123 years of argument for primary prevention in healthcare

Here’s a new take on the better sense of trying to prevent ill health rather than merely treating it. It’s from a speech last week by a Conservative member of the House of Lords, Lord Prior of Brampton, a former UK Minister for NHS Productivity:

“Simply putting more money into the NHS and hoping for the best will not work. With funding must come radical reform. We need a shift from ‘diagnose and treat’ to ‘predict and prevent’. Care must be joined up around - and tailored to - the patient.”

And here’s the take on the issue from 1895 – 123 years ago – with which everyone is familiar.

The Fence or The Ambulance
by Joseph Malines, "an American physician"

‘Twas a dangerous cliff, as they freely confessed,
 Though to walk near its crest was so pleasant:
 But over its terrible edge there had slipped
 A duke and many a peasant;
 So the people said something would have to be done.
 But their projects did not at all tally:
 Some said, “Put a fence around the edge of the cliff”
 Some, “An ambulance down in the valley.”

But the cry for the ambulance carried the day.
 For it spread to the neighbouring city:
 A fence may be useful or not, it is true,
 But each heart became brimful of pity
 For those who had slipped o’er that dangerous cliff,
 And the dwellers in highway and alley
 Gave pounds or gave pence, not to put up a fence,
 But an ambulance down in the valley.

“For the cliff is alright if your careful,” they said,
 “And if folks even slip or are dropping,
 It isn’t the slipping that hurts them so much
 As the shock down below - when they’re stopping,”
 So day after day when these mishaps occurred,
 Quick forth would the rescuers sally
 To pick up the victims who fell off the cliff,
 With their ambulance down in the valley.

Then an old man remarked, “It’s a marvel to me
 That people give far more attention
 To repairing results than to stopping the cause,
 When they’d much better aim at prevention.
 Let us stop at its source all this mischief, cried he.
 “Come neighbours and friends, let us rally :
 If the cliff we will fence, we might almost dispense
 With the ambulance down in the valley.

“Oh, he’s a fanatic.” the others rejoined:
 “Dispense with the ambulance Never!
 He’d dispense with all charities, too, if he could:
 No, no! We’ll support them forever.
 Aren’t we picking up folks just as fast as they fall?
 And shall this man dictate to us? Shall he?
 Why would people of sense stop to put up a fence?
 While their ambulance works in the valley?”

But a sensible few who are practical too,
 Will not bear with such nonsense much longer
 They believe that prevention is better than cure
 And their party will soon be the stronger
 Encourage them, then with your purse, voice and pen
 And (while other philanthropists dally)
 They will scorn all pretence, and put up a stout fence
 On the cliff that hangs over the valley.

PPS (Post Poem Script): When Bruce Harris sent me a copy of this poem in 1997 as part of my training for work in the health sector he commented – with his usual wit and wisdom – as follows:

“From the parable:

– choose to live in a place with no cliffs – ideal but unlikely;
– don’t go near the cliff – education, expects too much;
– build a fence – authoritarian, expensive.

Until these happen, some of us have to man the ambulances!”

 

Solstice and Sunlight

The Winter Solstice in Canberra is on Thursday, 21 June 2018 at 8:07pm AEST.

After the Winter solstice the days get longer, and the day has therefore been celebrated in many cultures as a time of rebirth.

“In the Southern Hemisphere the Winter solstice, also called Hibernal solstice, is the moment when the path of the Sun in the sky is farthest north. At the Winter solstice the Sun travels the shortest path through the sky, and that day therefore has the least daylight and the longest night.”

“When the Winter solstice happens in the Southern Hemisphere, the South Pole is inclined about 23.4° away from the Sun, with its vertical rays are overhead at their northernmost position, the Tropic of Cancer (23°27′ N).”

“According to the astronomical definition of the seasons, the Winter solstice marks the beginning of the season of winter, which lasts until the vernal equinox (September 22 or 23).”

On the shortest day

on the shortest day i lie in the sun
 but feel the shade sweep over me
 hoping the dark will turn to light
 and that chance might four-leaf-clover me

this sun through glass has kept me here
 and belief in tasks worth doing
 but suppose that jobs are over now
 the agendas changed or going

suppose a canker is really inside
 not cured by sunshine at all
 where will we be – my friends and i
 when the long summer evenings call

it’s not in a bottle, not in a pill
 and not in these fears of mine:
 it’s on the breath and in the soul
 where even the sun can’t shine

if contentment comes but once a year
 when the shortest day is now over
 it might after all be just enough
 – and time will grow the clover



gg    21/6/2008

 

Bob Carr, Anthony Powell and me

Apart from sundry genes, the most important thing I have given my children has been a full set of Anthony Powell’s A dance to the music of time.

