Endometriosis costs women and society $30,000 a year for every sufferer



It can be difficult to get pain from endometriosis under control.
Shutterstock

Mike Armour, Western Sydney University and Kenny Lawson, Western Sydney University

The average cost for a woman with endometriosis both personally and for society is around A$30,000 a year, according to our research, published today in the journal PLOS ONE.

Most of these costs are not from medication, or doctors’ visits, although these do play a part. Rather, they’re due to lost productivity, as women are unable to work – or work to their usual level of efficiency – while experiencing high levels of pain.

Remind me, what is endometriosis?

Chronic pelvic pain is pain below the belly button that occurs on most days for at least six months. The most common identifiable cause is endometriosis. Endometriosis is the presence and growth of tissue (called lesions) similar to the lining of the uterus that’s found outside the uterus.

Women with the condition have a variety of symptoms, including non-cyclical pelvic pain (which is like period pain but occurs regularly throughout the month), severe period pain, pain during or after sexual intercourse, and severe fatigue. Gastrointestinal problems, such as severe bloating (often called “endo belly” by those who suffer from it) and pain with bowel motions, are also common.




Read more:
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Currently, surgery (a laparoscopy) is the only way to make a formal diagnosis of endometriosis – this is where a small camera is inserted into the pelvic/abdominal cavity to investigate the presence of endometriosis lesions.

Both medical and surgical treatments are commonly used for women with endometriosis. Medical therapies include non-steroidal anti-inflammatories (such as ibuprofen and naproxen), oral contraceptive pills and other forms of hormonal treatments.

While these medications can be effective for some, many women experience side effects and need to stop using them.

Surgery is the current “gold standard” of treatment, but despite successful surgery many women find their pain and symptoms can return within about five years after surgery.




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How many women have it?

Around 7% of Australian women aged 25–29 and 11% of women aged 40–44 are likely to have endometriosis, which is similar to the worldwide estimate of one in ten women.

Delays in diagnosis are extremely common, and combined with needing surgery for a diagnosis, means many women suffer for years with chronic pelvic pain before being diagnosed with endometriosis later in life. This contributes to the difficulty in getting exact figures for how many women in Australia have endometriosis.

Worldwide estimates of chronic pelvic pain range from 5% to 26% of women. In New Zealand, it’s around 25% and is likely to be similar in Australia but we are lacking any up-to-date and reliable statistics on this.

What did our study find?

Endometriosis and chronic pelvic pain affect all aspects of women’s lives – social activities, romantic relationships and friendships, education, and work attendance and productivity.

We surveyed more than 400 women aged 18 to 45 who were either diagnosed with endometriosis or experiencing chronic pelvic pain. We asked about health-care costs (both out of pocket and funded), employment-related costs, and other costs related to childcare and household maintenance. We also asked about their pain levels.

Women with endometriosis sometimes have to work when they’re in extreme pain, affecting their productivity.
Flamingo Images/Shutterstock

We found the average cost for a woman with endometriosis was around A$30,000 per year.

Around one-fifth of this cost was in the health sector, for medications, doctors’ visits, hospital visits, assisted reproductive technology such as IVF, and any transport costs to get to these appointments. Of this, A$1,200 were out-of-pocket costs.

The bulk of the costs (over 80%) were due to lost productivity, either because of absenteeism (being off work) or presenteeism (not being as productive as usual because you’re sick). Women with endometriosis often use up all their sick leave and then often have to work when they are in severe pain.

Overall, if one in ten women aged 18 to 45 do have endometriosis, the total economic burden in Australia may be as high as A$9.7bn per year for endometriosis alone.

Pain scores had a very strong link with productivity costs. Women with the most severe pain had a 12-times greater loss of productivity, in terms of working hours lost, than those with minimal pain.

Overall, taking into account all costs (health sector, out-of-pocket, carers and productivity) women with severe pain have six-times greater costs (A$36,000) a year overall compared to those with minimal pain (A$5,700).

Finally, we also looked at the cost of illness not only of those women with a diagnosis of endometriosis, but also of those that had other causes of chronic pelvic pain, such as vulvodynia (pain, burning or discomfort in the vulva) and adenomyosis (growths in the muscular wall of the uterus).

We found the overall costs between the two groups – those with endometriosis and those with other types of pelvic pain – were very similar.




Read more:
Adenomyosis causes pain, heavy periods and infertility but you’ve probably never heard of it


The more pain a woman has, the bigger the impact on her productivity and out-of-pocket costs.
Iryna Inshyna/Shutterstock

So what should we be doing?

The economic burden of endometriosis is at least as high as other chronic disease burdens such as diabetes. However, many women are not receiving the support they need.




Read more:
Women aren’t responsible for endometriosis, nor should they be expected to cure themselves


We also need to prioritise funding for endometriosis research, which until recentlyhas attracted comparatively little research funding.

Plans are underway to increase awareness and education, and improve diagnosis and pain management. Unfortunately, there is no such plan for women with other forms of chronic pelvic pain.

Reducing pain, by even a modest 10-20%, could improve women’s quality of life and potentially save billions of dollars each year.The Conversation

Mike Armour, Post-doctoral research fellow, Western Sydney University and Kenny Lawson, Adjunct Principal Health Economis, Translational Health Research Institute, Western Sydney University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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There’s no airport border ‘crisis’, only management failure of the Home Affairs department


Regina Jefferies, UNSW and Daniel Ghezelbash, Macquarie University

In the past five years, more than 95,000 people who arrived by plane have lodged a claim for asylum in Australia, new statistics show.

Labor’s Immigration Spokesperson, Senator Kristina Keneally, has labelled this a “crisis”, stating:

Peter Dutton’s incompetence and recklessness has allowed people smugglers to run riot and traffic record-breaking numbers of people by aeroplane to Australia.

But the “crisis” is not that visa-holding travellers are flying to Australia, then later lodging a claim for asylum. It’s not unprecedented for tourists or students to later lodge a claim for asylum due to circumstances beyond their control.




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In 1989, for example, after events in Tiananmen Square, Australia provided refuge to thousands of Chinese students who had entered Australia with visas.

