By the time you read this article, the 2014-15 Budget could have been shot down in flames, and we could have gone to a double dissolution and election campaign. But I don’t think so. I suspect that there may be items in this Budget which are designed to be jettisoned overboard at the first sign of trouble, and the proposed Medical Research Future Fund (MRFF) may be one of them.
I was surprised at the announcement of a $20 billion (over five years) extra funding program for medical research in Australia. Given that we’d pretty much been spent into a black hole by the Rudd–Gillard–Rudd governments, it was puzzling to find the Abbott government willing to commit such a large sum of money to the sort of luxury item you might consider when a budget is in surplus. In fact, even with a budget in surplus you might think twice before tying up $20 billion over five years in something as chancy as medical research.
So I wondered if it was just a bit of creative accounting—a way of making it look as if there was $20 billion on the income side of the ledger, rather than the expenditure side. It wouldn’t be the first time—after all, Wayne Swan included the NBN in the government’s assets, rather than its liabilities, when all it consisted of was a beer coaster and some asbestos trenches. Or, I thought, it could be a way of sweetening the $7 co-payment by showing that the apparently cruel Coalition was a big-spending socialist government at heart after all. Or—and here I got really carried away—what if it was an early warning shot across the bows of the Australian Research Council?
In the immediate wake of the Budget speech in early May, I heard two sensible voices on the MRFF. Both were on The Bolt Report panel of May 18: Judith Sloan pointed out that many medical discoveries have been accidental or serendipitous, while Michael Costa noted that government programs—any government programs—should be able to produce a measurable cost benefit. I have argued before about the whole question of government research funding for universities, especially via the ARC, and so this latest Budget suggestion—and they are all suggestions, until the Budget is passed—has forced me to ask myself some questions about medical research funding in general, and why we take it for granted that the Commonwealth should fund it out of taxpayers’ money.
What’s on offer
I love reading Budget papers; it’s easy to get sidetracked by fascinating anomalies. For example, did you know that under cover of the Health budget, the Commonwealth government will provide $156 million to the Queensland government in 2013‑14 as the Australian government’s contribution to permanent infrastructure for the 2018 Gold Coast Commonwealth Games? That’s the price of at least one nice new hospital somewhere.
There are several big-ticket medical research funding items. One of them has been sold as “finding the cure for dementia”, whereas it’s actually funding ($200 million over five years) to boost research “to improve the treatment of dementia in Australia”, as the Budget papers put it. In practice this means an increase in research grants, scholarships and fellowships, and additional funding (unspecified) for the Clem Jones Centre for Ageing Dementia Research, which is part of the Queensland Brain Institute, which is in turn part of the University of Queensland. Why this centre has been chosen over all the other dementia research institutes in Australia—and there are a few—is not clear.
Some of the $200 million—again unspecified—will also establish a National Institute for Dementia Research to identify and co-ordinate research priorities and translate existing dementia research into policy and practice. Alzheimer’s Australia, the peak non-government body for dementia care in Australia, runs the National Quality Dementia Care Initiative, which is already doing some of this work, but of course it will be so much better if a national body, funded directly by the Commonwealth, does the same thing. Won’t it?
No one likes dementia; it’s hard work having it, and hard work caring for it. But why does Australia need to spend so much money on this one area of research, when there are international bodies already funding huge amounts of research in the same area? For example, in the United States, the Alzheimer’s Association has been funding independent investigators worldwide since 1982. The Association is the largest US non-profit funder of Alzheimer’s research, and has so far awarded over US$315 million to more than 2200 projects.
The UK’s Dementia Research Centre is another example, affiliated with the National Hospital for Neurology and Neurosurgery. This is the UK’s lead centre for Alzheimer’s drug trials which have involved over 4000 patients and carers. The DRC has been involved in the process that identified the first Alzheimer’s gene, as well as imaging work to identify its onset and progression. And an international body, Alzheimer’s Disease International, was founded in 1984 and now comprises more than eighty Alzheimer’s associations in other countries.
I will be honest with you: a cure for Alzheimer’s disease and other forms of dementia is going to be very big business indeed. Among this happy global community of researchers, there is fierce competition. And so there should be, because whoever hits the jackpot will have a huge market to cater for, and will be able to name their price to any major pharmaceutical company.
