Doctor and activist


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Category: Public Health

Is There a Role for the Military in Vaccination?

10 July 2021

I felt that something was wrong when a Soldier started advising me about vaccinations.

Here is a good summary from Crikey of what seems to be happening. 

www.crikey.com.au/2021/07/07/administration-with-authority-how-putting-the-vaccine-rollout-in-military-hands-is-corrosive-for-the-country/?utm_campaign=Weekender&utm_medium=email&utm_source=newsletter&wkndr=RFdETTg0am9ucG5qc2dpcVpTeTU2QT09&success=krsmvj

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NDIS Individual Assessments; A Symptom of a Wider Problem

10 July 2021

The current issue in the NDIS (National Disability Insurance Scheme) is the government’s efforts to introduce ‘independent assessments’ of people on the scheme and those who want to get on the scheme.  The idea has been abandoned for the present, but that is not the end of the story. It is the beginning.

Some context is needed here.  I was on a State Parliamentary inquiry into disability funding during which we heard evidence of inefficiencies within the disability sector where often there were shortages of appropriate services, and in some areas there were none at all.  The real crunch time was when parents with children with disabilities realised that they were going to die eventually and wanted to make a plan for the rest of their child’s life.  People would apply at various facilities, and be turned away as there were no places.  They then assumed that they were on a waiting list, but usually no lists were kept. When a vacancy occurred, whoever applied at that time got it.  It was mainly luck.  Naturally the people trying to help their loved one wanted a guaranteed package that would continue after their death.  More articulate parents and carers, who had struggled for years just wanted the money to buy the services that they felt that they needed. Many carers simply wanted more services, and hoped that a national system that guaranteed services for disability.  

Given the political context of privatisation and reducing government involvement in everything, the scene was set to have disability services delivered by the private sector as a massive market for services.   The private sector naturally wanted to get access to services that had been provided by government as a source of business and profit.

Government also had a real estate agenda.  Some large institutions were on valuable land. The large facilities at Peat Island in the Hawkesbury and Stockton Disability Centre was on beachfront land just north of Newcastle.  There was a residence for the grossly disabled opposite Wollongong Hospital that had taken years of fundraising for the parents to achieve.   These could be sold off as the mental health facilities had been a few decades earlier, with the catchy slogan of putting the residents ‘back in the community’. The idea that the residents were better off isolated in a suburban homes with few facilities rather than in a community of people with the same problem and a well-structured programme of activities seemed a dubious proposition to me.  Resident groups such as the relatives of long-term psychiatric facilities at Bloomfield in Orange were very scared of the suggested changes.  There had been problems with the old system and some inappropriate facilities, but an overall lack of facilities was the major problem.  It was not even throwing the baby out with the bathwater; it seemed more like smoke and mirrors. 

The key question in dealing with any problem is how big a task is it?  When the Committee asked how many people with disabilities there were, there was no answer.  No register was kept.  The two ways of calculating it were:

  1. To add up all the people on all the types of possible benefits and get to a total. 
  2. To look at the AIHW (Aust. Institute of Health and Welfare) figures of what percentage of the population was disabled, then multiply this by the total population. 

The latter method gave figures about ten times greater.  So clearly if help or services were made more available, the numbers involved were going to blow out hugely from what was currently funded.

John Howard passed the Aged Care Act in 1998, which was the blueprint for the privatisation of the sector. Old people are very vulnerable. They have often sold the family home, so they are temporarily cashed up, looking for accommodation and long term care with mental and physical facilities failing, or they would not be there.  Carers faced with responsibilities that they were not used to and uncertain of what care was needed were easy pickings also.  The whole sector is more like a dysfunctional real estate market; a market failure due to insufficient ‘consumer information’, but also distorted incentives and priorities.

The NDIS was similar.  Private operators with slick marketing made promises which would not be tested for some time, but people were signed up now.  The not-for profit sector had never paid staff well, but most had a ‘care ethos’.  Some of the private providers did not, and regulatory supervision was minimal. The government was pro-business and trying to give away responsibility. 

