Introduction

This period turned out to be one of dramatic progress in the field. By the 1960s we knew we had seen the effective end of polio, diphtheria, scarlet fever, whooping cough, measles, tetanus, and of rubella-affected babies. Pneumococcal pneumonia virtually disappeared; staphylococcal pneumonia and osteomyelitis, which sometimes followed it, became controllable; rheumatic fever and acute nephritis became increasingly rare. Vaccination, antibiotics and sanitation worked quickly, eradicating mortality, morbidity and sometimes the disease itself.

I left Fairfield in 1964 for a pleasurable four-year stint at the Royal Children's Hospital and, in 1968, was invited by Bill Keogh to apply for his job as Director of the Anti-Cancer Council of Victoria, as he was finally retiring. He said I would enjoy it and I accepted his manipulation, happy in the conviction that he would never give me bad advice.

I was by then well informed about epidemiology and preventive medicine as well as about the treatment of infection. Progress had been rapid but was that not what progress was about? Certainly, I was unprepared for the slow rate of change in the battle against cancer.  

Public health and the Anti-Cancer Council of Victoria

The Anti-Cancer Council of Victoria, as a well known charity with over 140 000 donors and a high profile in the press, was particularly well equipped to operate in this favourable environment. The Council played a leading role in the initiation and development of virtually all the Victorian cancer control programs, from the establishment of the cancer registry, the first public education programs, cancer research, the cervical and breast cancer screening programs, sun and skin protection, and -- most difficult of all -- the anti-smoking battle.

The Anti-Cancer Council was set up by Act of the Victorian Parliament in the early 1930s as a volunteer-based, non-profit cancer charity. I responded to the Executive Committee, which had most of the powers, and the Finance Committee, both of which were advised by a group of issue-specific volunteer committees staffed by clinicians, research workers, business people, ethnic groups, and many others. I was advised by, and advised, distinguished Chairs of the Executive Committee -- Weary (Sir Edward) Dunlop, Tom Hurley, Max Whiteside and Brian Fleming. David Hume, as Chair of the Finance Committee, tolerated but controlled my preference for programs over financial reserves, and Allan Dick, as President, taught me much about management. Between them these individuals converted my creative opportunism into a series of strategies and, at least sometimes, a proper plan. As the frontispiece, I always had rock solid support and good advice.  

The cancer outcomes

Cervical cancer mortality is half what it was in the 1960s. The reduction is due to progressively more effective application of the Papanicolaou smear. It took a long time (too long) for the Pap smear to achieve its potential. The quality of the laboratory service was always there, but the mortality reduction owes as much to progressive social organisation over time, aided, in Victoria, by a helpful Parliament.

Melanoma in both men and women is relatively curable, but shows a doubling of mortality each decade in most white-skinned populations. Australian mortality has reached a plateau in men and shows a slight downturn in women -- a world first. This is the result of early detection, the achievement of which was apparent in the mid 1980s, when over half the melanomas in the Victorian Cancer Registry were less than 0.75 mm thick. Melanoma mortality will continue to decline in Australia. So, in due course, will the incidence of both this disease and non-melanotic skin cancer as the "Sunsmart" program continues to bite.

Although the management of breast cancer has become more patient-friendly, treatment has yet to deliver striking change, although modest improvement is apparent. Mammographic screening offers expectation of a mortality decline (if community practice can be brought to match clinical trials) of 30% or better as the technology improves. Its success is dependent on the participation rate and Victoria already promises to deliver a high one.

The social organisation developed for the cervical cancer program, and applied in a very similar way to mammographic screening, is theoretically simple but took years to devise and then to evolve. It is now accepted that a Victorian woman of relevant age will receive through the mail, at appropriate intervals, personalised invitations to visit her doctor and enter a screening program based on the Pap smear and, separately, to visit one of the 40-years-plus mammographic screening centres and enter a breast screening program of similar design, again at appropriate intervals based on her age. I personally regard access to these programs in an affluent society as a human right, much the same as the right to be immunised at birth. Similar rights exist in the United Kingdom and Sweden, but not in Italy, France or Spain, or in the United States.

These Victorian programs are of excellent quality. The laboratories and mammographic facilities participate in quality control programs, and the results of cervical and breast screening tests are registered and linked with the Victorian Cancer Registry. Thus, mistakes become apparent, are investigated and further improvements made. Organising such systems is theoretically easy, and can be achieved in Victoria, but nothing is ever as easy as it should be. The ability of the Victorian Electoral Commissioner, at one stage, to withhold the Electoral Register -- which is the only public listing on which invitations can be based -- was an illustrative example of what single-minded obduracy can do. Senior political intervention was necessary, and was available, to circumvent this.  

Cancer research

Clinical research was harder to develop. Stimulated by Max Whiteside, we established the Victorian Co-operative Oncology Group (VCOG) in the late 1970s, and over time it became a force for the conducting of clinical trials, surveys of management and other analyses.

Both the Anti-Cancer Council Scientific Committee and the VCOG play important roles in Victorian cancer policy.  

Bringing about change -- how it all happened

The role of opportunism is clearly exemplified by my visit to David White, Minister for Health, in February 1987. The agenda was to tell him the background and basis of mammographic screening, to persuade him that its time had come, and that it should be an organised program, based on a proper pilot project, and that it should not be left happenstance to the private sector alone. He listened and accepted this advice, and said, as we finished, something to the effect that this was a non-election year and it might be possible to do something about tobacco. The easily drafted comprehensive submission branded into my brain over 20 years was soon on his desk, and was read.

