A familiar voice to millions, Dr Norman Swan is Australia’s best known health reporter. Having presented the ABC’s Health Report for more than three decades, this week he’s on the other side of the microphone.
Norman joins Ray to talk frankly about medicine and the media. He shares some of the joys and challenges of his work inside and outside of the ABC - including his stint as resident medic on commercial TV show The Biggest Loser and his work establishing a private media company that advertises in health clinics across Australia. A multi-award winning journalist and now popular podcaster, the common thread running through Norman Swan's distinguished career is a life-long interest in bringing new ideas, information and evidence to audiences of all kinds.
> Episode transcript
Ray Moynihan: Today, a conversation with one of the best known health reporters in the English speaking world, Dr Norman Swan. Hello, I'm Ray Moynihan, and this is The Recommended Dose produced by Cochrane Australia, and co-published with The BMJ.
A familiar voice to millions, Norman's been presenting The Health Report for more than three decades, starting as a weekly radio program on Australia's Public Broadcaster the ABC, the show recently expanded to Canada, and it's also become an extremely popular podcast.
Trained as a medical doctor and paediatrician, Norman's won many awards for his journalism, and in recent years founded a successful commercial business running a television network inside doctors' offices. In our conversation snatched within a busy schedule before he jumped back on a plane, Norman Swan reflects frankly on what drives his work and his world view, and he starts by describing how he sees his audience.
Norman Swan: Although there's a lot of health sector people who listen, that's not who I broadcast to, I broadcast to the general public. In my mind I have, in my mind's eye about the average Health Report listener, probably more female than male, probably 30s to 40s age group, and curious about health and wellbeing, and also the politics of health. So an intelligent, curious person, but there are a lot of people in Australia and around the world who are intelligent, curious, want to know more, but don't necessarily have a tertiary degree or even a PhD.
There're people who are just of their nature curious, and therefore I don't dumb down in any shape or form what we're communicating, so very happy to take on very complex topics, but the challenge is for people who may not have the health education or the professional health education, that really to make it understandable because I think I've failed if I haven't allowed people knowledge to make better decisions about themselves and their health and wellbeing, but I don't see myself in any shape or form as a lifestyle outlet. It's very much wanting to get kind of inside information about what's going on in health and medicine, and what the evidence is.
Ray Moynihan: We'll talk about evidence in a little bit, but it strikes me there's a lot of charm, there's a lot of humour - perhaps more and more over the years - in what you present and how you present it. You know even when you're talking about very serious issues, there seems like there's half a half a smile in your voice, is that right?
Norman Swan: You can't take it too seriously, even though they're serious topics because you would know Ray, as well as I do that, that this is what Cochrane is all about, is ironing out the zigs and zags in the road, and you … I mean, a lot of what I do, you know mea culpa mea culpa mea maxima culpa is that you know, I could be accused of exaggerating the zigs and zags in the road but you kind of know that the next time the result might be different, and therefore you don't want to take it too seriously, and you want to bring people to account in terms of their research, and kind of hear the questioning so that there's nothing holy, nothing saintly about people who do research. And you can take them on gently and courteously and respectfully, but you can take them on and question their evidence base.
Ray Moynihan: Let's talk about evidence, and the systematic review. I think I've noticed that a lot of the stories that you are running on the Health Report, on the podcast and on the radio are reporting on people who've done a systematic review of studies. You did one recently on a systematic review of evidence about anti-depressants, I mean, can you remind us what a systematic review is and why it's so important?
Norman Swan: Look, it's a very good question what a systematic review is and you've got to be careful, and it occupies a lot of time and energy of people who belong to the Cochrane Collaboration.
It is at its simplest, an amalgamation of evidence and a re-analysis to see where the balance of evidence lies. At least that's what I tell my audience. But of course in the practice of it, it can vary a lot and the debate within the Cochrane Collaboration is just how reliable some systematic reviews are in the inclusion, exclusion criteria. And increasingly over the years what I've noticed is that good systematic reviews really go back to individual data points and the original data, and real, and work back from there, whereas in the early days of systematic reviews it was much more of a summation of different studies, whereas now they're aggregating individual data points.
