(April 19, 23 and 26, this post has been updated and expanded. On May 15, a link was added at the bottom of the post to the University of Sydney event.)

The health sector needs to get much better at explaining the complexities and the challenges ahead. So much of what passes for communication is made impenetrable by jargon and obfuscation.

Metaphors are one of the more useful tools for engaging and explaining. In preparation for this University of Sydney event tonight about the challenges facing healthcare into the future, I asked panel members to suggest some metaphors.

Invest in the journalism that makes a difference.

EOFY Sale. A year for just $99.

SAVE 50%

Their preliminary suggestions are:

• a bullet train racing towards us

• the little train that can

• a leaky boat

• a dictionary that has all the words but they need to be turned into a song with music & sung

• our ‘Healthcare’ should be named ‘Sickcare’ as it’s like a smash repair centre – are we neglecting our regular service and tune up?

When I put the request out to Croakey contributors, they responded with some powerful images, with a few recurring themes.

These included:

• denial and ineffective action in the face of impending disaster

• insatiable growth in demand

• power imbalance between service users and providers

• muddling

• a fragmented picture.


Fiona Armstrong, Climate and Health Alliance

A giant ball is rolling down the hill towards the entire human population gathered together at the bottom. Some people have protective armour, some are on horseback, some are in wheelchairs, many of them are children. It’s quite apparent that no-one at the bottom of the hill can change the trajectory or speed of the ball; all that can be hoped for is that not all will be crushed in its path.

This is more about the ‘challenges’ for human health and human civilisation from the ecological, social and economic destruction we have created for ourselves than about ‘healthcare’ – but it’s what came to mind for me.

Our recent submission to the McKeon review argues that: “Australian policymakers, the health sector, and the Australian community are seriously underprepared for the predicted approaching environmental crisis, which will likely have severe implications for economic and social stability, and pose unprecedented risks for health and wellbeing.”

And that: “the broader determinants of health are currently being overlooked in public policy development. There is an important role for health and medical research to make more explicit the relationship between human health and broader determinants of population health in relation such as healthy ecosystems, biodiversity, energy production, waste, transport, food and agriculture, industrial practices, water use, and citizen engagement, for example.”


Chris Rissel, Sydney School of Public Health, University of Sydney

Greek King Sísyphos pushing an immense boulder up a hill, only to watch it roll back down


Tony Webber 

Watching a tsunami and knowing you are in its path.


Andrew Roberts, remote area pharmacist and blogger better known as Robbo 

The final slide in a lot of my talks is a picture of a mate of mine with two cans of coke in his hand resting on his belly with a garden hose in his other hand with this poor stream of water dribbling out.

In the background is a bushfire roaring closer but there is no worry in his face. I say this the fire is the burden of chronic illness racing towards the Indigenous population and the hose is the extent of our resources.


Merrilyn Walton, Professor of Medical Education (Patient Safety), University of Sydney

Pushing a snow ball up the mountain (As health care gets bigger/more complex it gets harder to control/manage)

Doing the same thing and expecting a change (policies and reforms come and go – but people keep doing the same thing)

Trust me I am a health professional  (in response to the commercialization of health care-it’s big business)


Jon Wardle

I find the “boiling frog” the most appropriate analogy/metaphor.

A bit dark maybe.

But I think apt particularly as collectively we really don’t seem to be able to comprehend the magnitude of what is coming up.


Gab Kovacs, Professor, International Medical Director, Monash IVF Pty Ltd

Technological changes in medicine are like a snowball rolling down the hill – expanding and uncontrollable.

Marie Bismark, University of Melbourne

A mother with increasingly vocal kids who want the latest technology

A marriage in which a previously silent partner is starting to find a voice.


Ron Batagol, pharmacy consultant

“Just thinking about it makes us feel like the sorcerer’s apprentice”- (can’t provide  all of the required resources  quickly enough to stem the torrent  of ever-increasing health demands which relentlessly and  inexorably threaten to overflow the best efforts we can muster!)