So it seems just possible that against this background, Australian dementia researchers feel left behind and under-resourced. They cannot draw upon the same large general populations of charitable donors and successful big businesses that one finds in the USA and the UK. And so it is equally possible that they have applied strategic and not entirely transparent pressure to the largest single source of money in Australia, the Commonwealth government. And this in turn may be why Joe Hockey chose to announce these funding measures in parliament with the following words: “As a result, it may be an Australian who discovers better treatments and even cures for dementia, Alzheimer’s, heart disease or cancer.”
These funds will be administered by the National Health and Medical Research Council (NHMRC), who will get $174 million over five years, and the ARC will get $26 million over three years. And there’s another little NHMRC sweetener tucked away in the Budget: $9.9 million over five years “to develop a nationally consistent approach to the way clinical research trials are overseen and conducted and to streamline and simplify National Health and Medical Research Council grant application and assessment processes.” (Some wag has suggested that this will encourage struggling researchers to buy white coats and start substituting the word “dementia” for “climate change” in their current draft grant proposals.)
And that’s the fundamental flaw in the argument that the Commonwealth can do things better than anyone else, including funding medical research, because it is impartial and has no vested interests. The Commonwealth government may be pure as driven snow; I have never met the Commonwealth government, so I can’t judge. But the Commonwealth government does not distribute our money directly, but rather through research funding agencies. And these research funding agencies are well-known hotbeds of the biases, blinkers, prejudices, ideologies, punctured romances and galloping internecine hatreds that make up any vibrant and colourful research community, medicine included.
Where the money is coming from
The MRFF– the “$20 billion” of newspaper headlines—is supposed to be kick-started with $276.2 million over three years from 1 July 2015. Payments from this managed fund are expected to reach around $1 billion per year from 2022‑23. The fund is also being fed by some remarkably sensible cuts to the health budget. Everyone differs on their pet peeves, but my favourites are:
- Ceasing funding for the following grant programs: Australian Community Food Safety Campaign; the eHealth Summit and Implementation of Clinical Trial Functionality into Jurisdictional eHealth Systems; Flat Out Incorporated Outreach Support Services for Criminalised Women; and Mental Health Better Access to Education and Training ($4.4 million).
What on earth is the “Australian Community Food Safety Campaign”? All I can find on the internet are references to how it’s been cut from the Budget. No one has put their hand up to defend it, so I’m guessing no one else knows what it is, either. Ditto the eHealth Summit.
I managed to find out more about Flat Out, which operates only in Victoria, has been running for twenty-five years, receives a range of grants from various organisations, and is also able to solicit charitable donations to help support its work. Its single largest funder is actually the Department of Human Services in Victoria ($253,041 in 2013), although it stands to lose around $180,000 of Commonwealth funding. Cutting funding to this program is not the same as axing the program altogether, although it will limit some of its activities.
The Mental Health Better Access to Education and Training program is a classic example of how one should read the fine print. Up front, this looks like the typical Coalition heartless slashing of a program designed to help individuals with mental health issues to access education and training. But the program is actually designed to provide training to help mental health practitioners (including psychiatrists and psychologists) understand mental -health-related Medicare Benefits Schedule item numbers, referrals and patient health care planning. So this is in effect extra training for people who already have at least one major university qualification, and who are trusted to make life-changing decisions on behalf of very vulnerable people, and who should be intelligent enough to read a printed guide to using the MBS.
- Deferring the establishment of the remaining thirteen Partners in Recovery organisations for two years from 2013‑14 ($53.8 million).
There are forty-eight Partners in Recovery organisations in Australia. They aim to provide people with serious ongoing mental illness and complex needs with access to co-ordinated clinical, housing, education, employment, income and disability services. But we don’t know whether the Partners in Recovery model is even working, because it hasn’t been evaluated, and so this deferral—deferral, not cut—buys the Commonwealth a break in which to get this done.
- Ceasing the National Partnership Agreement on Preventive Health ($367.9 million) and abolishing the Australian National Preventive Health Agency and integrating its activities into the Department of Health ($6.4 million over five years).
