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![and I am once more on the tongue of land, with a frightful gulf on
either hand, or I am saving myself by grasping that fern.
According to the statements of the officials, many years ago a
gentleman had the hardihood to attempt to ascend this mountain
alone. As he did not return at the expected time, a party of natives
was sent to search for him, and his dead body was found some
distance beneath the summit. The rocks to which he had intrusted
himself had probably given way, and the only sensation that could
have followed was one of falling and a quick succession of stunning
blows, and life was gone. Governor Arriens assured me that the
band of loose stones was the most dangerous place he had ever
crossed, though he had climbed many nearly perpendicular walls,
but always where the rocks were fixed and could be relied on for a
footing and a hold. If the ascent and descent were not so difficult,
sulphur might be gathered in such quantities at the summit crater
that it would form an important article of export. The authorities
informed me that much was obtained in former times, and that the
natives who undertook this perilous climbing were always careful to
array themselves in white before setting out, so that if they did lose
their lives in the attempt they would be dressed in the robes required
by their creed, and at once be taken to Paradise. The first European
who reached its summit, so far as I am aware, was Professor
Reinwardt, in 1821; the second was Dr. S. Müller, in 1828; and from
that time till the 13th of September, 1865, when we ascended it, only
one party had attempted this difficult undertaking, and that was from
the steamer Ætna, whose name we had found on a large rock in the
old crater.
The height of this volcano we found to be only two thousand three
hundred and twenty-one English feet. Its spreading base is
considerably less than two miles square. In size, therefore, it is
insignificant compared to the gigantic mountains on Lombok, Java,
and Sumatra; but when we consider the great amount of suffering
and the immense destruction of property that has been caused by its
repeated eruptions, it becomes one of the most important volcanoes
in the archipelago.[37] In 1615 an eruption occurred in March, just as
the Governor-General, Gerard Reynst, arrived from Java with a large](https://image.slidesharecdn.com/20772-250628091230-fef4dfa2/75/Health-Policy-and-Economics-State-of-Health-1st-Edition-Peter-Smith-32-2048.jpg)
![On the 22d of April, 1824, while Governor-General Van der
Capellen was entering the road, an eruption commenced, just as had
happened two hundred and nine years before, on the arrival of
Governor-General Reynst. A great quantity of ashes again suddenly
rose from its summit, accompanied by clouds of “black smoke,” in
which lightnings darted, while a heavy thundering rolled forth that
completely drowned the salute from the forts on Neira. This was
followed, on the 9th of June, by a second eruption, which was
succeeded by a rest of fourteen days, when the volcano again
seemed to have regained its strength, and once more ashes and
glowing stones were hurled into the air and fell in showers on its
sides.
But the people of Banda have suffered quite as much from
earthquakes as from eruptions, though the latter are usually
attended by slight shocks.[38] Almost the first objects that attract
one’s attention on landing at the village are the ruins caused by the
last of these destructive phenomena. Many houses were levelled to
the ground, but others that were built with special care suffered little
injury. Their walls are made of coral rock or bricks. They are two or
three feet thick and covered with layers of plaster. At short distances,
along their outer side, sloping buttresses are placed against them, so
that many of the Banda residences look almost as much like
fortifications as dwelling-houses. The first warning any one had of
the destruction that was coming was a sudden streaming out of the
water from the enclosed bay, until the war-brig Haai, which was lying
at anchor in eight or nine fathoms, touched the bottom. Then came
in a great wave from the ocean which rose at least to a height of
twenty-five or thirty feet over the low, western part of the village,
which is only separated from Gunong Api by the narrow Sun Strait.
The praus lying near this shore were swept up against Fort Nassau,
which was then so completely engulfed, as it was stated to me on
the spot, that one of these native boats remained inside the fort
when the water had receded to its usual level. The part of the village
over which the flood swept contained many small houses, and nearly
every one in them was carried away. The rapid outflowing of the
water of this enclosed bay (which is really only an old crater) was](https://image.slidesharecdn.com/20772-250628091230-fef4dfa2/75/Health-Policy-and-Economics-State-of-Health-1st-Edition-Peter-Smith-34-2048.jpg)
![probably caused either by the elevation of the bottom at that spot, or
else by such a sinking of the floor of the sea outside, that the water
was drained off into some depression which had suddenly been
formed. We have no reason to suppose that there was any great
commotion in the open ocean, and certainly there was no high wave
or bore, or it would have risen on the shores of the neighboring
islands. There are three entrances or straits which lead from the
road out to the open sea. Two of these are wide and one is narrow.
When the whole top of the old volcano, that is, Banda Neira, Gunong
Api, Lontar, and the area they enclose, was raised for a moment, the
water steamed out from the crater through these straits, causing only
strong currents, but as the land instantly sank to its former level, the
water poured in, and the streams of the two wider straits, meeting
and uniting, rolled on toward the inner end of the narrow strait. Here
they all met, and, piling up, spread out over the adjoining low village,
causing a great destruction of life. At the Resident’s house, a few
hundred yards east of Fort Nassau, the water only rose some ten or
fifteen feet above high-water level, and farther east still less. The
cause assigned above, though the principal one, may therefore not
have been sufficient in itself to have made the sea rise so high over
the southwestern part of Banda Neira and the opposite part of
Gunong Api, and I suspect that an additional cause was that the land
there sank for a moment below its proper level. Valentyn thus
describes another less destructive earthquake wave: “In the year
1629 there was a great earthquake, and half an hour afterward a
flood which was very great, and came in calm weather. The sea
between Neira and Selam” (on the western part of Lontar) “rose up
like a high mountain and struck on the right side of Fort Nassau,
where the water rose nine feet higher than in common spring floods.
Several houses near the sea were broken into pieces and washed
away, and the ship Briel, lying near by, was whirled round three
times.”[39]
However, all these events are but as yesterday when we glance
over the early history of this ancient volcano; for, if we can judge by
analogy, taking as our guide the great crater already referred to as
this day existing among the lofty Tenger Mountains on Java, we see](https://image.slidesharecdn.com/20772-250628091230-fef4dfa2/75/Health-Policy-and-Economics-State-of-Health-1st-Edition-Peter-Smith-35-2048.jpg)
![gathered on the shallow coral banks of these low islands, and in the
sea the dugong, Halicore dugong, Cuv., is seen. The great bird of
paradise, P. apoda, is found here, and also the red bird of paradise,
P. regia. The skins of these beautiful birds were probably brought
here to Banda and sold to the Chinese traders for many ages, but
the first account we have of them is by Pigafetta, who accompanied
Magellan’s fleet. He says that the king of Bachian, an island west of
the southern end of Gilolo, gave his companions a slave and nearly
two hundred pounds of cloves as a present for their Emperor,
Charles V., and also “two most beautiful dead birds. These are about
the size of a thrush, have small heads, long bills, legs a palm in
length and as slender as a writing-quill. In lieu of proper wings, they
have long feathers of different colors, like great ornamental plumes.
The tail resembles that of a thrush. All the feathers except those of
the wings are of a dark color. It never flies except when the wind
blows. We were informed these birds came from the terrestrial
Paradise, and they called them bolondinata,[40] that is, ‘birds of
God.’” This word the Portuguese translated into their language as
“ave de paraiso,” and hence our name “birds of paradise,” a name
well chosen, for in some species the feathers have all the
appearance of the most brilliant jewels. Southwest of the Ki Islands
lies Timur-laut, and passing on toward Timur we come to the
“Southwestern Islands,” composed of the Baba, Sermatta, Letti,
Roma, Wetta, and Lamma groups, which we noticed as we steamed
away from Dilli.
Returning northward from Wetta, we come to Gunong Api, an
uninhabited volcano, rising between six and seven thousand feet
above the sea. It is a well-known landmark for the ships bound to
China that have passed up the Ombay Passage, or those coming
down the Floris Sea, intending to pass out through that strait into the
Indian Ocean. Northeast of Gunong Api are the Lucipara and Turtle
(in Dutch Schilpad) Islands, which praus from Amboina frequently
visit for tortoise-shell. East of Gunong Api is Nila, an active volcano,
about seventeen hundred feet in height, and north of it is Serua,
which is merely a volcanic cone rising abruptly from the sea. In 1694
a great eruption took place in this volcano. A part of the crater wall](https://image.slidesharecdn.com/20772-250628091230-fef4dfa2/75/Health-Policy-and-Economics-State-of-Health-1st-Edition-Peter-Smith-38-2048.jpg)
Health Policy and Economics State of Health 1st Edition Peter Smith
- 1. Health Policy andEconomics State of Health 1st Edition Peter Smith download pdf https://ebookfinal.com/download/health-policy-and-economics-state-of- health-1st-edition-peter-smith/ Visit ebookfinal.com today to download the complete set of ebook or textbook!
