COUNTRY PROFILE

Country profile

Australia
Australians will gleefully show you a postcard proving that their national boundaries encompass the whole of western
Europe when the two are superposed. Yet the complaint “But we are a small country” is heard frequently. Both are
true: a vast country but with a population of only 19 million. This western democracy, with waning European ties, is
set geographically and economically in the Asia-Pacific region. Distinguished in her contributions to medical research
and innovative in her medical education Australia offers excellent health care. Australians are as frank about the
problems as they are generous with their time (and hospitality) in showing the visitor the many strengths. This the
last of The Lancet’s “Country profiles” tries to capture those strengths and weaknesses, via 14 people. That list
leaves unacknowledged many others who helped shape the project. Most notable of these is Prof Roger V Short,
in Melbourne.

Medical education
Pat Buckley, John Marley, Jeffrey Robinson,
Deborah Turnbull
Successive Commonwealth governments have considered
that Australia has an excess of doctors. The current
administration has proposed a reduction in medical
student entry from over 1200 (panel) a year to 1000. Not
surprisingly, the medical schools oppose this reduction,
especially since accurate workforce data are not available.
Special entry schemes are offered for disadvantaged
students, and the University of Newcastle has four places
for Aborigines; to date 27 Aborigines are registered as
medical practitioners in Australia.
The medical schools used to reserve almost all places for
applicants from their own states. Following a legal
challenge in 1990, medical education is now a national
process. This change has led many to question the
Government’s decision to investigate establishment of a
medical school at James Cook University, Townsville, in courses offered by Flinders, Sydney, and Queensland are
the hope that this new school would provide more doctors kept under review as the first students proceed through.
for rural Queensland. If this school is established, Darwin Australia’s medical schools offer a six-year (Adelaide,
in the Northern Territory and Canberra in the Australian Monash, New South Wales, Tasmania, Western
Capital Territory might press for undergraduate medical Australia) or a five-year (Newcastle) undergraduate
schools. The James Cook venture could be an expensive course or a four-year graduate course (Flinders,
and unnecessary precedent since clinical schools of other Queensland, Sydney). The University of Melbourne will
universities are already in place in those areas and now that be introducing dual school-leaver and graduate streams
existing schools are being asked to reduce numbers. from 2000. The programme for graduates will be 4!s
Two reports (the Karmel report of 1973 and the 1988 years; school-leavers will graduate in medicine after 6
Doherty report) have had a significant and lasting impact years with an additional BMedSc. In 1988 the Higher
on medical education in Australia. They encouraged a Education Contribution Scheme was introduced and
diverse approach to the undergraduate medical medical students pay $Au5593 per year or repay their
curriculum. The recommendations placed as much value debt when their income rises above a threshold. Several
on skills and attitudinal development as on knowledge, medical schools have places for fee-paying students from
and highlighted the desirability of early clinical exposure. overseas—eg, Adelaide’s has both the government-
Medical schools were encouraged to consider alternative sponsored Malaysian Assisted Tertiary Education
methods of student selection and to develop innovative Scheme and overseas fee-paying students.
curricula—and to evaluate the outcomes of both. There have been significant changes in student
Also the Australian Medical Council now reviews selection. All three graduate-entry courses select students
curricula with accreditation visits to every medical school by a ranking process based on a combination of the
every ten years or more often, and all ten schools have candidate’s prior degree, performances in the Graduate
now been through this process. Major changes to a Australian Medical Schools Admissions Test, and a
curriculum may initiate a full review by the AMC of the structured interview. Since one of the aims of graduate
education offered. For example, the new graduate courses is to attract candidates from a wide variety of
backgrounds the first degree can be from many
Lancet 1998; 351: 1569–78 disciplines.

