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.

    

   

  

 

 

 

 

29 January 2015

As the world commemorated the 70^th anniversary this week of the liberation of Auschwitz death camp, the Beehive’s flag fluttered at half-mast in tribute to the late King of Saudi Arabia, where women have no rights, beheadings are frequent and journalists and bloggers are whipped. A northern Maori leader warned that burqas would not be welcome at Waitangi celebrations next week and Winston Peters made his first racist statement of 2015.

The incongruent juxtaposition of these events is stunning. While Auschwitz stands forever shamefully head and shoulders above all other symbols of human intolerance and brutality, and while all memorial services in New Zealand and around the world were right to proclaim we must never let such events happen again, the above examples show we still have a long way to go in the tolerance stakes.

Yet the lessons of history are obvious. Take South Africa, for example. Our “bridge building” approach of the 1950s-70s did not work in changing the attitudes of the apartheid regime, and if anything reinforced its intransigence. It took the isolation and sporting and economic boycotts of the 1980s to free Nelson Mandela and usher in the development of the rainbow nation we know today.

Similarly with repressive states like Saudi Arabia. Lowering flags to commemorate the late King, or sending an incredibly high-powered delegation like President Obama has to pay homage to the new monarch merely reinforce the form and structure of the regime and its repressive practices. And, in their own way, incidents like banning burqas or racist statements by shallow politicians reinforce the prejudice that discrimination is more or less acceptable, provided your target is unpopular to start with, and you do not go too far.

Now one might have expected the loftily titled “state of the nation” speeches by our two major political leaders to have made at least some passing comment about these matters. But, not unexpectedly, both were silent in favour of the mundane. One was a speech about housing, the other a trip down memory lane. Neither had the gravitas or substance to justify the “state of the nation” title.

The grief and emotion that has accompanied the Auschwitz events reinforces the reality that human beings are more than just mechanistic, uncaring robots. Attitudes, feelings and what we quaintly call values are the true and important shapers of our destinies. Maybe that was the point behind Eleanor Catton’s forthright comments in India. While not agreeing with the particular sentiments she expressed – although she had every right to do so, without abuse – I have some sympathy with her underlying message that nation states ought to stand for something, and are more than just collections of people all furiously getting on with their own lives, like bees in a hive.

Yet our indifference to the incongruent events around us suggests that is exactly what we are doing. And perhaps, more seriously, that no-one really cares too much. It may well be an expression of the complacency the long hot summer is inducing, or a very successful political management strategy. Either way, it cannot last.

             

 

 

 

22 January 2015

Two acts of political crassness marked the holiday break.

The first was the befittingly silly comment from Ron Mark about putting shots across the bows of foreign fishing vessels illegally poaching toothfish in the southern ocean.

The second was Nick Smith’s speech to his Nelson constituents. This was no mere putting of shots across the bows of the Resource Management Act, but the launching of a full-scale assault.

National has long had the RMA in its sights. Even before it passed the Act in 1991 elements in National (notably then Local Government Minister Warren Cooper smarting over restrictions imposed on developing his motel complex in Queenstown) have been opposed to requiring development to be undertaken in an environmentally sustainable way. But, to date, wiser heads have usually prevailed.

Initially, that seemed to be likely outcome this time around, with National appearing to have taken aboard the criticism its 2014-14 reform attempts received. The Prime Minister spoke of “moderate and pragmatic” reforms – usually code for watering down the more extreme enthusiasms of some of his colleagues – but all that seemed to fly out the window this week. (One charitable, but probably far-fetched, interpretation of Dr Smith’s speech is that it is an elaborately Machiavellian attempt to prove to his more gung-ho colleagues just how difficult carpet-bombing the RMA will be in practice, and is really a carefully disguised plea for moderation. As Churchill once observed in a similar situation, if that is the case, it is a very effective disguise!)