Thus, opportunistically, began the coalition which was to drive the Victorian Tobacco Act through Parliament on November 17 that year -- one of the most serious political defeats suffered by the tobacco industry.

The Victorian tobacco story is long and can only be summarised. Health Warnings, given in 1970 by (Sir) Rupert Hamer over the grumpy opposition of Sir Henry Bolte, converted the Government from being pro-smoking (yes!) to anti-smoking, at least in theory, and saw our views gain their first political respectability. Television commercials voluntarily made by Warren Mitchell (as Alf Garnet), Miriam Karlin and local actor Fred Parslowe were dramatic and effective, particularly when Fred Parslowe's send-up of the Marlboro Country ("Cancer Country") advertisement was censored, as we had planned. We had not planned to have our "respectability" commercial, made by Nobel Prize winner Sir Macfarlane Burnet, censored also, but when it was he was delighted and the headlines were huge.

Action then moved to Canberra, where in 1975 Malcolm Fraser gave us a radio and television advertising ban, subverted in the closing minutes of debate by the Country Party with an amendment which was to legitimise sporting advertising and the take-over of sport by the tobacco industry for another 17 years. That simple slick manoeuvre taught us a good lesson.

The Victorian Tobacco Act of 1987 banned those forms of advertising susceptible to State control, such as billboards, competitions, giveaways, and applied a hypothecated (earmarked) tobacco tax to Victorian cigarettes. This tax was pioneering legislation, which was quickly copied by South Australia, Western Australia, California, Massachusetts and others. The idea of earmarking tobacco tax for buying back sport had surfaced in my correspondence as early as 1981.

This very public non-party-political battle was the single most difficult and testing event of my career, and brought into play all the goodwill, supportive networks and moral courage of the Council's officers, committees and staff.

This Victorian campaign started in February 1987 with a detailed plan which involved me meeting weekly or fortnightly with David White. Mark Birrell, a long-time supporter and Liberal Leader of the Upper House (as well as Shadow Minister for Health) was apprised early and planned much of the second half of the campaign. It was understood at the beginning that the hardest hurdle was likely to be the Liberal Shadow Cabinet, in which 11 out of 20 votes were needed in order to carry the party room. The plan required us to persuade Cabinet and the Labor Party by August of the need for a Bill, and for the Bill to be drafted within the Health Department by then. It would then be announced and followed by a 6-10-week public debate, during which time we had to persuade the Liberal Shadow Cabinet and back bench, then generate a vocal lobby as Parliament debated the Bill.

The plan was military in style, with set times, targets and marshalled resources. We conducted an opinion poll which showed clearly that tobacco tax increases were popular, that tobacco advertising was not, and that tobacco sponsorship of sport, while less unpopular, could be replaced by a tobacco-tax-funded body (which eventually was the Victorian Health Promotion Fund) without upsetting the voters. This impressed Cabinet and Parliament. The Age , after a visit to the editor (Creighton Burns), published a five-day intensive coverage of tobacco on the requested date (to coincide with a key Cabinet meeting). This gave both sides much publicity and allowed our public health case to be seriously contrasted with the rather ugly and certainly specious case of the tobacco industry. Sir Gus Nossal was hunted down in Japan and agreed, with typical generosity, to accept the Chair of the Victorian Health Promotion Foundation at a critical time. A dramatic television advertisement (entitled "Coroner", and depicting a cigarette packet as cause of death) focused attention and infuriated the tobacco industry, which responded with an advertisement we labelled "Commissar" which painted us, implausibly, as Big Government fascists.

Other industry blunders helped. One tobacco company reacted to the announcement of the Bill by asking their large staff to telephone, write or visit their parliamentarians. They blocked the parliamentary switchboard, often leaving the company switchboard as the call-back number, thereby enraging many politicians. Our 140 000 donors were requested to do the same and a large but unknown number did so, somewhat more temperately it seemed, but clearly representing grassroots opinion. We solicited support from innumerable community organisations and were rarely refused.

The then Opposition Leader, Jeff Kennett, may or may not have been surprised to receive about 20 calls from senior Liberals, including his Treasurer. They were organised by one phone call to a well connected businessman. Two calls to the Anglican and Catholic Archbishops (men I had never met) triggered contacts from them to five important members of the Shadow Cabinet just before the crucial vote.

So the Bill came to Shadow Cabinet, was passed, passed the Liberal Party room, and went to Parliament, where it was the object of a filibuster attempt by the National Party. Mark Birrell merely told them Parliament would sit until the Tobacco Bill had been dealt with. I watched the tobacco industry people leave Parliament about 5:30 pm, visibly angry, and stayed to see the Bill passed by a unanimous Parliament late on the night of November 17, 1987. Afterwards, the tobacco industry took their money away, at least temporarily, from the Liberal Party, and I was mortified to discover it was the equivalent of only about 10 per cent of our research budget. Should we have been spending our money on political party contributions instead of research?

In 1990, led by the Democrats, Federal Parliament abolished print advertising after a short but well-designed campaign. In 1992, Federal Parliament provided Australia with exemplary tobacco legislation, although the exemptions for Grand Prix advertising will probably remain until the United States and Europe act on this issue.  

Conclusion

Why DO research if the results are not used when known?

Nigel J Gray
European Institute of Oncology, Milan, Italy  

1. Peto R, Lopez AD, Boreham J, et al. Mortality from tobacco in developed countries: indirect estimation from national vital statistics. Lancet 1992; 39: 1268-1278.

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