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Enrolment in final-year medicine in 1997 Since 1996 provider numbers have been available only to
doctors in recognised postgraduate training schemes or to
Medical school Enrolment
those who have completed training—ie, postgraduate
Adelaide 99 training is now compulsory for all branches of medicine.
Flinders 73 The Australian Medical Association protested vigorously,
Melbourne 166
claiming that many junior doctors would be unemployed;
Monash 134
Newcastle 55 and the AMA led industrial action, effectively against its
New South Wales 158 own policy, which was that doctors should have
Queensland 214 postgraduate training. There has been no unemployment;
Sydney 204 indeed, training programmes are undersubscribed and
Tasmania 52 there is a shortage of doctors in small rural communities
Western Australia 106 and specialist services in country centres.
Total 1261 Postgraduate colleges have been progressively
introducing objective selection processes to choose
The undergraduate schools (except for New South applicants for training programmes. Further training lasts
Wales and Tasmania) select through a process which up to seven years after graduation, and to stay on the
variously includes a threshold matriculation score, a specialist register a doctor must participate in college-
medical admissions test, and a structured interview or approved further education.
oral assessment. The University of Newcastle has been a There is a widening gap between the requirement that
world leader in objectively evaluated selection. hospitals provide 24 hour services by junior doctors and
Candidates applying there must have a matriculation the employment conditions of those doctors (which have
score in the top 10%. They sit the Undergraduate reduced the number of hours worked) and their need for
Medicine Admissions Test (also used by Adelaide, training.
Melbourne, and Western Australia) which assesses logical Australia is examining options for the funding of
reasoning, problem solving, and critical thinking. Top- healthcare, realising that the only way to cap expenditure
ranked candidates, in a ratio of 3–4 for each place in a fee-for-service system is not to have such a system.
available, then attend a structured interview by teams of Coordinated-care trials are in progress and general
trained faculty and community assessors who rate practice has made tentative moves towards a mix of free-
candidates independently against established criteria. A for-service and block allocations (“blended”) payments
poor interview and a very high matriculation score for doctors. The Commonwealth and state/territory split
identify those likely to withdraw or to be excluded from in funding encourages cost shifting. It has even been
the course while a high rank at interview predicts success. suggested that the Commonwealth takes over
In the 1980s, there was almost unlimited entry for responsibility for all public hospitals. Our medical schools
foreign medical graduates, subject to their passing an will thus have to prepare graduates for an ever-changing
examination set by the AMC or satisfying a specialist work environment. Crucial, for the patient and taxpayer,
medical college. Sudden restrictions, introduced in 1992 will be graduates who promote evidence-based care
and lasting three years, limited entry to the final stages of which is responsive to community needs and who are
the clinical examination to the first 200 candidates in the committed to an equitable health service.
first AMC’s stage of the examination. This stranded 280
candidates who could no longer complete the process.
Equally suddenly, in 1998, the Minister of Health has Mixed heritage, uncertain
announced funding for further training of these
candidates, and he is negotiating with medical schools to
future in healthcare
provide a limited number of places for 1–3 years’ training. Stephen R Leeder
The new undergraduate courses make greater use of In the slang of horse-racing, there is a phrase which well
self-directed learning, problem solving, and describes Australia’s healthcare arrangements—“two bob
communication skills, and they expose students to a each way”, meaning to back the same horse for a win and
variety of experiences which relate to contemporary a place—you are not confident the horse will win, so you
practice in Australia (eg, aboriginal health and primary put some of your money on it to finish second or third.
health care). Newcastle has developed a problem-based Australians have much the same approach to the way
curriculum with an emphasis on integration of basic money is invested in the healthcare system.
science and medical science and community relevance. The Australian healthcare system accounts for about
Several studies have compared Newcastle graduates with 8·5% of gross domestic product, is said to be our third
those from Sydney and New South Wales, which were, at largest employer, costs $Au35–40 billion (depending on
the time, using traditional discipline-based curricula. what is included), is administered by both the states and
Newcastle graduates were at least as competent clinically territories and the Commonwealth (federal) Government,
as their peers and did much better on interpersonal and and is paid for in the ratio of 2 to 1 from the public and
organisational skills. They had enhanced communication the private purse. Public insurance (Medicare) is
skills; they were more positive about community designed to ensure open access to public hospital,
medicine but were not necessarily more likely to be general, and specialist care; private insurance does the
engaged in preventive medicine; and GPs who had same but for patients who may prefer treatment in a
graduated from Newcastle reported better quality of life private hospital. In short, Australia has a very mixed,
than their colleagues from the traditional schools. disintegrated, and confusing system, and patients,
Practice outside hospital in Australia, whether as a doctors, and visitors alike are shocked that it works at all,
specialist or a GP, is reimbursed by Medicare, and doctors let alone seemingly so well. It is probably fortunate, then,
need a provider number so that their patients can claim. that the public health system, excellent food supply, and

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general levels of prosperity create, by international of great interest for their potential to overcome some of
standards, a very good place to live if you wish to be these difficulties.
healthy. The health of Aboriginal people is an appalling Recently the states have diverged in the way they have
exception, their health status being dramatically below delivered public hospital care. Victoria has cut back
that of the majority of the community. substantially on public hospital investment and used case-
The Australian system has its origins in UK healthcare mix funding and private capital investment in
delivery before the NHS (1948) and it was only in 1961 combination with regional rationalisation to achieve its
that the Australian Medical Association was formed to goals. Other states have followed one or more of these
replace the British Medical Association. Many senior trends. Some states have area or regional devolution;
clinicians trained as specialists in Britain. Training shifted others follow a more centralised model. For some States
to the USA in the past 30 years so American accents and equity of access matters more than it does for others.
interests in technology have been imported, as has a US Three major challenges present themselves for the
style commitment to laboratory research and a modest future of health services in Australia.
interest in case mixes. Most public health practice has a First, the disintegrated and splintered nature of the
continued link to the UK, especially in epidemiology. system is at odds with microeconomic reform and good
Medical education was Scottish in style but with the management. The challenge will be to sustain an interest
advent of graduate medical-school entry there now is a in quality, the use of evidence, and a concern with health
distinct US and Canadian flavour. gain in an environment which, if not led professionally,
The biggest change in living memory was the will be driven to change by those with tight fiscal agendas
introduction 14 years ago of universal health insurance, relating to the use of public resources. A system such as
the premium being paid through taxation (a this, with hospital admission rates that are among the
Commonwealth responsibility). This has proved popular world’s highest, is ripe for takeover. Will the health
and durable and now has bipartisan political support. professionals, especially doctors, learn the lessons of
Visits to general practitioners can be charged to Medicare managed care from the USA and cease to be reticent in
on a fee-for-service basis. Some general practitioners participating in policy development?
charge the full fee and patients then seek reimbursement Second, barriers that separate private and public,
(say about 80%) from Medicare; others bill Medicare Commonwealth and state must be dissolved. New
directly. Waiting lists impede entry to public hospitals for coalitions—for example, using private capital to fund new
elective surgery but emergency care is excellent. hospitals and technology or collaborative research and
Public hospitals are managed by the six states and the development—need to be defined if Australian healthcare
Northern Territory and Australian Capital Territory. is to move in harmony with the current political and
They receive money from the Commonwealth specifically economic trends of western society towards decreased
for this purpose and also make a substantial contribution public-sector financing.
from their own general revenues which include Third, the relation of healthcare to an evolving sense of
Commonwealth general grants and state sales and what it means to be a 21st century civil society requires
gambling taxes. To cover public health, a “Medicare much better quality political debate and leadership than we
agreement” is transacted every five years with complex have seen to date. The medical professional organisations
choreography, trumpeting, offers, walkouts, and other have yet to face the future; they are marching backwards.
theatricals as state health ministers and their premiers Politicians need to lead and not strut around carrying
battle with the Commonwelath. Medicare is supported signposts such as “waiting lists” and “Medicare” and
partly by a Medicare levy, which is an explicit element in “financing”. Currently there is an activist federal Minister
personal tax contributing about one-ninth (roughly the of Health determined to face up to the need for reform,
same as the amount raised by private health insurance) of although whether he will be supported by his government
total costs. This false price signal is a shadowy reminder colleagues remains to be seen. Australia lacks a policy
that healthcare has to be paid for somehow, if not at the statement which says what the healthcare system is for, who
point of use. does what, who is accountable for what and what a
Many elements, such as public hospital expenditure, reasonable set of expectations of it might be. No small task,
are capped, and although prices are controlled for general that one. It is time to make a decision and nominate the
and special services, there is less limitation on volume horses we will bet on for a win.
and hence a perverse incentive to overservice. The
generally uncoordinated nature of the system allows for
major inefficiencies at this level, with patients moving
Medical research
from one professional to another. The Pharmaceutical Warwick P Anderson, Richard G Larkins
Benefits Scheme, which covers drugs prescribed outside Despite its small population, Australia has an excellent
the public hospitals, is also uncapped with regard to record in biomedical and public-health research. It
volume. In an attempt to control volume, copayments produces eight times as many publications in medical
have been progressively introduced here, while not journals as predicted from its population and Australian
tolerated for general-practitioner consultations. Thus scientists have been responsible for some notable
having a prescription dispensed can be far more expensive discoveries. Examples include those of its four Nobel
than seeing the GP who wrote it. This inconsistency does prizewinners in physiology or medicine—Howard Florey,
not seem to bother anyone. Allied health professional Macfarlane Burnet, John Eccles, and Peter Doherty. The
services such as physiotherapy are generally not covered list (panel) is not exhaustive—nor do we claim that it was
by Medicare, thus limiting the use that can be made of Australians alone who contributed to these significant
them as an alternative to drug therapy. Coordinated-care advances—but it does demonstrate that Australia has
trials currently underway with Commonwealth been a real player in the transformation of medical
sponsorship, using GPs as notional fundholders, are thus science and practice in the last part of this century.

