or just to garner hits for his miserable website.

One could be forgiven for supposing that, in the final analysis, Andrew Bolt wants to kill your Grandma with swine flu.

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How to improve the US health system without killing Grandma

Lateline presenter Leigh Sales asks economics correspondent Stephen Long about the state of health care in the US:

In economic or social terms it’s a disaster... America’s got the most expensive healthcare system in the world. They’re the only rich nation in the world that doesn’t have universal healthcare coverage.

The healthcare in the US costs about 17 per cent of GDP... That is roughly double the cost here, and yet it doesn’t reflect in the health outcomes, which are poor.

For example, adult mortality rates in the US are about twice the rate here where we have half the health costs. And the US is one of the few advanced nations that actually registers a very significant, relatively high child mortality rate, and I could go on.

And Stephen does go on...

The fact that employers provide the healthcare undermines the mobility of labour because people stick in a firm and a region rather than moving on to areas where it might be more personally and broader economically useful, and it’s just a very, very flawed, ineffective system.

Will Obama’s health reforms be an improvement — even if it kills the occasional Grandma?

I’m highly sceptical that it will make much difference at all and I question the strategy. If you look at what they’re doing over there, the basic core of the healthcare reform being put up by President Obama is to subsidise people to take up private health insurance, to subsidise poor people and middle income earners to take up private health insurance.

And private health insurance is at the core of the problem. They’ve got private health insurers who have been gobbling up a whole lot of healthcare expenses in profits and administration so I don’t see that it’s necessarily going to lower costs by subsidising them to seek rents. And you’ve got a very concentrated industry amongst the big players.

So that’s the major structural design problem and it doesn’t deal with the fact that it’s still largely provided by employers and not a situation you want when you’ve got double digit unemployment rates. And more than that, it doesn’t really — although it tries to tackle it at the margins — deal with the lifestyle issues and demographic factors. I mean, you’ve got huge disparities by race and socio-economic status with healthcare outcomes.

Plus you’ve got terrible diet, high rates of smoking and the disease that goes with those sorts of problems.

Gee, that sounds something like the third-world health outcomes which beset the indigenous aboriginal population here in Australia, for which our Government is attempting wide-ranging initiatives to close the gap.

Is there an alternative to Obama’s reforms? Or, in other words, how can they effectively close the gap between health outcomes in mainstream Australia and that in the US?

Well, an alternative which is probably completely politically unrealistic in America but makes more sense is to have something more akin to what we have here with a socialised core system that provides for basic healthcare costs for everybody and allow insurance as a top up on top of that, and it would actually economically make a whole lot of sense to get the insurers out of the system in America and put the money that you’d save on the massive administration costs and profits to which the healthcare budget is diverted to into preventative medicine and try and put the $350 billion that you’d save on estimates I’ve seen into programs to actually prevent rather than try and cure after the event’s happened.

Yep, makes a whole lot more sense, but as Leigh Sales sums up...

I’m glad we’re sitting here talking about it rather than trying to do it.

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Flash: Not all difficult situations solvable

Self neglect in at-risk groups, particularly the elderly, presents some unique problems for those working in the community care sector.

A recent Australian study (PDF) by Dr Shannon McDermott of the University of New South Wales explores the distinction between self neglect, squalor and hoarding.

Self Neglect: inability or refusal to perform essential self care tasks, such as adequate feeding, shelter or medical care for themselves.

Squalor: neglect of one’s immediate personal environment.

Hoarding: inability to throw objects away.

Such behavioural problems can present challenging practical and ethical dilemmas not only for community health professionals, but also the person’s loved ones, neighbours, etc. The study cites an extreme case in which

an older woman kept 500 pigeons inside her home. The birds were noisy and their faeces had an extremely strong odour, which prompted complaints from the neighbours.

The woman refused assistance and was determined by local authorities to be legally capable of making decisions; this meant that professionals were bound to respect her decision to refuse assistance. Eventually the local council became involved because they believed that the situation threatened public health.

The council spent thousands of dollars to remove the birds but, because the woman refused to stop leaving food out, the birds quickly moved back in.

One can only agree that this kind of thing does indeed present dilemmas in spades. It may be tempting for local councils to pass ordinances outlawing actions which, whether deliberately or inadvertently, give rise to a threat to public health. But then, assailing a little old lady with the full force of the local bylaws would be too much like breaking a butterfly on a wheel.

Dr McDermott suggests what might be thought of as a ‘middle way’:

Resolving these situations required that professionals strike a balance between the duties of autonomy, beneficence and justice with a wider organisational context which required that they also manage risk and provide services in an increasingly efficient and effective manner.

The research found that a pluralistic approach to decision-making, along with formal and informal support from their colleagues, was important to ensure consistency between ethical approaches and to accept that not all difficult situations could be resolved.

Leaving aside the challenge of unpacking all that jargon, it must be said that “accepting not all difficult situations can be resolved” is hardly a cutting-edge ‘finding’. Most people out in the field know only too well.

Clues to some solutions may be afforded in Dr McDermott’s research paper of some 340 pages. I’ve added it to my (interminably yawning) reading list, and suggest interested readers might like to do the same.

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Not only but also

The Lancet may well come in for some heavy criticism in the next day or so for what some will see as a politically inflammatory editorial “blasting” Israel for its actions in Gaza.

It likely will be asked, somewhere, by somebody: Why the obsessive emphasis on Israel, when there are far worse atrocities going on in the world?

Such quizzers may be comforted to know that The Lancet only last week editorialised thus:

As the world watches the terrible events unfolding in Gaza, several other conflict zones around the globe continue to be ignored. Since Israel's air and ground offensive against the Hamas regime in Gaza captured international political and media attention, hundreds of people — 400 in one day alone — have been killed in the Democratic Republic of the Congo and many more lack the medical attention they so desperately need.