And, that of course creates a problem for the reviewers which you may well have covered in this podcast before, and it was certainly very controversial a couple of years ago when Cochrane reviewers were trying to review Tamiflu - the anti-flu medication which, with a fear of a pandemic, people stockpiled maybe hundreds of millions if not billions of dollars worth of this drug - and yet the reviewers couldn't get a hold of the original drug company data, and of course, it turns out that Tamiflu is not nearly as effective as touted, does not get the benefits.
Uncomfortably, the same may be true actually with the flu vaccine. And so you've got to kind of be sure that … and you can never … the problem broadcasting is that you can never be entirely sure that it's a reliable systematic review, and I kind of take your, this is … we are doing this as live and unedited, and to be honest, sometimes it's just an act of faith. I look at the paper, I look at how they've done it, I look at the sort of way they've gathered together the published papers, and then dissected the evidence, and hope that I'm making the right decision, but I'm not a clinical epidemiologist. I'm certainly not a Cochrane reviewer, and some, it doesn't keep me up at night, but sometimes I just worry that systematic reviews may sometimes be as unreliable as quoting a single randomised controlled trial.
Ray Moynihan: As Dr Norman Swan mentioned, this conversation for the Recommended Dose was recorded as if we were doing it live and unedited, but for full disclosure, we've made a few tiny edits mainly to remove my coughs, and some in-house journalists to journalist chit- chat about the relative merits of radio versus television.
But back to the interview… As many listeners will know already, Norman's time presenting The Health Report over the past few decades has corresponded closely with the rise and rise of the new evidence informed approach to healthcare. Based on this simple idea that tests and treatments should be rigorously evaluated, and the results of that evaluation made available to inform all our decisions. But as Norman explains, the irony is that the more rigorous the evaluation, the less certain we are about exactly what works and how well it works.
Norman Swan: Still, after all these years, my impression is there's precious little solid ground. You know, my training was in paediatrics, and there've been almost… most drugs used in children have not had randomised control trial evidence. They're off label, applying what's known about adults. I mean, if you think about it too hard it's terrifying actually. And so paediatrics… the foundation for evidence informed or evidence based practice is precious little.
And, if you take asthma for example, we've condemned certain asthma drugs for example, that don't work very well in adults but might well work very well in children, but they've never been properly studied. And you know, so you've really got to end up having your combining judgment with the evidence and as long as you can justify it, and you're working in a sense the way your peers would work without returning to the good old boys sat around the table, and saying ‘oh this is the way we always do it in, and this what we'll do in the future.’ Then I think we are in a better place now than we used to be, but there's certainly a lot of random practices going on anecdotally.
Ray Moynihan: I think you're a big proponent of encouraging people to ask questions of their doctors and health professionals, and I think your partner who we might talk about a little later actually came up with a few key questions to ask, you know: what are my options? What are the benefits and harms of those options? And, how likely are those benefits and harms going to happen to me? And, particularly what happens if I do nothing? I mean are these … Do you think that people asking those questions can really help the care they get?
Norman Swan: Well, Heather Shepherd at the University of Sydney did a trial of this using Karen Carey's questions you're talking about, and showed that the people remember the questions when shown in the waiting room, and asked them of their clinician. I think there was a pilot done on oncology and a trial done in family planning, and it did change clinical behaviour. So the hypothesis here is that it's very hard to change clinical behaviour. Knowledge doesn't change behaviour. The hypothesis here is that if you change consumer behaviour, you'll change clinical behaviour, so the very act of asking those questions makes the clinician think, ‘Well, do I know it? Where am I going to get this information from?’ And, you create a demand for the evidence such as it is, and a pause for thought. And pause for thought is pretty good thing.
If you're in general practice and you've only got 15 minutes with a patient, it's complex and you've got to get to the bottom of things fairly quickly. It's really important just to pause for a moment, and think, and by asking those… they’re central questions, but they're a bit off … it's a funny thing to say, they're central to the consultation and they should be, but they’re also a bit off to the side in terms of what you've come in with - whether it's a pain in your tummy, diarrhoea and vomiting or whatever - they are a bit off to the side.
Ray Moynihan: They're about what, what one should do I guess.
Norman Swan: Yeah, I, well it's about as Chris del Mar and his group talk about your shared decision making. It's about sharing that decision, and understanding the basis of the decision, and also sharing uncertainty. People don't like uncertainty, but that's the nature of the clinical encounter. And people who are, you know I always say to people if your doctor or physio is absolutely certain that this is going to help, I'd run for the hills and find somebody who displays their uncertainty, and shares that with you without making you unduly anxious.