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- 5. Health Policy andEconomics State of Health 1st Edition Peter Smith Digital Instant Download Author(s): Peter Smith, Mark Sculpher, Laura Ginnelly ISBN(s): 9780335227938, 0335227937 Edition: 1 File Details: PDF, 1.67 MB Year: 2004 Language: english
- 6. REASONABLE RATIONING International Experienceof Priority Setting in Health Care “Reasonable Rationing is a must read for those interested in how to connect theory about fair rationing processes to country-level practices. The five case studies reveal a deep tension between political pressures to accommodate interest group demands and ethically motivated efforts to improve both information and institutional procedures for setting fair limits to care. The authors frame the issues insightfully.” Professor Norman Daniels, Harvard School of Public Health Priority setting in health care is an issue of increasing importance. Choices about the use of health care budgets are inescapable and difficult. A number of countries have sought to strengthen their approach to priority setting by drawing on research-based evidence on the cost and effectiveness of different treatments. This book brings together leading experts in the field to summarize and analyse the experience of priority setting in five countries: Canada, The Netherlands, New Zealand, Norway, and the UK. Drawing on literature from a range of disciplines, it makes a significant contribution to the debate on the role of information and institutions in priority setting, addressing issues such as: • How are different countries setting priorities for health care? • What role does information and evidence on cost and effectiveness play? • How are institutions contributing to priority setting? • What are the lessons for policy makers? Reasonable Rationing has been written for a broad readership. It will be of interest to policy makers, health care professionals and health service managers, as well as students of health and social policy at advanced undergraduate and postgraduate levels. Chris Ham has been Professor of Health Policy and Management at the University of Birmingham since 1992. In 2000 he was seconded to the Department of Health, where he is director of the Strategy Unit. He has written widely on health policy, including books on the National Health Service, health care reform in the international context, and resources rationing. Glenn Robert did his doctoral research on the introduction and diffusion of new health care technologies in the National Health Service. Now Senior Research Fellow at University College, London, in previous posts at Brunel University and the University of Birmingham, he was engaged in health services research and health technology assessment. S T A T E O F H E A L T H S T A T E O F H E A L T H HEALTH POLICY AND ECONOMICS PETER C. SMITH, LAURA GINNELLY AND MARK SCULPHER H EALTH POLICY AND ECONOMICS SMITH, GINNELLY AND SCULPHER Cover design: Barker/Hilsdon www.openup.co.uk Opportunities and Challenges
- 7.
- 8. STATE OF HEALTHSERIES Edited by Chris Ham, Professor of Health Policy and Management at the University of Birmingham. Current and forthcoming titles Noel Boaden: Primary Care: Making Connections Angela Coulter and Chris Ham (eds): The Global Challenge of Health Care Rationing Angela Coulter and Helen Magee (eds): The European Patient of the Future Chris Ham (ed.): Health Care Reform Chris Ham and Glenn Robert (eds): Reasonable Rationing: International Experience of Priority Setting in Health Care Rudolf Klein, Patricia Day and Sharon Redmayne: Managing Scarcity Nicholas Mays, Sally Wyke, Gill Malbon and Nick Goodwin (eds): The Purchasing of Health Care by Primary Care Organizations Ruth McDonald: Using Health Economics in Health Services Martin A. Powell: Evaluating the National Health Service (NHS) Ray Robinson and Andrea Steiner: Managed Health Care: US Evidence and Lessons for the NHS Anne Rogers, Karen Hassell and Gerry Nicolaas: Demanding Patients? Analysing the Use of Primary Care Marilynn M. Rosenthal: The Incompetent Doctor: Behind Closed Doors Richard B. Saltman and Casten von Otter: Planned Markets and Public Competition: Strategic Reform in Northern European Health Systems Richard B. Saltman and Casten von Otter: Implementing Planned Markets in Health Care: Balancing Social and Economic Responsibility Richard B. Saltman, Joseph Figueras and Constantino Sakellarides (eds): Critical Challenges for Health Care Reform in Europe Claudia Scott: Public and Private Roles in Health Care Systems Ellie Scrivens: Accreditation: Protecting the Professional or the Consumer? Peter C. Smith (ed.): Reforming Markets in Health Care: An Economic Perspective Kieran Walshe: Regulating Health Care: A Prescription for Improvement Peter A. West: Understanding the NHS Reforms: The Creation of Incentives? Charlotte Williamson: Whose Standards? Consumer and Professional Standards in Health Care Bruce Wood: Patient Power? The Politics of Patients’ Associations in Britain and America
- 9. HEALTH POLICY AND ECONOMICS: OPPORTUNITIESAND CHALLENGES Edited by Peter C. Smith, Laura Ginnelly and Mark Sculpher Open University Press
- 10. Open University Press McGraw-HillEducation McGraw-Hill House Shoppenhangers Road Maidenhead Berkshire England SL6 2QL email: [email protected] world wide web: www.openup.co.uk and Two Penn Plaza, New York, NY 10121-2289, USA First published 2005 Copyright © Peter C. Smith, Laura Ginnelly and Mark Sculpher 2005 All rights reserved. Except for the quotation of short passages for the purposes of criticism and review, no part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher or a licence from the Copyright Licensing Agency Limited. Details of such licences (for reprographic reproduction) may be obtained from the Copyright Licensing Agency Ltd of 90 Tottenham Court Road, London, W1T 4LP. A catalogue record of this book is available from the British Library ISBN 0 335 21574 2 (pb) 0 335 21575 0 (hb) Library of Congress Cataloging-in-Publication Data CIP data applied for Typeset by RefineCatch Limited, Bungay, Suffolk Printed in the UK by Bell & Bain Ltd, Glasgow
- 11. CONTENTS List of contributorsvii Series editor’s introduction xi Acknowledgements xiii Introduction 1 Peter C. Smith, Mark Sculpher and Laura Ginnelly 1 It’s just evaluation for decision-making: recent developments in, and challenges for, cost-effectiveness research 8 Mark Sculpher, Karl Claxton and Ron Akehurst Discussion by: Trevor Sheldon 2 Valuing health outcomes: ten questions for the insomniac health economist 42 Paul Kind Discussion by: Martin Buxton 3 Eliciting equity-efficiency trade-offs in health 64 Alan Williams, Aki Tsuchiya and Paul Dolan Discussion by: John Hutton 4 Using longitudinal data to investigate socioeconomic inequality in health 88 Andrew Jones and Nigel Rice Discussion by: Matt Sutton 5 Regulating health care markets 121 Richard Cookson, Maria Goddard and Hugh Gravelle Discussion by: Brian Ferguson 6 Efficiency measurement in health care: recent developments, current practice and future research 148 Rowena Jacobs and Andrew Street
- 12. 7 Incentives andthe UK medical labour market 173 Karen Bloor and Alan Maynard Discussion by: Anthony Scott 8 Formula funding of health purchasers: towards a fairer distribution? 199 Katharina Hauck, Rebecca Shaw and Peter C. Smith Discussion by: Matt Sutton 9 Decentralization in health care: lessons from public economics 223 Rosella Levaggi and Peter C. Smith Discussion by: Guillem López Casasnovas 10 European integration and the economics of health care 248 Diane Dawson, Mike Drummond and Adrian Towse 11 Health economics and health policy: a postscript 272 Peter C. Smith, Mark Sculpher and Laura Ginnelly Index 280 vi Health policy and economics
- 13. LIST OF CONTRIBUTORS RonAkehurst is Dean and Professor of Health Economics in the School for Health and Related Research, University of Sheffield. Karen Bloor is Senior Research Fellow in the Department of Health Sciences, University of York. Martin Buxton is Professor of Health Economics and Director of the Health Economics Research Group at Brunel University. Karl Claxton is Senior Lecturer in the Department of Economics and Related Studies and Centre for Health Economics (CHE), University of York. Richard Cookson is Senior Lecturer in Health Economics in the School of Medicine Health Policy and Practice at the University of East Anglia. Diane Dawson is Senior Research Fellow in the Centre for Health Economics (CHE), University of York. Paul Dolan is Professor of Economics at the University of Sheffield. Mike Drummond is Professor of Health Economics and Director of the Centre for Health Economics (CHE), University of York. Brian Ferguson is Professor of Health Economics and Director of the Yorkshire & Humber Public Health Observatory, University of York. Laura Ginnelly is a Research Fellow in the Centre for Health Economics (CHE), University of York. Maria Goddard is Assistant Director and leads the Health Policy research team at the Centre for Health Economics (CHE), University of York. Hugh Gravelle is Professor of Economics and leads the National Primary Care Research and Development Centre at the Centre for Health Economics (CHE), University of York.
