Map of life expectancy at birth from Global Education Project.

Friday, February 24, 2006

Cleaning out the in-box

Well, I'm back in the real world, from my sojourn in the bowels of the federobble gummint. Let me say that there are still innumerable career civil servants toiling away to do what's right as best they can, but they are wading upstream through rivers of sewage.


1. Iraq. With Baghdad locked down, and today being the sabbath, violence has subsided, at least for the time being. While we can still hope that Iraqis will pull back from the abyss, the prospects are dim. The U.S. military stood by and made no attempt to provide security during the past two days, according to all accounts. (I have read the New York Times coverage, and additional coverage is available here and of course, here.) The reason is that they are trying to validate the policy of turning over security to the Iraqi forces. The problem is that there are no Iraqi forces -- the security services that the U.S. has been arming, financing, and training, are simply the militias of Shiite religious parties, in new uniforms. The Sunni Arabs are forced to defend themselves. It has long since become obvious that the U.S. has no discernible or coherent objectives in Iraq, and that the administration is just trying to play for time so as not to admit total failure before the November election. Too late.

2. Environmental Tobacco Culture. Professor Banzhaf, he of the friendly advice to local school board members about sugary soft drinks in the cafeteria, has an interesting take on efforts underway in Canada to ban smoking in most public outdoor spaces. Very few people in the public health community advocate prohibition of tobacco, both because we respect the liberty interests of people who smoke, and because of the counterproductive effects of prohibition of other drugs. However, there has been widespread support for measures, now very widely adopted, to ban smoking in indoor public places such as restaurants, theaters and workplaces, because environmental tobacco smoke is hazardous to non-smokers. As the saying goes, your right to swing your fist ends at the tip of my nose. Outdoors, though, smoke dissipates very quickly and there is no real hazard to anyone who isn't standing right next to the smoker.

Banzhaf, testifying on behalf of an ordinance to ban outdoor smoking in Calabasas, California, offers this rationale:

[C]hildren, as well as some slow adults, will begin to see and appreciate that smoking is no longer the norm to be emulated. Rather, smoking will join gambling, boozing it up, spitting, and certain sex-related pastimes as activities which, while not illegal, should nevertheless be done in private where they do not adversely affect or influence others."

Now this is interesting. It is an argument from the standpoint of public morality -- that allowing the practice to take place where people can observe it is corrupting, particularly of children. We may believe this to be true but there is a catch: this casts smoking in public as a form of expression. While meaning to trump the liberty interest, it actually elevates it by bringing in one of the freedoms we most zealously protect. This is a tough one, for me.

3. Cultural competency in mental health. In case you want to know what I was doing in Rockville, Maryland, it was talking with numerous of my colleagues about this question. To quote a person very close to me, "To try to measure cultural competency in mental health care is to enter an epistemological hall of mirrors." To provide mental health care means to apply diagnostic labels to people and then to try to cure or control the disease which you have declared them to have. That entire procedure can only exist within the context of your culture as a provider. The "client" or "patient" who you are "treating" may very well not believe that any such disease even exists, let alone that they have it, and his or her idea of cure or wellness may be very different from your own.

But you can't just let the client decide what constitutes a good outcome. The result could be highly offensive to society, to your career, or to the client's life expectancy. The culture does impose norms of behavior and wellness. We can criticize them, re-think them, even choose to violate them. But we cannot dispense with them.

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