26 February 2015

American surgeon and health researcher Atul Gawande’s new book “Being Mortal: Medicine and What Matters in the End” is an extremely readable, radical and powerful critique of contemporary society’s approach to the inevitable questions of ageing and dying. He argues that much of conventional medicine’s approach to these stages of life runs counter to the expectations of patients and their families.

This is not intended to be a book review – Gawande’s work speaks for itself – but rather, to raise in the New Zealand context the issue which he speaks about. Already, our Health Quality and Safety Commission is starting to become much more involved in this space, and will be hosting Dr Gawande when he visits here in a couple of months.

There has been concern for some time that resources dedicated to a person in their last five years of life are substantial and go well beyond a level and type of care that they may actually want. At the same time, there is increasing focus on the last six months of life and its management, although as an eminent French oncologist, with a typically Gallic shrug of the shoulders, said at a conference I was at in the United States recently, “How do you know when the last six months begin?”

There are signs in New Zealand of health care providers starting to think more laterally about these matters and to realise that the quality of  intervention rather than the quantity is the true reflection of effective and responsive health care. Only a couple of weeks ago, I was pleased to be at Enliven’s Cashmere Home in my own electorate when it became just the second elder home in New Zealand to achieve the 10 “Eden Standards” for elder care, a hallmark lauded by Gawande as marking the way of the future in residential elder care.

Gawande’s approach can be replicated across the entire health care system – from elder care, through to terminal and other restrictive conditions. What he is focusing on is a patient centred approach, understanding and meeting a patient’s needs and wishes, not forever trying to shape the patient’s requirements to fit the prevailing medical model.

There is a link here with the government’s better public services approach, where the focus is on delivering services in a more convenient and client-centred way. So far, the emphasis has been on the achievement of specified targets, and considerable progress has been made in that direction. There is no reason, however, why it cannot be extended to encompass what Gawande is advocating.

The significant common point is that the provision of quality public services is no longer about fitting everyone into a particular structure and then making that work as best it can, but rather, much more about services that meet actual needs, expectations and convenience. While Ministers, senior policymakers and citizens are increasingly getting it the real challenge will be ensuring those who actually provide the services get it too.

Gawande has released an exciting proposition – one in the end which will impact upon all our lives and change them for the better.

 

 

   

  

 

 

 

 

19 February 2015

Most New Zealanders will have never heard of the Nairn brothers. But from 1923 until the late 1950s, these two New Zealanders operated the famous Nairn Bus to Baghdad. At the time, it was “the” way to make the 1,040 kilometres journey over often dusty desert roads from Beirut to Baghdad. While the Nairns have long since passed on, it still seems to be a case of all roads lead to Baghdad, as far is New Zealand is concerned.

Within the week, New Zealand will decide on a military deployment to Iraq to combat the rise of ISIL. Of course, no formal decision has been made as yet, but all the signs are pretty obvious, and when I overhear young soldiers at Auckland Airport talking about how exciting their role in Iraq will be, I know our forces are as good as on their way. And forget the niceties – regardless of whether they are just training advisers, or whether they are under the protection of the Iraqi armed forces, they are in fact military personnel and will thus be subject to all the perils that implies. And remember too, that the innocuous term “trainer/adviser” seldom stops there. Kennedy sent a few hundred advisers to help South Vietnam in the early 1960s – by the time the Vietnam War ended in (in American  defeat) in 1975, over 210,000 young Americans and more than 220 young New Zealanders had been killed or wounded.

I have been a keen student of Middle Eastern politics since the early 1970s. The intervening years have seen massive upheaval and changes in the region, the fall of old regimes and dynasties and the rise of new ones. But no matter how the lines on maps have been drawn, or which governments have been backed by the West, and which have not, the one constant has been the failure of Western policy. Mainly, this has been the fault of the United States, although the British and the French must also take their share of culpability.

In their heyday, the Nairns had to battle all manner of political and other obstacles, from the inhospitably hot weather to the marauding intentions of hostile Bedouin tribesmen (who were even then subject to RAF bombing and strafing in Iraq). Nearly 90 years later, not a lot has changed, except that the brutality and precision intensity of weaponry has increased dramatically. ISIL and its ambition to establish a new Caliphate is hardly new either. The Rashidun Caliphate was established almost 1,400 years ago. The Ottoman Caliphate lasted from the sacking of Constantinople in 1453 until 1924. The Crusades of the 11^th and 12^th centuries were Christian Europe’s first ultimately unsuccessful response to the rise of Islam. ISIL, whatever one thinks of its depraved brutality, is the modern expression of those traditions. History suggests it is not going to be bombed or blasted away.

I oppose New Zealand becoming militarily involved in the ISIL campaign for one simple reason – it will not work. In doing so, I am not condoning ISIL’s atrocities or barbarism in any way. But external intervention as now proposed will be ultimately unsuccessful and much innocent blood on all sides will be spilled in the process. Whether or not ISIL’s desire to establish the new Caliphate succeeds depends far less on the exercise of external military might than it does on the support of the people in the region to let it happen.

So any intervention we feel obliged to make should be at the diplomatic and humanitarian aid ends of the spectrum, working with and alongside local people to strengthen civil society. And if the international system is to count for anything (and given our role on the UN Security Council should we not be doing our best to ensure it does?) any such action should be under a UN Mandate.