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Some important biomedical advances from Australians

internationally competititve biotechnology industry is in
its infancy. Success rates for clinical research applications
Name Area to the NHMRC are lower than they are for non-clinical
Florey Clinical use of penicillin
applications, and, as in other countries, there is concern
Burnet Clonal selection theory in immunology
Eccles Neural synapses
for the next generation of clinical researchers. Public
Doherty Restriction of cellular immunity health research grew strongly from a very low base over
Gregg Rubella and congenital malformations the past decade but is still weak by international
Campbell Role of oxygen in retrolental fibroplasia standards. Research into the delivery of health services
Cade Lithium in manic-depressive psychosis remains underdeveloped and not well integrated with the
Marshall and Warren Helicobacter pylori in peptic ulcers rest of health research. NHMRC has recently established
Metcalf Colony-stimulating factors a Strategic Research Development Committee to develop
Martin Malignant hypercalcaemia methods to direct funding towards important areas where
Burger and de Kretser Inhibin the research effort is currently underdeveloped or where
Niall and Tregear Relaxin
Clark Cochlear implants
there is a need for urgency.
Stanley Folate deficiency The NHMRC and its research committees are
Dwyer Sudden infant death considering how best to meet the challenges that face
Coghlan Detecting mutations Australian health research in the next decade.
CSIRO “Gene shears” technology Government research funding (via NHMRC and the
Australian Research Council) is “marginal”—that is, it
The Australian National Health and Medical Research provides for the immediate costs of the research but none
Council is more than 60 years old. It funds broadly in all of the infrastructure needed to do the research. However,
areas of health research and, unusually for a developed all sectors of the research effort are under financial
country, its funding comes via the government pressure—the universities from federal government cuts
department that oversees health care. It has been and unfunded salary increases, the hospitals from state
successful in developing biomedical research in Australia, government health changes, and the independent
in gaining Australian health researchers a “seat at the institutes because they cannot always count on secure
table” of international health research and health policy infrastructure support. Grant requests to the NHMRC in
formation, and in ensuring that key healthcare money terms have been growing at several times the
practitioners are trained in research and thus in the national inflation rate over most of the 1990s; this reflects
evaluation of research. Areas where individual Australian reduced infrastructure support from hospitals and
resarchers have international reputations include universities and has led to a success rate for project grant
immunology, endocrinology, oncology, and applications that is now only 25%.
cardiovascular science. Medical research institutes such The NHMRC is simplifying its grant procedures and
as the Walter & Eliza Hall Institute of Medical Research, giving more responsibility to the individual researcher; it
Baker Institute, Garvan Institute, and the Queensland is developing multidisciplinary “network” grants in
Institute of Medical Research are first-class by any partnership with other research funding organisations and
international standard. government; it is reviewing and extending its fellowship
However, strains are beginning to show in the national scheme into clinical and public health research; and it is
research effort. The NHMRC struggles to retain a broad analysing Australia’s effort in the major areas of health
coverage; despite strong growth in bipartisan government and burden of illness, with a view to a more strategic
support over most of the past decade the initial base was attack on the nation’s health needs.
low. The NHMRC will spend almost $Au165 million in In March, 1998, the Commonwealth Government
1998. Excluding pharmaceutical research, this represents announced an independent inquiry into health research,
about 25% of health and medical research funding in headed by a Sydney businessman, Peter Wills. This
Australia. Central government also funds the review comes at the right time. We hope that its
Commonwealth Scientific and Industrial Research recommendations will allow a more comprehensive
Organisation and the John Curtin School of Medical health-research effort, with a more robust financial base.
Research, Australian National University, Canberra, and Australia can be proud of its past in health and medical
it provides the infrastructure for research undertaken in research, it must now position itself to exploit its strong
universities. State governments provide research human resource and the opportunities afforded by the
infrastructure for research institutes and hospitals and biotechnology revolution.
some direct funding of public health and health services
research. Other sources of funds are the charitable trusts
and foundations with disease-specific or non-specific
Medical links with Asia-Pacific
agendas. Industry provides a disappointingly low Frank Shann
contribution to health research funding. Australia is a rich country with a small population.
50% of NHMRC expenditure supports three-year Although the manufacturing sector of the economy is
project grants; nearly 15% supports research fellows on small, the medical research and healthcare sectors are
five-year grants; and about 18% is supplied to six large, disproportionately large. Beside the tiny island nations of
block-funded medical research centres (the Walter & the south Pacific, Australia is a giant; many of these
Eliza Hall, Howard Florey, Baker, Garvan, Murdoch, countries are so small that it is very difficult for their
and Queensland institutes). About 33% of NHMRC governments to provide effective health care. Several
supported research is done in independent or university- Asian nations do have much larger populations and
based research institutes, 20% in hospitals, and the economies than Australia’s but with much lower gross
remainder in universities. national products per head, higher mortality rates, and
Our basic research effort remains strong but an less developed medical services. The exception is Japan,