Amen to that. Preventive health is a minefield of good intentions and unproven assumptions.
4. Reducing Australia’s voluntary additional contribution to the World Health Organization ($2.3 million).
Why just “reducing”? According to the DFAT website, up to 2013 we’d given them something like $64 million over five years as a “core voluntary contribution”. This payment should be eliminated completely; anything to do with the United Nations will be well-padded with graft, bribes and cronyism, and will not improve the health of anything except certain officials’ bank balances. If it’s to help health care in the South Pacific region, then grants direct to the countries involved will probably do much the same thing. This is throwing good money after bad.
Three big revenue sources for the MRFF will involve consumers actually paying a small amount for things they once got for “free”: $3.5 billion from the $7 Medicare co-payment, $1.3 billion by increasing the Pharmaceutical Benefits Scheme (PBS) co‑payments, and $89.6 million from reducing the Medicare Benefits Schedule rebate for optometry services.
Then there are the cuts that aren’t cuts at all, but just pauses in indexation or deferrals of some programs: $1.7 billion by pausing the indexation of some Medicare Benefits Schedule (MBS) fees; $197.1 million from pausing indexation of various Health portfolio flexible funds; $390.0 million by deferring a planned dental health reform; and $266.7 million from simplifying Medicare safety net arrangements.
Only a piddling amount of the MRFF’s money will come from genuine cuts. And yet, these savings are still only pretend savings. They involve everyone hoping that in a few years’ time it will be possible to get rid of certain programs altogether, and that by then Twiggy Forrest will have discovered unobtainium in the Pilbara and will be busily selling it to the Chinese for their space program.
What medical research funding delivers
But criticisms of the MRFF have not, to my mind, asked the important questions. So let’s assume that it isn’t just some fiscal sleight-of-hand, and ask: Why does the Commonwealth think it should fund medical research to this extent in Australia, or indeed at all?
The argument goes something like this: we need medical research to find better treatments and cures for diseases. Australia has a small population, and people here can’t be expected to fund expensive medical research out of their own pockets. Therefore the Commonwealth should do it for them. If the research finds better cures and treatments, it might save the Commonwealth some money in the future.
In other words, this is a gamble, and it’s not even played with weighted dice so that the Commonwealth (as the “house”) can always win. It’s a gamble made with very unpredictable odds, involving a large amount of other people’s money. If this were done anywhere near King’s Cross, those involved would be called “colourful local identities”. But if it’s done by Canberra, we are supposed to be pleased about it.
The NHMRC has grown spectacularly from its inception in 1937. In fact, it’s survived two major reviews which actually recommended increasing its funding—the Wills Review in 1999, and the Grant Review in 2004. The NHMRC website also showcases the 2003 report (updated with a second edition in 2008) by Access Economics, Exceptional Returns, which modelled estimates of possible savings and returns from “investment” in medical research in Australia. But even Access Economics had to admit that they were guessing in many cases—and one of those cases was dementia.
The report estimated that if the incidence of Alzheimer’s disease could be reduced by 5 per cent through Australian research and development, then over the period 2005–10, cumulative savings of $195 million would be realised. How this measures up against the $200 million being directed towards it under the 2014-15 Budget is unclear, even allowing for the fact that these estimates are now six years out of date.
It seems a very slim return for such a large investment, and it’s also predicated on that wonderful word if—if the incidence of Alzheimer’s disease could be reduced by 5 per cent through Australian research. Of course, if the incidence could be reduced through overseas research, we’d have spent our money for nothing, which is why this kind of “investment” is more of a risky gamble than anything else.
Exceptional Returns is an honest attempt to estimate how much benefit Australians receive from Australian health and medical research, but the authors return throughout to the uncertainty of their modelling and the many complexities that might confound their findings. Any data modelling of this sort has to be hedged around with many caveats, and this is no exception, but it also presents many quotable statistics that can be used—if left unexamined—to justify an increase in health research and development spending on populist grounds.