Instead, the “crisis” is the Australian government’s failure to properly manage the refugee-processing system. It gutted the ranks of experienced decision-makers and made organisational changes that undermine the quality of decisions, contributing to long processing delays and backlogs.

These organisational failures may have contributed to the increase in asylum applications over the last five years.

High staff turn-over

Protection visa decisions are highly complex. They must examine a variety of factors, including country-specific conditions and individual circumstances.

Yet, as the Australian National Audit Office noted in 2018, the Home Affairs department experienced a significant loss of “corporate memory” due to staff turn-over, “with almost half of SES officers present in July 2015 no longer in the department at July 2017”.

In a Senate Estimates hearing last year, Home Affairs officials said the average processing time for permanent protection visas, from lodgement to primary decision (not including appeals), was 257 days, or 8.5 months.

And the department’s training deficiencies are well-documented. The most recent Australian Public Service Employee Census put the department’s organisational management problems into stark relief: only 35% of employees said the department inspired them to do their best work, while two-thirds of respondents said they did not consider department senior executives to be of “high quality”.

These publicised problems raise important questions about the quality of decision-making at the primary level.

Stacking the AAT with political allies

Poor decision-making at the primary level can lead to higher numbers of appeals. So it’s perhaps unsurprising that appeals to the Administrative Appeals Tribunal (AAT) from people who arrived by plane are also experiencing significant blowouts.

The number of active refugee cases to the AAT has ballooned from 8,370 two years ago, to 23,063 in 2019.




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This results in a backlog. In 2017, the tribunal made 5,153 decisions on refugee claims, and so far this financial year, only 815 claims have been concluded.

In part, these worrying figures are due to the federal government appointing people with Liberal Party ties to the AAT over the last couple of years.

The Attorney-General recognised these problems in the 2019 Report on the Statutory Review of the Tribunal, which pointed to “competencies of members” as a key contributor to complications in the operation of the tribunal.

Stacking the AAT with political allies, many of whom are not lawyers and who are not appointed on merit, has removed independent expertise from the tribunal, risking errors and further delays.




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And with more errors come further appeals in the courts. This not only places a heavy burden on the resources of the Federal Circuit Court and Federal Court, but also leads to more delays and backlogs in the AAT, where the court sends matters which were unlawfully decided for re-determination.

Address organisational failures

The solution is in proper organisational management. Instead of blaming refugees for fleeing persecution by safe means, the government must address the failures of its refugee processing system.

To this end, an urgent review of the Department of Home Affairs policies and organisational failures is needed. A review could find out whether there’s a management culture stopping Home Affairs from attracting and retaining staff who can make reasoned and well-supported decisions in an environment they can be proud of.




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Similarly, there must be a transparent and independent system for appointing AAT members that prioritises skills and experience over politics – exactly what was recommended by the Attorney-General’s recent review.

If people seeking asylum can have their claims assessed quickly and fairly, then those who are not refugees can be sent home, while those needing safety could receive it.

Without the chance to remain in Australia for years while their claims are assessed, there would be no loophole for traffickers and others to exploit.

In turn, the number of non-genuine claims will go down, allowing decision-makers to focus on those who are actually fearing persecution.




Read more:
Yes, Peter Dutton has a lot of power, but a strong Home Affairs is actually a good thing for Australia


We should be supporting refugees to access safety by air. If people fleeing persecution can access a flight to Australia, they won’t risk a dangerous journey by boat to find safety.

This is not an airport border “crisis”, it’s a management failure that can be fixed with more staffing, better resourcing, and transparent and meritorious appointments of decision makers.


Correction: A previous version of the article stated 815 refugee claims were concluded this year. This has been updated to clarify that 815 of claims were concluded during this financial year.The Conversation

Regina Jefferies, Affiliate, Andrew and Renata Kaldor Centre for International Refugee Law, UNSW and Daniel Ghezelbash, Senior Lecturer, Macquarie Law School, Macquarie University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Define the boundaries in new phase of Australia-China relationship: Wong


Michelle Grattan, University of Canberra

Shadow foreign minister Penny Wong says Australia needs to “define the boundaries” of its engagement with China now the relationship between the two countries is in a new phase.

Focusing on China policy in a Monday address – released ahead of delivery – Wong acknowledges the “substantial and growing differences” in the bilateral relationship.

“It is inevitable that Australia will make more decisions that China doesn’t like. This means that the way the relationship is handled will become even more important,” she says in the speech, to the Australian Institute of International Affairs.

“Although there continues to be convergence of interests, the divergences have become more apparent and acute – due to both Beijing’s increasing assertiveness and greater awareness in Australia as to the implications of the [Chinese Communist Party’s] behaviour and ambitions. We must look at how best to engage effectively with China while always standing up for our values, our sovereignty and our democratic system.”

Wong says where limitations around engagement are needed, the “boundaries should be as restricted as possible and as robust as necessary,” with opportunities and risks identified.

Boundaries and terms of engagement would differ between issues and between sectors.

Thus on research collaboration, engagement shouldn’t be ruled out across entire fields, but export controls and visa checks could be used for “a narrow set of the most sensitive defence oriented technology”.




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Wong says while the government has to provide the leadership all stakeholders, including the opposition, foreign policy community and business, “need to work together to identify those opportunities for deeper engagement where our interests coincide and to manage differences constructively”.

She puts the onus on the media “not only to hold the government of the day to account but to ensure they themselves don’t unthinkingly or inadvertently reinforce China’s tactics or narrative”, including by amplifying CCP claims.

Wong says Labor wants to engage in a bipartisan way on China policy, but the government isn’t willing to do so and Scott Morrison “has no plan for dealing with this new phase in Australia’s relations with China”.

“There’s no doubt Scott Morrison is the best political tactician in Australia right now… Is it enough to be a clever political tactician, when key relationships with our nearest neighbours are at stake? Is it enough to play short term political tactics on something so profoundly important as the integrity of our political system or the assertion of our national interests?

“Australia’s Prime Minister needs to look beyond the next manoeuvre, stop undermining his foreign minister and trade minister, and develop a serious long-term plan for Australia’s engagement in the region and the world.