The first in this 12-volume novel was published in 1951, the last in 1975. The stories, the writing style and the humour have fascinated and entertained me ever since I came across the first volume, A question of upbringing, around 1970.

At some random stage in the young life of each of my four children they have been presented with a set of the books and given the understanding that it is my favourite work. There is no other rite of this sort to which they have been subject. This makes Anthony Powell and these 12 books matters of great significance to me and, I hope, to them.

Family gatherings have occasionally been regaled with a reading of the opening scene of the first book, which sets the tone for both subject and style of the whole work.

"The men at work at the corner of the street had made a kind of camp for themselves, where, marked out by tripods hung with red hurricane-lamps, an abyss in the road led down to a network of subterranean drain-pipes. Gathered round the bucket of coke that burned in front of the shelter, several figures were swinging arms against bodies and rubbing hands together with large, pantomimic gestures: like comedians giving formal expression to the concept of extreme cold."

The works of Anthony Dymoke Powell (1905 – 2000) have remained in print continuously and have been the subject of TV and radio dramatisations. In 2008, The Times named Powell among their list of “The 50 greatest British writers since 1945”.

Some of the key facts of his life serve almost as a synopsis of the subjects of A Dance to the Music of Time. His father was an officer in the Welsh Regiment and his mother “came from a land-owning family in Lincolnshire”.  He went to Eton and Balliol College, Oxford, where he “was awarded a third-class degree at the end of his academic years”. He married Lady Violet Pakenham in 1934. During the second war he served in the Welch Regiment and later the Intelligence Corps. In 1973 he declined an offer of knighthood.

Anthony Powell died near Frome, in Somerset, in March 2000.

One of the characteristics of Powell’s novel is the occurrence of coincidence at what might be regarded as an unlikely rate. People keep meeting in unexpected circumstances with those with whom they have had previous contact; newly-introduced characters turn out to have links with people and events that have gone before.

I have often defended the notion that ‘coincidence’ is more of a reality of life than is connoted by a normal understanding of the word, which goes to its rarity and surprise. Events do seem to recur, albeit with different personnel, and certain people encountered years ago seem incapable of escaping the ebb and flow of one’s own life.

This of course is the dance to which Anthony Powell refers. Often life has a kind of circularity which eventually brings back the partner with whom one traced figures around the floor when the music began.

One of the latest of such coincidences to affect me occurred three weekends ago. Having just read a biography of Paul Keating gave me an appetite for more Australian political biography. Browsing in the splendid Canty’s second-hand bookshop in Fyshwick I selected four titles without too much consideration, one of which is Bob Carr’s My Reading Life –  Adventures in the World of Books. Flicking the pages, what attracted me in the Introduction was Carr’s wish that his choice of reading had been informed by what he calls ‘How to Read’ books:

"I needed someone, in effect, to place a comforting arm on my shoulder and say, now Tolstoy isn't that hard. Persist with the Russian names in the first 50 pages. Remember that there are two key characters, Andrey and Pierre.' A bit of guidance, a few clues. That would have been enough. A reader needs a handful of notions so they don't think they're going to drown, some idea of 'Where is this writer taking me?' And that's enough to start."

It wasn’t until I was browsing the book a little more carefully at home that I came across the second chapter entitled Laughing out loud – the best comic writing. Carr begins the chapter with: “This twelve-volume novel may be the best I have ever read. I’ve reread some volumes and felt confirmed in that view.” Later on:

“Powell’s is the major postwar achievement in the English novel. While his work has been described as a combination of Proust and Wodehouse, Powell is consistently funny in a way Proust is not, and his story has none of the roadblocks that sit like indigestible lumps in the middle of Proust’s volumes.”

In order to compile the necessary collections for family members I have frequently made a beeline for “po” on the shelves of the better second-hand bookshops. If they have authors shelved in alphabetical order they almost certainly have also recognised the value and popularity of Anthony Powell’s books.

In the 28 May 1998 issue of the New York Review of Books there is a long essay by the redoubtable Christopher Hitchens (1949-2011)** about Powell and his major work https://bit.ly/2I1tPdw. In typical Hitchens style he provides a strongly intellectual analysis of the politics of the work and its relationship to real political developments of the period. (Incidentally, Hitchens makes half a dozen references to the use of coincidence in Pwell’s work.)

