Small is Beautiful — Eisenhower’s Last Smoke from New Zealand (Part 2)

On my first full day in New Zealand, I met the founder of 1000Minds, a company that develops decision-making software and tools for prioritization and group decision-making; the chief economist for the ministry of health and her policy team; and the chair and CEO of PHARMAC, the crown jewel of New Zealand’s health care system, the pharmacy management arm that has achieved incredible results in managing costs while pharmacy utilization rises like it does everywhere else.  And I realized, there are some major advantages to living in a small place (“New Zealand is a small town”). For instance, you can meet the board chair and the CEO of the crown jewel of the country’s health care system even though you ostensibly represent no value to them whatsoever.

One of the other advantages of being small is that you can get away with stuff. PHARMAC negotiates hard, and achieves phenomenal pricing and terms from pharmaceutical companies. Contrary to what many people think about PHARMAC, they do not get to those results via bulk purchasing and leverage. In fact, they purchase nothing (they serve as agents on behalf of the district health boards, local or regional entities that administer the public health scheme), and they have no scale to speak of. New Zealand, with only four million people, represents just 0.1% of the global pharmaceutical market. So they don’t get what they get because they’re big. Rather, they get what they get because they’re small. It matters a lot less to drug makers what New Zealand pays for drugs than it does in a place like the U.S.

When you’re small, you can also do things like establish a national framework for the patient experience in hospitals across the country. I heard about this initiative, just kicking off, from the Ministry of Health policy analysts. Perhaps because many New Zealanders do not have a choice of providers because of limited supply of doctors and hospitals outside the main urban areas, the way in which hospitals treat patients matters. It’s also a society that espouses fairness, and seems to actually embody an authentic “niceness” As a New Englander, I’m bred to be pretty wary of people who are too nice, and I’ve honed an instinct for people who are faking. My read is that these people are not. At least everyone I met went out of their way to help me and seemed genuinely not to think there was another option. In this environment, you can imagine gathering a robust and representative assortment of experts and constituents, and working with them to set a standard, and then having just about 50 hospitals in the whole country actually adhere to them. Isn’t small beautiful?

The New Zealand health system is not perfect. There can be long waiting lists in the public sector for elective procedures (that probably stop feeling elective over time). There is the ACC (the Accident Compensation Corporation), a public, no-fault personal injury scheme which covers anyone for any accident-related injury and thus creates incentives to throw yourself down the stairs if you have a trick knee to cut the line for elective surgery (I hope no one actually does that, but the incentive is there). There is a theoretically sufficient supply of high-quality doctors, but those doctors aren’t distributed well, and so rural areas suffer capacity shortages. Additionally, New Zealand, like Australia, allows doctors significant latitude to charge whatever fees they like on top of the government reimbursement, so many people grumble about the ever-increasing gap payments they must make to GPs.

There are ethnic disparities here, despite a society deeply rooted in fairness. The native Maori people make up about 15% of the population, and have shorter life expectancy, less access to care, and greater disease burden. Sound familiar? Like every indigenous and minority population? The Maori, though, seem to have a respected place in Kiwi society. They have a treaty with the crown, which brought New Zealand under British rule, and that treaty provides respect and protection for the Maori people. Nearly all signs and postings are displayed in Maori along side English. And many of the places retain their Maori names. Unlike most parts of Australia, you can see people who look plausibly like indigenous people (though many no doubt come from a range of Pacific locales). Not ideal or close to perfect, but it seems that Maori issues and language and culture are threaded throughout the mainstream culture and language. That seems like a road going in the right direction towards greater equity.

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New Zealand’s focus on fairness doesn’t result from a perfect or clean history with regards to injustice. Of course there has been (and probably still is) injustice. But they have had the humility and the courage to acknowledge their history and confront it.

Throughout the world New Zealanders are known as neutral and practical. This position gets them seats at much bigger tables on the world stage than they otherwise would. They seem to broker deals and offer positions that many factions can get behind. They seem reasonable after all, and they’re not threatening. We may as well go with what the Kiwis suggest.

My sense is also that Kiwis are doers. They’re organized. They’re competent. They may not bother much with conceptual frameworks, but rather, they’ll just dig in and figure things out. “New Zealanders are very good at making things work on the smell of an oily rag.” And they’re relaxed. When my host one evening learned that I’m allergic to peppers (capsicum here), he tossed aside his plan to cook chili con carne with what seemed like an awfully genuine and almost delighted chuckle. “Not to worry. I hadn’t started yet. I’ll make a Bolognese instead!”

After all, they live here:

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And here:

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I might find an inner peace if I lived here, too.

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American Guns, Postscript

American Guns, Postscript

Painting by Mike Del Visco, Truro/Provincetown

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Friends in High Places – Eisenhower’s Last Smoke special edition from the Land of the Long White Cloud (Part 1)

Getting out of Sydney airport was a bit of a dog show. As I experienced many times, my cab driver dropped me off in approximately my intended destination (at the Qantas area instead of Virgin Australia). Signage was horrible. It was crowded. And of course, my bags were heavy. It also turned out that I was not flying on Virgin but on Air New Zealand, who’s check-in practices, felt, at least in that moment, wicked inefficient.

I got through security, found my way to a coffee shop, ordered my skinny flat white, and waited to board. Once on the plane, I spent 2.5 of 3 hours listening to an 18-month old behind me wail uncontrollably and kick my seat continuously. Now, I’ve been there, and the mom was so nice, I tried not to let it bother me. But let’s just say I wanted to tear off my skin.