- 14. Katharina Hauck isa Research Fellow in the Centre for Health Economics (CHE), University of York. John Hutton is Senior Research Leader at MEDTAP International Inc, London. Rowena Jacobs is a Research Fellow in the Centre for Health Economics (CHE), University of York. Andrew Jones is Professor of Economics and Director of the Graduate Programme in Health Economics at the Department of Economics and Related Studies, University of York. Paul Kind is Senior Research Fellow and leads the Outcomes Research Group at the Centre for Health Economics (CHE), University of York. Rosella Levaggi is Professor of Public Economics in the Department of Economic Sciences at the University of Brescia. Guillem López Casasnovas is Professor of Economics and Director of the Centre for Research on Economics and Health (CRES) at Pompeu Fabra University. Alan Maynard is Professor of Health Economics, Department of Health Sciences and Director of the York Health Policy Group, University of York. He is also Chairman of the York NHS Trust. Nigel Rice is a Reader in Health Economics at the Centre for Health Economics (CHE), University of York. Anthony Scott is a Reader in Health Economics and Director of the Behaviour, Performance and the Organization of Care Pro- gramme at the Health Economics Research Unit, University of Aberdeen. Mark Sculpher is Professor of Health Economics and leads the team for Economic Evaluation and Health Technology Assessment at the Centre for Health Economics (CHE), University of York. Rebecca Shaw is a Research Graduate in the Department of Sociology, University of York. Trevor Sheldon is Professor in the Department of Health Sciences, University of York. Peter C. Smith is Professor of Economics at the University of York, where he is based in the Centre for Health Economics and the Department of Economics and Related Studies. Andrew Street is Senior Research Fellow and Assistant Director of the Health Policy Team at the Centre for Health Economics (CHE), University of York. Matt Sutton is Senior Research Fellow in the Department of General Practice and Primary Care at the University of Glasgow. Adrian Towse is Director of the Office of Health Economics. viii Health policy and economics
- 15. Aki Tsuchiya isLecturer in Health Economics at the University of Sheffield. Alan Williams is Professor of Economics at the Centre for Health Economics (CHE), University of York. List of contributors ix
- 17. SERIES EDITOR’S INTRODUCTION Health servicesin many developed countries have come under crit- ical scrutiny in recent years. In part this is because of increasing expenditure, much of it funded from public sources, and the pressure this has put on governments seeking to control public spending. Also important has been the perception that resources allocated to health services are not always deployed in an optimal fashion. Thus at a time when the scope for increasing expenditure is extremely limited, there is a need to search for ways of using existing budgets more efficiently. A further concern has been the desire to ensure access to health care of various groups on an equitable basis. In some countries this has been linked to a wish to enhance patient choice and to make service providers more responsive to patients as ‘consumers’. Underlying these specific concerns are a number of more funda- mental developments which have a significant bearing on the per- formance of health services. Three are worth highlighting. First, there are demographic changes, including the ageing population and the decline in the proportion of the population of working age. These changes will both increase the demand for health care and at the same time limit the ability of health services to respond to this demand. Second, advances in medical science will also give rise to new demands within the health services. These advances cover a range of possibilities, including innovations in surgery, drug therapy, screen- ing and diagnosis. The pace of innovation quickened as the end of the twentieth century approached, with significant implications for the funding and provision of services. Third, public expectations of health services are rising as those
- 18. who use servicesdemand higher standards of care. In part, this is stimulated by developments within the health service, including the availability of new technology. More fundamentally, it stems from the emergence of a more educated and informed population, in which people are accustomed to being treated as consumers rather than patients. Against this background, policy makers in a number of countries are reviewing the future of health services. Those countries which have traditionally relied on a market in health care are making greater use of regulation and planning. Equally, those countries which have traditionally relied on regulation and planning are moving towards a more competitive approach. In no country is there complete satisfaction with existing methods of financing and delivery, and everywhere there is a search for new policy instruments. The aim of this series is to contribute to debate about the future of health services through an analysis of major issues in health policy. These issues have been chosen because they are both of current interest and of enduring importance. The series is intended to be accessible to students and informed lay readers as well as to special- ists working in this field. The aim is to go beyond a textbook approach to health policy analysis and to encourage authors to move debate about their issues forward. In this sense, each book presents a summary of current research and thinking, and an exploration of future policy directions. Professor Chris Ham Professor of Health Policy and Management University of Birmingham xii Health policy and economics
- 19. ACKNOWLEDGEMENTS Numerous people contributedwittingly or otherwise to the prepar- ation of the book. We must acknowledge the constructive comments of the discussants, some of whom have contributed short commen- taries to the book chapters. The participants at the CHE conference provided invaluable observations on many of the contributions. Rachel Gear and Hannah Cooper at Open University Press offered timely support throughout the project. Mike Drummond, the dir- ector of CHE, has provided unstinting support throughout, and our colleagues Stephanie Cooper, Helen Parkinson and Trish Smith con- tributed excellent secretarial and administrative assistance. The con- tributions of these and others undoubtedly improved considerably the contents of the book, and our thanks are due to all.