Last year the NHMRC distributed over $850 million of medical research funding in Australia. The NHMRC has a website where you can inspect “Research Results” but it has no information more recent than 2005. The summary on the website, however, is illuminating. It lists six principal categories of result: collaborations that leveraged additional funding, funding that was leveraged from overseas and other bodies, commercial activity, publications, higher degree completions, and media attention.
I would struggle to call any of these categories “research results”, with the exception of the commercial activity (which included twenty start-up companies). The results seem to be measured by how well you used your grant to get more money, and how many publications and higher degrees you can produce. These are research results that benefit universities, rather than the general public, as there is a financial kickback for publications and higher degree completions. That media attention is listed at all as a research result is profoundly depressing, but it reflects how critical media attention has become to getting any kind of competitive edge in the grants market.
Publications are important in other ways; don’t get me wrong. They’re how you disseminate your research findings and get them scrutinised by some people and replicated by others, which helps to make your findings more robust. But they shouldn’t be measured and valued by sheer numbers alone. There’s an argument to be made for dividing published results into two groups: “found something” and “didn’t find anything”. I’m not suggesting one is better than the other, principally because if the “found something” group is given any advantage, suddenly every single publication will “find something”. The “didn’t find anything” group also makes it easier for other researchers to avoid that blind alley—and we can all hope that the real pot of gold, such as the cure for cancer, is not up at the end of that apparently blind alley.
The NHMRC website also presents its “Research Achievements”. This covers from 2004 to 2012, with more than 5700 End of Grant Reports, and you can read a range of summaries, including the ubiquitous media summary. It’s rather hard work, because the grants are divided up into categories—arthritis, asthma, cancer, cardiovascular disease, dementia, diabetes, indigenous health, injury, mental health and obesity. By far the largest category is cancer, followed by cardiovascular disease.
If you want to know why medical research actually is important, you’d be better off going straight to the NHMRC website’s Research Translation section. This is the part that really matters: turning research findings into treatments and treatment guidelines. But research findings can come from anywhere; they don’t have to be Australian, and they don’t have to be paid for by the Australian taxpayer.
The refrain that occurs over and over in the summaries of research achievements is, “More research is needed”. I accept that in complex medical and scientific research a lot of money can be spent on a very small step forward in the long journey towards understanding the mechanisms underlying all sorts of phenomena, including sickness and disease. But this is perhaps why the Commonwealth government—which has a very poor track record of picking winners—shouldn’t be in this game at all.
It’s customary at this point to start talking about the March of Dimes and polio research in the United States. The accepted story is that government funding cracked the polio code and led to the Salk and Sabin vaccines being developed, and thousands of lives being saved from death and disability. But it isn’t true. The March of Dimes and the National Foundation for Infantile Paralysis may have been set up under government auspices, but they were initially funded by charitable donations from the general public. Salk developed his vaccine using funding voluntarily donated by ordinary people: possibly the first example of crowd-funded medical research.
So what about Gardasil? This is a vaccine against certain types of human papillomavirus (HPV) which was developed in part by work by Professor Ian Frazer and the late Dr Jian Zhou, with funding from the NHMRC. The work was carried out in collaboration with other bodies including Commonwealth Serum Laboratories (CSL) Australia, the US Cancer Research Institute, the University of Rochester (New York) and Merck Sharp & Dohme.
Gardasil has been a commercial success for CSL, but three quarters of the patents that Merck used to develop Gardasil come from American institutions: the University of Rochester, the National Cancer Institute and Georgetown University. The trouble with estimating the benefits of Gardasil in Australia is that most Australian women are not eligible for the immunisation program, and many are already exposed to HPV. If the average age of receiving Gardasil is thirteen and the average age of contracting cervical cancer is around fifty, this leaves a thirty-seven-year time lag before the real benefits can be measured.
There is one other notable case study about which people are silent: Australia’s arguably most well-known Nobel laureates in Medicine, Professor Barry Marshall and Dr Robin Warren. In 1984 Marshall and Warren were able to prove that Helicobacter pylori infections caused peptic ulcers, which led to their Nobel Prize in 2005. This discovery, complete with its story of self-experimentation, was the result of painstaking and unfunded research carried out by Marshall and Warren in West Australian hospitals. Marshall later wrote of his discovery:
In the next two years at Fremantle [Hospital, 1982 to 1984] I had an enthusiastic group of people working with me. … I was still officially unfunded. The hospital was picking up all the costs of my work. It was at Fremantle in those two years that the first effective treatments were devised. I solved the conundrum of why bismuth has been such an effective stomach treatment for the past 200 years. I did my famous self experimentation and the early urease tests were developed.