Major difficulties in bringing assistance to people affected by conflict is a prominent feature of the top ten most neglected humanitarian disasters, compiled annually by Médecins Sans Frontières. According to the list, massive forced civilian displacements, violence, and unmet medical needs in Somalia, which is top of the list for the third consecutive year, the Democratic Republic of the Congo, Iraq, Sudan, and Pakistan are some of the worst humanitarian and medical emergencies in the world.

It is a scar on society that some lives are still deemed more important than others, especially when viewed through a lens distorted by politics, economics, religion, and history...

(The whole document is accessible free upon registration.)

Well, so why all of a sudden are The Lancet editors dumping on Israel?

The explanation could be as simple as that a number with three zeroes after it is inherently impressive. That such a number has been produced by a nation which pines desperately to be accepted as part of “the West” may also have a bearing here.

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Invisible wounds of war

Since October 2001, approximately 1.64 million U.S. troops have deployed as part of Operation Enduring Freedom (OEF; Afghanistan) and Operation Iraqi Freedom (OIF; Iraq). The pace of the deployments in these current conflicts is unprecedented in the history of the all-volunteer force. Not only is a higher proportion of the armed forces being deployed, but deployments have been longer, redeployment to combat has been common, and breaks between deployments have been infrequent.

At the same time, episodes of intense combat notwithstanding, these operations have employed smaller forces and have produced casualty rates of killed or wounded that are historically lower than in earlier prolonged wars, such as Vietnam and Korea. Advances in both medical technology and body armor mean that more servicemembers are surviving experiences that would have led to death in prior wars.

However, casualties of a different kind are beginning to emerge — invisible wounds, such as mental health conditions and cognitive impairments resulting from deployment experiences.

• Territa Nielian & Lisa H. Jaycox (eds.), Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery, RAND Corporation (Center for Military Health Policy Research), 2008

Thus is sketched the broad context of a study on psychological and cognitive injuries suffered by US service personnel as a result of deployment to Afghanistan and Iraq since 2001.

The study focuses on three broad types of those ‘invisible wounds’ — post-traumatic stress disorder, major depressive disorder and depressive symptoms, and traumatic brain injury.

It seeks to explore the dimensions of prevalence of these injuries among returned personnel; the costs attendant upon these conditions “stemming from lost productivity and other consequences”; and provision — and, more to the point, gaps in provision — of the care system intended to meet the health-related needs of service personnel and veterans.

The authors also seek to make recommendations to address what they recognize will be a significant ongoing concern with continued mass-deployment of personnel to combat zones.

The work is constrained in its aims by a recognised paucity of “available data”. As a reviewer in The Lancet observed:

The lack of such data illustrates their point more clearly than any calculations could do — these are battle injuries that are underdiagnosed, poorly understood, and under-resourced.

• Piers Page, The Lancet, Vol 372, 15/11/2008, p. 1724 (subscription reqd.)

One troubling aspect identified in the study is that veterans are hampered in seeking and accessing care by institutional factors, such that it is perceived accessing services “will negatively affect employment and constrain military career prospects, thus deterring many of those who need or want help from seeking it.” The stigma of mental illness apparently yet persists in the “never explain, never complain” military culture of machismo.

The study, however, seems almost at pains to avoid being a controversial or polemical document. Indeed, the authors write almost glowingly of efforts at all levels of the US government “to study the issues ... quantify the problems, and formulate policy solutions.”

And they have acted swiftly to begin implementing the hundreds of recommendations that have emerged from various task forces and commissions. Policy changes and funding shifts are already occurring for military and veterans’ health care in general and for mental health care in particular.

Nor does this study essay into any broader questions about the conduct of US foreign policy and the “global war on terror”; on the contrary, it studiously avoids such matters.

Rather, the authors merely assert the US’s national “responsibility not only to recruit, prepare, and sustain a military force but also to address Service-connected injuries and disabilities.” Essentially, this is a commendable work of advocacy for and on behalf of US service personnel and veterans.

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All anxieties tranquilised

The exit doors have been disguised so as not to be discerned by confused and enfeebled perceptions.

An ‘alternative pathway’ leads inmates through a corridor of rooms, which eventually and inevitably takes them back to the common room from which they’d hoped to escape.

This artifice has been contrived not only to constrain movement of the inmates, but also to reduce their awareness of constraint.

Lies are told to the inmates so as to avoid any responses which might cause them distress and thus upset the smooth running of the institution. Your mother may have died thirty years ago, but you will be told lies, to expect a visit from her, if it suits the powers-that-be.

No, this is not some sinister, nightmarish Cabinet of Doctor Caligari, but rather is presented as enlightened practice in the care of old people suffering progressive cognitive impairment, a.k.a. senile dementia.

The onset of dementia in advancing years is a problem which is growing with the increase in the aged population in many countries. It’s also a problem that many of us may have to personally face, whether it affects loved ones or (worst case scenario) our own selves.

To lose one’s marbles is indignity enough, but is it really necessary to be further insulted with lies and subterfuge?

Many experts increasingly would have it so, but there persists an opposing school of thought preferring an approach which favours ‘reality orientation’ — chiefly, so as to preserve the dignity of the sufferer.

Rubbish! say the cognitive engineers. The ‘reality orientation’ school are theorists, whereas we are realists. Better to be lied to — into believing, for instance, that your long-dead mother will soon come visit — in order to induce a pleasurable, rather than painful, reaction.

Better to induce reactions that are pleasurable than painful with which to colour their remaining twilight days.

Which would you choose to dispense?

Think on it carefully now, because when your time comes you’ll be unlikely to have any say in it.

• Working with the mind in dementia, not against it

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