- 21. INTRODUCTION Peter C. Smith,Mark Sculpher and Laura Ginnelly Health policy poses some of the greatest challenges for modern economies. The proportion of gross domestic product (GDP) attrib- uted to health care is growing rapidly in almost all developed coun- tries, yet traditional methods of financing health care are coming under strain. Life expectancies are increasing, but health disparities are an enduring policy issue in many countries. The providers of health care – especially doctors – are uniquely powerful interest groups that policymakers challenge at their peril. New technologies arrive at an accelerating pace, and there are often formidable pres- sures to adopt them quickly. And the expectations of an increasingly assertive citizenry grow steadily. These challenges reflect an increasing need to deploy scarce resources to the best possible effect. Management of scarcity is a central preoccupation of the economics discipline, so it is not surprising to find that policymakers have turned to economists for advice. This book documents many of the successful influences of economic ideas on health policy. However, its more important purpose is to look forward to future policy challenges, and to assess the potential contribution economic analysis might make to address- ing them. In doing so, we recognize that, when used as a basis for policy analysis in the health field, traditional economic methods often need to be complemented by insights from other perspectives. Where possible, we therefore seek to emphasize the important links with other disciplines. Modern economics is usually traced back to 1776, when Adam Smith published The Wealth of Nations. That work irrevocably associated the discipline with the functioning of markets. However, in the intervening period, economists have sought to extend their
- 22. purview to almostall aspects of human endeavour. They came to health quite late. The genesis of what we now know as health economics is often said to be the seminal 1963 article by Kenneth Arrow, which sought to apply traditional economic principles to the analysis of health care (Arrow 1963). Since the publication of Arrow’s paper, it has become clear that health and health care offer an abundance of problems to which the tools of economic analysis can be applied, and that the analytic and empirical findings have very important messages for policy. The Handbook of Health Economics documents just how extensive the scope and policy impact of economic analysis in the health domain has become (Culyer and Newhouse 2000). The contributions embrace micro models of the behaviour of individual patients and health professionals, evaluative studies of health care organizations, public health and medical interventions, design of financing and incentive mechanisms, and macro issues of law and regulation. A particularly noteworthy characteristic of health economists has been their willingness to work with other disciplines (such as physicians, epidemiologists and statisticians). In the UK, our colleague Alan Williams was one of the first to realize the potential of economic analysis applied to health, and in a distinguished career has made numerous influential contributions to academic and policy debates (Culyer and Maynard 1997). The Health Economics Study Group met for the first time in York in 1972, as a conscious attempt to establish health economics as a distinct discipline, and has since gone from strength to strength (Croxson 1998). A distinctive feature of the group has been a strong interest in and influence on policy (Hurst 1998). Many nations have established their own health economics associations, and in 1993 the International Health Economics Association was established. It now has about 2500 members and has held four conferences, the third of which was in York in 2002, attracting over 1300 delegates and presentations from two Nobel laureates. In 1983 the University of York established the Centre for Health Economics (CHE), one of the first research institutes specializing in the economics of health, with Alan Maynard as the first director.1 The Centre has flourished, and is now led by Mike Drummond. This book arises from a conference held to celebrate the twentieth anniversary of its foundation. At least one author of each conference chapter was a current member of CHE, and each chapter was discussed by a distinguished alumnus or former associ- ate of CHE. We include most of those discussions as postscripts to 2 Health policy and economics
- 23. the relevant chapter.For obvious reasons, the book focuses espe- cially on UK health policy. However, we have sought to draw out the implications of our findings for mature health systems of all sorts. The logic of the book is to start with micro, patient-level issues and to progress to macro, whole-system issues. In the concluding chapter we argue that – at least in principle – the micro/macro distinction is artificial. However, we hope the reader finds the progression to be a useful organizing principle. Chapters 1 and 2 therefore address the problem of determining the most cost-effective forms of management to offer patients. Chapters 3 and 4 then consider issues of fairness and the distribution of health within the population. In Chapters 5, 6, 7 and 8, we move on to examine performance measurement and incentives for organizations and individual workers. In conclusion, Chapters 9 and 10 examine the implications of the simultaneous pressures for both increased decentralization and increased internationalization of health systems. We conclude this introduction by briefly summarizing the contribution of each chapter. Almost all health systems have – either explicitly or implicitly – to make decisions about which health care programmes and interven- tions to fund from collective resources. These ‘reimbursement decisions’ are in practice unavoidable, even in situations of severe limitations in the evidence base. In this domain, seeking to select the most cost-effective interventions has been widely accepted as a guiding principle. England and Wales has therefore established the National Institute for Clinical Excellence (NICE) to make such principles operational, and equivalent institutions are being created in many other countries. However, as Sculpher, Claxton and Akehurst (Chapter 1) explain, the work of such organizations has exposed thorny methodological issues that have previously not been dealt with explicitly. They argue that conventional neoclassical welfare economics has limitations in assessing the value of health care programmes. Rather, the problem of identifying efficient health care interventions should be seen as one of constrained maximization. This requires careful definition of the objective function and of the range of constraints facing the system. This process, as well as that of synthesizing available evidence and the analytical tasks of identifying cost-effective interventions and assessing the value and optimal design of future research, emphasizes the multi-disciplinary nature of health technology assessment and economic evaluation. Introduction 3
- 24. The valuation ofhealth outcomes is central to the delivery and evaluation of health care. In its infancy, health economics (and its practitioners) demanded intellectually rigorous but simple tools with which to prosecute its science. This resulted in the development of instruments such as quality-adjusted life years (QALYs). The widespread practical acceptance of such methods is, in many respects, a triumph for those researchers. It is also a beacon for other, more mature areas of economic inquiry to emulate. However, as Kind documents (Chapter 2), there remain some important methodological and practical challenges to resolve if the QALY approach is to continue to answer the needs of policymakers in the future. Disparities in health status and access to health care are dominant themes in many policy debates. However, debates on the concept of fairness are often confused and lacking in rigour, and equity has hitherto played hardly any explicit role in the conduct of economic evaluations of health care technologies. Yet NICE and similar bodies are explicitly charged with taking equity into account. Williams, Tsuchiya and Dolan (Chapter 3) consider how the views of citizens might be elicited in an intellectually coherent manner, such as to be usable by bodies like NICE. The intention is to offer an economic framework within which considerations of efficiency and equity can be balanced. There is a rich tradition of economic analysis of income inequal- ity. Within this tradition, Jones and Rice (Chapter 4) examine the extent to which health and health care utilization are unequally dis- tributed by income. They argue that only by developing a proper understanding of the causal mechanisms generating these inequal- ities will it be possible to develop effective policies. Their methods involve the analysis of panel data (repeated observations for indi- vidual respondents) rather than the more usual cross-sectional (one-off) survey data. Such data resources are becoming increasingly common, and offer the prospect of gaining important insights into the dynamics of health and its relation to socioeconomic character- istics. The analysis entails the use of advanced econometric tech- niques which – while challenging in detail to the lay reader – offer the prospect of major advances in policy understanding of inequalities. Mainstream economics offers numerous prescriptions for the organization and regulation of complex industries. It is therefore somewhat surprising that – outside of the USA – the economics of industrial organization has had little impact on health policy. Cookson, Goddard and Gravelle (Chapter 5) examine the relevance 4 Health policy and economics
- 25. of economic analysisin this domain, and raise questions that policymakers should be asking. Examples of policy issues include the link between the size of organizations and performance, the impact of different risk-sharing arrangements, the design of incen- tives, the role of private sector providers, the design of purchaser- provider contracts and the implications of patient choice. The chapter demonstrates the importance of having good economic models with which to address such questions and to guide empirical research. A particularly central concern for empirical work is the need to develop good measures of organizational performance. The World Health Report 2000, and subsequent work at the Organization for Economic Co-operation and Development (OECD), has identified performance measurement as a crucial instrument for securing sys- tem improvements. Yet health care is in many respects a uniquely complex industry, and many existing measurement instruments are very weak, particularly in the domain of clinical quality. Jacobs and Street (Chapter 6) examine future prospects for the measurement and reporting of organizational performance in health and health care, with a particular emphasis on efficiency measurement. Increas- ingly, sophisticated econometric tools are being used to draw infer- ences about organizational efficiency, but are they ready for such use? Health care is a labour intensive undertaking, so it is hardly surprising that workforce planning and the health labour markets are key concerns for most health systems. The policy concern is heightened by acute labour shortages in some countries. Mainstream economics offers insights into how substitution possibilities and incentives can be used to promote labour force flexibility, encouraging efficient changes in the mix of inputs into the produc- tion process. Bloor and Maynard (Chapter 7) demonstrate the importance of rigorous designs in evaluating these issues, illustrated with recent trends and reforms in the UK labour market. Fair financing is a core issue in all types of health system. Traditionally, the intention has been merely to create a level playing field, with the aim of ensuring that all citizens can gain access to the current standard level of health care (securing horizontal equity). The question of whether the current standard is in line with policy intentions is rarely addressed. However, recent policy in England has shifted to a more radical concept of fair financing, in the form of reducing avoidable health disparities (moving towards vertical equity). Hauck, Shaw and Smith (Chapter 8) examine from a Introduction 5