Hitchens is clearly impressed and intrigued with the novels and, like Bob Carr, laments the weakness of the TV production of the work. And rather in the same way as Carr, Hitchens is ultimately unsatisfied, particularly with the closing volume:

"To invert, in fact, what has been so often and unfairly said against Powell, the verdict here [about the last volume] must be that events are random and unstrung rather than intricately coincidental. The series does not end or conclude, still less achieve a resolution. It just stops."

I have been unable to feel dissatisfaction of this  type. I kept collecting – perhaps against the possibility of there being yet more members of my immediate family still to come.

Despite the care with which I collected it has been difficult to make collections of all twelve volumes in a single publishing edition. When I began collecting, the titles were in Penguin with that familiar orange livery and some with cover drawings by Osbert Lancaster.

The books were in fact first published by Heinemann in 1960 and then by Penguin in 1964. Once Penguins had become rarer the commonest version was the black-covered series produced by Fontana from 1967. Later editions in Fontana had cover caricatures by Mars.

There followed Flamingo editions (still Fontana) from 1983  – my favourites –  with cover drawings by Mark Boxer and, from 1991, Mandarin paperbacks with artwork by the same person.

There is a biography of Anthony Powell by Hilary Spurling. I am yet to find a copy.

** re Christopher Hitchens, from Wikipedia: "Having long described himself as a socialist, Marxist and an anti-totalitarian, he broke from the political left after what he called the "tepid reaction" of the Western left to the Satanic Verses controversy, followed by the left's embrace of Bill Clinton and the antiwar movement's opposition to NATO intervention in Bosnia and Herzegovina in the 1990s. His support of the Iraq War separated him further. - - he regarded concepts of a god or supreme being as a totalitarian belief that impedes individual freedom. He argued that free expression and scientific discovery would eventually replace religion as an ethical code of conduct for human civilization. The dictum "What can be asserted without evidence can be dismissed without evidence" has become known as Hitchens's razor."

 

Progress on UN’s Sustainable Development Agenda

Artwork by Jordana Angus

The Government has just released a report on the progress made in Australia on implementation of the UN’s 17 Sustainable Development Goals (SDGs) (https://bit.ly/2JV66Rj). Together the 17  constitute the 2030 Agenda for Sustainable Development, to which Australia is one of 193 signatories.

The first four SDGs are:

  1. No Poverty
  2. Zero Hunger
  3. Good Health and Well-Being, and
  4. Quality Education.

Together, the 17 are described as a “global blueprint for a sustainable future for our planet, our communities, our families and our economies”.

The Report ( a “Voluntary National Review”) is a ‘whole of Australia’ document, providing evidence of what the business sector, civil society, academia, communities and individuals are contributing to achievement of the SDGs, as well as governments.

It is the result of a range of activity, including outreach events, expert analysis, case studies and the 2018 SDG Summit.

It lists the Departments that have had the lead responsibility for Commonwealth Government input to the Report relating to each SDG. So, for example, the Department of Health led on input about SDG 3, for which the tagline is “Ensure healthy lives and promote well-being for all at all ages”.

What’s important now is to be assured that those lead Departments will continue to promote active engagement of governments and other entities in the SDG for which they have special responsibility. For further progress to be made, responsible departments and other entities need to give the SDGs priority as frameworks within which their ongoing policy development and program management activity will sit.

The Report makes the point that being faithful to two mantras that are of particular resonance in Australia – ‘Caring for Country’ and ‘A fair go for all’ –  would result in good progress towards several of the Goals.

This progress can be assisted through a range of means, including businesses adopting the SDGs into their operations; supporting the work of volunteers, youth, community and business networks; and through application of the expertise of national organisations like universities, libraries and scientific institutions.

The recently-released Report will be presented at a United Nations Forum in New York in July.