Just as we started our descent, I realized I was no longer in possession of a poster tube containing an aboriginal painting I had bought. The chaos in Sydney’s international terminal had been more than my caffeine-starved brain could handle. And I had left that painting somewhere.

Upon landing, I trekked all over the airport to someone the flight attendants had said might help (after the first person they had thought might help could not). He did let me hang out in the baggage services office while I called the Sydney airport (“They usually don’t answer. And they don’t really get back to you,” my new friend told me.) Then I found a phone number for the Gloria Jean coffee place in the international terminal. OK, that means there’s only one? Cautiously optimistic, I called. And yes, they had my poster! And some kind soul offered to take it to the post office for me. Well, this put me in a better mood, and I finally ventured out into Wellington.

And that’s when I started to be glad I had tacked on this leg of my trip. My cab driver, through the usual “First time in Wellington?” script, learned that I’d been here for my friend’s wedding, and we pieced together that he had been my friend’s Gujarati teacher in the late 70s when she was a young child. (Later, a member of Parliament I had opportunity to chat with also said knew my friend and her family, so either the Indian community in Wellington is extremely tight, or there are a lot of Parbhus in Wellington, or both). And I felt connected despite how far from home I was.

We rode up to the Parliament building and the driver laughed, “Where else in the world could you drive right up to the door of Parliament? No security?” It is amazing in this day and age, and speaks volumes about New Zealand society.

IMG_1630 (this is the “Beehive” where the ruling party has their offices — sorry I didn’t get a photo of the older building where the opposition party has their offices. Actually, that building is elegant, classic, and the offices seem pretty nice to me!)

Getting out of my taxi with three months worth of luggage (yes, I know I’m only traveling for six weeks. Have you been reading the blog??), a gentleman delighted that a cab had pulled up quipped, “It’s not a hotel you know!”

Inside at security I started to feel like actually it might be. Phil, the security guard, helped me with my bags through the x-ray machine, and while I was waiting to be collected by Natalie, David Clark’s executive assistant, Phil came back to me and asked if I’d be leaving soon and did I want him to store my bags rather than having to lug them up and then back down (Yes!). And once I was collected and Natalie, ever conscientious, wanted to locate my bags, Phil offered to bring them up to the apartment I was staying in (in an adjacent building with offices and a few apartments reserved for ministers high up in the government). So actually, it was very much like a hotel. And the “service” was amazing.

Natalie, whisked me through the beautiful old Parliament building to David’s office. Not bad for being in the opposition party, as it was elegant and spacious. Natalie gave me a quick course in parliamentary politics, showed me how David had moved up from the back row to the middle following a promotion. I asked her, did someone need to be demoted? She just looked at me and said nothing. And then, ‘Well, that can happen.”

Natalie made me a coffee and instructed me to chill out. I gladly drank the coffee and let the Sydney airport, screaming baby, and lost artwork recede. I noticed David’s bike in his office and asked Natalie if he rides to work (knowing he lives a plane ride away from Wellington, I hadn’t gotten my travel-addled mind around where or how he might do that). “Oh no, he’s a lazy bastard!” she said (of the former Iron Man) for his benefit, and I turned around to find my Kiwi friend had arrived from a meeting. Natalie then proceeded to instruct David on an important call he needed to make and an errand he needed to run, and reminded him approximately three times to make that call before she took me down to watch Parliament in session. (I love Natalie by the way. Every busy, stretched executive or leader needs someone like her to keep us on track, on time, and most importantly, in line).

Inside the Parliament itself were just a dozen of the 121 members (they have an extra one right now as a result of some peculiarity of the party vs electorate votes which resulted in a minor party being entitled to a number of seats by the party votes plus to the seats their candidates won through the popular, candidate vote. Confused? Yes.) They were arguing over (or essentially offering testimony for) the GCSB bill, about government surveillance (spying) on New Zealanders. Apparently, what I witnessed was quite boring compared to “question time,” when all the members are in the chamber. I gather it gets heated and boisterous (and that my friend David has the first or second loudest voice in the din – go David!). Even with this small group I watched, there’d be occasional outbursts from “the peanut gallery.” “That’s not true!” shouted a member of the government during a Labour MP’s speech. They milled about, chimed in, and flat out heckled. It was awesome.

Then, right on time in a perfect break in the action, Natalie took me to meet the Honorable Paula Bennett in the Beehive, the modern building where the government (majority party) sits. Her office was modern, with a lobby and several smaller offices for staff. Paula Bennett is the Minister of Social Welfare I think officially number seven (or something like that) in the pecking order of the ruling party in the New Zealand Parliament. She is an Eisenhower Fellow from 2010, and I had heard that she is hot stuff. She is. Decked out in a stylish black coat-dress, chunky colorful jewelry, and hot blue shoes, she told me about her Eisenhower Fellowship experience, her current role and portfolio of responsibilities, and political history.

IMG_1582 (Paula Bennett (@paulabennettmp), me, and David Clark (@DavidClarkNZ))

Paula, 1/8 Maori (indigenous New Zealanders), who began her career as a dishwasher in a rest home, went on to win an election to represent her district. Since 2009 she has risen within the ranks of her party, and is seen as quite a force. She even has a menu item named after her at Backbenches, the “gastropub” where I stationed myself one evening to catch up on thank-you notes (I closed the place down. I wouldn’t let myself leave until I had finished them all and let me tell you, I had a lot of thank you notes to catch up on.)