Hudson Birden, Sydney School of Public Health

As we used to say in Texas: Every one of us is going to be busier than a one-legged man at an arse kicking contest.


Ben Harris-Roxas, health impact assessment consultant

A bottomless pit?

A hole in the bucket?


Vern Hughes, National Campaign for Consumer-Centred Health Care

Dr John Paterson, as Secretary of the Vic Department of Health under Kennett, used a series of analogies with the Soviet model where “the providers hold all the resources and tell the consumers what they can have”. The Soviet image works for me – when you look at the establishment of the Medicare Locals, the assumption from both government and the services is that consumers are a captured market, bordered by lines drawn on a map – it does not occur to them for one nanno-second that consumers might want to purchase a service from someone outside their political boundary. This is pretty much how the Soviet system worked.

Paterson also referred to the “Balkanisation” of our health system, following the break up of Yugoslavia, where a series of providers (medical, dental, allied health, public hospitals, private insurers) share control of a broken health system, each powerful enough to maintain control of their territory as a fiefdom, but not powerful enough to take over the others.


John Menadue, Centre for Policy Development

Muddling through


Peter Sainsbury, Sydney School of Public Health

It’s like a train with lots of engines and carriages but few tracks because no one wants to commit to where they want to get to.


Psychiatrst Alan Rosen

The 3 key challenges that we must overcome are:

1. Australian Governments can’t combine to produce a coherent service  model for health & mental health. Governments have concentrated on  operating in a permanent muddle a la Stephen Leeder in his recent Croakey piece. 

Thus, they have become like the fabled “muddle-headed wombat”,  resigned to trying to survive with a perpetually addled brain, with  little hope of ever emerging from the chaos. Rather they should be  only intermittently encouraging “muddling thru” a la Joseph Meeker,   or invoking disruptive technologies to shake up traditional or  habitual services, or living and sitting pluralistically with a  “buzzing confusion” of contradictory realities a la Isaiah Berlin,  to  eventually resolve complexities in social systems.

2. Most Australian governments state and federal, do not provide incentives or pricing signals which will shape integrated health systems (see IHPA paper, available on request to Croakey). Their initiatives often appear to be  piecemeal and to primarily serve  political expediency. They rarely seek, build or abide by any unifying vision, model or trajectory.  Rather they leave dis-articulated silos of public, NGO and private fee-for-service elements, trying to support and grow both community and archaic stand-alone institutional mental health services at the same time. Most of our states have uncritically backed all these approaches at once. Spreading your resources too thinly while trying to be everything to everyone is not a clinical strategy but a  theological one. Consequently, we have  ended up with “ambivalent  non-systems of care”, rushing off madly in all directions at once, and  ultimately petering out, with shrinking human and other resources completely weary & spent.

3. Australian Governments politicise their attempts at health service  reform so much that they often turn out to be an unworkable mess or  uncoordinated tangle of fragmented services, sometimes duplicating  each other, and failing to plan or work together. This is like “a  reverse sausage machine” which starts with a well-formed sausage at  one end, and produces a limp pile of mince at the other, leaving it to service providers on the ground to pick up the randomly spat-out bits and desperately fashion them into a vaguely useful system of care, which may provide some rough semblance of a service. I have another absurdist or dada project like this in mind: finely mincing a good steak in the attempt to reconstitute a mock-soy bean.


Author David Gillespie

A plane being assembled in flight



A maxim for our times: “Let’s have an aged care facility at the top of the cliff – not an ambulance at the bottom”.

Let’s have a fence at the top of the cliff: with good prices for beta blockers.

Our health system is a thief in the night: head down and up to no good.

The health sector is blighted by teenage Federalism: all blame and no responsibility.



A blackout is a metaphor for government transparency

Health reform is the Augean stable of the modern world

Health reform is the ‘get out of jail card’ of accountability

Health reform will be complete when the first plane lands at the new Sydney airport.