“A serious and long-term plan that can proactively navigate us through the strategic competition between the US and China, and manage this new phase in our relationship with a more assertive China.”




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In a series of sharp criticisms of Morrison’s handling of the government’s policy towards China and foreign policy more generally, Wong includes as examples the PM’s claim Labor was using racism in its attack on Liberal MP Gladys Liu, his labelling of China a developed economy, and his attack on globalism.

Wong’s speech follows the blunt words on China on Friday from Home Affairs minister Peter Dutton, who said the government had a very important relationship with China, but it was going to “call out” instances where the wrong thing was done.

“We have a very important trading relationship with China, incredibly important, but we’re not going to allow university students to be unduly influenced. We’re not going to allow theft of intellectual property and we’re not going to allow our government bodies or non-government bodies to be hacked into,”he said.

Dutton stressed the issue was not with the Chinese people or the local Chinese community in Australia, but with the Chinese Communist Party.

The Chinese embassy reacted with an angry statement, saying that Dutton’s “irrational accusations” were “shocking and baseless”, and a “malicious slur on the Communist Party of China” and “outright provocation to the Chinese people”.

“Such ridiculous rhetoric severely harms the mutual trust between China and Australia and betrays the common interests of the two peoples,” the statement said.

Morrison at the weekend sought to play down the Dutton comments. “What Peter was talking about was the fact that there are differences between Australia and the People’s Republic of China. Of course there are,” he said. Australia was a liberal western democracy; China was a Communist Party state. “I would warn against any sort of over-analysis or over-reaction to those comments. Because I think they just simply reflect the fact that we’re two different countries”.The Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.

A national drought policy should be an easy, bipartisan fix. So why has it taken so long to enact a new one?



The Coalition has been promoting its $7 billion drought relief package, but critics say what’s needed is a more effective national drought policy.
Dan Peled/AAP

Linda Botterill, University of Canberra

In a country as dry as Australia, surely it is a no-brainer that we have in place a coordinated, national drought response that can be rolled out the same way that the Natural Disaster Relief and Recovery Arrangements are triggered when the country experiences cyclones, floods or bushfires.

Drought used to be part of these arrangements but, for good policy reasons, was removed in 1989.

Our last attempt at national drought policy

Once upon a time, Australia had a national drought policy. It was enacted in 1992 following a comprehensive review and report by an independent panel, the National Drought Policy Review Task Force, and detailed negotiations between Commonwealth and state ministers and their officials.

The policy included commitments by both state and Commonwealth governments to implement a coordinated and comprehensive package of programs covering drought preparation and response.

At the Commonwealth level, these measures were centred around:

  • the controversial “exceptional circumstances” provisions of its revised Rural Adjustment Scheme, which were aimed at supporting farm businesses by subsidising up to 100% of the interest paid on commercial loans.

  • a farm household support scheme that provided short-term income support to farmers and also offered grants for those who decided to leave the land.

  • farm management bonds, later known as farm management deposits, that allowed farmers to set aside pre-tax income they could later draw on in times of need.

  • a drought relief payment (added to the policy in 1994) that provided income support for farmers in areas declared to be experiencing “exceptional circumstances” drought. By May 1995, over 10,000 families were accessing this payment every month.

Grain feed left for sheep grazing on a failed crop in NSW.
NSW drought stock/AAP

Flaws in the policy

As anyone familiar with these programs will know, the exceptional circumstances program was plagued by problems.

The first was the lack of clarity around defining when a drought moved from a “normal” situation that was expected to be managed by farmers, to an “exceptional” situation with which even the best manager could not be expected to cope.

The definition of an “exceptional circumstances” drought became the subject of ongoing debate, along with concerns that drought assistance was based on administrative boundaries, leading to inequities that became known as the “lines on maps” problem.




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Just because both sides support drought relief, doesn’t mean it’s right


The second issue was the amount of information farmers were required to provide in order to demonstrate eligibility for “exceptional circumstances” assistance. The process was considered onerous and time-consuming.

Amid these concerns, a comprehensive review of drought policy was conducted in 2008 by the Productivity Commission. This was accompanied by a report by the Bureau of Meteorology and CSIRO on the likely impact of climate change on the frequency and severity of droughts in Australia, and an independent report on the social impact of drought.

Following the review, the government decided to end the “exceptional circumstances” program in 2009. This effectively gutted the national drought policy.

Since then, there has been no further attempt at developing a comprehensive, predictable drought policy response from the federal or state governments. There have been intergovernmental National Drought Agreements, but these have done little more than restate the principles underpinning the country’s drought policy since 1992.

In recent years, the Coalition government has appointed a drought envoy, Barnaby Joyce, and drought coordinator-general, Stephen Day, to study the impact of drought on farmers and recommend possible solutions, but we have yet to see what either has come up with.

Drought envoy Barnaby Joyce says he has sent drought reports directly to Scott Morrison, but these have not yet been made public.
Lukas Coch/AAP

Providing meaningful, timely and predictable support

Much of the criticism levelled at the government’s response to the current drought relates to its ad hoc and knee-jerk nature. This reactive way of dealing with drought highlights the need to return to a more predictable approach. This would avoid perceptions of pork barrelling and provide certainty to farmers about what support is available and under what circumstances.

A new national drought policy needs to take several forms. First, it needs to support farmers to prepare for drought before it happens. This is one area where the current policy has been moderately successful.

As of August 2019, Australian farmers had set aside a total of $5.809 billion in farm management deposits. These deposits have encouraged farmers to manage financial risk by building up cash reserves in high-income years, which they could then use during times of drought.

Individual farmers can currently hold a total of $800,000 in deposits. One possible improvement is to raise the ceiling on annual deposits in the years following drought recovery to allow a rapid rebuilding of cash reserves.

Second, a strong drought policy needs to provide support to all farmers during drought, not just those who have accumulated sufficient deposits to help them ride out the lean years.

In recent years, many farmers have taken advantage of long-term, low-interest loans to help during drought, and some have called for zero-interest loans to be made available, as well. But loans are not an ideal solution, as repayments are generally required even when farm incomes remain low.