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which is bigger, wealthier, and healthier than Australia. In contribution is small in absolute terms. Even so, Australia
many of the “tiger economies” of Asia, rural poverty has has had an important role in promoting reform of the
remained virtually unchanged over the last 20 years, and multilateral agencies, and has made substantial
the recent economic problems in several of these contributions to the WHO ARI and malaria programmes.
countries mean that mortality rates will rise sharply, NGO programmes are less likely than government ones
especially in rural areas. to be influenced by political and commercial
Like most developed countries, Australia has considerations, and NGO activities now constitute an
substantially reduced overseas aid in recent years, from important part of Australia’s official aid programme.
0·51% of GNP in 1983 to 0·29% in 1996–97, an Australian NGOs have been good at forging strong
increasing proportion being used for crisis control rather bilateral links in the region. In one interesting
than for more productive long-term development aid. experiment, several of the specialist medical colleges have
The 1993 World Bank report Investing in Health contracted with AusAID to run bilateral aid projects. One
concluded that improved health contributes to economic example is the Papua New Guinea Medical Officer,
development. This is rather like concluding that people Nursing and Allied Health Science Training Project
are a good thing because they contribute to the economy, (MONAHP), which assists in planning and running
but it had the effect that Australian aid in the health programmes that educate health professionals—it helps to
sector increased between 1991 and 1996. train the trainers. MONAHP is administered by the
Australian aid has been given for political and Royal Australasian College of Physicians.
commercial reasons as well as altruistic ones, and Australia used to pay for many Asian students to attend
sometimes aid has been of scant benefit or even her universities under the Colombo Plan. However, the
counterproductive. There has been a sudden switch from government now pressures universities to make a profit
large untied grants for Papua New Guinea to short-term from fee-paying middle-class students from Asia. Despite
project-oriented programmes contracted out to consortia the current economic crisis in Asia, the number of
of private companies and non-governmental overseas students at Australian universities has not yet
organisations. The government aid agency (AusAID), fallen; fewer have come from Hong Kong, Malaysia,
private sector, and NGOs did not have time to prepare Indonesia, and Singapore but there has been an increase
for this change and there were major problems. from other Asian nations.
Vertical programmes, such as the acute respiratory Many doctors from Australian hospitals have visited
infection (pneumonia) control programme, are effective the Asia-Pacific region for short periods, giving lectures
in the short term, but it is now widely accepted that long- or treating patients, and many doctors from the region
term results are better if aid is used to strengthen an have come to Australia for postgraduate training. Some of
integrated health service at the local district level rather the richer Asian countries benefit from these links, but
than to set up many different vertical programmes. they have limited public health benefits for the less
AusAID has substantially increased aid aimed at developed Asia-Pacific countries, and they can even be
improving healthcare at the district level but there should harmful if they emphasise the importance of tertiary-level
be more systematic independent evaluations of these hospital medicine at the expense of primary care.
bilateral aid programmes. Useful contributions to the Medicine in developing countries is just as much a
Asia-Pacific region have been made by applying specialty as cardiology or neurosurgery is in Australia,
Australia’s expertise in managing emerging diseases, such and Australian specialists should not assume that their
as AIDS and hepatitis C, and in addressing the health skills will always be helpful. Expensive procedures that
problems of remote impoverished communities. benefit a few may cause many others to be denied cheap
Many health departments in Asia-Pacific desperately but effective care. The specialists’ motives are usually
need help with the planning and implementation of altruistic, although some Australian hospitals foster links
projects, and Australia could substantially increase its role with Asia in the hope of getting referrals of wealthy fee-
in this sector. There is gross underfunding of research on paying patients who can be treated profitably. The
diseases that predominantly affect people in developing number of people coming to Australia for medical
countries—for example, pneumonia and diarrhoea treatment increased from 1900 in 1991–92 to 4400 in
accounted for 15·4% of the global burden of disease in 1996–97.
1990 but they received only 0·2% of the world’s 40% of Australia lies in the tropics geographically
expenditure on research and development. Australia is speaking. We may have dangerous snakes and spiders not
well established in medical research and should provide found in other westernised areas but tropical diseases and
more support for research projects and research institutes tropical public health are not strong features of Australian
in the region. An encouraging example, funded by medical practice. Where it is a focus of attention—eg,
AusAID, is the support given by Melbourne’s Walter and Queensland and at the Menzies School of International
Eliza Hall Institute to the Eijkman Institute for Medical Health in the Northern Territory—it is outward-looking.
Research in Jakarta, Indonesia. Applied research in fields
such as epidemiology, behaviour, and policy development
is in urgent need of more support.
Aboriginal health
The UN agencies such as WHO and the World Bank Fiona Stanley, Ted Wilkes
may have unwieldy bureaucracies that are slow to change It was Millicent’s story from Western Australia in the
but they play a very important part in promoting an Human Rights and Equal Opportunity Commission’s
internationalist approach to world health. Australia 1997 report Bringing them Home, on the “stolen
already gives a higher proportion of its aid to these generation” of Australian indigenous children, which
multilateral agencies than many other countries do, and upset us most. Millicent was removed from her family
there are good reasons for this support to be further group at age 4 and never saw them again. She spent her
increased. Australia’s small economy means that the childhood in an orphanage and was then sent to work as a