Marshall and Warren’s discovery almost immediately led to measurable benefits for ulcer sufferers.
Alternatives to Commonwealth funding for medical research
We can’t really demonstrate a causal link between increasing medical research funding and the exciting new discoveries that are used to sell ideas like the MRFF. Perhaps this is the real problem, and medical research needs to be more honest to the general public about the long, slow, chance-ridden processes it follows to discover anything at all, let alone anything useful. If it were a case of more research money equals better results, we would have solved most of the world’s problems by now. Instead, more research money equals just that—more research money. And at the end of five or ten years, we might know very little more than we already know about a lot of diseases, and be no closer to finding the magic bullets.
The heretical historian of medicine in me longs to posit a counterfactual. What if government-funded research is actually making people wait longer for important discoveries? What if our reliance on publicly-funded research is actually slowing down the process of discovery? What if by legislating to make it easier to carry out privately-funded research (tax breaks, for example), more discoveries could be made more quickly? Government-funded research might be able to tell us which genes are not linked to schizophrenia, or which therapies don’t work for ovarian cancer, but there may be a cheaper way of failing.
The coding of the human genome is a case in point, when private research made huge inroads where publicly-funded research lagged. It’s also an example of how medical research was spurred on to faster discoveries by the threat of competition. Whether privatised medical research would be more effective is speculation, but so is planning to spend $20 billion on medical research that may simply strike a mass of dead ends. Privatising it might end up costing the country less.
A provocative suggestion is to fund medical research randomly. If so many discoveries are serendipitous, then why not harness this (call it chaos theory, if you like) to distribute funding? You could assemble representatives from every institute and have a draw. I’ve always thought that this exercise could be made much more fun if you put all the grants inside a giant piñata in the shape of someone appropriate (members of the public could nominate their candidates, and the winner would also be chosen at random). The ABC could televise the draw on New Year’s Eve; it couldn’t be any worse than last year’s viewing.
Or we could simply split it up evenly. There are forty-three universities in Australia. Let’s say that each one can field at least three big medical research teams, which gives us around 130 teams. With $20 billion to go around, that would give them each a total of $153,846,154 over the next five years. That’s a lot of money, and given the hit-and-miss nature of medical research, it might not be spent any more unwisely than the current distribution of funding. If each university could field ten medical research teams, that would be $46,511,628 each over five years. Teams could, of course, return any money that remained unspent at the end of five years, notwithstanding that strange variation of Parkinson’s Law which means that research activity inevitably expands to spend the funding available.
Another idea would be to give the money earmarked for the MRFF back to the people it originally came from, namely Australian taxpayers. Over five years $20 billion is around $170 a year for every man, woman and child in Australia. Or it could be a job lot of $800 up front, if you prefer. Sound familiar? If we just returned it to people who pay income tax, it would be more like $360 each, or about $1800 for the full five years. Some people would then be able to use this money to offset the cost of their private health insurance, if they wanted. Or they could use it to pay for procedures that many of them can and should pay for themselves, such as eye tests and medications.
They could also make a tax-deductible donation to a medical research fund of their choice, or donate it via crowd-funding to a small start-up project that normally wouldn’t attract the attention of the NHMRC. This initiative has been trialled at the crowd-funding website Experiment (formerly Microryza), which is well worth a visit so that you can see how little some projects need to get going, compared to the bloat often inflicted upon them by that research-related Parkinson’s Law.
If you still insist that the Commonwealth has to have the MRFF, and has to spend it constructively, I will make one final suggestion. Spend a portion of it—not all of it—on service analysis. Service analysis is a type of research that investigates how well programs and services are delivering. It’s not just a question of customer satisfaction; service analysis looks principally at hard data and measurable outcomes. So, for example, if you run a grant-funded program that’s designed to get kids to wear sunscreen at all primary schools in the state, how do you measure how successful it was, so that you can report back to the funding body?