Ray Moynihan: You've won lots of awards for your work, very, very big awards over the years, including major awards for investigative reporting. You've worked not just in radio, but in television as well. You've made several Four Corners Programs for people outside Australia, that's the-
Norman Swan: Declaration of interest, the first one was with you Ray?
Ray Moynihan: That's right, thank you. That's the … Four Corners is the leading investigative television program in Australia. Yes, we made one together 20 years ago on the controversial diagnosis of ADHD. That controversy hasn't gone away, has it?
Norman Swan: It hasn't, you know, spectrum disorders - talk about uncertainty - you talk about spectrum disorders from hypertension, from diabetes, things that you think are solid, like diabetes, hypertension, I mean this is your area Ray about overdiagnosis. We tend to think of spectrum disorders being autism spectrum, attention deficit hyperactivity disorder, maybe depression, but things that you think are physical disorders like high blood pressure and diabetes, those are spectrum disorders. In other words, where is the line in the sand? And, people draw that arbitrarily at some point. It should be drawn at a point where the risks of not diagnosing a greater than not, but there is creep there. Yep, so that was the very first one we did, and if you remember rightly, we had trouble in making that program in drawing that line in the sand. There was a very … it was an interesting program to make.
Ray Moynihan: Let's change gear a little bit, move from your work in the public sector to some of your work outside that in the commercial sector. One of the things you've done recently in the last few years is, is work as a medical expert or resident expert in a long running show on commercial television called The Biggest Loser.
Norman Swan: I knew you were going to drag my reputation into the mud Ray, I just knew it before you started…
Ray Moynihan: That's right, so for listeners who haven't seen The Biggest Loser, can you describe it and to save me asking about the controversy, you can tell me about it too.
Norman Swan: Yeah, yeah (laughs), so I was approached, so Biggest Loser, it's a reality television show in these days of Donald J trump, nobody needs to be told there's nothing real about reality television except what walked cross your television screen in Singapore or Pyongyang.
But essentially a reality television show with people who are obese, and they have to get to the end point of, he or she who loses most wins the show. There's 22 people of are on the show. Incredibly controversial, you have trainers who try and get their weight off… very popular in its heyday, but it lost popularity there. So the criticisms of it are, well do these people, this is unrealistic, you know, they eat a carrot a day and do eight hours of exercise a day - is this a realistic representation of dieting? And you know there are lots to criticise about The Biggest Loser format.
And so I was approached to be the medical host on Biggest Loser. When they first approached me - it was in those days with Fremantle Media - they wanted me to be the biggest bastard on The Biggest Loser, and I'd say, ‘well, I'm not doing that’. And, we negotiated a long time because, not over money because they weren't prepared to pay very much, but it was over why would I want to do it?
Well, why I would want to do is, I spent my career in the ABC, so if people are listening in Canada, CBC or Britain is the BBC, if are you listening in Europe, it's one of the public broadcasters in Europe. It's the same audience wherever, whether you're in France, Germany, Canada, or listening to NPR in United States or ABC here, it's an intelligent, lay curious or the sort of person I described at the beginning of our interview, that's who I broadcast to. I know how to broadcast to them. What I don't have much experience of is going to the majority of the population who would watch a program like Biggest Loser, and it's an important, and so, untrammelled, then you can get, so you've got this … On a negative side, you can get very negative messages being portrayed, on the positive side there's an opportunity to actually convey this.
So we did a deal, and the deal was I'd go along with some of the showbiz elements that you have to have for commercial television and a reality show, but they would go along with me when I wanted to communicate a complicated message. So to a general commercial audience, not an ABC audience, I would do things like - and they let me do it and it got to air unedited or relatively unedited - was things like absolute risk scores talking to the contestants about, well you know, it actually doesn't matter what your cholesterol is, it matters what your total risk is, and you actually communicate – I actually did it better on the day than I'm doing right now to you - but, it's complicated ideas like that.