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domestic on a farm, where she was physically and

sexually abused. She felt she would at last have somebody
to love when, in 1966 at the age of 16, she went to have
her baby in a major obstetric hospital. But her baby too
was taken away, and it took Millicent 16 years to find her.
One of us (FS) was a medical student in that hospital in
1966, completely ignorant then of a catastrophe that has
been so devastating for these people.
The indigenous population of Australia (the Aboriginal
and Torres Strait Islander peoples) is estimated to be
about 372 000 (figure 1) with 76% in large cities and
rural towns and 24% scattered in remote rural
communities. More than a quarter live in NSW, although
the Northern Territory has the largest proportion.
Many reports (a list of references is available from FS)
paint a depressing picture of the health of the Australian
Aborigine. Whilst infant mortality has improved, it is still
three to four times higher in the indigenous population
than the total population of Australia, and even after
infancy, indigenous chidren are 10 times more likely to
die from infections than non-indigenous children are.
Figure 1:Distribution of Australia’s indigenous people
Mortality at other ages seems to have changed little Adapted from Australian Bureau of Statistics data (1994).
during the 1980s and 1990s. The major causes of this
excess mortality are circulatory conditions, injury and completing school or higher education. And Australia is
poisoning, respiratory diseases, cancer, and diabetes. well behind New Zealand in training; there are very few
Sudden infant deaths are decreasing amongst the non- lawyers, doctors, and other trained professionals from the
indigenous population but are now the most common indigenous population.
cause of death for indigenous infants. How does Australia differ from New Zealand, Canada,
Data from South Australia, Western Australia, and the or the USA, say, in its recent indigenous history? The
Northern Territory (where the identification of 1994 report on Aboriginal deaths in custody and Bringing
indigenous people is reasonably accurate), and average them Home do suggest part of the answer. Australia had
death rates for 1992–94, suggest an expectation of life at no formal recognition of her indigenous people, no treaty
birth of 56–61 years for indigenous males and 61–65 for obligation, the legal concept of terra nullius (ie, that
females, compared with 74·9 for all Australian males and Australia was empty land before European colonisation)
80·6 for females. This gap is widening, and constitutes a prevailed until 1990. Nor has Australia responded as
serious challenge to Australia since indigenous strongly as it should to the “19th century” public health
populations in other countries with a colonial history, and educational issues that need to be addressed.
such as Maoris in New Zealand and Indians in North If Aboriginal health is to improve, Australia has to
America, have expectations of life that are much closer to acknowledge its history and the indigenous people within
those of the corresponding total populations. The that history; we need a national reconciliation and self-
Australian Aboriginal mortality statistics are determination for indigenous people with an emphasis on
overshadowed by high rates of infectious diseases and the cultural revival and maintenance. Control of services, so
so-called diseases of unhealthy lifestyles, particularly that Aboriginal people take responsibility for their own
diabetes, renal failure, heart disease, and health, is fundamental to improved health outcomes.
injury/poisoning. There is a nationwide network of health organisations
The underlying reasons are suggested in figure 2. controlled by indigenous communities who are delivering
These living conditions, unhealthy lifestyles, and poor effective and culturally sensitive health care. This network
outcomes are almost identical to the conditions in Britain requires more people and more money. It is a myth that
and amongst white Australians 150 years ago which vast amounts of money have already been spent (and
stimulated the modern public health and educational wasted) on indigenous health. Despite higher levels of
movements. However, in Australia there is the additional morbidity, health spending per head is lower for
trauma of the loss of traditional lands and the forced aboriginal communities than it is for the rest of the
removal of children. In many cases language and cultural population. All indigenous Australians should have access
imperatives such as kinship and marriage rules have been to community health organisations with health
lost too. Extended family obligations and a history that promotion, primary health care, and research skills. The
depicts human suffering in the extreme and the Bibbulung Gnarneep (“solid kid”) project in Western
consequent struggle to hold on to sufficient self-esteem Australia is a good example. Ownership by and guidance
merely to survive are other factors. from the indigenous community, together with
Consequently, psychosocial morbidity is very high for quantitative and qualitative research, yield outcomes that
indigenous Australians, manifesting in crime, family can be rapidly transformed into community action or as
violence, and suicide and self-harm. These people are leverage for funding. This is also the model for the new
also more likely to be unemployed, to live in rented National Cooperative Research Centre in the Northern
premises, and to leave school early. Tragically, the change Territory. Government departments have been reluctant
from paternalistic attitudes to the indigenous population, to hand over funds and responsibilities to Aborginal
which resulted in compulsory education, towards more people in areas such as health, and with many new
self-determination has resulted in fewer children activities, unrealistic expectations are put on the

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which to prove the product and iron out teething

problems, the investment often does not get initiated.
There are some exceptions, such as Amrad, Biota, and
Circadian Technologies, three companies in Australia
which have funded early stage scientific research and have
links with major international pharmaceutical companies.
Recognising the fundamental problem, the Australian

Confocal microscopic reconstruction of 40 optical “slices” of

fruitfly
The confocal microscope was developed by Optiscan Imaging Ltd, a
Circadian Technologies controlled company.