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Paula then took me on a tour of her apartment in Bowen House, where she stays during the week while Parliament is in session and to which she is entitled by virtue of her high place in the pecking order. This apartment is something else, and I would be staying there through the Eisenhower Fellowship connection. It’s on the top floor of a 20-story building, with floor-to-ceiling views of Wellington Harbor. It had more space than any two hotel rooms I’d seen so far put together. And it had a laundry room I was free to use.

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Later that evening, I enjoyed a casual staff get together with the opposition party MPs and stafffers. We ate pizza, drank wine, and generally discussed the state of New Zealand politics and policies. I learned a lot. I was also (jealously) struck by how young many of the MPs are, how capable the staff seemed, and how well versed in policy issues they were across the board. They are clearly trying to work as a team, and are fighting for a true cause bigger than just their own political ambition. I felt like I was on a mini-episode of the West Wing. I felt cool. And I had only just arrived.

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The Recap

I’m not done posting. I’ve still got posts cooking from my time in Australia, let alone New Zealand and Singapore. But I really like to make lists. And while I have nothing but time on planes for the next 24 hours, it seemed like a good moment to reflect on what has just transpired.

IMG_2854 (these are the notebooks I took notes in during my meetings. they are completely full!)

Packing up to return home from five weeks abroad for my Eisenhower Fellowship was much like coming home from camp at the end of that junior high school summer. The anticipation (or really, anxiety) of that initial bus ride has been replaced by a kind of satisfaction – “Look what I just did.”

I have been away from home for 38 days. I have visited three countries, took 12 plane flights (including this bumpy one to Tokyo to start my long journey home) with two more to go to get all the way to Boston. I slept in 13 different locations. (There were only two snafus – one each with a flight and hotel – and both worked out fine in the end.) To get around, I rode trams, ferries, subways, countless taxis, and one helicopter, but no touts.

DSC_0783 (this is the view from that helicopter ride)

Going from memory, I had something like 74 meetings with approximately 127 people, including meals or coffee with 12 Eisenhower Fellows (and I have to say, they are an incredible bunch, including the former chairman of the largest mining company in the world, the president of a national political party, a national TV journalist, a successful entrepreneur, Ministers of various government agencies, and two members of parliament, just to name a few).

DG singapore fellows (here I am lunching with the Singapore Eisenhower Fellows and the 2013 Finland Fellow)

I met Australia’s federal secretary of health and ageing, Singapore’s Minister of Finance, and the chairman of New Zealand’s pharmacy purchasing agency. I met hospital CEOs, health insurance executives, entrepreneurs, consumer advocates, policy leaders and academics, economists, and journalists. I had dinner with two world-renowned geneticists and their three children in Brisbane, and breakfast in Singapore with the outgoing vice dean of Duke-NUS medical school and his wife.  I learned about public policy, health care financing, culture, history, market forces, and incentives. I covered health care costs, health benefit design, transparency of cost and quality data, efforts to integrate care, rural health, Aboriginal health, palliative and end-of-life care, public engagement, health promotion, “the patient experience”, and most importantly, leadership.

I took 5,612 pictures with my actual camera and my phone. I’ll try to restrain myself here.

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I’m embarrassed to say I can also count the number of times I worked out. It’s not zero, but it’s too small a number to share.

For fun, I hiked in the oldest rainforest in the world and took a helicopter ride over the largest coral reef in the world. I went spearfishing with Aboriginal guides (and did an excellent job not actually getting close enough to spear anything) and toured Melbourne’s Open House. I rode on a roller coaster, a giant ferris wheel (the Singapore Flyer), and to the top of two super high buildings (88 stories high in Melbourne and 58 stories high in Singapore) – just to catch the views.

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I toured a Synagogue, saw a wedding in a Malay mosque, visited a Buddhist temple during a prayer service, and paid a $3 photo fee to take pictures in a Hindu temple (worth it).

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I went to high tea at a historic 5-star hotel, tasted the best oysters I have ever eaten at an exclusive men’s club (where women can be guests), and ate the most delicious street food for ridiculously low prices. Unbelievably (for me), I only had sushi once. For breakfast I ate vegemite, marmite, and kaya. I drank an avocado shake, a Singapore Sling (from the place that invented it), and a chendol. And of course, all manner of coffee. I also learned how to eat dinner out by myself. It’s not my first choice, but a life skill nonetheless.

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IMG_2759 (chendol, an Indian drink with palm sugar, coconut milk, and pea flower ‘worms’)

IMG_2775 (simple, delicious noodles from QQ Noodle House near Bugis in Singapore)

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Last night, as I came down off the high of successfully squeezing my new purchases into my already-over-stuffed suitcases (which did at first seem like it would be an impossible feat), I settled into my few hours of sleep with these experiences washing over me. Bits of conversations, impressions, and ideas both souvenirs of a “once-in-a-lifetime” trip and the fuel for whatever comes next.  

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Flat White – A few words on (Australian) coffee

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Long black. Flat white. Cappuccino. Latte. These are the Australian coffee concoctions I’ve managed to pick up. They’re all good, but require some orientation. What follows is my uneducated interpretation (I haven’t Googled anything to get the official definitions).

Long black – It’s like a drip coffee but stronger than what you’d typically find in American coffee, as Jerry Ellis, former chairman of BHP (world’s largest mining company) and president of the Australian Eisenhower Fellowships organization explained to me at lunch at the Australia Club in Sydney.