The Report is at https://bit.ly/2JV66Rj

The website is Australia SDGs website

Enquiries can be directed to 2030Agenda@dfat.gov.au

Bloggs 1-63 with direct URL links

No. Title Cat.* Date published
1 How did rural people vote in the (2016) Federal Election? Pol 6 July 2016
2 English rugby: no longer Down Under Rem 15 July 2016
3 Does the Brexit vote mean an end to the not-keeping-sheep industry under the CAP? Pol 16 July 2016
4 For Leanne Coleman’s birthday (17 July) P 17 July 2016
5 Quad bike safety RH 20 July 2016
6 The tale of a cowslip Rem 24 July 2016
7 Tour Defiance 2016 P 1 Aug. 2016
8 Marriage equality and greyhounds Pol 9 Aug. 2016
9 Dear Dr Gillespie: Don’t narrow the rural health agenda RH 10 Aug. 2016
10 Submarines and greyhounds: industry policy with a heart PWE 13 Aug. 2016
11 An agenda for the Minister for Rural Health RH 17 Aug. 2016
12 The language of ‘health promotion’ RH 19 Sept. 2016
13 Fields of Gold: the 2016 AFL Grand Final P 6 Oct. 2016
14 Rolling over P 6 Oct. 2016
15 “Look at the tyres!” Rem 2 Nov. 2016
16 On electoral ‘mandates’ and furphies Pol 2 Nov. 2016
17 For good rural health we need good rural jobs RH 2 Nov. 2016
18 On holiday with Anne Cahill-Lambert and (photogenic) Rod P 2 Nov. 2016
19 Parliamentarians and the plebiscite Pol 4 Nov. 2016
20 Pounds, shillings and common sense Rem 4 Nov. 2016
21 Structural change in the economy: a real life and political issue PWE 4 Nov. 2016
22 Dreams of home: Beardy Street, Armidale P 21 Nov. 2016
23 To market, to market, to buy a fat pig…two case studies of economic change PWE 14 Dec. 2016
24 A jogger’s diary P 17 Jan. 2017
25 parkrun: healthy movement P 24 Jan. 2017
26 The Art of Professional House Cleaning F 24 Feb. 2017
27 Health advocacy needs to be more specific, less ‘motherhood’ Pol 9 March 2017
28 Comments on accepting Louis Ariotti Award for Excellence, 6 March 2001. RH 9 March 2017
29 Quad bike accidents: “It’ll never happen to me” RH 17 March 2017
30 Extracts from debate in House of Representatives on Bill to establish a National Rural Health Commissioner (NRHC) RH 21 March 2017
31 Adelaide Crows Women: next year can we police have the chorus too? F 4 April 2017
32 “Julia Gillard is not a liar” – written in April 2012 Pol 12 April 2017
33 Reflections on retirement P 19 April 2017
34 Surfing the ‘waves of health reform’ in Australia Pol 31 May 2017
35 Drones: workers of the future? P 1 June 2017
36 The challenge for the National Rural Health Commissioner RH 8 June 2017
37 Lines in the Trouser – Introduction and Part One P 12 June 2017
38 Lines in the Trouser – Part Two P 18 June 2017
39 Rural Generalism: One of the best games in town for rural health? RH 20 June 2017
40 A poem for the Winter Solstice P 22 June 2017
41 Lines in the trouser – Part Three P 23 June 2017
42 For Bev Glover P 2 July 2017
43 On politics, paramedics and the Sunburnt Country Pol 30 July 2017
44 ‘Reasonable expectations’ of human services in remote communities RH 3 Aug. 2017
45 “This was the most unkindest cut of all.” (Julius Caesar, Act 3, Scene 2)[1] P 14 Aug. 2017
46 Dual citizenship explained – by Duncan Kerr – in 1989!! Pol 1 Sept. 2017
47 Rural people face high, unmeasured and increasing out-of-pocket health care costs RH 29 Oct. 2017
48 Dear Scott, So you want to clearly understand about split infinitives? P 10 Nov. 2017
49 Lawrence’s daffodils P 15 Nov. 2017
50 Marriage equality – a case study in too much democracy Pol 18 Nov. 2017
51 Obstructing the field – Alex Ross is out P 11 Jan. 2018
52 How Green Was My Lily & other terrible Fotopuns F 14 Jan. 2018
53 Much to report – September 2008 P 30 Jan. 2018
54 Two-wheeler Kate: in praise of speech recognition software P 16 Feb. 2018
55 Retiring slowly – Match report for Saturday 20 January 2018 P 19 Feb. 2018
56 Command and control F 13 March 2018
57 Rural and remote gaps in NDIS rollout RH 15 March 2018
58 NRL: a bird in the hand is worth 30% of what’s in the bush P 19 March 2018
59 Just Loving It (Our theatrical holiday in the UK) P 19 May 2018
60 Stalking George Gently P 19 May 2018
61 ANZAC Day in Knaresborough, North Yorkshire P 19 May 2018
62 Paddling his own canoe: for Dane P 24 May 2018 (re-posted)
63 Australia’s health research effort RH 5 June 2018

Cat* = Category: P is Personal; RH Rural health; F Fantasy; Pol Politics; Rem Reminiscence; and PWE People’s wellbeing and the economy.