General practice will be the landfill of failing hospital systems

Too many prescribers spoil the (antibiotic) broth

The patient is in the corner of the roundtable of health reform   (I did not see any patients on your panel)

The only certainties are death, taxes and health reform



We need a box to get out of so we can adopt a new paradigm – I know thats cliche not metaphor


Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW

Taking back what we had handed over to others

Looking for quality at the end to our lives

Giving life back to the elderly

Balancing money and human need

Remembering the dispossessed


Amanda Wilson, Media Doctor Australia

Anything that isn’t a business metaphor – public healthcare isn’t a business; it’s a tax funded, patient focused right.

Healthcare crushed between the rock and hard place of state and federal funding.

Nothing very cheery there but somehow I don’t think the future of healthcare is looking all that rosy.


Kishan Kariippanon, public health researcher

In the context of reinventing the wheel and resistance from certain quarters to change: “where we going, we won’t be needing wheels” (taken from Back to the Future Pt II)


Ian Cameron NSW Rural Doctors Network 

An upside down oriental rug, we can see all the knots but can’t see the glory of the other side – I first heard Alan Wallace from Cairns use this analogy in 1996


Ian Hickie, Brain and Mind Research Institute, University of Sydney

Disconnected puzzle pieces. No idea of the picture that it would create if linked.


Wendy Oakes, public health advocate

My suggestion would be jigsaw puzzle …I’m sure there’s a picture there somewhere but I’m not totally sure that we’ve even got all the pieces.


Lesley Barclay, professor and director, University Centre for Rural Health North Coast

A jigsaw puzzle – let’s finish the pieces and make a picture.


Clinician who wishes to remain anonymous

It’s not specifically my area – but I have heard that obesity and type II diabetes are going to consume all the Medicare budget by 2030 at current trajectory.  Ultra plentiful cheap fast carbs and bad fats compared to pricey fresh fruit and veg and healthy meat/fish protein and good fats foods is bad economics.

I’ve also been reading that type-II diabetes and abdominal obesity are linked via inflammatory processes and that “Diabesity” is perhaps a good new term to describe what has become an epidemic.

So:  healthcare sinking under the weight of diabesity.   Healthcare totally gobbled up by diabesity.


Yvonne Luxford, Palliative Care Australia

Maybe this is more about reform than challenge, but how about: the air was thick with anticipation.


Meanwhile, David Briggs, health policy expert from the University of New England and Editor of the Asia Pacific Journal of Health Management, sent through a copy of an article published in the journal in 2007, titled “Metaphors of Healthcare” (if you’d like a copy, please email me or leave your details below.)

It notes that the use of metaphors in health care “might stimulate a wider debate around important issues for our profession and the future direction of our health services”.

He cites as an example the common use of the term gatekeeper. Another example describes the health system in terms of frogs and bikes –  the frog representing the organic organisational perspective, the bike a mechanistic perspective.

He wrote: “There are a number of further meanings proffered for this metaphor, the first being that the bike can be dismantled and reassembled in different ways, a metaphor for restructure. The question is while we might still recognise it as a bike, will it continue to effectively perform as a bike?

“Of course we can’t take the same approach with the frog but the other meaning ascribed to that metaphor suggests that, like the frog sitting contentedly in the pond, some people are content to sit quietly in the health system ignoring all the change and risk their survival by not being engaged and responding to change.

“Another respondent to the Editor’s research talks of feeling powerless like the princess in the pond, using a spoon with holes in it to empty the water while nearby tankers are busily refilling the pond! This suggests that being in control is not necessarily with the manager or the clinician during restructure but resides elsewhere and that managers are participants in the change process rather than being in control.

“Another senior health manager talks of the importance of resilience in the role, utilising the metaphor of patiently trimming away at the hedge while waiting for the preferred public policy opportunity to arise allowing the manager to break through the hedge and seize the opportunity presented.”


And finally…

Meanwhile, my pick of the metaphors would be something like an unbalanced scales of justice, which could be employed in so many ways.