Flat white – Another Australian Eisenhower Fellow explained this one to me. Jenny McAllister, President of the national Labour party, described her U.S. travels while on fellowship, searching in vain for a way to order the coffee she really wanted. Towards the end of her travels, she told some barista, “What I really want is an coffee made this way (I would fill in the specifics if I could remember them. I just recall at the end she said, with about ‘this much’ hot milk).” The barista went off and tried to figure it out. She returned to Jenny and proudly proclaimed, “There’s a name for what you’ve ordered. It’s a FLAT WHITE!”

This was my second Flat White in a row, my third day in Australia. A little strong for two in a row, but delicious nonetheless (at Bambini Trust Cafe in Sydney).

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Cappuccino, Latte, etc – I think this is just what Americans would know as a cappuccino, though there may well be some slight differences that I cannot detect.

The upshot is that the caffeine delivery here is very good. As for me, in the mornings, if I had time to sit (say in a hotel restaurant), I would order a Long Black with cold skim milk on the side. I’m sure that’s an American-ish thing to do. Any other time I would order a Flat White with skim. Turns out that’s a Skinny Flat White. Well, obviously. It’s just that I’ve been trained to think of ‘skinny’ as some god-awful, fake-sweetener abomination. But here, skinny just refers to using skim milk. There’s no question of fake sugar – just sugar or no sugar.

It hardly seemed fair that I missed Sydney’s Aroma Festival. Had I known, I would have booked a later flight to Perth. I seriously would have.

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I paid $5 for this one in Melbourne. Seriously. That’s what addiction will do to you.

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When I arrived in New Zealand (posts to come) and met my friend David Clark for breakfast, I was delighted to hear him order a Flat White. Not only do I know what that is, I love it! David explained these drinks originated in New Zealand, and were imported to Australia. Regardless, I was just so happy to “get” coffee here. Only modification – my kind of milk makes a “Trim” Flat White here. I’ll take it.

Here’s how the Kiwis do it:

In Wellington

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In Auckland (chocolate kiss is a nice touch, isn’t it?)

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Now I’m in Singapore, and finding that to order a coffee here at a counter produces a strong coffee of some form with a dollop of sweetened condensed milk. I haven’t been here very long, so there may be more to report on this later, but for now, yum! (not so skinny or trim, but delicious).

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More of my tour highlights are depicted below:

SYDNEY, at Max Brenner – The plate says: “Drink your coffee in a decent way (don’t forget you are an adult), then lick the chocolate leftovers to keep the child in you forever.”

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SYDNEY, Queue for Coffee – People are serious about it here, and willing to wait. I saw a line like this in the morning as you’d expect, but also at 3pm in the afternoon. Must be really good coffee.

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SYDNEY, Sunday morning – I was desperate to get a quick breakfast before my flight to Perth, so I succumbed to this. Yes, that’s a Starbucks. But in my defense, I did order Australian coffee. This is, in fact, a skinny Flat White.

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MELBOURNE, Brioche by Philip – Maybe the best I’ve had so far, skinny flat white with some yummy breakfast treat. And friend, who was working the first day I came to this café and gave me all sorts of ideas for what to see and where to go in Melbourne. When I returned before I headed out for the day on Monday, he was there, dressed to go to work somewhere else, now a customer.

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WHITSUNDAY ISLANDS, I was also able to secure skinny Flat Whites while on vacation. In paradise.

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MELBOURNE, On one of my two weekend days out in Melbourne, I came across Jasper’s Coffee, Caffeine Dealers. These people understand me as a coffee addict, I mean consumer.  Their packaging refers to “addictive excellence.” Yes, I am Jasper’s kind of consumer. When can we get Australian caffeine dealers at home? Jasper, you looking to expand?

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OK, you get it. I really love coffee.

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Australian Egalitarianism — Leaving No One Behind?

“Paging So-and-So to Gate Whatever,” went the airport overhead announcements throughout Australia. “Your plane is ready to depart and your fellow passengers are waiting for you. Please proceed to the gate immediately.” I really like the attempt to draw on people’s sense of obligation to other passengers. Or at least to use public shame to get planes out on time.

“We’re a society that doesn’t want to leave anyone behind,” said one of my hosts at a lovely lunch at the Sydney Women’s Club early in my stay. Rebecca Davies is the consumer representative on the National Health and Medical Research Committee, and has an accomplished history in the Australian health system, having previously served on the Private Health Insurance Administration Council. In this genteel setting of the Women’s Club, where sherry was served in the anteroom but not allowed in the dining room itself, Rebecca explained her take on the Australian safety net system, Medicare, and the way in which Australians look out for one another. “We don’t mind paying a bit of taxes to make sure no one goes without.” (I’ve always felt this way at home, but of course that makes me a socialist.)

In this regard, Australia has the U.S. beat by a mile. Let’s say by many many miles. There is no one in Australia who is not covered by the public insurance system. That doesn’t mean people don’t have challenges accessing services – there can be long waiting lists for procedures in the public system and high price tags in the private system. But literally everyone is provided for. By contrast, in the U.S., 45 million Americans have no health insurance, which means the only health care they can reliably access is emergency services, which, by law, must be provided regardless of ability to pay.