We can hardly expect others to play by the international rules, if we are not prepared to do so ourselves.

   


 

  

 

 

 

 

 

12 February 2015

It is very likely that within the next couple of weeks two Australian drug dealers will be executed in Indonesia. There is an understandable sense of revulsion developing about that probability, leading to a renewed focus in this part of the world at least about the barbarity of the death penalty. A New Zealander is about to go on trial in Indonesia on drug-related charges and could well face the same fate, which gives added relevance to the outcome of the case of the two Australians.

While we do not, nor should not, condone their crimes – even they admit their guilt – we are as a civilised society repulsed by the fate that waits them.

But we are also a hypocritical society. Virtually every week, there is an execution or two in the United States – the victims often being of low intelligence, and the execution process botched and unnecessarily prolonged and painful – and we do not bat an eyelid. Our new best friend, China, routinely executes miscreants for all manner of offences, and we stay silent for fear of upsetting them. The Saudi Arabian regime beheads, stones, hangs or maims people after prayers each week, yet we honour the late King by flying our flag at half-mast on official buildings. There is no difference between each of these situations and the firing squads now being lined up in Indonesia.

Well, you might ask, aside from chest-thumping and expressions of outrage, what can New Zealand do, if anything, about all this? Is this not a matter of national sovereignty, been left for countries to deal with as they see fit, without the interference of well-meaning external busy bodies?

There are two courses of action New Zealand could follow. We should be prepared to speak out against the death penalty, as and when it is applied, on the principle that no state has the right to deprive its citizens of life. We should be strongly supporting the advocacy work of groups like Amnesty International and generally not giving succour to the death penalty states.

Over the next two years we have the advantage of being a member of the United Nations Security Council. As a small, independent state, generally recognised as having a good human rights record, we should be using that role to promote an international campaign for the elimination of the death penalty. In 1994, we were, as a member of the Council, able to bring a human rights focus to the resolution of the Rwandan crisis, being widely applauded and still remembered for that achievement. We have the credibility to be similarly effective, were we to take on the death penalty challenge during our current term.

It will be too late for the Australians in Indonesia and for others immediately similarly threatened, but being part of a successful international campaign for the abolition of the death penalty, however idealistic and impractical it may seem, is a worthy goal to strive for. It would be great to see New Zealand pick up the challenge.

  

 

 

 

 

 

 

 

 

5 February 2015

The tsunami that washed away the Queensland government last weekend has unleashed a number of other massive waves of discontent, all aimed at Australian Prime Minister Tony Abbott. No-one seems to quite know what will happen next, other than it is unlikely to be good in any way for Mr Abbott.

I served in a government that faced a similar implosion – the Fourth Labour Government after 1987 – so can offer a few insights.

Over time all governments become unpopular – often quite suddenly and unexpectedly. Churchill’s surprise defeat in 1945 is often cited as such a case (although the then rudimentary science of opinion polling had been pointing in that direction as early as 1944, and Britons had not had the chance to vote in an election since 1935.) Even John Key, despite his unique distinction of three resounding election victories by ever widening margins, knows too his day will inevitably come.

In the case of the Fourth Labour Government, that inevitable slide was aided by the aftermath of the 1987 sharemarket crash, but was primarily fuelled and accelerated by the government’s own kamikaze determination to self-immolate through inter-necine warfare. The Beehive was literally a floor-by-floor war zone – one floor was Lange loyalists, the one below was Douglas controlled, and so on. The Caucus was simply bewildered. When one backbencher tried to mediate between the factions Lange ridiculed him as needing a brain transplant, the only problem being they could not find a compatible hare.

The Opposition was irrelevant and ignored. The media thought they fulfilled that function anyway. And while the real Opposition was softly but surely sleepwalking to victory, the government was doing its own fair impression of a one party state, being both government and its own opposition at the same time. (There was even brawling between delegates at an Auckland regional conference.) It was all very insular as we got on with the job during 1988-90 of destroying the very government we claimed to be proud to represent.

Lange threw in the towel in 1989. Palmer tried bravely and vainly to right the ship over the next year. Then third officer Moore led a further mutiny of the nervous just eight weeks before the election to seal the government’s fate. And Jim Bolger won the biggest landslide of any New Zealand Prime Minister ever.

Tony Abbott’s behaviour over the last week brings all that back to mind. Telling his MPs they have no right to vote against him because he has been elected by the people, and then having MPs break ranks all sounds very familiar. If things run true to form, he may  limp on, but even that now seems to be wishful thinking, as the polls deteriorate, the backbench becomes more spooked, and the likely contenders deny any interest in public, while doing their numbers in private. Either way, Abbott will go, either forced out by his Caucus, or because he has had enough of the infighting.

His successor will try to patch things up – and may even succeed for a while – but then things will start to slip again. It will be everyone else’s fault: a public that does not understand the government’s true message; a hostile media; or, both. The government will be too busy fighting itself to notice.

If I were Bill Shorten right now, I would be presenting a very relaxed and quietly assured air, trying not to look too earnest (difficult for him, I know), but knowing all good things invraibly come to those who wait.