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- 27. appointed hour; thedaring of the others had evidently been dispelled by portentous dreams. From the western end of the village we crossed “the Strait of the Sun” to the foot of the mountain. Some coolies had preceded us, and cleared away a path up the steep acclivity; but soon our only road was the narrow bands where large masses of rocks and sand, which had been loosened from some place high up the mountain, and shot down in a series of small land- slides, ploughing up the low shrubbery in their thundering descent. As long as we climbed up among the small trees, although it was difficult and tiring, it was not particularly dangerous until we came out on the naked sides of the mountain, for this great elevation is not covered with vegetation more than two-thirds of the distance from its base to its summit. This lack of vegetation is caused by the frequent and wide land-slides and by the great quantity of sulphur brought up to its top by sublimation and washed down its sides by the heavy rains. Here we were obliged to crawl up on all fours among small, rough blocks of porous lava, and all spread out until our party formed a horizontal line on the mountain-side, so that when one loosened several rocks, as constantly happened, they might not come down upon some one beneath him. Our ascent now was extremely slow and difficult, but we kept on, though sometimes the top of the mountain seemed as far off as the stars, until we were within about five hundred feet of the summit, when we came to a horizontal band of loose, angular fragments of lava from two to six inches in diameter. The mountain-side in that place rose at least at an angle of thirty-five degrees, but to us, in either looking up or down, it seemed almost perpendicular. The band of stones was about two hundred feet wide, and so loose that, when one was touched, frequently half a dozen would go rattling down the mountain. I had got about half- way across this dangerous place, when the stones on which my feet were placed gave way. This, of course, threw my whole weight on my hands, and at once the rocks, which I was holding with the clinched grasp of death, also gave way, and I began to slide downward. The natives on either side of me cried out, but no one dared to catch me for fear that I should carry him down also. Among the loose rocks, a few ferns grew up and spread out their leaves to the sunlight. As I felt myself going down, I chanced to roll to my right
- 28. side and noticeone of them, and, quick as a flash of light, the thought crossed my mind that my only hope was to seize that fern. This I did with my right hand, burying my elbow among the loose stones with the same motion, and that, thanks to a kind Providence, was sufficient to stop me; if it had broken, in less than a minute— probably in thirty or forty seconds—I should have been dashed to pieces on the rough rocks beneath. The whole certainly occurred in a less space of time than it takes to read two lines on this page. I found myself safe—drew a long breath of relief—thanked God it was well with me—and, kicking away the loose stones with my heels, turned round and kept on climbing. Above this band of loose stones the surface of the mountain was covered with a crust formed chiefly of the sulphur washed down by the rains, which have also formed many small grooves. Here we made better progress, though it seemed the next thing to climbing the side of a brick house; and I thought I should certainly be eligible to the “Alpine Club”—if I ever got down alive. At this moment the natives above us gave a loud shout, and I supposed of course that some one had lost his footing and was going down to certain death. “Look out! Look out!—Great rocks are coming!” was the order they gave us; and the next instant several small blocks, and one great flake of lava two feet in diameter, bounded by us with the speed of lightning. “Here is another!” It is coming straight for us, and it will take out one of our number to a certainty, I thought. I had stood up in the front of battle when shot and shell were flying, and men were falling; but now to see the danger coming, and to feel that I was perfectly helpless, I must confess, made me shudder, and I crouched down in the groove where I was, hoping it might bound over me: and at that instant, a fragment of lava, a foot square, leaped up from the mountain and passed directly over the head of a coolie a few feet to my right, clearing him by not more than five or six inches. I took it for granted that the mountain was undergoing another eruption, and that in a moment we should all be shaken down its almost vertical sides; but as the rocks ceased coming down we continued our ascent, and soon stood on the rim of the crater. The mystery concerning the falling rocks was now solved. One of our number had reached the summit before the rest of us, and, with the aid of a native, had been
- 29. tumbling off rocksfor the sport of seeing them bound down the mountain, having stupidly forgotten that we all had to wind part way round the peak before we could get up on the edge of the summit, and that those of the party who were not on the top must be directly beneath him. The whole mountain is a great cone of small angular blocks of trachytic lava and volcanic sand, and the crater at its summit is only a conical cavity in the mass. It is about eighty feet deep and one hundred or one hundred and fifty yards in diameter. The area on the top is elliptical in form, about three hundred yards long and two hundred wide. This, on the eastern side, is composed of heaps of small lava-blocks, which are whitened on the exterior, and, in many places, quite incrusted with sulphur. Through the heaps of stones steam and sulphurous acid gas are continually rising, and we soon hurried around to the windward side to escape their suffocating fumes, and in a number of places we were glad to run, to prevent our shoes from being scorched by the hot rocks. On the western side of the crater the rim is largely composed of sand, and in one place rises one hundred and twenty feet higher than on the eastern side. The top, therefore, partly opens toward the east, and from some of the higher parts of Lontar most of the area on the summit of this truncated cone can be seen. In the western part were many fissures, out of which rose sheets and jets of gas. When we had reached the highest point on the northwest side, we leaned over and looked directly down into the great active crater, a quarter of the distance from the summit to the sea. Dense volumes of steam and other gases were rolling up, and only now and then could we distinguish the edges of the deep, yawning abyss. Here we rested and lunched, enjoying meanwhile a magnificent view over the whole of the Banda group when the strangling gas was not blown into our faces. Again we continued around the northern side, and came down into an old crater, where was a large rock with “Ætna,” the name of a Dutch man-of-war, carved on one of its sides, and our captain busied himself for some time cutting “Telegraph,” the name of our yacht, beneath it. Great quantities of sulphur were seen here, more, the governor said, than he had noticed on any mountain in Java, for the abundance of sulphur they all yield is one of the characteristics of
- 30. the volcanoes ofthis archipelago. It was now time to descend, and we called our guide, to whom some one had given the classical prænomen of Apollo (a more appropriate title at least than Mercury, for he never moved with winged feet); but he could not tell where we ought to go, every thing appeared so very different when we looked downward. I chose a place where the vegetation was nearest the top, and asked him if I could go down there, to which, of course, he answered yes, as most people do when they do not know what to say, and must give some reply. I had brought up with me an alpen-stock, or long stick, slightly curved at one end, and with this I reached down and broke places for my heels in the crust that covered the sand and loose stones. For hundreds of feet beneath me the descent seemed perpendicular, but I slowly worked my way downward for more than ninety feet, and had begun to congratulate myself on the good progress I was making. Soon, I thought, I shall be down there, where I can lay hold of that bush and feel that the worst is past, when I was suddenly startled by a shout from my companions, who were at some distance on my right. “Stop! Don’t go a step farther, but climb directly up just as you went down.” I now looked round for the first time, and found, to my astonishment, that I was on a tongue of land between two deep, long holes or fissures, where great land-slides had recently occurred. I had kept my attention so fixed on the bush before me that I had never looked to the right or left—generally a good rule in such trying situations. To go on was to increase my peril, so I turned, climbed up again, and passed round the head of one of these frightful holes. If at any time the crust had been weak, and had broken beneath my heels, no earthly power could have saved me from instant death. As I broke place after place for my feet with the staff, I thought of Professor Tyndal’s dangerous ascent and descent of Monte Rosa. At last I joined my companions, who had found the way we had come up, and after some slips and sprains, and considerable bruising, we all reached the bottom safely, and were glad to be off the volcano, and, landing on Banda Neira, feel ourselves on terra firma once more.
- 31. ASCENT OF BURNINGMOUNTAIN; BANDA. For a few days I could scarcely walk or move my arms, but this lameness soon passed away; not so with the impressions made on my mind by those dangers: and even now, when I am suddenly aroused from sleep, for a moment the past becomes the present,
- 32. and I amonce more on the tongue of land, with a frightful gulf on either hand, or I am saving myself by grasping that fern. According to the statements of the officials, many years ago a gentleman had the hardihood to attempt to ascend this mountain alone. As he did not return at the expected time, a party of natives was sent to search for him, and his dead body was found some distance beneath the summit. The rocks to which he had intrusted himself had probably given way, and the only sensation that could have followed was one of falling and a quick succession of stunning blows, and life was gone. Governor Arriens assured me that the band of loose stones was the most dangerous place he had ever crossed, though he had climbed many nearly perpendicular walls, but always where the rocks were fixed and could be relied on for a footing and a hold. If the ascent and descent were not so difficult, sulphur might be gathered in such quantities at the summit crater that it would form an important article of export. The authorities informed me that much was obtained in former times, and that the natives who undertook this perilous climbing were always careful to array themselves in white before setting out, so that if they did lose their lives in the attempt they would be dressed in the robes required by their creed, and at once be taken to Paradise. The first European who reached its summit, so far as I am aware, was Professor Reinwardt, in 1821; the second was Dr. S. Müller, in 1828; and from that time till the 13th of September, 1865, when we ascended it, only one party had attempted this difficult undertaking, and that was from the steamer Ætna, whose name we had found on a large rock in the old crater. The height of this volcano we found to be only two thousand three hundred and twenty-one English feet. Its spreading base is considerably less than two miles square. In size, therefore, it is insignificant compared to the gigantic mountains on Lombok, Java, and Sumatra; but when we consider the great amount of suffering and the immense destruction of property that has been caused by its repeated eruptions, it becomes one of the most important volcanoes in the archipelago.[37] In 1615 an eruption occurred in March, just as the Governor-General, Gerard Reynst, arrived from Java with a large
- 33. fleet to completethe war of extermination that the Dutch had been waging with the aborigines for nearly twenty years. For some time previous to 1820, many people lived on the lower flanks of Gunong Api, and had succeeded in forming large groves of nutmeg-trees. On the 11th of June of that year, just before twelve o’clock, in an instant, without the slightest warning, an eruption began which was so violent that all the people at once fled to the shore and crossed over in boats to Banda Neira. Out of the summit rose perpendicularly great masses of ashes, sand, and stones, heated until they gave out light like living coals. The latter hailed down on every side, and, as the accounts say, “set fire to the woods and soon changed the whole mountain into one immense cone of flame.” This happened, unfortunately, during the western monsoon; and so great a quantity of sand and ashes was brought over to Banda Neira, that the branches of the nutmeg-trees were loaded down until they broke beneath its weight, and all the parks on the island were totally destroyed. Even the water became undrinkable, from the light ashes that filled the air and settled down in every crevice. The eruption continued incessantly for thirteen days, and did not wholly cease at the end of six weeks. During this convulsion the mountain was apparently split through in a north-northwest and south-southeast direction. The large, active crater which we saw beneath us on the northwestern flanks of the mountain, from the spot where we stopped to lunch, was formed at that time, and another was reported higher up between that new crater and the older one on the top of the mountain. A stream of lava poured down the western side into a small bay, and built up a tongue of land one hundred and eighty feet long. The fluid rock heated the sea within a radius of more than half a mile, and nearer the shore eggs were cooked in it. This stream of lava is the more remarkable, because it is a characteristic of the volcanoes throughout the archipelago, that, instead of pouring out molten rock, they only eject hot stones, sand, and ashes, and such materials as are thrown up where the eruptive force has already reached its maximum and is growing weaker and weaker.