An alternative to low- or no-interest loans are income contingent loans. Similar to the HECS-HELP scheme in higher education, these types of loans only require repayment when the borrower can afford to do so.

This would not only give farmers greater flexibility when it comes to repayment, it would also greatly reduce the extensive red tape that strangled the old “exceptional circumstances” scheme.




Read more:
Farm poverty: an area of policy aid built on sands of ignorance


Third, we need a serious rethink of the way we provide income assistance to farmers in a broader sense. Providing income support to farmers who are asset-rich, for instance, raises questions about fairness when compared with poor people in cities who are struggling to get by on Newstart payments.

This imbalance has come into stark focus in recent weeks, particularly on social media, as government ministers have discussed the introduction of drug testing for Newstart recipients, and in the debate around the Indue card.

There has been no serious attempt in the past 45 years to measure the extent of poverty among farmers. We can develop more appropriate and equitable income-support policies if we can better understand the genuine nature of their need.

The elephant in the room

While the government has assiduously avoided making the link, an effective national drought policy also cannot be divorced from discussions about climate change.

The 2008 Productivity Commission report was pretty clear in its conclusions about the impact of climate change on drought in Australia. A growing number of farmers are now acknowledging this reality. Denying the need for serious consideration of climate change is not doing our agricultural producers any favours.




Read more:
Is Australia’s current drought caused by climate change? It’s complicated


Developing an effective national drought policy is hard work. But in another sense, it should also be easy. This is because, unlike many other areas of government policy, it can be bipartisan.

Although the National Party has historically been aligned with rural voters, all parties are broadly sympathetic to farmers and value their contributions to the economy and, importantly, our national identity. The public also generally regards farmers positively and is responsive to their plight when they are faced with hardship.

As such, this should be one area where our politicians can come together to develop a coherent national response — one that is known in advance, forward-looking, equitable with other income-assistance programs in the community, and provides meaningful support before, during and after drought.The Conversation

Linda Botterill, Professor in Australian Politics, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Pay pharmacists to improve our health, not just supply medicines



Pharmacists receive no financial incentive to counsel patients about how to take their medicines. That needs to change.
from www.shutterstock.com

John Jackson, Monash University and Ben Urick, University of North Carolina at Chapel Hill

When you have a medicine dispensed at your local pharmacy under the
Pharmaceutical Benefits Scheme (PBS), two things happen. The federal government determines how much the pharmacy receives for dispensing your medicine. It also decides what you need to pay.

This so-called fee-for-service funding means pharmacies maximise their revenue if they dispense many prescriptions quickly.

Rather than fast dispensing, it would be better for patients and the health-care system if the funding model paid pharmacists for improving the use of medicines, not just for supplying them.

This is possible, according to our research published recently in the Australian Health Review. And it should be considered as part of the next Community Pharmacy Agreement, which outlines how community pharmacy is delivered over the next five years.




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Dispensing medicine is more complex than it looks

Dispensing medications may seem simple but this can be misleading: it includes both commercial and professional functions.

Under the PBS, the pharmacy receives a handling fee and mark-up on the cost of the drug to cover the commercial cost of maintaining the pharmacy and stock.

It also receives a dispensing fee for the pharmacist’s professional activities. These include reviewing the prescription to ensure it is legal and appropriate, taking into account factors such as your age, whether you are pregnant and which medicines you’ve been prescribed before; creating a record of the dispensing; labelling the medicine; and counselling you, including providing a medicine information leaflet if needed.

Higher dispensing fees are paid for medicines needing greater levels of security (such as controlled drugs including opioids) and for medicines the pharmacist must make up (such as antibiotics in liquid form).




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But for the vast majority of PBS prescriptions, a pharmacy receives the same basic dispensing fee, currently A$7.39.

If you have a medicine dispensed for the first time, if it has a complicated dose, or it carries particular risks such as side effects or interactions, a pharmacist is professionally obliged to provide counselling matched to the risk. The more detailed the counselling, the greater the time needed.

However, at present, the dispensing fee to the pharmacy does not change depending on the level of counselling you need. Indeed, the current funding model is a disincentive for the pharmacist to spend time with you explaining your medicine. That’s because the longer they spend counselling, the fewer prescriptions they can dispense, and the fewer dispensing fees they receive.

What could we do better?

Performance-based funding, in which payment is adjusted in recognition of the efforts of the service provider or the outcomes of the service delivered, is becoming more common in health care and can correct some of the volume-related issues mentioned above.

It’s already being used in Australia. For instance, GPs are paid a Practice Incentives Program (PIP) to encourage improvements in services in areas such as asthma and Indigenous health.

However, performance-based funding has yet to be used for pharmacists’ dispensing in Australia.

We propose dispensing fees should be linked to the effort pharmacists make to promote improved use of medicines. This is based on the principle that counselling means people are more likely to take their medications as prescribed, which improves their health.

In other words, pharmacists would receive higher dispensing fees when more counselling is required or if counselling leads to patients taking their medications as prescribed.

Pharmacists who spend longer counselling, for instance if someone’s health status has changed, should be rewarded for it.
from www.shutterstock.com

Dispensing fees could be linked to the actual time taken to dispense a prescription: the longer the time, the higher the fee. The time taken would depend on the nature of the drug; the complexity of the patient’s treatment; recent changes in the patient’s health status or other medicines that need to be taken into account; consultation with the prescribing doctor; and the level of advice and education provided.

A blended payment model could include a fee-for-service payment for commercial processes and a performance-linked payment for professional functions.

The most experience with performance-based payments to pharmacy is in the United States, where evidence is developing of patients taking their medicine as prescribed and lower total health-care costs.

In England, the government’s Pharmacy Quality Scheme is similar to the Australian Practice Incentives Program for GPs. It funds improved performance in areas such as monitoring use of certain drugs and patient safety.

There is some concern about performance-linked payments. Performance targets need to be achievable without being onerous. And performance needs to be clearly linked to the payment being made, but not if other services suffer.

Incentives could apply to you too

Cost is a barrier to some people taking their medicines with over 7% of Australians delaying or not having prescriptions dispensed due to cost.