And, the anecdotal feedback was that the audience kind of got it, and so in amongst all that, I probably communicated some important concepts (immodestly) to our general audience that they wouldn't otherwise get from the diet they have - to use a pun - they wouldn't normally get from commercial television. So that's why I did it, and the thing that worked really well on one occasion was that we actually chose a whole town in rural Victoria, a south eastern state in Australia called Ararat, which was the second highest prevalence of obesity in Australia. And we actually did a population based intervention. And in those days the Victorian Health Department wasn't interested, and they were doing various little interventions, and I think the producers spent 50, 000 bucks or something like that in Ararat. They built a walking track, and anyway, to cut a long story short, the average weight loss per capita was 3.5 kilos, which is just an enormous population intervention using showbiz.
And, so you know, there's certain things that I'm uncomfortable about, uncomfortable about the whole rapid weight loss thing, uncomfortable about some of the things that were said to contestants and so on as part of that whole thing, but in balance do you run away from these things or do you join in and try, and get the message better? There's no right answer to that question.
Ray Moynihan: I think I'm right in saying that you're now also running a growing private business called Tonic Media with your partner at Karen Carey. Can you tell us briefly what that does and how people might see it?
Norman Swan: The premise here is what I've mentioned earlier, which is very hard to change clinician behaviour by giving them knowledge. There's not a lot of evidence that that happens. And the hypothesis is if you change consumer behaviour, you can change clinician behaviour. Now a lot, and some people would say this is what we're talking about here is health literacy and health system literacy, and that is indeed what we're talking about, but it's knowledge into action is really how I prefer to talk about it.
Now, a lot of money, at least in the Australian context, probably about half a billion dollars a year is spent on improving health literacy. Some fantastic campaigns and so on and people listening in countries across the world would have same similar experience. The trouble is, either people don't know where to get it when it's online, or they, or if it's in a general context on commercial television or poster boards or whatever, wherever it might be, people aren't thinking about their health. So a lot of the creative is actually to grab your attention, so if you only got a 30 second TV ad in social marketing, then the first 10 or 15 seconds is to grab you in, and then you've only got 15 seconds left to communicate your message.
So, our hypothesis was that people are in a health frame of mind in the 30 minutes before they see their primary care physician or their general practitioner or the family doctor, and so that's where we play. We play in the waiting room while people are waiting for an episode of healthcare knowing that they're going to see a practice nurse, a doctor or an allied health professional within 30 minutes. And around the world, the average wait time is about 30 minutes to see a health professional. So we do a couple of things. We have a health television channel, well it looks like a health television channel. It's actually on a digital platform that can be programmed down to the individual practice. It has news, weather, background content - which is lifestyle evidence - it's all evidence based.
We've got an ethical advertising code, so we won't take alcohol, we won't take un- healthy food. If we take supplements, it's got to be evidence against the supplements, which means that we hardly ever run supplement advertising on there. So it’s things like pregnancy, immunisation for the flu in pregnancy or Hepatitis C treatment for governments. Our biggest users are in fact governments and not for profit, so that we do have for-profits like Woolworth's the supermarket chain will use time on the system for healthy food.
We're in a trusted environment here, and if we abuse that trust just to make money, the business would not be sustainable, and so what we've been able to do… and so, we have brochure boards as well, we have digital panels, we're in pharmacies, and now we've acquired the third most traffic website in Australia called mydoctor.com.au and these are all commercially funded either through not for profits, government, non-government or commercial organisations.
And we've been able to show, for example, we did one trial with the Federal Government here, and we decreased antibiotic prescribing by 5%. And that doesn't sound a lot, but when you've got 60 or 70% inappropriate prescribing for antibiotics, that's actually quite a lot. And that was done by running amusing pieces of information to the consumer about not trying to argue your doctor out of antibiotics.
And, then with the doctor, I went with the behavioural economics piece which is, I know you don't want to prescribe and here are the five reasons why you do, and here's some solutions for you. And we measured it in two ways, pharmacy dispensing and the doctor's software and it was actually the doctors not writing the prescriptions in the first place. And we've done the same in the opposite direction with asthma where we've improved adherence to asthma evidence, also interestingly about 5%, and we've shown that in other areas that we can shift the dial, so it does seem to work. It is a commercial business. It is about making money, but we are … Our original investors are some of the most respected investors in Australia, and they're also just kind of socially aware investors, so they came in with the belief and the hope that what they were doing was doing good as well as making money, and so far I don't think we've disappointed them.