But an absolute shortage of services was still a big factor.  A neighbour who was a 95 year old retired academic widower wanted 2 hours a week of home help.  For some reason he could not get a community nurse.   The best deal he could get was 2 sessions of 2 hours at $65 an hour.  The lady delivering the service was paid $21/hr.  So much for private services; the ‘overheads’ are huge.  I had suggested to Kevin Rudd’s 2020 Vision in 2000 that the Government needed to licence service providers as individuals if they wanted a market model, and our neighbour could have selected a person on a one to one basis.  (I never even got an acknowledgement).

Now the government wants ‘independent assessors’ to evaluate cases, presumably to lessen costs.  A number of points can be made about this.  It assumes that the assessors will learn more about the patient in an interview than the people who work with them already know.  The new management philosophy since the 1980s always assumes that a manager at the top will know more than the person actually doing the job.  Naturally if the object is to save money and have the person at the bottom paid minimally, requiring no skills and interchangeable in staffing, this may be true.  But if the people at the bottom were respected, trained and empowered, the need for the middle level experts might be much less.

‘Independent Medical expert’ assessors are used in the Workers Compensation and CTP systems.  They work for agencies hired by insurance companies.  Often they find the patients either have nothing wrong with them, or it is degenerative and not related to their injury.  These experts are even flown from interstate and save insurers money by denying treatments. Presumably if they find in favour of the patients, their agency gives them less work.  The agency takes its cut and has to please the insurer.  So the systems are more complicated and an ever higher percentage of the money is spent in trying not to give services.  The NZ National Accident Compensation scheme, though it was government owned, went to a private insurance model and the same thing happened.  Doctors who had a track record of denying liability were flown around the country to do their medicals.

The assumption may still be that well intentioned assessors still can do better.  My widowed mother lived alone in the family home and had a stroke.  A neighbour noticed her confused, walking on the balcony.  She recovered, but seemed to have lost some judgement.  She was assessed by an ACAT (Aged Care Assessment Team) who said that she could live alone in supported accommodation. So we got her into a unit in the grounds of an old house, where she could book a dinner at a days’ notice in the communal dining room, have a nurse onsite during the day, and had a right to a nursing home bed if she ever needed one.  Seemed perfect.  She said that she could look after herself. Can you microwave a dinner?  Yes. OK. Do it.  It got done.  No problem. Dinners in the frig. Sweets in the jar on the mantelpiece; see you in 2 days.  Arrive in 2 days.  Dinners still in the frig. Lolly jar empty. Very hungry- can we go to lunch?  She could do anything when asked, but could not initiate a process. She could not think to get a dinner from the frig, or book lunch tomorrow in the communal dining room, nor ask for help.  The one-off team could not pick this.  Neither did the family. But it emerged when the situation at home was known. This is just a story, but a carer who is savvy and properly trained will know more than a university-qualified assessor who has only a short knowledge of the patient.  And naturally the person on the job actually delivers the service and is not an extra cost. They can also judge relative needs of people on a run or in an area if resources are limited.

So the scheme to bring in assessors is the tip of an iceberg. 

Private insurance models have huge problems at many levels.  The overheads of Medicare are a bit under 5%. The overheads of Private Health Insurers are about 12%, and they cannot refuse to pay doctors.  The overheads of US Health insurers are about 12-36%, as the best way to improve profits is to cut costs (payments to patients) rather than increase services and then try to prove you have and sell on that basis.  At the bottom of the efficiency barrel is our own NSW CTP system with overheads of almost 50%. The question has to be what is the focus of the system?  Delivering services, or saving money?  The US health insurers, like our CTP scheme are very good at making money.  What they make their money from just happens to be people rather than widgets.  The main cost savings of privatisation seems to be destroying award conditions and lowering ‘staff costs’.  The immense administrative savings from universal systems, where determining entitlement and paying for profits are eliminated cannot be matched by any private system, despite what the ideologues might pretend.