The number-one question I got – I think from every Australian I met, was about the impact of Obamacare. “What’ll it mean?” or “What do you think of it?” people asked me (without realizing that “Obamacare” is typically used pejoratively). Bernie Kelley, managing director of Intelog Business & Healthcare Performance Group and one of my wonderful hosts and collaborators in Australia, translated this questions for me (I paraphrase): ‘We couldn’t really understand what the big deal was. There seemed to be such a fuss over it and it doesn’t even cover everyone.’ Bernie also explained that Australians can’t generally fathom medical bankruptcy. It’s simply not something they need to worry about here. Score one (or many) for Australia.

I heard these themes over and over in Australia, and a statement something like this: “Look (many sentences start with ‘Look’), our system isn’t perfect, but we’re just not going to let people go without.”

That is, until my lunch with a bunch of entrepreneurs looking to shake up how consumers purchase products like electricity or health insurance: “Nah,” the 30-something, tall, brash founder of One Big Switch said over lunch. “We just want to make sure that there’s something there for us when WE need it.” Whatever the motivation, it’s true that everyone is covered here.

In Perth, with Sydney far behind me (far, far behind me; have you been to Perth? It’s damn far), I got another view of the egalitarian story. Here, I heard a lot more about Aboriginal health. In Perth, I didn’t have to ask before the topic arose organically, and the people in health care I spoke with seemed genuinely focused on how to improve health access and outcomes for Australia’s indigenous people. It’s not that the people in Perth are nicer or more liberal than the folks in Sydney (in fact, based on my visitor’s understanding of Australian politics, I actually believe Western Australia to be more conservative.). Rather, in Perth, they have no choice but to face the issues of Aboriginal health. Their emergency rooms and dialysis wards are full of Aboriginal patients. Western Australia is 3.8% Aboriginal, compared with 3% in the country as a whole. Doesn’t seem like a big difference, but when you have only ~2.5 million people in a land mass one-third the size of the U.S., I think you notice small population differences.

Aboriginal health disparities are well documented. Mick Gooda, Australia’s Social Justice Commissioner and an Aboriginal leader, explained that “what we don’t know about Aboriginal health would fill a postage stamp,” while the solutions are scant. And the list of problems is extensive. Here are just a few:

  • Aboriginals have life expectancy approximately a decade (11.5 for men and 10 for women) shorter than non-indigenous Australians[1].
  • Two times as many Aboriginal and Torres Strait Islanders are born with low-birth weight than non-indigenous people in Australia[2].
  • The infant mortality rate amongst Aboriginal people is higher than for non-Aboriginals; in the Northern Territories, for example, the state with the highest percentage of Aboriginals (nearly 30% of the state population is Aboriginal), has an infant mortality of 13 deaths per 1,000 live births, compared with the national average of 4.
  • Almost half of Aboriginal people consider themselves a current smoker[3].
  • Estimates are that between 10% and 30% of Aboriginals have diabetes, with approximately half not realizing it.

A bit of history. Aboriginals didn’t have the right to vote in federal elections until 1962, in the country they had inhabited for somewhere between 40,000 and 80,000 years.

The first real land-rights act, granting “inalienable” rights to some traditional lands passed in 1976. In 1992, an Australian High Court decision legally recognized certain land claims. In 1992, I was a sophomore in college. It doesn’t seem that long ago.

As Mick Gooda put it, there was a strategy of “smoothing the pillow”, essentially waiting for full-blooded Aborigines to die out. There were village massacres, carried out by European settlers in the 1800s, and as late as 1928, reportedly in the living memories of some Aboriginal elders alive today.

I heard about the “stolen generation” – Aboriginal children who were taken from their families, for their own good of course. This practice took place between the early 1900s and as late as 1970s. Children of ¼ or ½ Aboriginal ancestry (“half-caste”) were taken and given an “opportunity” to be integrated into European-Australian society, whereas full-blooded Aborigines were left to extinction. I heard stories from my contemporaries in Perth who had known children in grammar school whom they suspected of being “stolen.” In some states, laws enabled the government to take children without having to prove their parents were unfit. In other states, rules were less clear but government officials took similar latitude.. In 2008, then (and current, for now) prime minister Kevin Rudd issued an official apology to the victims of these policies, recognizing the detriment it had caused to individuals, families, and the Aboriginal community.

I am no expert on the plight of Native Americans, but I think it is a generally consistent story. As U.S. schoolchildren, we learn about the sometimes horrific treatment of Native American, in age-appropriate lessons of course. (Actually, most of what I remember from school has to do with Thanksgiving and the Pilgrims). But these stories are generally presented to us as remote history, certainly not something that has happened within our lifetimes.

In Far North Queensland, I heard from a Dutch-born retired engineer that he had been told to ‘go home, back where he came from’, in Brisbane, a cosmopolitan city in southern Queensland. In modern times. He also described great discrimination against the Italian immigrants who had settled in Mossman (and elsewhere), and how they would refuse to note their country-of-birth in health forms at the local hospital for fear of discrimination for being ‘not really white’. “Every country has its share of dickheads,” my driver quipped. “But Australia has more than its fair share.”

Australia is struggling with the effects of generations of inequity and mistreatment of the nation’s original owners. Some of my Australian contacts called it racism. Others acknowledged a troubled history with a long way to go. The current conditions of Aboriginal people in Australia illustrate how harmful that history has been. Campaigns such as Closing the Gap and organizations across Australia are working to remedy the disparities that indisputably exist. I met one health care leader in Melbourne whose office proudly displayed the Aboriginal flag alongside the Australian one, and who opens every meeting where there are Aboriginals present recognizing the original owners and paying respects to the elders.