Ray Moynihan: I'm sure you can predict my next question. I think I'm right in saying that you also have advertisers there from the pharmaceutical industry and others. Does this create a fundamental conflict of interest for you as a public broadcaster? Also, at the same time a private entrepreneur accepting income from the very industries that you're covering regularly in your program?
Norman Swan: So, the good thing about Tonic is that my involvement as a founder has receded, and I actually don't run the business anymore, nor do I make direct money out of what we do on the advertising screen. And there's an arm's length relationship there. I am personally not that comfortable with, like you are not that comfortable with disease awareness campaigns. We run the ruler over them, and hope that they are, and that they are evidence based, and that we try very hard not to make them as blatantly commercial as some of them have been, but yes the network does take those.
I don't feel personally compromised because they have no influence over what I do. I don't book those ads, and then, in some senses they're a necessary evil to actually keep the network going, and they provide a very small part of what the network does. But yep, they do accept those ads. And so I'm sort of… I'm not easy with it, but I've have made sure that as the very early days of the business I was very hands on, now I'm much less hands on. That doesn't abdicate me from responsibility for running unethical stuff on air at all.
Ray Moynihan: Is it the sort of thing that your engagement with Tonic, should that be listed let's say, on your profile on the ABC? Is that something your listeners should know about?
Norman Swan: So, we've discussed that in the ABC. So the ABC has discussed that, and I'm very relaxed about that. Tonic would love it if I were to list it as part of … so, we had quite, we had a really interesting discussion at the ABC at a senior level about this. Should this actually be declared? And, there's a good argument for doing it, and we actually came to the conclusion that was more in Tonic’s benefit than the ABC’s benefit to declare it because, for the reasons that, it was kind of free advertising on air, and my promise to the ABC was that nothing that happens on Tonic would actually appear on air in the ABC nor have any influence. And I think that any, I'd be very comfortable with an open audit of what we've done on Tonic, and what you've seen on the Health Report in my line of questioning, and I don't think you'd actually see the two, any crossover between the two, but that discussion was had about whether or not we do it, and the decision was that we don't.
But, if there was a conflict in a topic area where I've say, done or given a speech at a conference and that's conflicted, that I would do that, that I would actually declare that conflict. And I actually self-edit there. I steer clear unless it's a really important topic that needs to be covered because most of the time when I do things it's a keynote at a conference where there might be some pharmaceutical sponsorships -hard to get away from that - and so, I'm in the clear most of the time, but I will declare it. The risk … I think the serious risk is when you're out there giving talks where there could be industry sponsorship and so on, is that you don't, you actually go the opposite way that you avoid stories, because you've got a potential conflict there, and I try not to do that and if I do, I declare an interest.
Ray Moynihan: Norman I know you've got to run but just before we finish up, some questions about you and where you come from and what shaped you as a person. With the deepest respect there's a deep sort of pragmatic vein running through your body. Do you agree and can you talk a bit about where that might come from? Can you talk a bit about growing up in Glasgow… some of those early years, some of the experiences that might've shaped that?
Norman Swan: Yeah, I'm pragmatic. I mean, you mean conservative? So, if you talk to conservatives, they think I'm left wing, and if you talk to people who are on the left, they think I'm on the right. So I grew up in Glasgow which is one of the, which has some of the greatest disparities in any city in western Europe, some of the worst slums when I was growing up in western Europe and still huge disparity, so I grew up with that in my face.
My parents came from, both sides of my family were migrants round at the end of the 19th century, early 20th century. They were Jewish escaping pogroms, so in my background is racial discrimination, migration, making it in a new country, being part of a minority ethnic group, and that sort of, and I'm very attracted to the side of Judaism which is the social activist side of Judaism if you read the prophets, and so on, it's a very, it's not a conservative religion at all despite what horrible things go on in occupied territories at the moment in Israel.
It's more of that traditional left of centre view of the world that Jews tend to have still, but it has been a bit … I use the word corrupted loosely by what's going on in the Middle East. Anyway, that's how I grew up, and I developed and I was part of a youth movement that was very kind of socially focused and socially aware and very ideological as well. So that's my background. And I suppose what I have dealt with over the years, and I ran Radio National for a while by the way, and what I confronted when I started running Radio National in the late 80s was really quite a lot of ideological purity, a lot of people with very kind of rigid views, and the result of that was really moving away from where the community and the population was at, and the ability to actually have a conversation with the general community.