The NDIS is currently a fund supposedly to help people with disabilities.  These people apply to get ‘packages’ of money and services.  Businesses persuade people to spend their packages with them. It is a market.  But there are more people with disabilities than was expected, for the reasons discussed above.  So a new level of assessors, were to be rolled in, but a huge outcry has prevented this temporarily.  But the problems that led to the need for the assessors remain implicit in the design of the NDIS, which is fatally flawed.  The government, particularly this one, is not going to take this very large bag of lollies from the private sector.  The totally inefficient Private Health Insurers (PHI) give money to political parties and advance by stealth, letting Medicare become irrelevant for health care. Disability is now also privatised, and a new private lobby is in there.  It has not yet generated a Royal Commission into its rip-offs, but it will, not that the Aged Care Royal Commission has stopped the privatisation of aged care.  The political forces are too great.  It is ironic that as Medicare is starved and pays less and less of the doctors’ fees its levy was increased, using a wave of sympathy for people with disabilities to make a bigger pool of money for increasingly private disability providers.

How to fix the problem?

I do not pretend to have all wisdom on this, but in dealing with difficult political problems I think it is wise to set a direction, take some basic steps and consult widely, looking for advice particularly from those who do not get an immediate financial benefit.

Here is a start:

Recognise that disability is not a sickness.  Some disabilities are inherited; others are acquired due to accident, illness or aging. The sector is quite diverse, often divided up by the type of disability or how it was acquired.   Sickness has an ‘episode’ model, based on traditional infectious diseases or surgical treatment models. Disability tends to be long-term and may improve or be worked around, or may degenerate gradually. As such it needs long-term solutions like welfare, but using the term ‘welfare’ now implies charity. Disability funding is funding to enable those less fortunate to have as normal a life as possible. From our common wealth, we give more to those who need more so that our society has equal opportunity for all. We are being taught that tax must be minimised and if we are getting less than we pay we are being ripped off.  A better model is to consider the statement by Rhonda Galbally, ex-CEO of VicHealth, ‘There are two populations, the disabled and the not-yet disabled; if you are lucky enough to be in the second group, you should be happy to help pay for the first’.

The idea of a universal service obligation is the cornerstone.  We should start with the assumption that people with disabilities should live in our  society with as  normal a life as possible and we should adapt to support them in as cost-effective way as possible. 

My suggestion is that the Community Nursing service is the basic structural framework.  We assume that people with disabilities will be living in society, and need varied and integrated support.  If they are born with a disability or acquire one, they will come in contact with the acute hospital system, which will hopefully document their situation and alert the community support system.  People on the ground will then liaise with family to see what support there is for independent living, and organise resources, calling in specialists of required. The cost of home support may be part of a package or allowance.  Individuals may register to offer services for everything from shopping, cleaning and lawn mowing to medical or paraplegic support services.  The government will register and insure both practitioners and those who use their services and may put training requirements on those who wish to register for some skills.  A market with consumer feedback as exists for restaurants or other practitioners will allow people to hire help directly without big corporations adding massive overheads.

Whether the monies are paid separately of via Centrelink is an administrative question, but Centrelink has to have a major makeover so that it is not the niggardly decider of the ‘worthy poor’ with its chief function being to avoid paying anyone, or paying as little as possible.  If society cannot find everyone employment, we must share what we have to those who are disadvantaged by disability or circumstance. This will collide head on with the problem of increased numbers of those with disabilities, but the extra load must be seen as part of having a decent society. 

The way we are going seems to be privatising, allowing huge profits, then running out of money and shutting the gate on those who do not yet have packages.   The independent assessors were merely the instruments of Managers who were not able to make their own assessments and did not trust the people who actually deliver the services.  The assessor problem was the tip of the iceberg of a system that has all its underlying assumptions wrong, but sadly has a lot of  political power that having been created, may not be able to be undone.  The first step is to understand what is happening.  Hence this lengthy post.

www.abc.net.au/news/2021-07-09/ndis-disability-independent-assessments-model-dead-after-meeting/100277324

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COVID19 Vaccines Reduce Transmission

9 July 2021

www1.racgp.org.au/newsgp/clinical/mounting-evidence-suggests-covid-vaccines-do-reduc?fbclid=IwAR0HwSRf56I6awyVZfsN1O-CbCjeOHJWZk9PwxbgJE_L2V9TwRJPxalSLu8

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NSW Govt tries to Blame Limousine Driver for New Sydney COVID Outbreak

26 June 2021

The pathetic efforts of Gladys Berejeklian to blame the limousine driver for the latest COVID outbreak, which has now caused a city-wide lockdown and an increasing number of cases needs to be judged on its demerits.  Obviously there should have been regulations that anyone on the front line had to be vaccinated, and surely driving a limo from the airport to the quarantine hotel is ‘front line’. 