Government in the 1980s redirected large sums of money

into research and development by the indirect route of
150% R&D tax deductions and tax effective investment
syndicates. Investors took advantage of the opportunity to
minimise tax but the merits of the projects were of
Figure 2: Historical impact of white society on Aboriginal
secondary importance. In the mid-1990s the government
culture
(Redrawn, with permission, from Matthews JB. Rec Adv Microbiol changed direction, reducing the R&D tax deduction to
1997; 1: 257–334) 125% and putting more emphasis on grants of up to
several million dollars given on the basis of a review of a
indigenous services to perform. competitive application. This shifted the emphasis from
National action is required in housing, public utilities indirectly supporting investors who chose to minimise
(including clean water), education, and welfare. their tax to supporting the best of a large number of
Responsibility is too fragmented between Commonwealth applications reviewed by experts.
state, and local government. The NPDP and START grants are currently in force.
Perhaps the one most important positive step is for The START grants are limited to companies having
Australians to realise the importance of land and culture turnover of less than $Au50 million. As part of the
to the Aboriginal and Torres Strait Islanders and to automatic pruning process, many applications are culled
acknowledge the trauma of the removal of children, an before they are even submitted because, unlike the US
error of judgment by the white authorities that continued government’s small business innovation research grants,
until the 1970s. A survey in 1994 found that more than these Australian Government grants require matching
10% of indigenous people aged 25 years and over had funds by the applicant or an industry partner on a 50/50
been taken away from their natural families by Wadjella basis. This requirement weeds out frivolous ideas, but it
(white) systems, including the missions and government disadvantages some worthwhile inventions that cannot
welfare organisations. obtain private financial support for half of the
Australia will probably soon become a republic, with a development costs. Here the inventors are forced to turn
written constitution, and that is the opportunity to to Australia’s very small technology venture capital
enshrine the rightful place of indigenous Australians. community. Australians have traditionally invested their
research capital in mining and have been reluctant to
R&D with small market base commit to risk funding of scientific achievements. So far,
Australia’s merchant banks have not chosen to back
Alan Finkel, Leon Serry technology companies.
Australian scientists and development engineers are Last year the Government implemented a system of
continually stymied by the lack of sizeable funding combined Government and privately funded investment,
required to stoke a major development effort. The the Innovation Investment Fund scheme. Experienced
problem starts with the well-recognised limitations of fund managers raise private capital to the tune of $Au10
having a small domestic market. The likely return is million and the Government contributes $Au20 million.
insufficient to entice investors to pour money into a major In early 1998 $Au130 million of government funds was
development. The chicken-and-egg conundrum rears its allocated in this area. The IIF focus is developing
ugly head. If the investment were made and the products technologies. To date none of the funds have begun to
designed with a major engineering effort in a timely invest their money because an unanticipated taxation
fashion, the products might compete well on the world problem makes investment unattractive, despite the large
market. However, without a large domestic market in Government contribution; this problem is being resolved.

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In contrast to the support for industry, Government diverse ethnic communities. Together, ABC and SBS
funding of university science and engineering courses and have around 17% of the television audience. The radio
research is continually being eroded. Over the next three industry is large, with many stations in every city. Most
years, $Au98 million in federal Government funding will are commercial with music formats but most cities have a
be cut from scientific research. Compounding this lack of powerful commercial talk station, often featuring
funding is a lack of incentive for students to enter conservative “jocks”. ABC has 20–40% of radio listeners,
engineering and science degree courses. High-school through local stations, a national talk network similar to
graduates know that five years after completing a science the BBC’s Radio 4 (Radio National), a 24-hour news
degree, if they can find a job in their chosen field, they service, and two music networks, one aimed successfully
will at best be earning half the salary of their companions at 18–24-year-olds.
who became lawyers or accountants. Between 1993 and Media gatekeepers in Australia are little different from
1996, enrollments in the State of Victoria in biology, their colleagues elsewhere. News and current affairs
chemistry, and physics fell by 15%. editors and producers are addicted to economics and the
Culturally, R&D in Australia faces formidable barriers. antics of politicians. The public, when asked, nominate
Institutions control most of the funds generated by health, medicine, and science at the top of their interests.
pension schemes and investment and they perceive their ABC Radio and one or two newspapers pioneered
duty to lie in supporting large, well-established science and medical journalism in Australia. ABC Radio
companies and real estate. Wealthy individuals and has had a science unit for 30 years, currently broadcasting
investment institutions understand real estate, industries weekly programmes on science, medicine, and the
such as paper and steel, and the more speculative mining environment and which are turned round in short-form
sector better than they understand the computer and for the 24-hour news service and the youth rock station.
biotechnology industries. This is compounded by a The weekly programmes cover Australian and
shortage of biotechnology and computer sector analysts at international research, policy issues, and the social impact
the broking houses. It is only in the last six months that of science, and they carry an effective stream of
the Australian Stock Exchange has established a investigative reporting. As with public broadcasters
healthcare and biotechnology index. Finally, there is a elsewhere, budgets are shrinking rapidly and the science
common but misplaced deprecation of our ability to unit is now about half the size it was in the early 1980s.
compete in the world technology market. Americans are ABC Television has had a shaky commitment to
quicker to back inventions and have the advantage of a science and rarely runs a regular medical programme. It
large domestic market and Asians can manufacture has only one science outlet, mostly documentary based.
everything more cheaply than we can—so, the thinking In the mistaken belief that outsourcing is cheaper, ABC
goes, Australians cannot compete effectively. Australians Television has been reluctant to guarantee that in-house
do not see themselves as creators of high-technology science production will last much beyond 1998.
added value, despite the fact that many Australian The quality of daily medical news journalism varies but
scientists are world leaders. within a narrower range than you see in the UK or USA.
To enhance Australian industrial science and Australian outlets, at least in news, tend to avoid the
technology, financial institutions and pension funds need depths to which British and US tabloids sink. Every
to allocate a small percentage of their moneys to this commercial television station has at least a national
sector, taking a more long-term view of investment to medical reporter for its news services. One or two are
create pharmaceutical, biotechnology and computer doctors or former nurses, and by and large the networks
industries to supplement the traditional manufacturing have learned that life is easier if they “get it right”.
and mining industries that have recently been hurt by the Current affairs on commercial (“tabloid”) television
Asian financial crisis. channels can be different; in a cut-throat chase for
ratings, anecdote and the need to create dread and
Medicine and the media outrage may substitute for fact.
Most newspapers have medical reporters and The Age
Norman Swan and Sydney Morning Herald have invested in small science
An understanding of medicine in the Australian media units. A few years ago, the common pattern was for the
needs a brief description of the “market”. Australia, like most junior staff to be assigned to the medical round,
the USA, has state-based media with significant national usually for short periods, and the scientists being
elements, especially in television. interviewed would complain that they were always having
Rupert Murdoch, who owns many of the city-based to explain themseleves to “kids who didn’t have a clue”.
papers, including tabloids in Sydney and Melbourne, Nowadays medical journalism is seen as a more attractive
dominates newspapers. The quality press comprises The career option and the relative stability allows journalists
Sydney Morning Herald, The Age (Melbourne), and the to gain confidence and skill. The glamour jobs, though,
Australian Financial Review (all in the Fairfax group) are still in politics and economics, and coveted overseas
while Murdoch’s News Limited publishes The Australian, postings often go to those reporters.
our only national broadsheet. A large proportion of No newspaper in Australia has a health supplement
Australia’s thriving magazine sector is controlled by Kerry similar to those in the better US and European papers.
Packer, through his Australian Consolidated Press Nonetheless, the quality and volume of medical stories
(ACP). The main national newsmagazines are the are reasonably impressive by international standards.
Australian edition of Time and ACP’s Bulletin. Australian medical researchers and clinicians have the
Of the five television stations, three are commercial. same concerns about communicating with the public as
The Australian Broadcasting Corporation (ABC) has one their colleagues overseas do. They do not want to be
channel and carries no advertising or sponsorship. The misquoted; they have no desire to be seen to be media
Special Broadcasting Service (SBS) serves Australia’s “groupies” but do recognise the need to let the