(a) “We spent all the money, and the teachers told us they really liked it.”
(b) “We did a survey of some schools one week after the program finished, and found that 20 per cent of kids were using sunscreen.”
(c) “We did a survey of twenty-five randomly chosen schools at the beginning of the program to find out how many kids were using sunscreen already (around 30 per cent on average). Then we did the same survey at the end of the program to see if the number had increased (it had, to 86 per cent). Then we did a follow-up survey three months later to see if the message stuck (numbers had gone down to 50 per cent overall, but this is still an improvement on the baseline of 30 per cent).”
Which of these responses would give you the most confidence in the project’s value? And yet, surprisingly, many health grant-funded programs and projects are not evaluated in this way to see what they actually achieved.
Unless a robust evaluation structure is built in at the beginning of a health program or project, it shouldn’t be funded at all. Why spend thousands—and in some cases, hundreds of thousands—of dollars on projects and programs that make little difference to anyone’s health? There are immediate necessities that could be addressed instead with that funding, such as ear clinics for Aboriginal children in remote areas, or subsidising immunisations for hard-to-reach clients. Are you willing to say publicly that your Community Mums Painting and Wellbeing group is more important than that?
Good service analysis is a form of research that could be funded by the Commonwealth, because it should be an integral part of any health service that is using other people’s money to provide goods and services. Service analysis can identify problems with moribund and congested services, identify programs and projects that don’t actually achieve anything and so should not be given recurring funding, and find efficiencies to make the limited pot of money go further. Naturally the people on the receiving end hate this kind of thing, especially when they run Community Mums Painting and Wellbeing groups, but this is what happens when you ask the Commonwealth for money, instead of the community mums.
Don’t get me wrong; I’m not anti-research, or anti-medicine. But what worries me is this kind of increased involvement by the Commonwealth, the amount of money being talked about, and how it will be distributed. You can’t tell me that the MRFF will ensure that money is distributed objectively and fairly—it’s going to be just as easily influenced by pet causes, trendy projects and government pressure, with the same embarrassing consequences. Setting up Commonwealth research institutes is also not the answer, as anyone who has anything to do with the CSIRO will tell you.
Making cuts is a good idea. Stopping the rollout of programs that should probably never have left the drawing board is also a good idea. But these two rights don’t make a wrong—they don’t mean that the amount of Commonwealth money going into medical research should be increased. If the Commonwealth really wants to talk about a “sustainable” health care system, then perhaps there are alternatives to spending critical tax savings on medical research.
Philippa Martyr is a Perth-based writer and historian who blogs at Transverse City. She is aware that by the time this article appears, the cure for dementia may have emerged from an NHMRC grant-funded project. If so, she’s still not sorry.
 See for example Budget 2010-11, http://www.budget.gov.au/2010-11/content/bp1/html/bp1_bst7-01.htm—accessed 28 May 2014.
 See, for example, Christopher Mayes, Jenny Kaldor, Stacy Carter, Miles Little ,Ian Kerridge, ‘Joe Hockey’s medical research fund is nothing more than a distraction’, The Guardian, 23 May 2014, http://www.theguardian.com/commentisfree/2014/may/23/joe-hockeys-medical-research-fund-is-nothing-more-than-a-distraction—accessed 28 May 2014.
 The Bolt Report, Sunday 18 May 2014.
 Philippa Martyr, ‘Taken for granted’, Quadrant, https://quadrant.org.au/magazine/2012/10/taken-for-granted/; see also Nicholas Graves, Adrian Barnett, Philip Clarke, ‘Fingers crossed: the role of randomness in medical research funding’, The Conversation, 28 September 2011, http://theconversation.com/fingers-crossed-the-role-of-randomness-in-medical-research-funding-3536—accessed 28 May 2014.
 Budget 2014/15, Budget Paper No 2, Part 2: Expense Measures, ‘Health’, http://www.budget.gov.au/2014-15/content/bp2/html/bp2_expense-14.htm—accessed 28 May 2014.