She said that she ‘could not control the subcontractor of the subcontractor.’  Actually, she could have. Now she has the regulation that she should have had months ago- front line staff have to be vaccinated.

Of course, the reason for the spread of the virus from the Melbourne quarantine hotels months ago was the fact that the support staff had many jobs, because they were not permanent and had shifts everywhere.  The same problem occurred with transmission in Victorian Nursing homes- casual shifts.  Now it is Sydney drivers. 

The farmers are moaning that they will not be able to pick the fruit without the visas for backpackers, foreign students and Pacific Islanders.  Skilled migrants?  I do not think so.  It is about sub award wages and poor conditions.  If Australia is a rich country we need also to remember our roots as the country of a ‘fair go’. If top wage are high by world standards, so they should be at the bottom. If wages were high enough Aussies would pick the fruit, and  cleaners and limousine drivers would have regular jobs and award wages.

But here was the NSW Government trying to blame the limo driver for the outbreak.  But today’s Sun Herald has the Police Commissioner saying that the driver had committed no crime.   Neither has the NSW Government- they are just incompetent, but no one seems to blame them.

www.abc.net.au/news/2021-06-17/nsw-quarantine-worker-may-have-breached-health-order/100223120

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Clotting Risk from Vaccines and COVID19 Infection

28 April 2021

A new Oxford Study compares the incidence of Cerebral Venous Thrombosis with the Astra-Zeneca vaccine, the Pfizer or Moderna mRNA vaccine and the risk if you get COVID19. The risk from the A-Z vaccine is 5 per million, the Pfizer and Moderna 4 per million and the risk if you catch COVID19 is 39 per million. The sample size is large with over half a million cases in each group, so the reliability of the research is quite good.While there is no COVID19 about, it is obviously safer to have no vaccine and no risk, but the COVID19 situation could change at any time. The Business Council and other non-medical political groups are calling for a more open society and for the case chasers to try to keep a certain level of infections once the gates are opened. i.e. We get the money- someone else fix the problems. Presumably they will try to stop further lockdowns, particularly as the percentage of the population who have been vaccinated increases.The bottom line is that the A-Z vaccine is almost as safe as the Pfizer one, and it is a good idea to be vaccinated ASAP in case the situation changes for the worse. I had the A-Z almost 2 weeks ago and only noted a slight headache, and tiredness on the evening of the vaccine, and a bit of local tenderness at the injection site the next day. I will have the second shot in 10 weeks.

www.ox.ac.uk/news/2021-04-15-risk-rare-blood-clotting-higher-covid-19-vaccines-0?fbclid=IwAR2TIjtz8C7ku_M1OXcELaa2BfrC4hBTwBSoD_svCfdhwWQORr6K4sx4BOI

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Politicisation of Vaccine Rollout has caused the Problems

13 April 2021

Scott Morrison’s objective was to have a low risk strategy. He got the States to handle the COVID19 crisis, while he merely took the credit for its success. Then he wanted to have a successful vaccination programme, and go quickly to an election. He announced a lot of vaccine deals, waving a chequebook with our money to put us high in the world’s vaccine queue. (Tough luck poorer countries with much more cases).

But the deals were soft, the Qld vaccine had problems with false positives for the HIV/Aids test, and it seems the Astra-Zeneca vaccine is not quite as effective as the others, and had a few side effects. So his loudly-touted intervention has just made him look ineffective.

The problems in the health system with the overlapping Federal/State responsibilities and cost-shifting, and the starving of Medicare with subsidies to the private system have all been swept under the carpet in the crisis. But the government’s new dynamic, which is to ignore good advice and treat everything as a political problem, with Morrison giving advice on every subject from weather forecasts, to fires to vaccines is part of the replacement of knowledge by politics, which is a problem in many areas.