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community know what is happening with the public’s departmental advice?

research dollars. As a result there is rarely a problem with You can have one from the last hour. I’m battling over an
access of scientists to reporters and vice versa. issue to do with health claims and food, where there
One example of the commitment to communication on seems to be an interest that is extraordinarily anti-
both sides is a very successful project of the Australian industry—yet you’ve got something that to me is utterly
National University, Canberra, and the University of clear-cut, folate supplementation. I just want women of
Technology, Sydney. Several times per year, usually in childbearing age to get folate into them. Ideally one
Sydney, they hold a day-long conference just for the would do it through a very well-balanced diet but that is a
media on a research topic of public importance. The terribly middle-class view, with little immediate relevance
February, 1998 briefing was on emergent zoonoses in to women from less advantaged backgrounds. Breakfast
Australia. During the day, leading researchers, assisted in cereal companies have been very helpful and they
their preparation by the organisers, gave highly legitimately want to put a health claim on their products.
structured, concise presentations, informing the 20 or so The advice that came up to me was “This is the end of
journalists present on the latest in the field. Easy to the world; the end of civilisation as we know it”. I will
understand abstracts were produced in advance and win eventually, and within the next six months breakfast
circulated around the country to radio stations and to cereals that supplement folate will have health statements
journalists unable to attend. The organisers set aside on them. The wording will be under the control of the
ample breaks and facilities for television, radio, and press independent Australian and New Zealand Food Authority.
interviews timed to match their deadlines, and the
coverage was considerable and reliable. Are there problems between the Commonwealth health
Despite such activity, many still look to the ABC as a department and the State ones?
leader in science journalism. However, damaging Weekly. If you are moving to a more federal system in the
Government cuts and nervous managers who ape the UK, which you clearly are, you would be very wise to
BBC “reforms” rather than boldly setting their own shift all health funding to one level of government. The
agenda, mean that the enterprise is increasingly fragile. worst thing you could do is keep paying doctors and part
of healthcare out of the national budget and put hospitals
and something else under regional government. We have
Doctor with a health portfolio to do a lot by negotiation and there are always problems
Dr Michael Wooldridge studied medicine at Monash at the boundary from one government to another. That
University, Melbourne, graduating said, the system’s not a bad system. Federal Canada has a
in 1981. He was elected to the lot more problems than we have.
Federal Parliament as a Liberal in
1987; in opposition he was
involved in aboriginal and youth Immunisation cover does seem to be a particular worry
affairs. In 1996 he was appointed We used to have a much higher immunisation rate. In
Minister of Health and Family 1987 a previous government decided to give
Affairs in the centre-right coalition responsibility to the states, who then shared it out in
government. He was interviewed by varying forms—in Victoria largely with local government
David Sharp for The Lancet on Feb
and in other states through general practitioners.
13, 1998, at his Chisholm
constituency office in east Everyone was responsible and no-one was responsible. By
Melbourne. 1995 we were second from the bottom among countries
in the OECD and 68th in the world. Public health in my
Some people say that you view is not a private matter; it is not a matter of
should not have a doctor as health minister individual choice, and I have managed to convince even
I can’t tell you the number of times over ten years I’ve sat the most conservative and dry in my party of that. There
round a table with my colleagues and had someone say are other factors, that we share in common with other
you could never have a doctor as health minister. I pick a countries—for example, the fact that these illnesses have
lawyer out around the table—which is usually very easy largely vanished from sight—but Australia has had a
because there are a lot of them—and say “That’s fine. I much worse result than other countries so you do have to
don’t want the health portfolio, I want to be Attorney- ask what is different. I think we will have it pretty much
General”. Lots of muffled choking sounds from the fixed within two years . . .
lawyers—“But you have to have a lawyer for Attorney-
General”. . . . by a health-education approach?
The weakness is that you do risk having preconceived Partly, but far more than that. Publicity is easy. We have
views and being captive to the medical profession. There a national child immunisation register now that keeps
are, however, immense strengths. The biggest is that you track of every child and their immunisation status and
have the capacity to make decisions yourself, independent links it into their healthcare number. Even though we
of departmental advice. And you have a scientific basis don’t have patient identification (patient linkage to a
for your reasoning that is much stronger than what you general practice) 90% of people see one general
are likely to get from any bureaucracy. Two hallmarks practitioner almost exclusively. We now send out follow-
of my time as minister both probably surprised people. up notices. We are giving GPs feedback on the level of
One is a very strong emphasis on public health, which immunisation of the children. We have tied in the level of
people did not expect from a centre-right government. immunisation in a GP’s patients to part of the system of
The other is that I’ve tried to put a strong scientific basis payment of GPs. In addition, the maternity allowance is
to health policy. Both are a direct result of my medical now in part contingent on complete child immunisation
training. and for mothers to qualify for childcare assistance for
. . . an example of where you have gone against children at 2–5 years of age they have to show complete