However, there is currently no financial incentive for you to have a generic (non-branded) medicine dispensed, which would save on PBS expenditure. So it makes sense for generic medicines to be a lower cost to you.




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There is also currently no financial incentive for you to take your medicine as prescribed, which would likely improve your health and save the health budget in the long run. We are not aware of any country varying patient charges based upon this, although there are ways of monitoring if people take their medicines as directed.

However, countries such as New Zealand and the United Kingdom have lower or no patient prescription charges, minimising costs as a barrier to patients taking their medicine.

What would need to happen?

Dispensing a prescription should be an invitation for the pharmacist to interact with you and help you with advice on the effective and appropriate use of your medicine. At present, there is no incentive, other than professionalism, for pharmacists to add such value.

The proposed changes would require a major restructure to the funding of dispensing to provide incentives that are equitable and transparent and that did not adversely affect disadvantaged, rural and Indigenous people.

There would need to be agreement on reliable and valid performance measures and reliable information systems.

However, funding based on a professional service model rather than a dispensing volume model would support your pharmacist to provide greater benefit to you and the health-care system.The Conversation

John Jackson, Researcher, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University and Ben Urick, Research Assistant Professor, University of North Carolina at Chapel Hill

This article is republished from The Conversation under a Creative Commons license. Read the original article.

It’s easy to get us walking more if we have somewhere to walk to near our home and work



It doesn’t take much to get us walking more.
Flickr/alina gnerre , CC BY

Rebecca Bentley, University of Melbourne and Hannah Badland, RMIT University

We know walking more and increasing our levels of exercise are good for our health.

But how can we walk more in our busy lives?

Our research shows people walk more if the city’s design provides them with places to walk to near where they live, work or study.




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The research also shows people walk even more if they live in a place that has good public transport and plenty of jobs or employment opportunities they can easily access.

What gets us walking

Our study examined walking behaviours in nearly 5,000 adult commuters in Melbourne, drawn from the Victorian Integrated Survey of Travel and Activity between 2012 to 2014.

We looked at what level of access they had for destinations to walk to, typically within about 800 metres, close to their home, work or study place. This could be local cafes, shops, supermarkets, libraries and other services, often referred to as local accessibility.

The amount walked on an average day by those with good local accessibility at home or near where they worked or studied was around 12 minutes. Those with limited access to local facilities walked only seven minutes.

People with good local accessibility near their homes walked five minutes more per day than those with poor local accessibility. People with good local accessibility near where they worked or studied walked nine minutes more.




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But to get our activity to the next level we needed to look beyond what was locally accessible to people.

We looked at people’s relative travel commute time by public transport compared with driving, the level of public transport service accessible from where they lived, worked or studied, and the number of jobs within 30 minutes of people’s homes by public transport. These are sometimes referred to as measures of regional accessibility.

We found that the greater access people had to resources and public transport regionally, the more they walked.

For example, after accounting for local accessibility, people living in places with a higher number of jobs available within a 30-minute public transport journey walked just over four minutes more on average than people in areas with very low job availability.

People living in places where taking public transport was more efficient timewise than driving, walked more than seven minutes extra a day compared with people with low levels of public transport.

A little extra help

Our study also looked at the combination of local and regional accessibility to see if they encouraged people to walk even more.

We found that high exposure to both local accessibility and public transport accessible opportunities beyond the immediate neighbourhood was associated with greater walking benefits than exposure to just one or the other alone.

This combination of factors supported people to do around ten minutes more (give or take depending on the measures used) of walking on average per day.

We know people who travel by public transport are likely to walk more than those who travel by car.

Public transport effectively separates people from their own vehicle, be it at home or a park-and-ride stop. Public transport delivers them as pedestrians close to their destination, which in turn promotes walking throughout the day.

If people walk more in their residential environment (say to the shops, library, or post office), take public transport to their workplace or place of study and then walk more in this environment too (at lunchtime for example), they do ten more minutes of physical activity in a day than their counterparts who drive.

A message to planners

The message this new research tells us is simple.

City and urban design and transport planning have the potential to deliver a regular extra dose of what’s been described as the “miracle cure” of exercise by encouraging us to walk more.

A variety of walkable destinations that support people’s daily living needs to be designed into existing and, more importantly, new developments. That means at locations where we live, work, and study.




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This can be done by locating shops, schools, post offices, GPs and public transport stops within good walking distance. Jobs need to be located close to where people live. This will encourage walking, cycling and public transport commuting. When this is not possible, employment opportunities should be embedded within well connected and efficient public transport networks.

Cities that support people to walk more will provide population health benefits through increased physical activity, helping them to become truly smart and healthy cities.The Conversation

Rebecca Bentley, Associate Professor, Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne and Hannah Badland, Principal Research Fellow, Centre for Urban Research, RMIT University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Why we need ‘crazy’ ideas for new city parks



Sea Line Park, one of the shortlisted entries in the competition to design a new park for the Melbourne of 2050.
Future Park Design Ideas Competition, Author provided

Wendy Walls, University of Melbourne

Two seemingly unrelated but important things happened in Melbourne last week. One was a memorial service for David Yencken AO; the other was the exhibition opening of the Future Park Design Ideas Competition. The connection between the two is that both gave us radical ideas for Melbourne’s open space.

David Yencken was a visionary man who had a profound impact on Victoria and Melbourne. He was responsible, among many things, for the transformation of Southbank and co-founding Merchant Builders. But one of his wildest ideas was the 1985 Greening of Swanston Street, when vehicle traffic was closed and a weekend street party was held right in the middle of Melbourne.




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As the secretary (chief executive) of the Ministry for Planning and Environment, Yencken had been charged with changing perceptions of the city by rethinking its public spaces. At a time before pop-up parks and guerrilla gardening, his radical idea demonstrated what was possible for the inner city and sowed the seed of the idea of closing Swanston Street to traffic.

The project was not without controversy – it was costly and came in for political criticism as a stunt. But looking back to a time when inner Melbourne was underutilised and dominated by traffic, we can see how that radical idea sparked the imagination about what was possible for the city centre.