Here is an analysis of this fiasco by Steven Duckett, one of Australia’s leading health economists.

https://theconversation.com/4-ways-australias-covid-vaccine-rollout-has-been-bungled-158225

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Vaccines and Probabilities

April 9 2021

Many years ago as I tried to tell sceptical people that smoking killed people, the research was all about the probability of smokers getting diseases more often than non-smokers.  People would often reply, ‘Lies, damn lies and statistics’ as if this was some sort of frightfully clever response that neutralised any sensible discussion.

Statistics have been used by researchers for years and are the basis of the experimental method to get towards scientific truth.  Things are rarely ‘proved’ in science, they are just rendered more and more likely, so that the probability of their not being true becomes infinitesimally small. 

Where there are number of variables the statistics become ever more complicated and the proofs more arguable.  Some of us get a bit lost as the complexity rises, and try to retreat to ‘common sense’, with is another way of saying what is most probable based on facts we are already sure of. 

The Astra-Zeneca vaccine has been pushed in Australia, and there is a world shortage of vaccines, despite Prime Minister Morrison running around with an open chequebook for a long time and boasting that we were at the front of the queue for was it 4 different ones ‘in development’?

The loss of the Uni of Qld. vaccine because it gave a false positive in the HIV/Aids test was a bad blow, given that it was ‘ours’ and the vaccine against cervical cancer had been so successful. 

As more and more countries expressed reservations about the A-Z vaccine, it was becoming harder and harder to stick to the line that they were panicking and there was nothing in the stories about blood clotting in dangerous body locations. 

Now A-Z  is not recommended for the under 50 age group, which is most of the country.  Presumably this means that because under-50s are less likely to die of COVID19 even if they get it, the risk of dying from a clot becomes more significant.  Obviously in Australia, if we can keep COVID isolated forever, we will not need a vaccine at all unless we want to venture overseas.  So we are looking at the probability of the virus escaping, and the probability of other vaccines being available as well as the chance of dying at whatever age we are with whatever existing medical problems we may have, versus the chance of having a bad reaction to the vaccine. 

I want to get vaccinated so I can go on an overseas holiday at last, but the A-Z vaccine may be less effective against new and dastardly strains, and if I take that risk will I be stuck in a hotel in Mongolia unable to fly home because the government has changed its policy on my vaccination status or the absolute numbers who can be quarantined?

It is very hard to answer all these questions for anyone, and when older patients who have clotting problems ask for advice, it is very hard to give them an answer.  Doctors will have to spend a lot of time on this.   Our practice is not vaccinating at all, the red tape scared us off, despite the fact that we had bought a new vaccine frig and have been vaccinating people for 40 years.  Call me a coward if you will.  But for myself, I do have an appointment to have the A-Z vaccine next week.

Here is the SMH article:

AstraZeneca blood clot cases force major vaccine shake-up; Pfizer now preferred for under-50s

By Rachel Clun

April 9, 2021

Pfizer is now the preferred vaccine for people aged under 50 and the timing of Australia’s rollout is in doubt after medical experts expressed concerns about rare blood clots potentially linked to the AstraZeneca vaccine – the mainstay of the country’s existing COVID-19 strategy.

Prime Minister Scott Morrison said on Thursday night the government will review Australia’s vaccine portfolio and accept medical advice that will preference the Pfizer vaccine over AstraZeneca’s in adults aged less than 50 years old who have not already received a first dose of AstraZeneca, putting plans to vaccinate the entire population by October in doubt.

Australia’s decision follows changes by European medical regulators after a review of data confirmed a rare blood clotting condition seen in a small number of patients was linked to the AstraZeneca vaccine.

Mr Morrison said the new advice from the Australian Technical Advisory Group on Immunisation was not a prohibition on the use of the AstraZeneca vaccine in people aged under 50.

“This is not a directive. This is not an instruction,” he said, noting they were taking “an abundance of caution” with the new advice. He said the impact of this decision on the timeline of the rollout was uncertain.

“Tomorrow, and over the weekend, there will be a recalibration of how the program will need to be adjusted to take into account decisions the government’s taken tonight to accept those recommendations from ATAGI,” he said on Thursday evening.

Chief Medical Officer Professor Paul Kelly said the rare but serious blood clot disorder was discussed in the meeting, taking into account what was decided overseas and looking at what that would look like in Australia.