- 34. On the 22dof April, 1824, while Governor-General Van der Capellen was entering the road, an eruption commenced, just as had happened two hundred and nine years before, on the arrival of Governor-General Reynst. A great quantity of ashes again suddenly rose from its summit, accompanied by clouds of “black smoke,” in which lightnings darted, while a heavy thundering rolled forth that completely drowned the salute from the forts on Neira. This was followed, on the 9th of June, by a second eruption, which was succeeded by a rest of fourteen days, when the volcano again seemed to have regained its strength, and once more ashes and glowing stones were hurled into the air and fell in showers on its sides. But the people of Banda have suffered quite as much from earthquakes as from eruptions, though the latter are usually attended by slight shocks.[38] Almost the first objects that attract one’s attention on landing at the village are the ruins caused by the last of these destructive phenomena. Many houses were levelled to the ground, but others that were built with special care suffered little injury. Their walls are made of coral rock or bricks. They are two or three feet thick and covered with layers of plaster. At short distances, along their outer side, sloping buttresses are placed against them, so that many of the Banda residences look almost as much like fortifications as dwelling-houses. The first warning any one had of the destruction that was coming was a sudden streaming out of the water from the enclosed bay, until the war-brig Haai, which was lying at anchor in eight or nine fathoms, touched the bottom. Then came in a great wave from the ocean which rose at least to a height of twenty-five or thirty feet over the low, western part of the village, which is only separated from Gunong Api by the narrow Sun Strait. The praus lying near this shore were swept up against Fort Nassau, which was then so completely engulfed, as it was stated to me on the spot, that one of these native boats remained inside the fort when the water had receded to its usual level. The part of the village over which the flood swept contained many small houses, and nearly every one in them was carried away. The rapid outflowing of the water of this enclosed bay (which is really only an old crater) was
- 35. probably caused eitherby the elevation of the bottom at that spot, or else by such a sinking of the floor of the sea outside, that the water was drained off into some depression which had suddenly been formed. We have no reason to suppose that there was any great commotion in the open ocean, and certainly there was no high wave or bore, or it would have risen on the shores of the neighboring islands. There are three entrances or straits which lead from the road out to the open sea. Two of these are wide and one is narrow. When the whole top of the old volcano, that is, Banda Neira, Gunong Api, Lontar, and the area they enclose, was raised for a moment, the water steamed out from the crater through these straits, causing only strong currents, but as the land instantly sank to its former level, the water poured in, and the streams of the two wider straits, meeting and uniting, rolled on toward the inner end of the narrow strait. Here they all met, and, piling up, spread out over the adjoining low village, causing a great destruction of life. At the Resident’s house, a few hundred yards east of Fort Nassau, the water only rose some ten or fifteen feet above high-water level, and farther east still less. The cause assigned above, though the principal one, may therefore not have been sufficient in itself to have made the sea rise so high over the southwestern part of Banda Neira and the opposite part of Gunong Api, and I suspect that an additional cause was that the land there sank for a moment below its proper level. Valentyn thus describes another less destructive earthquake wave: “In the year 1629 there was a great earthquake, and half an hour afterward a flood which was very great, and came in calm weather. The sea between Neira and Selam” (on the western part of Lontar) “rose up like a high mountain and struck on the right side of Fort Nassau, where the water rose nine feet higher than in common spring floods. Several houses near the sea were broken into pieces and washed away, and the ship Briel, lying near by, was whirled round three times.”[39] However, all these events are but as yesterday when we glance over the early history of this ancient volcano; for, if we can judge by analogy, taking as our guide the great crater already referred to as this day existing among the lofty Tenger Mountains on Java, we see
- 36. in our mind’seye an immense volcanic mountain before us. From its high crater during the lapse of time pour out successive overflows of lava which has solidified into the trachyte of Lontar. That period is succeeded by one in which ashes, sand, and hot stones are ejected, and which insensibly passes into recent times. During one of these mighty throes the western half of the crater-wall disappeared beneath the sea, if the process of subsidence had gone on so far at that time. Slowly it sinks until it is at least four feet lower than at the present day, for we found on the western end of Lontar a large bank of coral rock at that height. The outer islands are now wholly submerged. This period of subsidence is followed by one of upheaval, but not till the slow-building coral polyps had made great reefs, which have become white, chalky cliffs, and attained their present elevation above the sea. A tropical vegetation by degrees spreads downward, closely pursuing the retreating sea, and the islands become exactly what they are at the present day. The Banda group form but a point in the wide area of the residency of Banda. All the eastern part of Ceram is included in it, the southwest coast of New Guinea, and the many islands south and southwest to the northern part of Timur. Southeast of Ceram are the Ceram-laut, that is, “Ceram lying to seaward,” or Keffing group, numbering seventeen islands. Their inhabitants are like those I saw on the south coast of Ceram, and do not belong to the Papuan or negro race. They are great traders, and constantly visit the adjoining coast of New Guinea, where they purchase birds of paradise, many luris or parrots of various genera, “crown pigeons,” Megapodiideæ, scented woods, and very considerable quantities of wild nutmegs, which they sell to the Bugis traders, who usually touch here at Banda on their outward and homeward passages. I saw many of the wild nutmegs that had been brought in this way from New Guinea. Instead of being spherical, like those cultivated here at Banda, they are elliptical in outline, frequently an inch or an inch and a quarter long, and about three-fourths of an inch in diameter. They do not, however, have the rich, pungent aroma of the Banda nutmegs, and this, I am assured, is also the case with all wild ones wherever found, and even with those raised on Sumatra and Pinang from seeds and plants originally carried from these islands. Wild nutmegs
- 37. are also foundon Damma southwest of Banda, and on Amboina, Ceram, Buru, Batchian, the Obi Islands, and Gilolo, also on the islands east of the latter, and on the northern coast of the western part of New Guinea. This fruit is widely planted by the “nut-crackers,” two large species of doves, Columba ænea, Tem., and Columba perspicillata, Tem., which swallow the nuts covered with the mace, the only part digested. The kernel enclosed in its hard, polished shell is soon voided, while it yet retains the germinating power, and a young tree springs up far from its parent. East of this group is that of Goram, composed of three islands, inhabited by natives who are Mohammedans. Southeast of Goram is the Matabella group. Indeed, these groups are so united that they form but one archipelago. The Ceram-laut Islands are low, but those of Goram and Matabella are high. On the island Teor, or Tewer, in the last group, there is a volcano which suffered a great eruption in 1659. Mr. Wallace describes the Matabellas as partly composed of coral reefs raised from three to four hundred feet. Sometimes these people go as far west as Sumbawa and Bali. The “Southeastern Islands” begin on the north with the Ki group, ten in number, south of the former archipelago. Three of the Kis are large islands and two are high, a peak on one being estimated at about three thousand feet. They are so well peopled that they are supposed to contain over twenty thousand souls. The natives are very industrious, and famous as boat-builders. The wood they use comes from their own hill-sides, and they need no iron to complete boats of considerable size, which they sell to the inhabitants of all that part of the archipelago. Farther to the east are the Aru (in Dutch, Aroe) Islands, that is, “the islands of the casuarina-trees.” They number about eighty, and are very low, forming a chain about a hundred miles long and half as broad. When seen on the west they appear as one continuous, low island; but on coming nearer, intricate channels are found winding among them, through which set strong tidal currents. The people are said to closely resemble those of Haruku, Saparua, and Nusalaut. The total population is given at only fourteen thousand. A few are Christians, and two or three native schoolmasters from Amboina are employed there. Papuans are said to live on the most eastern island. Large quantities of tripang are