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immunisation or conscientious objection. years before any doctor graduated, independent of the
year of graduation! The medical profession is not very
You are in favour of evidence-based medicine . . . good at looking forward and coping with change.
Strongly. Actively promoting it and introducing systems For the changes being made in hospitals the evidence
to incorporate it into the policy process. was perhaps post hoc but what has been done with case-
mixes has massively increased productivity in hospitals.
. . . but EBM is a bit like motherhood, who can be Health ministers from other countries are now coming
against it—so what drove you to do it? through my office and saying “This is really interesting,
It may be “motherhood” but that doesn’t mean it’s done. we want to have a look at this. We think this applies to
One should never in politics underestimate the our country”. If I was being critical I would like to have
importance of anecdote. In 1983 I did a three-month seen more work on outcomes. In economic terms the
stint at a cancer hospital in Melbourne, working in the restructuring has been brilliantly post hoc justified but
breast cancer unit. By 1983 we had Veronesi’s evidence there is a sneaking suspicion that outcomes have slipped
that if patients had chemotherapy with mastectomy in a touch. If you look at what we’re doing with
stage 2 disease they had better 5-year results. This was coordinated care, which no examination of Australia
well known at that hospital and they were practising it. would be complete without, we are doing exactly what
Back at my parent teaching hospital no-one had heard of you suggest. We are putting a massive amount of money
Veronesi. We were still doing mastectomies without into trialling systems of better managing chronic illness.
chemotherapy. I was a second-year resident and you can
imagine what success I had in trying to spread this What else would you highlight as health successes?
message. It wasn’t until the early 1990s in Australia that What Australia has done well is to marry a reasonably
chemotherapy became routine. I never quite got over that large private sector with public sector provision. Despite
experience. It is massively in the public interest if we can the fact that there is much in the newspapers about
incorporate science into clinical practice. drop-outs from private health insurance, we still have the
No country in the world does not in some way have to third largest private sector in the OECD and about $1 in
try and ration the health dollar. I find the notion of trying 3 in healthcare comes through the private sector. Austria
to make allocative decisions on science far more is slightly ahead and the USA is vastly ahead. And we
attractive. If you make them on politics you either make it have managed to have a high degree of cost control, as
on the basis of whoever screams loudest or on the basis of distinct from individual provider control—and you have
whoever has access to the minister. to have that. Any system has to be affordable otherwise
eventually it implodes. I think Australia’s success has
How do you cope with patient pressure where it is been to have a mixed system of public and successful
“anti” the evidence? private provision while not going the way of the USA
I make sure I have a group of eminent scientists standing and having that lead to massive cost blow-outs.
somewhere between me and the bullets! I also think we do well on information. Through the
We have worked hard in this country to have an Health Insurance Commission we probably have the best
approach that is free of politics. The area which is the
information system in the world.
focus for some of my attention at the moment is hepatitis
One challenge is to find ways to make our federation
C. On any sort of rational economic analysis hepatitis C
work better although there is no evidence that our
demands more attention from government; it demands
system has many more problems than, say, Canada’s.
more research funding, just as HIV did 12 or 13 years
Our relative success internationally doesn’t seem to
ago. Left to the devices of politics and the marketplace
make the medical profession any happier with life.
hepatitis C will be a catastrophe. We are trying to act
ahead of catastrophe, and trying to use the HIV model of Contributors
community consultation and involvement, and taking an Jeffrey Robinson (Department of Obstetrics and Gynaecology,
approach based on science. University of Adelaide, Adelaide, South Australia 5005) with
Pat Buckley, John Marly, and Deborah Turnbull have a special
interest in medical education and the evaluation of its methods.
Why was an EBM approach not brought to bear on Stephen R Leeder (Medical School, University of Sydney, Sydney,
policy changes such as hospital restructuring? NSW 2006) is dean of the Faculty of Medicine, University of Sydney.
Hospitals are run by state governments. I’m happy to Warwick P Anderson and Richard G Larkins chair, respectively, the
NHMRC’s Research Committee and the National Health and Medical
comment but what we are talking about is not a Research Council (GPO Box 9848, Canberra, ACT 2601).
Commonwealth matter. The medical profession in Frank Shann (professor of critical care at Melbourne’s Royal Children’s
Australia has a huge difficulty at the moment. Health is Hospital, Parkville, Victoria 3052) formerly worked in Papua New
Guinea, East Timor, and Kenya.
undergoing massive change. One of the best thinkers on Fiona Stanley (TVW Telethon Institute of Child Health Research, PO
health in this country was in my office about 12 months Box 855, West Perth, Western Australia 6872) is Variety Club professor
ago and he told me he had come to the conclusion that in of paediatrics, University of Western Australia, Perth; Ted Wilkes directs
the Perth Aboriginal Medical Service and the Western Australian
the next 15 years health would undergo about as much Aboriginal Community Controlled Health Organisations.
change as Australian banking had in the previous 15. His Alan Finkel is chief executive officer of Axon Instruments (1101 Chess
worry was that doctors would have as much influence on Drive, Foster City, CA 94404, USA and 6 Wallace Avenue, Toorak,
the outcome as bank clerks had had. Victoria 3142); Leon Serry is managing director of Circadian
Technologies Ltd, Melbourne, Victoria.
He may be right. My observation of my former Norman Swan (PO Box K637, Haymarket, NSW 2000) is presenter of
profession is that the golden age of medicine was two ABC Radio National’s The Health Report.

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