All of which is a huge pity. National’s blunderbuss attempts to obliterate the RMA, egged on by ACT which fears National is not going far enough, are obscuring the vast areas of agreement for change across the political spectrum, upon which a responsible package of change could be developed.

There is little disagreement that some of the RMA’s processes are cumbersome and outmoded, and a break on responsible development, and a solid Parliamentary majority could be deftly and quickly assembled for a package of measures to address these. That has not changed since National first began its latest RMA assault in 2013, and it is a genuine mystery why it has not taken the opportunity to build such a majority before now. After all, if the “crisis” is as pressing as National keeps saying, its all or nothing approach seems a very curious way to proceed.

For the record, UnitedFuture’s position is clear and unchanging. We are prepared to work with National and other parties – like the Maori Party and possibly even Labour if Andrew Little’s initial comments mean anything – on changes to streamline the processes of the RMA to make them more responsive and efficient, and not an unnecessary impediment to responsible development. But we will not support any changes to the principles of the RMA that have the effect of weakening the environmental protections it enshrines. The RMA is not just one piece of the development jigsaw as its critics would wish, but the fundamental backdrop. That principle must remain inviolate.

From my perspective, the door is ajar for further discussion, but I get the sense that National is now less inclined to that, having tucked away the ACT vote to secure its majority. Suggestions I have heard this week that National will only talk to support partners if it can be certain in advance that it will get their agreement reinforce that view.

That was this week. The Prime Minister returns next week and it will be interesting to see if “moderate and pragmatic” returns to the RMA agenda as a consequence. For the sake of the environment and future generations, I hope so.       

  

 

 

 

 

17 December 2014

We are in that slide towards the Festive Season where everyone suddenly becomes nice to each other, where the year’s problems no longer seem as grim or pressing, and where we start to think about our plans and hopes for next year. Christmas always seems to usher in a brief period of optimism, which is usually dashed once we return to work.

This year, there seems to be a sense that the woes of the Global Financial Crisis are now well and truly behind us and that there is more hope of some prosperity gains in the future. But how sustainable are those? Some of the international signs are not as encouraging as they might first appear, as a quick survey of a few other economies shows.

In Ireland, similar in size and type to New Zealand, but one more savagely ravaged by the GFC, growth is forecast to lift to about 3.5% this year. But that improvement has hardly led to dancing in the streets. The government is facing a bitter battle over its water pricing plan, and President Michael D. Higgins recently told a Chinese audience that Ireland’s modern economic history has been “poverty, illusory affluence, and poverty.”

In Britain, where growth is hovering around 3%, Prime Minister David Cameron, facing an uncertain election in May and the rise of myopic xenophobia in the form of UKIP, is arguably even more despondent, pointing to “red warning lights flashing on the dashboard of the global economy”. In the United States, despite his foreign policy failures and racial discord at home, President Obama appears more optimistic although still rather cautious, commenting that with growth at 3.9% the US is “primed for steady, more sustained economic growth.” In Australia, the Abbott government’s recovery hopes have been knocked by the Budget deficit blowing out to more than $40 billion. And in the “rockstar” (a term we do not hear any more) New Zealand economy the prospect of a Budget surplus seems to have receded, and Mr English restrains himself to saying our growth rate (similar to the US) means that we are “on track for solid growth.”

Sadly, all of this means we are not out of the economic woods yet and that prudent fiscal management and restraint will remain the order of the day for some time to come. Magic bullets will again be in short supply under the Christmas tree, but in comparative terms, the performance of the New Zealand economy does give cause for a little more optimism next year, as Mr English’s comments appear to imply. So, there is scope for some cheer over the Christmas barbies after all, even if economic Nirvana is still a little while off.

On that warily optimistic note, Dunne Speaks takes its leave for 2014. I will be back in 2015 after a few weeks break. In the meantime, my best wishes to all of you for a peaceful and happy Christmas with those that are nearest and dearest to you, and my hope that 2015 will enable you to achieve your hopes and dreams. Merry Christmas!