 Alzheimer’s Australia, ‘National Quality Dementia Care Initiative’, http://www.fightdementia.org.au/quality-dementia-care-initiative.aspx—accessed 28 May 2014.
 Alzheimer’s Association (US), ‘Our Commitment to Accelerate Global Research’, http://www.alz.org/research/funding/alzheimers_our_commitment.asp—accessed 28 May 2014.
 Dementia Research Centre (UK), http://www.ucl.ac.uk/drc—accessed 28 May 2014.
 Australian Medical Association, ‘Boosting dementia research’, 15 May 2014, https://ama.com.au/ausmed/boosting-dementia-research—accessed 28 May 2014.
 I highlighted the climate change ‘epidemic’ in humanities grant applications in 2012 in ‘Climate change where you’d least expect it’, QED, 24 July 2012, https://quadrant.org.au/opinion/qed/2012/07/climate-change-where-you-d-least-expect-it/, but I was not the wag in question; it was on CatallaxyFiles in the wake of the Budget announcement, but I can’t remember who said it.
 Flat Out, Annual Report 2013, http://www.flatout.org.au/wp-content/uploads/2012/04/FLAT-OUT_AR_2013_WEB3.pdf—accessed 28 May 2014.
 Education and training component—Better Access initiative, http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-ba-edu—accessed 28 May 2014.
 Department of Foreign Affairs and Trade, ‘Health- WHO Contribution’, http://aid.dfat.gov.au/aidissues/health/Pages/initiative-who-core-funding.aspx—accessed 28 May 2014.
 F William Engdahl, ‘WHO Scientists Corruption Scandals Appear Endemic’, http://www.financialsensearchive.com/editorials/engdahl/2010/0111.html—accessed 28 May 2014.
 NHMRC, ‘A history of the NHMRC through research and researcher activities’, http://www.nhmrc.gov.au/grants/research-funding-statistics-and-data/history-nhmrc-research—accessed 29 May 2014.
 NHMRC, ‘NHMRC research funding retrospective 1990-1999 and 2000-2007’, http://www.nhmrc.gov.au/grants/research-funding-statistics-and-data/history-nhmrc-research/nhmrc-research-funding-retrospect; Access Economics, Exceptional Returns: the value of investing in health research and development in Australia. Prepared for the Australian Society for Medical Research, Canberra 2003, http://www.asmr.org.au/Except.pdf; and the 2008 update can be read here—http://www.asmr.org.au/ExceptII08.pdf—accessed 29 May 2014.
 Exceptional Returns 2008, ix.
 See for example Exceptional Returns 2008, 27.
 NHMRC, ‘NHMRC research results’, http://www.nhmrc.gov.au/grants/research-funding-statistics-and-data/nhmrc-research-results—accessed 29 May 2014.
 NHMRC, ‘Research achievements’ http://www.nhmrc.gov.au/grants/research-funding-statistics-and-data/research-achievements—accessed 29 May 2014.
 NHMRC, ‘Research translation’, http://www.nhmrc.gov.au/research-translation—accessed 31 May 2014.
 Exceptional Returns 2008, 50.
 Exceptional Returns 2008, 51 n16.
 Exceptional Returns 2008, 51-52.
 Barry J Marshall—biographical, http://www.nobelprize.org/nobel_prizes/medicine/laureates/2005/marshall-bio.html—accessed 29 May 2014.
 Melissa Southey, ‘Explainer: What is the Human Genome Project?’, The Conversation, 7 August 2012, http://theconversation.com/explainer-what-is-the-human-genome-project-7559—accessed 29 May 2014.
 Philippa Martyr, ‘A torture story the ABC won’t like’, QED, 31 January 2014, https://quadrant.org.au/opinion/qed/2014/01/torture-story-abc-wont-like/, and ‘Only $25 million!’, Transverse City, 18 October 2012, http://philippamartyr.blogspot.com.au/2012/10/only-25-million.html—accessed 29 May 2014.
 Experiment, https://experiment.com/—accessed 31 May 2014. See also David McNamee, ‘Crowd-funding is all the rage, but can it work for medical research?’, Medical News Today, 5 February 2014, http://www.medicalnewstoday.com/articles/272247.php—accessed 31 May 2014.