The Greening of Swanston Street in 1985.
Victorian Ministry of Planning



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Future Park fires imaginations and debate

This is just what the Future Park competition needs to achieve. The open competition held by the University of Melbourne and the Australian Institute of Landscape Architects has attracted global interest, with 123 entries from 20 countries.

The brief was simple but provocative. Designers were to find space within 10 kilometres of the city centre and design a future park that responds to the challenges of Melbourne today. The design responses from the 31 shortlisted entries ranged from manufactured lagoons to urban wildlife corridors and street transformation parks that Yencken would be proud of.

Melbourne from Past to Last, a vision of a city street park.
Future Park Design Ideas Competition, Author provided

The first wave of media coverage on the competition inspired a range of public comments about Melbourne’s open space. For example, from the online comments in The Age:

Royal Park is a massive area of underutilised space. Driving down Elliott Av it’s just an open wasteland. Grassland and scattered gum trees does not make a welcoming “park”.

How about bulldozing the eyesore known as Federation Square and putting a park in its place?

These designs forget to include the things that make it a Melbourne park, graffiti, vandalism, weeds and the homeless.

Architects and landscapers rarely, if ever, have a grasp on what will work for people … they are too busy trying to be creative, and not busy enough trying to make people happy.

What the public comments show us is that there is no single or obvious solution to our parks and public spaces. Some people like it busy, some people like the quiet. Some want European trees and others desire native plantings. It’s complicated, and each of these opinions make valid points.

Just like Yencken’s Greening of Swanston, there will always be debate about what makes good public space. And that is exactly why we need more radical ideas – some might call them “crazy” – for our cities.

We know the future of our cities will be complicated. Like it or not, there will be more people, a changing climate and increasing pressure on infrastructure and services.




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Wicked problems call for radical thinking

These messy issues are often described as wicked problems. Popular in public policy and management, the term is used to explain problems with debatable cause and effect. Critically, the lack of agreement about wicked problems produces conflicting goals towards resolution.

Obviously, we need science, governance and planning, but finding solutions to wicked problems will also require creativity and collaboration. We need debate and we need ideas that can expand our imagination about what our cities can be. This is why it is so important that the competition entries for the Future Park explore new and outrageous possibilities.

Ideas throughout the shortlisted entries include plans for a new NBN: the National Biodiversity Network, which creates ecological corridors across the country. Others propose transforming schools into parkland; parks designed for bees; designs that return darkness to our urban landscapes; and sculpting new islands as rising sea levels engulf our coastline.

Multi-deck parks: as cities grow and space becomes ever more precious, urban parks replace car parks.
Future Park Design Ideas Competition, Author provided

As design solutions, these ideas reflect the challenges of our world today. While many of these schemes are technically, socially or economically unfeasible, they remind us of the power of thinking outside of the box. Importantly, the competition format puts all of these ideas together in one place for us to think about and discuss.

In Australia, we have a limited culture of “open design competitions” for either built projects or speculative solutions. But design competitions provide opportunities for new voices and discovering unexpected solutions within these wild ideas.

Radical ideas are important and so is having the freedom to voice them. Especially as a way of expanding the discussions we need to have about the challenging future.




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The Future Park competition winners will be announced on Friday, October 11, at the 2019 International Festival of Landscape Architecture in Melbourne. The Future Park exhibition is at Dulux Gallery, Melbourne School of Design, University of Melbourne, from October 4 to November 1.The Conversation

Wendy Walls, Lecturer in Landscape Architecture, University of Melbourne

This article is republished from The Conversation under a Creative Commons license. Read the original article.

View from The Hill: Malcolm Turnbull delivers the unpalatable truth to Scott Morrison on climate and energy


Michelle Grattan, University of Canberra

Sometimes birthdays are best let pass quietly. The Liberals are finding the 75th anniversary of their founding another occasion for the blood sport they thought they’d put behind them.

Tony Abbott and Malcolm Turnbull are out of parliament – for which Scott Morrison is much thankful – but their passions are unabated. Each has let fly in interviews with The Australian’s Troy Bramston to mark the anniversary.

Abbott repeated that it was Turnbull’s undermining which did him in (only the partial truth) and indicated he wouldn’t mind returning to parliament but didn’t think the Liberal party would ask him (absolutely true).

Turnbull’s was the more pertinent and, from where the government stands, pointed interview because it fed very directly into central issues of the moment, climate change and energy policy.

“The Liberal Party has just proved itself incapable of dealing with the reduction of greenhouse gas emissions in any sort of systematic way,” Turnbull said.

“The consequence … is without question that we are paying higher prices for electricity and having higher emissions.”




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He knows what he’s talking about. These issues were critical (though not the only factor) in Turnbull losing the leadership twice – first in opposition and then in government. And that was despite doing deals and trade offs to try to satisfy the right in his party.

He still frets about the battles which cost him so much for so little gain. He told the Australian, amid boasts about what his government had done, that his biggest regret as PM was not settling a new energy policy.

What Scott Morrison really thinks on the climate challenge, or what he would do if he were just driven by policy concerns without regard to party considerations or electoral judgements are in that category of known unknowns.

In few areas can Morrison’s beliefs be divined free of political context.

But we do know two things.

Firstly, we don’t have a satisfactory energy policy: emissions are rising; power prices are too high; investment is being discouraged. An analysis released by the Grattan Institute this week was damning about how federal government policies were discouraging investment including by “bashing big companies” (the so-called “big stick” legislation, allowing for divestment when an energy company is recalcitrant, is still before parliament).

Secondly, climate change is again resonating strongly in the community.




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Critics dismiss the attention young activist Greta Thunberg has received internationally, and this week’s “Extinction Rebellion” demonstrations, and many in the government would point to the election result to note that climate change did not carry the day with the “quiet Australians”.

The Morrison win, however, doesn’t mean the issue lacks cut through, or won’t have potency in the future. And although the Liberals like to talk about the miracle victory, it should be remembered the win was by a sliver, not by 30 seats. What made it so notable was that it defied expectations.

Turnbull said in his interview the Liberal party had been influenced by a group that was denialist and reactionary on climate change.

It still is, but this group is not giving trouble at the moment because Morrison, unlike his predecessor, is not provoking them.