“This is a rare event,” he said. “But it is serious and can cause an up to 25 per cent death rate when it occurs.”

For those over 50, Health Department secretary Professor Brendan Murphy said AstraZeneca was strongly recommended.

“It is a vaccine that is very, very effective,” he said.

ATAGI spent hours on Thursday considering the medical evidence. It then issued new advice on the AstraZeneca vaccine, which it provided to the government just after 7pm.

The medical experts made three recommendations, including that AstraZeneca was preferred in adults over 50, after a lengthy meeting. They also recommended adults under the age of 50 should only be given AstraZeneca where the benefits clearly outweighed the risks. Third, it recommended that adults under 50 who had already received their first doses without experiencing serious side effects could safely be given their second dose.

Professor Kelly stressed the data on the rare clotting side effect, venous thromboembolism, was still only preliminary.

Britain’s vaccine advisory committee says adults under 30 should be offered an alternative to AstraZeneca’s COVID-19 vaccine when possible, due to a very rare side effect of blood clots in the brain.

“There are very few cases of this extremely rare event that have happened anywhere in the world, but the ones we’ve seen, there’s definitely a tendency for the younger people [to develop it],” he said.

The UK regulator has decided to offer an alternative vaccine for those aged under 30.

Australia has purchased 20 million doses of the Pfizer vaccine and has been relying on the AstraZeneca vaccine as the workhorse of the rollout. The country is expecting its first deliveries of the Novavax vaccine, pending regulatory approval, some time in the fourth quarter of the year.

Late on Thursday, Australian pharma giant CSL said “it remains committed to meeting its contracted arrangements with the Australian government and AstraZeneca for locally produced AstraZeneca COVID-19 vaccines.”

AstraZeneca Australia added that it respected the decision outlined by the government.

“Regulatory agencies have reaffirmed the vaccine offers a high-level of protection against all severities of COVID-19 and that these benefits continue to far outweigh the risks.” a spokeswoman for the company said.

Earlier, the Prime Minister said the risk of severe side effects with the AstraZeneca vaccine is much lower than with common drugs including paracetamol and the oral contraceptive pill.

Mr Morrison said it was important to know the risk of developing venous thromboembolism was much lower following the AstraZeneca vaccine than the risk of death from COVID-19.

“Let’s note that in the UK, the advice is that some 6000 people’s lives have already been saved by this very vaccine. So we need to consider the positive benefits,” he said.

From UK data, the risk of venous thromboembolism following the vaccine was about one to five per million people.

“To put that in some sort of perspective, the combined oral contraceptive pill, that can include adverse side effects of venous thromboembolism – that’s seven to 10 per 10,000,” Mr Morrison said.

The advice has been shared with the expert medical panel, the Australian Health Protection Principal Committee, which comprises all state and territory chief health officers and led by federal Chief Medical Officer Professor Paul Kelly.

The matter will also be discussed in national cabinet on Friday and in meetings with state and territory health ministers, who were due to meet on Thursday night to discuss the revised advice and its implementation.

On Wednesday 75,880 doses of the Pfizer and AstraZeneca vaccines were administered across the country, Scott Morrison said, taking the national total to 996,214 doses administered so far during the rollout.

The states and territories have administered 509,802 doses. Through the federal government, 486,343 doses have been administered, including more than 125,260 through aged care.

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Health Effects of Coal

14 February 2021

Here is Dr Peter Sainsbury, Prof of Public Health. writing about the health effects of coal. Many of the deaths related to the polluting effects are not in Australia, which is not a very reason for us not to be concerned about it.

Some years ago, as we tried to stop the subsidy to Tobacco Growers in Australia, the number of deaths of tobacco-caused disease was compared to the number of jobs in the tobacco industry, which was orders of magnitude lower.

Sainsbury says it will be about 6 deaths per year per job in the coal industry, which is yet another good reason to transfer to renewable energy.

The practice of looking at the number of deaths caused versus the number of jobs created seems a sound basis for looking at the cost benefit of industries. The ‘defence’ industry needs to be looked at in a similar way.

The other interesting fact in this article is that he estimates that Electric Vehicles will be the same price as petrol ones in about 3 years because of the falling price of batteries. Presumably the Morrison government cannot retard progress forever.

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