- 38. gathered on theshallow coral banks of these low islands, and in the sea the dugong, Halicore dugong, Cuv., is seen. The great bird of paradise, P. apoda, is found here, and also the red bird of paradise, P. regia. The skins of these beautiful birds were probably brought here to Banda and sold to the Chinese traders for many ages, but the first account we have of them is by Pigafetta, who accompanied Magellan’s fleet. He says that the king of Bachian, an island west of the southern end of Gilolo, gave his companions a slave and nearly two hundred pounds of cloves as a present for their Emperor, Charles V., and also “two most beautiful dead birds. These are about the size of a thrush, have small heads, long bills, legs a palm in length and as slender as a writing-quill. In lieu of proper wings, they have long feathers of different colors, like great ornamental plumes. The tail resembles that of a thrush. All the feathers except those of the wings are of a dark color. It never flies except when the wind blows. We were informed these birds came from the terrestrial Paradise, and they called them bolondinata,[40] that is, ‘birds of God.’” This word the Portuguese translated into their language as “ave de paraiso,” and hence our name “birds of paradise,” a name well chosen, for in some species the feathers have all the appearance of the most brilliant jewels. Southwest of the Ki Islands lies Timur-laut, and passing on toward Timur we come to the “Southwestern Islands,” composed of the Baba, Sermatta, Letti, Roma, Wetta, and Lamma groups, which we noticed as we steamed away from Dilli. Returning northward from Wetta, we come to Gunong Api, an uninhabited volcano, rising between six and seven thousand feet above the sea. It is a well-known landmark for the ships bound to China that have passed up the Ombay Passage, or those coming down the Floris Sea, intending to pass out through that strait into the Indian Ocean. Northeast of Gunong Api are the Lucipara and Turtle (in Dutch Schilpad) Islands, which praus from Amboina frequently visit for tortoise-shell. East of Gunong Api is Nila, an active volcano, about seventeen hundred feet in height, and north of it is Serua, which is merely a volcanic cone rising abruptly from the sea. In 1694 a great eruption took place in this volcano. A part of the crater wall
- 39. fell in, andthe lava overflowed until the whole island is represented as having become one “sea of fire,” and all the inhabitants were obliged to flee to Banda. Again, in September, 1844, after a rest of a hundred and fifty years, another eruption began, which compelled every one to leave its inhospitable shores once more. Since that time it has been settled again, and here in Banda are many of the boats its people bring in the latter part of this month, when continuously for days not a breeze ripples the glassy sea—halcyon days indeed. As the natives have no iron, the whole boat is built of wood. The central part is low, but the bow and stern curve up high, quite different from all I have seen in any other part of the archipelago, and reminding one of the representations usually given of those used in some parts of the South Sea. While I had been turning my attention to geology, the native who was assisting me to collect shells was searching for a “hunter,” that is, one who can skin birds. He soon had the good fortune to find one, who was also a native of Amboina, for all these natives dislike those of another village, and only associate with them when they can find none of their own people. During the few days we were at the Bandas they collected several species of most beautiful kingfishers; indeed, those who have seen only our sombre-colored specimens can scarcely conceive of the rich plumage these birds assume in the tropical East. They were also so fortunate as to find a few superb specimens of a very rare and valuable bird, with scarcely any tail, and having eight very different colors, the Pitta vigorsi. An allied species is found on the Arru Islands, and another on Buru, a third on Gilolo, and a fourth on Celebes, but none is yet known on the great island of Ceram. We now steamed back to Amboina, and while the yacht was taking in coal and preparing to go to Ceram, I crossed over Laitimur with the governor. Our procession was headed by a native carrying a large Dutch flag, and after him came a “head man,” supported on the right by a man beating a tifa, and on the left by another beating a gong. Then came the governor, borne in a large chair by a dozen coolies, and I, in a similar chair, carried by the same number. From the city we at once ascended a series of hills, sparsely covered with
- 40. shrubbery, and composedof a soft red sandstone, which is rapidly disintegrating, and is evidently of very recent origin. It is found on the highest elevation we crossed, which is from fifteen to eighteen hundred feet above the sea. Near this point we descended into a small ravine, where the soft sandstone had been washed away, and the underlying rocks were exposed to view. Here we found feldspathic porphyry and serpentine. Thence we crossed other hills of sandstone and came down to the sea-shore at the village of Rutong. We were hoping to find a small hill of granite that Dr. Schneider had discovered, but we were not able to identify the places he describes. Dr. Bleeker, who crossed over to Ema in 1856, remarks that the first hills he ascended were composed of coral rock, and that he came on to it again when he descended toward the sea- shore. We did not notice it at this time, but, on my first excursion to the cocoa plantation on Hitu, I found a long coral reef, fully five hundred feet above the sea. It was a perfect repetition of the reef I visited in the bay of the Portuguese village of Dilli, at the northern end of Timur. A small place had been cleared on its crest, and there I found several pairs of the huge valves of the Tridacna gigas, which appeared from their relative position to have been once partially surrounded by the soft coral rock, which, having been washed away, allowed the valves to fall apart. They were much decayed, but had not lost more than half their weight. They had evidently never been brought there by men; because the natives rarely or never use them for food. There is no need that they should take the trouble to gather such enormous bivalves when they have a plenty of sago-palms, and all that it is necessary for them to do to obtain an abundance of food is to cut down these trees and dig out the pith. If, in former times, they did collect the Tridacna for food, they never would have carried these great shells, each of which originally weighed a hundred pounds or more, a mile back among the hills, but would have taken out the animal and left them on the shore. Governor Arriens, who had carefully studied these recent reefs, stated to me that he had found them as high up as eight hundred feet above the sea, but at that elevation they seem to disappear. When returning we stopped for some time on the hills back of the city to enjoy a magnificent view of the bay and the high hills rising on
- 41. the opposite side.Just then the broad strati, floating in the west, parted, and rays of bright sunlight, darting through their fissures, lighted up the dark water beneath us. There were not many vessels and praus at anchor off the city at that time, but I was informed that in about a month later many would arrive, for the dry season, with its clear sky and light winds, had set in about the 15th of September, when we arrived from Banda. About two hundred vessels and praus of all kinds come to Amboina in a year. The praus are owned and commanded by the natives themselves, but most of the vessels are commanded by mestizoes and owned by Arabs and Chinese, who carry on the larger part of the trade in the eastern part of the archipelago. Since a line of steamers has been established, these Arabs and Chinese avail themselves of that means of importing their goods from Batavia and Surabaya, where they are received directly from Europe. The total value of the imports is from a half to three-quarters of a million of guilders. The chief article is cotton fabrics, and the next rice, which is shipped here all the way from Java and Sumatra for the sustenance of the troops. Very little rice is raised on any of these islands, because there are no low, level lands suitable for its cultivation. In the Bandas the whole attention of the population is so devoted to cultivating the nutmeg that they are entirely dependent on other islands for a supply of food. The most important exports from this island are cloves, cocoa, kayu-puti oil, nutmegs, various kinds of woods, and mace. Formerly the inhabitants of Ceram-laut, Goram, and the Arru Islands were accustomed to bring their tripang, tortoise- shell, paradise birds, and massoi-bark to this port to sell to the Bugis, but for the last forty or fifty years the Bugis have gone from Macassar directly to those islands and traded with the people at their own villages. In 1854, Amboina, Banda, Ternate, and Kayéli, were made free ports, but this has not materially increased the trade at any of those places. The period when the trade at Amboina was most flourishing was when it was last held by the English, from 1814 to 1816. The port was then free, but, when it once more passed into the hands of the Dutch, duties were again demanded, which forced the trade into
- 42. other channels, whereit still remains, notwithstanding there are now no duties. The proper remedy has been applied, but applied too late. This is also the history of the trade at Batavia, where the heavy duties have induced the traders of the eastern part of the archipelago to sail directly to the free port of Singapore. I had been at Amboina a long time before I could ascertain where the grave of Rumphius is located, and even then I found it only by chance—so rarely is this great man spoken of at the present time. From the common, back of the fort, a beautifully-shaded street leads up to the east; and the stranger, while walking in this quiet retreat, has his attention drawn to a small, square pillar in a garden. A thick group of coffee-trees almost embrace it in their drooping branches, as if trying to protect it from wind and rain and the consuming hand of Time. Under that plain monument rest the mortal remains of the great naturalist. The inscription, which explains itself, and shows how nearly this sacred spot came to be entirely neglected and forgotten forever, reads as follows: memoriæ saorum georgii everardi rumphii, de re botanica et historica naturali optime merita tumulum dira temporis calamitate et sacrilegia manufere dirutum, Manibas placatis restitui jussit et pietatem reverentiamque publicam testificans hoc monumentum ipse consecravit Godaras Alexander Grardus Phillipus Liber Baro A. Capellen Totius Indiæ Belgicæque prefectus regius. Amboinæ Mensis Aprilis, Anno Domini m.dccc.xxiv.