The problem for Morrison is that keeping his party calm doesn’t solve the policy problem. Unless that is more effectively tackled, it could come back to bite him, regardless of the positive tale he tries to spin, such as in his United Nations speech.

Turnbull also said in his interview that, among much else, in government he had been “very focused on innovation” which, as we remember, was his catch cry in his early days as PM.

And, if we take information from the Harvard Kennedy School’s Center for International Development, reported in Tuesday’s Australian Financial Review, Australia needs innovation to be a much higher priority.

Australia fell from 57th to 93rd between 1995 and 2017 on the index of economic complexity, which measures the diversity and sophistication of countries’ exports. Our wealth comes from the minerals and energy that form the bulk of our exports but “Australia⁩ is ⁨less complex than expected⁩ for its income level. As a result, its economy is projected to grow ⁨slowly.⁩ The Growth Lab’s ⁨2027⁩ Growth Projections foresee growth in ⁨Australia⁩ of ⁨2.2%⁩ annually over the coming decade, ranking in the ⁨bottom half⁩ of countries globally,” the data says.

“Economic growth is driven by diversification into new products that are incrementally more complex. … ⁨⁨Australia⁩ has diversified into too few products to contribute to substantial income growth.⁩”




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Turnbull’s talk of innovation, agility, and the like was seen by many in his ranks, particularly in hindsight, as too high falutin’. It certainly went down badly in regional areas, which is why in 2016 the Nationals sharply differentiated themselves in the election campaign.

The Harvard work suggests Turnbull’s innovation ambition was on the right track. But the political evidence showed he was a bad salesman for this (and a lot else).

Morrison is a good marketing man. But the test of his prime ministership will be whether he can use his marketing skills to sell policies that the country needs, rather just what he thinks will go over easily with his constituency.

The most effective leaders (and that excludes both Abbott and Turnbull) can both identify what the nation requires and persuade enough of the voters to embrace it, even when it’s difficult. They operate not on the principle of the lowest common electoral denominator, or simplistic descriptions of their supporters – rather they pursue the highest achievable goals.The Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.

‘Stop playing politics’: refugees stuck in Indonesia rally against UNHCR for chronic waiting


Chrisanthi Giotis, University of Technology Sydney

One evening last month, the young man from Afghanistan, of Hazara ethnicity, arrived in Jakarta. His people-smuggler dropped him at the UNHCR entrance reserved for refugees, where he was told to wait.

The next day, mid-morning, he was still outside waiting to speak to someone. He was too afraid to give me his name or even his age, but he appeared to be in his early 20s.

He had been fleeing for 20 days, ten days hiding in wait in Kabul, then another ten days in transit through three countries. His choice to come to Indonesia was based solely on escaping immediately.

Through a translator he said:

I needed to get out quick. I just wanted to come as soon as possible so I came through an agent. My agent brought me here, I have no shelter so I am just waiting for the UNHCR for information.




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I’ve been working with a refugee-run school in Indonesia for the past year. There, refugees aren’t allowed access to education or work, and asylum seekers can be arrested at the whim of authorities. This, compounded with chronic waiting, has led to a straining relationship with the UNHCR, the key institution in their lives.

Only 509 of 14,016 people (3.5%) were resettled in Indonesia last year. Of those , only 84 came to Australia. And so far this year, the number of people resettled from Indonesia to Australia is just eight.

Figures like these explain why, for many months now, the UNHCR office in Jakarta has been the subject of ongoing protests made up of street protests outside the building in the city centre and civil disobedience in the upscale suburb of Kalideres. Refugees and asylum seekers have refused to vacate a disused military building temporarily allocated to them.

Like false advertising

Refugees argue the very existence of the UNHCR Jakarta office is a kind of false advertising.

Twenty-four-year-old Ali Jawad Haidari has been in Indonesia for over seven years. He said:

If you cannot support refugees you should close your office. You should say we cannot support refugees, announce in the media we cannot do anything.

At Kalideres, the broken trust is visceral. People question the staff’s willingness to prosecute cases, and why they visited Kalideres with security guards when there was never a hint of violence in the months of protest (and for that matter, why they were not allowed to enter the main UNHCR building through the front door).

They also questioned the ethics of the UNHCR, when the institution offered a one-off payment of roughly a month’s living expenses to the refugees in exchange for leaving the Kalideres site. The refugees initially thought this would be the beginning of ongoing UNHCR support.

And they questioned why the agency supposed to protect them would turn off their electricity and water.




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In fact, “The UNHCR is making me sick” is a refrain I heard multiple times during interviews.

Hassan Ramazan, a spokesperson for the Hazara refugees at Kalideres, said the sit-in protests exist because their community and the relatives who support them by sending cash, are at breaking point. He said:

There are people here since 2009, 10, 11, 12, 13, their supporters can not support them any more.

The refugees who wait

Ramazan also points to the seeming arbitrariness of resettlement. Interview wait times to determine refugee status vary, with some who arrived more recently resettled than those who’ve been waiting for years.

What’s more, single men believe they are treated with suspicion in western countries. Twenty-eight-year-old Muhammad Hanif is one of those single men, who received his refugee registration in 2013. He said:

Lots of singles have been here seven or eight years, we also pray for families to be resettled, but also for us, it should be fair.

And Haidari points out people may have arrived alone but are still family members – brothers, sons, fathers.

My friend arrived alone and is still waiting. Recently his 13-year-old son was injured in a bomb blast in Afghanistan, spent two months in hospital, and still the UNHCR said they can’t do anything.

My friend when he came here his son was six, now he’s 13-years-old and injured.

Work rights could alleviate chronic waiting

Waiting is a contemporary strategy of migration management.

But chronic waiting must be taken into account in refugee policy, as it causes and prolongs psycho-social damage and changes the nature of societal and institutional relationships.




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For the majority of refugees, chronic waiting is unlikely to result in effective protection unless a refugee’s country of origin becomes safe to return to. This is unlikely in the foreseeable future for the major refugee producing countries.

Even in countries with major refugee populations, their plight is mostly ignored.

But not always. In Malaysia – where the refugee population is ten times that of Indonesia and work has been informally accessed for years – there are moves to make work legal for refugees.