There is a lot to the Australian “brand” of egalitarianism, which America doesn’t even come close to achieving or aspiring to (remember “Obamacare” is a negative term and if you support it, you may as well be a communist). But Australia’s history and culture are nuanced, with residual damage that will take generations yet to remedy. At least their goal is to leave no one behind.


[1] Australian Indigenous HealthInfoNet (2013) Summary of Australian Indigenous health, 2012. Retrieved [access date] from http://www.healthinfonet.ecu.edu.au/health-facts/summary

[2] Australian Institute of Health and Welfare website

[3] National Aboriginal and Torres Strait Islander Social Survey, 2008

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American guns. Ridiculous.

I digress from health care for a moment. I need to address the topic of guns. Actually, guns in America probably explain much of the difference in life expectancy between Americans and Australians because so many Americans die young due to gun violence, accidents, and suicides, whereas few Australians do. So actually, it is a health issue.

From nearly the start of my travels in Australia, people have been asking me to explain guns in America. They literally cannot understand why, particularly after the school shooting in Newtown, we would not pass “common sense” gun legislation.

To put guns (or lack thereof) in Australia into context, even the wife of the head of Eisenhower Fellowships Australia, a self-proclaimed staunch conservative, was pretty animated about a recent Australian policy shift to allow guns in national parks. She was concerned about what might happen if people were hunting and accidentally shot other visitors. No pun intended, but she was pretty up in arms.

I had many conversations with Australians that went something like this:

“How do you explain guns?” –Any Australian

“Um…I really can’t and wouldn’t try.” –Me

“Did people actually think arming teachers was a good idea?” –Any Australian

“Uh…I think so. But most of us didn’t.” –Me

“We actually thought it was a farce when people suggested that America needs MORE guns after the school shooting (Newtown). We literally thought it was a joke. It took us a while to realize that was a serious position.” –Any Australian

“I know. I think people were serious about that. But the vast majority of Americans supported some kind of legislation. If ever there was a time when we could have passed something, it should have been after 20 children died. The fact that we couldn’t pass anything is simply a failure of leadership in my opinion. We just lack leadership courage.” –Me (May as well just own this national embarrassment. I could see no other way to explain it.)

Carol Bennett, CEO of Consumers Health Forum of Australia said it well. “We look at guns in the U.S. and we think, ‘That’s ridiculous.’ We just don’t understand how the rights of one lobby is allowed to impact the lives of so many people.”

I heard the word “ridiculous” on almost every occasion where the topic of guns arose.

In the context of consumer empowerment in health care, I had asked Carol what she would do in the U.S. She said she’d start with a question, which I think applies perfectly to guns, too. Her question: “You have to decide, what kind of society do you want to have?”

Yes. I reckon we do.

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Consumer Central? — Canberra, the Capital

My last stop in Melbourne before I had gone to the airport for Canberra had been at Cabrini Hospital, where Dr. Simon Woods shared a quote from a British actor whose name I didn’t capture. The quote went roughly like this: “Australia is the most civilized place in the world. In all other nations, they allow politicians to roam amidst the population. In Australia, they quarantine them all in one place. It’s like a free range zoo for politicians.” (I learned here that disdain for elected officials, even in a place that generally accepts government intervention, is universal.)

At the airport, which I spent about 6 hours in just to travel 1 (faulty radio, waiting for part, etc), I met a resident of Canberra who called it “the most boring city in the world” which I think is a common saying, not just his opinion. He also  told me that Canberra itself represents Australian pragmatism. When Sydney and Melbourne squabbled about which would be the capital city, they decided instead to split the difference and create a capital roughly in between.

I had travelled to the capital because there’s no way around that some of the people you want to meet need to be in the capital. For example, I met with the people who oversee operations of Medicare, the government insurance program. The division I met is responsible for the service centers (remember all Australian health care is retail), billing, data analysis, utilization management, and ultimately, the results of the program. They do not set policy, but they have to make the policy work.

They outlined the history of Medicare as more than just a safety net, as many people see it today, but an actual universal coverage system. Though Medicare began with no real sense of limitations on services, there had always been small gaps between what many general practitioners charged and the portion that Medicare picked up. Those gaps are growing – in some cases dramatically – causing some to wonder, “What has happened to our universal system.” Like virtually every other nation, Australia is recognizing they can’t, or won’t be able to continue to afford their health care system at current growth rates. And people are feeling it.

The upside of the increasing consumer cost sharing is some amount of market power for consumers. Consumers can choose not to go to a GP who charges above and beyond what Medicare covers. They can also negotiate are protected by their ability to vote with their feet (sounds like a market to me). My host here described consumer empowerment in terms her father, who, upon hearing of what he felt to be an outrageous price of a procedure, argued, “Fred down the road charged my golf buddy less, so maybe I’ll go see Fred instead.” And wouldn’t you know, he got a reduced fee.

Australia’s Medicare is also meeting consumers naturally evolving behaviors. For example, patients have had the option to submit claims right in the doctors’ office for almost a decade, and as of last year, the government eliminated cash payments and now offers direct deposit and electronic funds transfers. They’re even working on a system where people can snap a photo of their bills or other documents about which they have questions, upload them, and get help over the phone.