So, do … am I pragmatic? I suppose. I'll give you an example of a comment that I got recently from this Four Corners, this documentary I made two or three weeks ago as we speak on out of pocket expenses with doctors. So this is kind of a traditionally I suppose left view of the world which is the doctors are overcharging, and it's affecting things, and the criticism I got was, ‘Well, why didn't you tell people in the program there's a strong public system in Australia and that's where they should go?’ And, my answer to that was well that’s a very (and it wasn't the ABC that asked me that) that that would be a very typical ABC thing to do - when really the premise here was that what you've got in Australia like it or not, but it's what most people live with in Australia, unlike Canada in a sense, is that we've got a mixed health economy where we've got a private sector, and we've got a public sector and they co-exist.
We don't do too badly. It's not perfect, and really the premise behind this story is that the private sector has been threatened, and really just focused on the private sector. And I felt kind of unnecessary necessarily to make a big deal that there was a public sector has kind of taken for given … for … as a given. And I suppose that's part of what the pragmatic side of it is, is trying to go where the audience is and move them into - not a new way of thinking, I'm not trying to convert them, I'm not trying to create revolution - but just go where they are and give them new information to actually make up their mind, and have a different view of the world.
And I think if you come from too rigid a point of view, then it becomes hard to enter their world. And I think that quality journalism, you know good quality journalism enters the world of the reader, the listener, the viewer, and then takes them on a journey and tells them stories that they can choose to believe or not, and provide the evidence accordingly. And I think that does require pragmatism. It does leave… involve leaving behind what you might personally believe and enter their world. Most social democracies around the world are actually quite conservative. They're not radical, and to ignore that fact would alienate a lot of people, and because of that alienate them from the stories you want to tell them to see if they think they're interesting stories and ones that matter to their lives.
Ray Moynihan: We've mentioned your partner Karen Carey a couple of times. She is a very well known consumer advocate in Australia. Do you want to talk a little bit about why she ended up as a consumer advocate and how that partnership may have influenced the way you report on healthcare?
Norman Swan: So, Karen had a failed heart valve procedure, and she litigated both the surgeons and the manufacturer believing that there was a flaw in the valve and discovered that the regulatory procedures here in Australia were not as sound as they should be. And as a result, became a consumer advocate and learned how to advocate effectively on, at the same table as government and doctors.
She ended up chairing Consumers Health Forum, the national organisation here after chairing the state based one in Western Australia. She sits on the council of the National Health and Medical Research Council and other organisations, and so she … and, I think that what she has done in terms of my attitude towards the world is reinforced the belief that you do start with the consumer and enter their world. I was already doing that as a journalist, but I think that that has been reinforced.
Ray Moynihan: And, just before we finish Norman, I think you have several children that I'm imagining they might be in their 20s and 30s now, how central has that role of being a father been in your life?
Norman Swan: Very central. So I've got three kids. I've got one daughter who's done a Masters in public health, and works actually in a private health insurer here in Australia doing special projects, and I've got a middle child who works in marketing - both great kids, they're in their late 20s, early 30s. And I've got a son, Jonathan who works in Washington as a White House reporter for an American broadcaster. He's doing quite well. And I'm proud of them all. They've changed me probably far more than I've changed them.
Ray Moynihan: And, at risk of sounding very old fashioned, are there any prospects of being a grandfather?
Norman Swan: Not that I know of [laughs].
Ray Moynihan: Norman Swan …
Norman Swan: I'm too young, too young. I started, I didn't say that, I started at age of 12...
Ray Moynihan: Norman Swan, thank you so much for your time. I know you've got to fly literally, great to have you on The Recommended Dose.
Norman Swan: My pleasure.
Ray Moynihan: That was Dr Norman Swan on The Recommended Dose funded by Cochrane Australia, co-published by BMJ, produced by Shauna Hurley and edited by Jan Muths.
You may also enjoy recent conversations from season 2 with John Ioannidis and Rita Redberg. They're both highly recommended. I'm Ray Moynihan, and thanks so much for listening, and if you enjoy this podcast, you could subscribe to the show, rate us or recommend us to others.