Work could help alleviate economic pressures and restore agency and dignity lost in waiting. But the refugees are keenly aware of Indonesia’s local poverty and insecure work conditions. And because Indonesia is not a signatory to the 1951 Refugee Convention, it is not obliged to look after refugees.

Masooma, her two-year-old daughter Zahra and her husband Ali are one of the families protesting in Kalideres.
Author provided

Nevertheless, ways for refugees to sustain themselves are supposedly being discussed in Indonesia.

For Haidari, a martial arts champion, work would solve many of his problems. But the authorities have stopped him from competing. He said:

If I could just fight I would never knock on the UNHCR door again.

Refugee spokesperson Ramazan doesn’t see work rights as the ultimate solution, but he does ask what sort of generation is being created. They’re living on the streets, without access to education or the example of seeing their parents work.

Thirty-seven-year-old Masooma, who is in the Kalideres complex with her husband and two-year-old daughter, has another, pointed, question.

They say the first priority is for people with critical problems, who are sick, and that’s the reason resettlement is slow.

Since they don’t give us support and assistance of course we will get sick, and then what should we do with that process? What will we do if we get sick and then go to another country?

Essentially, there is no point in breaking people, then helping them.The Conversation

Chrisanthi Giotis, Postdoctoral Research Fellow, School of Communication, University of Technology Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

There are differences between free speech, hate speech and academic freedom – and they matter


Academic freedom protects free speech, but also sets conditions.
from http://www.shutterstock.com, CC BY-ND

Dominic O’Sullivan, Charles Sturt University

Last week, posters appeared at the University of Auckland inviting young white men to “assume the mantle of re-taking control of our own country” and to confront “anti-racism ideology”.

The group was obviously unaware of the significance of the British High Commissioner’s expression of regret, in the same week, for the killing of several Māori people during their first encounter with the English explorer James Cook in 1769.

At least 1,300 academics and students signed an open letter, arguing that racism and white supremacy have no place at the university and challenging the Vice Chancellor’s initial position that there is no justification for removing the posters.

This week, the Vice Chancellor changed his position, telling staff that a debate about free speech should be put to one side for now, as the most important matter was the “real hurt and sense of threat that some people in our university community feel in response to these expressions of white supremacist views”.




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Free speech vs academic freedom

Neither the Vice Chancellor nor the signatories to the open letter bring academic freedom into the debate. But minister of justice Andrew Little, a former president of the New Zealand University Students’ Association, argued that there is “no principle of academic freedom” that says white supremacy ought to be protected.

Free speech, hate speech and academic freedom are related but different. And the differences matter.

Free speech is the right to say whatever one likes. It is unconstrained by the disciplines of reason and objectivity. It doesn’t require factual accuracy. As with academic freedom, it doesn’t matter if one’s opinion is unpopular. Both free speech and academic freedom are essential to democracy.

Free speech belongs in universities as much as anywhere else. It is the right to hold opinions and to challenge the opinions of others. A Chinese student in New Zealand once asked me if it was alright to criticise the prime minister in an essay. This underscores the importance of free speech, but also the need for great caution in setting its limits.

Academic freedom protects free speech on the one hand, but conditions it on the other. Universities cannot support the unrestricted pursuit of knowledge if one cannot think freely. But knowledge cannot be tested and doesn’t advance if there isn’t also a duty to be well informed and reasoned – and willing to have one’s ideas scrutinised by others.

In a university, the test of a reasonable opinion is higher. One cannot say whatever one likes and call it academic freedom.

Hate speech as a limit

Both free speech and academic freedom are limited by hate speech.

According to the United Nations, hate speech is:

any kind of communication in speech, writing or behaviour, that attacks or uses pejorative or discriminatory language with reference to a person or a group on the basis of who they are, in other words, based on their religion, ethnicity, nationality race, colour, descent, gender or other identity factor.

When people say that they want to “reclaim” a country as their own and contest “anti-racism” they are saying overtly and unapologetically that they don’t want others to have a democratic presence. They are saying that they don’t want others to have free speech. Nor do they want academics who are not “young white men” to have academic freedom.

These aren’t democratically legitimate differences of opinion because “toleration is not the solution to intolerance”.

There are differences between what is wrong and what is intolerably wrong. There are some views that a free society can’t tolerate.

Racism is intolerably wrong because it denies some people human equality. It creates a hierarchy of human worth and causes serious harm to its targets.




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A ‘right to be bigots’

In Australia, free speech is restricted under the Racial Discrimination Act 1975 which provides that:

It is unlawful for a person to do an act, otherwise than in private, if:
(a) the act is reasonably likely, in all the circumstances, to offend, insult, humiliate or intimidate another person or a group of people; and
(b) the act is done because of the race, colour or national or ethnic origin of the other person or of some or all of the people in the group.

There are significant qualifications to these restrictions. But, in spite of these, in 2014 the attorney general told parliament that the act imposed unreasonable constraints on people’s “right to be bigots”.

The conservative think tank the Institute of Public Affairs claimed in 2018 that university policies curtailing free speech had dramatically increased in the preceding two years. The University of Sydney’s Vice Chancellor argued that robust processes “ensure that freedom of speech from all parts of the spectrum is alive and well on our campuses”.

But earlier this year, a government-commissioned inquiry found that “claims of a freedom of speech crisis on Australian campuses are not substantiated”. The review also found that universities should not allow visitors to use their premises to “advance theories or propositions … which fall below scholarly standards to such an extent as to be detrimental to the university’s character as an institution of higher learning”.

Defending a right to bigotry, or to express hate speech, trivialises what the denial of both free speech and academic freedom can really look like.
In China, for example, the state has warned against the presence of “mistaken views” in universities, including the study of constitutional democracy, civil society, economic liberalisation, freedom of the press, challenges to socialism with Chinese characteristics and discussion of universal values including academic freedom.

In the case of the white supremacy posters, it would seem that University of Auckland academics, not the Vice Chancellor, had the stronger argument.The Conversation

Dominic O’Sullivan, Associate Professor of Political Science, Charles Sturt University

This article is republished from The Conversation under a Creative Commons license. Read the original article.