The Medicare retail centers are also evolving with the times. The government has realized it’s inefficient to have different retail arms side by side, run independently from one another all with taxpayer money. Moreover, fewer people are visiting Medicare branches in person since they can do more transactions online. So the new Centerlink sites combine a range of government services. However, Centrelink has a primary focus on lower-income residents who qualify for assistance programs, whereas Medicare had been a broadly middle class program; there is some concern that middle class people won’t seek services in a Centrelink branch. It’ll be interesting to see how Australian stated values of egalitarianism play out in this arena.

After Medicare, I met the CEO of Consumers Health Forum (CHF), Carol Bennett. Consumers Health Forum is known as a “peak body” for Australian health care consumer advocacy. I knew about CHF from my research and it was the reason I had booked time in Canberra. I couldn’t think of a more fitting person to meet given my focus area.

I found Carol to be more than up for the task of representing consumers in the Australian health care policy world. She is clearly media savvy and strategic about how to get issues on the public policy radar screen. Among CHF’s top issues is the rising out-of-pocket costs hitting consumers, particularly vulnerable ones, and on the huge variability in doctors’ fees (sounds familiar). Of course consumers have no idea why prices vary, and Carol argues that for price signals to work, there should be some rationale for the differences. Thus, you could argue that Australia in fact has a market failure in this regard. “We should have access to comparison data to make informed decisions.” (If I knew Carol better I’d say, ‘Amen Sister!’). CHF is also about to start a body of work on informed financial consent, wrapping financial disclosures and consent into the existing clinical informed consent framework. Pretty genius. Hopefully it’ll work.

Carol had really interesting views on the need for more pay-for-performance and less fee-for-service in the Australian system. While this is the conventional wisdom in the U.S., I found it rather a rare view. One reason for less blind faith in incentive-based payments is that it would require a broader adoption of a medical home model, which would in turn require residents to sign up with a single provider and apparently, Australians don’t like to be locked in. Perhaps it’s a residual effect of arriving in Australia as convicts.

One of my favorite parts of my meeting with Carol was her explanation of how Australia fits sort of in between the U.S. and the U.K. (I had heard shades of this before and being in the country, it feels intuitive though I wouldn’t have been able to articulate it on my own). Australians are worried about turning into America, paying way too much for lower-quality outcomes with a sense that government should have no role. On the other extreme, the U.K. is seen as way over-regulated and providing insufficient choice to suit the Aussie independent streak.

Australians see a role for government in public health, in preventing market failures, and in protecting the public good. On the other hand, their acceptance of government programs is by no means “socialist” or particularly based on a “rights” framework. Rather, there’s a sense that “we’re taxpayers, so we’re paying for this system, and we use it when we need to.” In this way, Australians are every bit consumers in the way I have been arguing Americans need to be. They understand that they pay for their health care one way or another. They expect good information, good results, and to be part of the process. Australians expect government to operate responsibly and transparently, and to fix it if the system fails.  They hold the government accountable because, after all, they are paying the bill.  “We are active participants not passive recipients.” And thus, I had gotten what I came for and the capital seemed worth the long journey.

On my flight from Auckland to Brisbane later the following week, I caught the first half of “Canberra Confidential,” a show done by my fellow Eisenhower Fellow Annabel Crabb (@annabelcrabb) who I’d gotten to meet in Sydney. Her show was a sort of satirical expose looking for clues into the scandalous history of this very boring capital city. Though I didn’t catch the conclusion, and though I am every bit the Annabel Crabb fan (as was everyone I met), I am not sure I’m convinced that the place itself is at all interesting. But for me, Medicare, Consumers Health Forum, and several others that I met sure were.

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Small things

One of the perils of traveling alone is that there’s no one to lean over and say, “hey, look at that.” So, on my last night in Australia (for now), I thought I would share some of the small things that I noticed while I’ve been here.

1. The soap dish 

I hate to admit but I did not find this on my own. I had returned to my suite after a long day and realized the cleaning people had simply moved the bar of soap from the bathroom counter where I’d left it to this tidy, clever little soap dish. Luckily there was no “you are an idiot” note with it. (Do we have these at home? I’ve never seen it before.)

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2. Electric outlets, on demand

Sometimes at home electric outlets only work when a switch is on.  Good luck finding the right one. Here, outlets only work if you turn them on and it’s obvious how to do it. I know nothing about electricity; I assume it’s more safer and maybe more efficient? Anyway, I think that’s kind of elegant.

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3. Target. 

So we’ve exported an American staple. But why does it need punctuation here? (My friend and collaborator here told me it’s a totally different company, but it looks awfully similar. Except for the period.)

Target

4. Phantom drivers

It took me about a week to get used to seeing no one where a driver ought to be.

5. Look right

It’s also quite a miracle that I didn’t get hit by a car because it wasn’t until a few days ago that I started to intuitively look in the right direction (most of the time). (Yes, I know you’re supposed to look both ways, but I do think it’s best to look in the direction that cars might get you first).

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In Melbourne, I would reliably wait for the tram on the wrong side of the street. I really struggled with this one, but would eventually ask someone for help and be pointed to the opposite side from wherever I was.

I also didn’t really ever think about the fact we walk on the side of the street we drive. So, I would also invariably get in people’s way while walking on the right side of the sidewalk. I only had one or two true stand-offs though.

6. Food courts

In Sydney anyway, I felt like everywhere I looked there was a food court. Some were like what I think of as a food court at home – open spaces with lots of fast food stations. Others, were more high-end, like this one in the No. 1 Martin Place building that I stumbled upon my second night in Sydney. At one of my meetings later in the week, my host was appalled that I called it a food court, as it had high-end food options like oysters, a wine and cheese bar, and a sushi restaurant. But in the end, he agreed that’s what it was. A very fancy one.