The imbalance between the health of the world’s wealthy nations and people, and the rest; the imbalance within the system between public health and primary health care versus big bucks medicine; the population health perspective versus the clout of the medical industrial complex; the power of the most vulnerable patients and people versus that of the powerful lobbies; the imbalance between what really matters and what we pay attention to. And so on…


Now, wouldn’t it be nice if some cool graphics person wanted to turn all these suggestions into a great big image or artwork??


Update, April 19 and 23

Rob Loblay, physician, University of Sydney

The centenary of the sinking of the Titanic provides a rich source of metaphors:

The band played on … while health administrators & bureaucrats rearranged the deck chairs …

The well-to-do got priority seats in the lifeboats … while the working class passengers got trapped on the lower levels.

The longer you think about it, the more comes to mind:

Hitting a demographic ice-berg … a still & starry night … the captain asleep at the wheel … a great crash … ship listing badly … stuff sliding off the tables … breaking up on the way down …

Drowning without a life-vest … the elderly & infirm … going down with the ship … leaping into the water … throwing a lifebuoy … getting eaten by sharks … etc

I’m sure you can pick it up & run with it yourself. It can take you in any direction you want to go.


Health economist Gavin Mooney

Medieval life: building more and more cathedrals while the peasants in the community suffer.

International Hood Robin: stealing from the poor (in developing countries) to give to the rich (in Oz).

National Hood Robin: the private insurance rebate.

The Eurozone: the people have no say; only money counts; blame the victims; and the poorest suffer.

He who’s paid by Pfizer, calls the tune: clinical trials.


Ken Hillman, intensive care specialist, University of New South Wales  

In a recent panel interview, Sir Richard Attenborough, when asked what he considered was the greatest challenge of our age, suggested the cost of maintaining human life.  In the same interview Stephen Dawkings agreed (The Weekly Guardian 24th September 2010 page 26).

In relation to the increasing age of our population, the increasing co-morbodities that people collect as they age, and the increasing admission to acute hospitals for end-of-life care and the cost implications to our society, I would suggest the word “Tsunami”.


Gawaine Powell Davies, CEO, UNSW Research Centre for Primary Health Care and Equity, University of NSW, finds these images useful for portraying the health system and says audience members generally nod in recognition.


On a similar theme, Stephen Leeder has provided these images taken by a friend, Ken MacWilliams, a retired investment banker and member of the Brigham Institutional Review (ethics) Board.


Ken MacWilliams also provided this example of an amazing wooden contraption:


And another version is here.


And some contributions from the Twitterverse… 



And a large thanks to Ed Butler, former healthcare IT professional and one of the #hcsmanz Twitter Chat facilitators for providing this Wordle…


Update, 26 April

These suggestions are from a master of metaphor in public health communications, Simon Chapman, professor of public health at the University of Sydney, and are relevant to many situations (think tobacco, alcohol, junk food, polluting industries etc….)

“… is like the Titanic’s captain assuring the passengers that there are no splinters in the handrails.”  An infallibly effective way of describing myopia about or avoidance of major risk while reassuring the public on some minor or cosmetic action that has been taken.

“X are like cockroaches: they spread disease and don’t like sunlight.” First used by the University of California’s Stan Glantz to describe the tobacco industry, but applicable to any disease promoting industry that declines to be publicly accountable.”


Update, 15 May

The University of Sydney forum is now available online (some interesting comments about former Health Minister Tony Abbott’s views on preventative health – that it is all about individual responsibility).





Save this EOFY while you make a difference

Australia has spoken. We want more from the people in power and deserve a media that keeps them on their toes. And thank you, because it’s been made abundantly clear that at Crikey we’re on the right track.

We’ve pushed our journalism as far as we could go. And that’s only been possible with reader support. Thank you. And if you haven’t yet subscribed, this is your time to join tens of thousands of Crikey members to take the plunge.

Peter Fray
Peter Fray
SAVE 50%