Australia’s health research effort

A recent article in the Australian Journal of Rural Health (Vol 26, Issue 2, April 2018) makes the case that, at 2.4 per cent by value of the National Health and Medical Research Council total in 2014, the amount of research aimed specifically to deliver health benefits to Australians living in rural and remote areas is low given the health status and health service deficits faced by the 30 per cent of the population who live there.

Issues relating to health research in Australia were the subject of discussion at Senate Estimates on Tuesday 29 May 2018. This bloggpiece consists of a summary of some of the numbers and other facts from that discussion, sourced from the Hansard record.

In the period 2018-19 to 2021-22, the four years of forward estimates, some $6 billion is to be committed by the Australian Government for health and medical research. The main programs through which this money will be allocated are the National Health and Medical Research Council (NHMRC) (around $800m per year), the Medical Research Future Fund (c.$500m a year), and the Biomedical Translation Fund (c. $60m a year).

It would be interesting to compare this amount funded directly through the Federal health budget with the total through the private sector – dominated, presumably, by the pharmaceutical companies – and through other sources such as hospitals, State budgets and specific health condition interest groups (the Heart Foundation, for example).

The discussion at Estimates referred to the fact that many people in the research community are unclear about how funds in the Medical Research Future Fund (MRFF) are being disbursed.

Historically there has been a considerable amount of investigator-driven research funded by the NHMRC. The MRFF, on the other hand, is “priority setting research” and can fill gaps that are identified. The priorities are determined by the Government, through the Minister of the day and advice received by them. The Act requires the MRFF Board to consult with the community and the sector about its priorities.

"The Australian Medical Research and Innovation Strategy 20162021 was prepared by Australian Medical Research Advisory Board. It sets out the vision, aims, objectives, impact measurement and strategic platforms of the MRFF. The strategic platforms provide a framework for identifying MRFF priorities."

The first disbursements from MRFF were in 2016-17 and were for one year only. The next batch, announced in the 2018-19 Budget, are for four to five years.

There has been criticism of the relatively small amount allocated to research related to illness prevention, both within the MRFF envelope and in the overall health research effort. It has been suggested that as little as one per cent of the total health research allocation has been directed at prevention which, if true, would reflect poorly on the priorities in place.

At Estimates the Health Department referred to a number of grants for what could be considered ‘illness prevention’, including to the Australian Prevention Partnership Centre, some mental health research, Keeping Australians out of Hospital, Maternal Health in the First 2,000 days, the Advanced Health Research and Translation Centres, and the Centres for Innovation in Regional Health. These last are obviously of particular interest to the rural health sector.

"The aim of the Centres for Innovation in Regional Health (CIRH) initiative is to encourage leadership in health research and translation of direct relevance and benefit to regional and remote areas of Australia."

"To achieve recognition as a CIRH, groups are required to demonstrate competitiveness at the highest international levels across all relevant areas of health care."

In 2017 the NHMRC recognised two groups in the CIRH program: the Central Australia Academic Health Science Centre and NSW Regional Health Partners.

Departmental officers spoke at Estimates of there being two main problems along the research pipeline. One is where a researcher or a team has a great idea but does not have the funds or the resources to prove the idea, to bring it to ‘proof of concept’ and start it down the pathway to trials. The other is where the idea has been proven through trials and the need is commercial energy and capital to bring the concept to market.

This second is where the Biomedical Translation Fund (BTF) fits in: it is designed to stimulate the venture capital sector and increase Australia’s ability to invest in good-quality late-stage research.

The BTF is leveraged 50:50 with private capital. It was announced in December 2015 under the National Innovation and Science Strategy and, after the identification of three fund managers, began operation in January 2017. The fund managers search out deals for advanced commercial-ready health and medical research innovations. To date there have been nine deals at a total value of about $42 million.

It has been suggested that if all goes well the health and medical sector could be the source of 28,000 new jobs, 130 new clinical trials, and a 50 per cent increase in exports. To hit all the desirable targets will require a suitably trained health research workforce and the MRFF is helping with this. It is working with the NHMRC to ensure there are more fellowships available to attract Australians into health and medical research.

Let’s hope the individuals and agencies involved have at least a third of an eye on the special opportunities and challenges in rural Australia.