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7. Expressions

I would often stop people in meetings and ask them to repeat and sometimes define their Australianisms. Here are some of the ones I heard the most.

  • Chockers (Chock full)
  • Nutter (Crazy)
  • Selfie (Self portrait. My husband informs me that if I read the New York Times with any regularity I would have heard this phrase already)
  • Bub (Baby, which was on the news constantly as Kate Middleton gave birth while I was in Perth)
  • Oldies (Seniors, older people (apparently this is not offensive)
  • Like chalk and cheese (different)
  • Uni (university)
  • Sorted (sorted out or settled in)
  • Carers (we would say ‘caregivers’)
  • Footy (football)
  • Squillions (I heard that today – like ‘gazillions’)
  • Good on you (good for you)
  • How are you going? (how are you doing? OR how is it going?)

footy

8. Things they really say here: 

They really say “mate”, and “g’day”, and sometimes in the same phrase.

I also noticed a common speech pattern was to say, “Yeah yeah” in the way Americans would mean, “Yes I know.” So I’d ask, “Do you know this?” and they’d say, “No no.”

9. Cab rides (approximately) 

About 1 in 2 cabs dropped me off at approximately my destination. This happened to me in every city. Sometimes it was due to traffic. Other times the drive would wave his hand towards a pedestrian walkway and explain he couldn’t get there (of course, the actual destination was well on the other side of that walkway and he could have driven me). Even at the airport leaving the country, the cab driver dropped me off at Qantas, not Virgin. Grrr.

I had heard that it’s culturally appropriate to ride in the front seat of taxis. So I found it interesting when hotel valets would open the back door for me. But when I hailed cabs, I would hop in the front. Here I am getting used to that practice:

me in front seat of taxi

10. Street sculptures

Not sure what these are doing here. They were all over and totally random.

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statue of kid on street in Sydney

museum statue close up (this guy is standing at the counter of one of the museums in Melbourne. It’s kind of creepy, and hilarious at the same time)

11. Australian winter

It has been unseasonably warm here, but still, I can’t believe what folks here call ‘winter’. Even in Melbourne, which is supposed to be consistently colder in winter, they sit outside (these stools are empty but I saw lots of people outside).

red stools

12. Burger King?

hungry jack

13. They really eat vegemite. On toast. With cheese, or avocado. I kind of like it. Kind of.

vegemite            vegemite tubes

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Heading Out, in Melbourne

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“There’s art oozing from every orifice of the city,” an artist at the Rose Street Market told me. And walking through Fitzroy, it was clear. Murals decorate every other building or corner on Brunswick Street and its side streets. More than simple graffiti, this stuff is art. It is literally everywhere you look. Here’s where pictures come in:

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There is even art hanging off buildings. With a sense of humor.

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And randomly placed in the middle of the sidewalk.

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They even make art out of themselves (I’m in there somewhere, too).

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(this one’s a bunch of people dancing during Open House Melbourne)

Melbourne is a, and many argueTHE, cultural center in Australia. People here say that on all measures but beauty (on which Sydney would win), Melbourne gets highest marks. By all accounts, it is the culinary capital, a coffee mecca, and the fashion center as well. (Please don’t take offense if you’re from another part of Australia – I’m reporting what the people here tell me). It’s a European-style city, with dense neighborhoods, old-world style buildings, and infinite cafes and restaurants. They even call the part of town where I’m staying the “Paris-end”.

In terms of health care, too, it seems to be on the vanguard. The CEO of General Practice Victoria shared with me a document called “Doing it with us not for us”, a framework for consumer and community participation in health planning and policy produced by the Victoria state government in 2006. This document apparently underpins much of what has come out of Canberra (the central government) on these topics.

Among other examples is Health Direct Australia, a national call service to help people who need after-hours care determine where to go. It’s like nurse lines we have in the U.S. This service hasn’t totally evolved in Victoria because this state has had a nurse on-call system in place for years.

I’m not sure this is particularly innovative, but I did learn from the CEO of Bang the Table (www.bangthetable.com) (more on that in another post) that the hotel where I’m staying is like a hospital annex. Specifically, after women give birth, they come to this hotel to recover. It’s cheaper than the hospital, and it makes room for new patients. I did see a teeny tiny baby in the elevator (with his mom and a valet bringing up the luggage). This might be a necessity due to overcrowding in the hospitals, but I think it’s a damn good idea for routine deliveries. I wonder if they bring clinicians over to check on these patients. If I were a nurse, I might be persuaded to work in a luxury hotel/hospital.

Victoria sounds a bit like Massachusetts – progressive, on the leading edge in implementing health reforms, and often a model for the national policy framework. Now, if only we had a fraction of the public art…

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P.S. I ran into my artist friend again on Sunday, at a Sunday market near the Melbourne Arts Complex. It being the annual Open House Melbourne, I was thankfully not the only tourist clutching a map. And I got to see the inside of a bunch of buildings that are usually closed to the public.

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(These are bowls in a pool in the National Gallery of Victoria. They move with the water, so this is a moving art piece — it changes constantly, and it makes noise when the bowls clink up against each other. The rest of what I saw in the gallery was pretty great, but I could have stopped here and been happy I went.)

Ahhh, art.

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