- 43. George Everard Rumpf,whose name has been latinized into Rumphius, as an acknowledgment of the great service he has rendered to the scientific world, was a German, a native of a small town in Hesse-Cassel. He was born about the year 1626, and, having studied medicine, at the age of twenty-eight went to Batavia, entered the mercantile service of the Dutch East India Company, and thence proceeded to Amboina, where he passed the remainder of his life. At the age of forty-two, while contemplating a voyage back to his native land, he suddenly became blind, and therefore never left his adopted island home; yet he continued to prosecute his favorite studies in natural history till his death, which occurred in 1693, when he had attained the ripe age of sixty-seven. His great work on the shells of Amboina, which was not published till 1705, twelve years after his death, was for a long time the acknowledged standard to which all conchological writers referred. His most extensive work, however, was the “Hortus Amboinense,” which was only rescued from the Dutch archives and published at the late date of forty-eight years after his death. It contains the names and careful descriptions of the plants of this region, their flowering seasons, their habitats, their uses, and the modes of caring for those that are cultivated. When we consider that, in his time, neither botany nor zoology had become a science, and consider, moreover, the amount and the accuracy of the information he gives us, we agree with his contemporaries in giving him the high but well- merited title of “the Indian Pliny.”
- 44. CHAPTER VIII. BURU. Sept. 25th.—Steameddown the bay from Amboina, this time not without a slight feeling of sadness as I recalled the many happy hours I had passed gathering shells on its shores and rambling over its high hills, and as I realized that it would probably never be my privilege to enjoy those pleasures again. Only three months had elapsed since my arrival at Batavia, but I had passed through so many and such different scenes, that Amboina appeared to have been my home for a year—and so it seems to this day. As we came out of the mouth of the bay, we changed our course to the west, and kept so near the land, that I had a fine opportunity to reëxamine the places I had visited during a heavy storm, when the sea was rolling into white surf and thundering along the shore. Off the western end of Ceram lie three islands, Bonoa, Kilang, and Manipa. Bonoa, the most easterly, is a hilly island about twelve miles long and half as broad. Its population is divided into Christians and Mohammedans, and each has such a bitter hatred against the other, that the Christians at last determined to expatriate themselves, and accordingly, in 1837, migrated to Bachian. The clove-gardens in Bonoa were thus in danger of being neglected, and the man who was governor of the Moluccas at that time therefore sent messengers to induce them to return; but, when this measure proved unavailing, he went himself in a war-ship, and brought them back. From Amboina we passed up the strait between Kilang and Manipa, which is less than a mile wide, and made much narrower by long tongue-shaped reefs of coral which project from several points. A fresh breeze had sprung up from the south, and, under a full head of steam and a good press of canvas, we ploughed through the waves which rolled up against the wind. In all these straits the tidal
- 45. currents are verystrong, and in many places so swift that a good boat cannot make headway against them with oars, and this makes many of these narrow channels very dangerous for the native boats. That evening the bright fires built by the fishermen on the shores of Bonoa were seen on our larboard side, and the next morning we were near the Seven Brothers, a group of islands on the west side of Sawai Bay. Here are three dangerous reefs not laid down on the charts, a mile or more from the shore. As we passed, mountains three or four thousand feet in height were seen standing by the sea near the head of the bay. At noon we came to anchor in the little harbor of Wahai, which is formed by coral reefs that are bare at low tide. Unfortunately, it is too small for sailing-ships to enter safely, or it would be visited occasionally by those of our whalers who frequent these seas. The whole village consists of a small fort, a house for the commandant, who has the rank of captain, a house for the doctor, and a few native huts on either hand. The only communication the inhabitants of this isolated post have with the rest of the world is by means of coolies, who cross over from the head of Elpaputi Bay to the head of Sawai Bay, and then come along the shore. All the natives in the interior are entirely independent of the Dutch Government, and the coast natives, who carry the mail, are liable to be robbed or killed at any moment while on their journey. My hunter at once began collecting birds, while I searched the shores for shells, and bought what the natives chanced to have in their miserable dwellings. The most common shell here is an Auricula. Its peculiar aperture, as its name implies, is like that of the human ear. It lives on the soft, muddy flats, where the many-rooted mangrove thrives. The rarest and most valuable shell found here, and indeed one of the rarest living in all these seas, is the Rostellaria rectirostris. It is so seldom found that a pair is frequently sold here for ten guilders, four Mexican dollars. My hunter soon returned with two large white doves, the Carpophaga luctuosa, and a very perfect specimen of that famous bird, the Platycercus hypophonius, G. R. Gray, called by the Malays the castori rajah, or “prince parrot,” from its being the most beautiful of all that brilliantly-plumaged family. It is a small bird for a parrot. The head, neck, and under parts are of a
- 46. bright scarlet; thewings a dark, rich green, and the back and rump a bright lapis-lazuli blue, that shades off into a deeper blue in the tail, which is nearly as long as the body. These birds generally fly in pairs, and as they dart through the evergreen foliage, and you catch a glimpse of their graceful forms and brilliant plumage, it seems like the momentary recollection of some dream of Paradise. Large flocks of red luris, Eos rubra, Gml., other species of parrakeets, and many sorts of doves, frequent the surrounding woods, and several species of kingfishers and snipes live by the shore. For three days I enjoyed this rare hunting. We then steamed out of the little bay of Wahai for the island of Buru. While passing Bonoa we kept near the shore, and saw a large white monument which was erected by the Portuguese, and is probably one of the padroes, or “pillars of discovery,” placed there by D’Abreu when he first reached these long-sought isles. Soon we passed Swangi, “Spirit Island,” a lonely rock near Manipa, supposed by these superstitious natives to be haunted by some evil spirit. Buru, the island to which we were bound, lies a few miles west of Manipa. Its area is estimated at about twenty-six hundred geographical square miles, so that it is one-half larger than Bali or Lombok. Its form is oval, with the greatest axis east and west. Its shores, instead of being deeply indented, like those of all the larger islands in that region, are entire, except on the northwest corner, where they recede and form the great bay of Kayéli. The entrance to this bay is between two high capes, three or four miles apart, so that on the northeast it is quite open to the sea. Within these capes the shores become low, forming on the southwest a large morass; and the bay expands to the east and west until it is about seven miles long. In the low lands bordering the south side of this bay is the Dutch “bezitting,” or post, also named Kayéli. Here is a small, well- built fort, in which are stationed a lieutenant and doctor, and a company of militia from Java or Madura. A controleur has charge of the civil department, and the governor had kindly given me a note to him, and he and his good lady at once received me kindly, and, as it proved, I made my home with them and the doctor for a long time. The plan the governor proposed was that we should leave for Ternate and New Guinea in five days after the steamer landed me at
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