No-brainer

Scott Shields at MyDD is right on target regarding an issue, universal health care, that should be both a no-brainer for GM and a no-brainer for Democrats. And that's a good trick.

More than $1500 of every GM car goes to pay for employer-based health benefits--benefits that are being reduced in ways that cut into worker productivity and security, even as they continue to put GM and other US automakers at a severe competitive disadvantage to Asian and European automakers.

It has puzzled many that US automakers and other corporate interests with the same problem do not jump on the universal healthcare bandwagon. Shields points to one explanation from Dave Lindorff at In These Times:

How can the same corporations that in Canada recognize the bottom-line logic of a national health system be so opposed to the idea here?

One answer is ideology. The notion of having the government take over an industry that represents about 15 percent of the U.S. economy gives U.S. executives the willies. But in backing insurance company interests, GM runs counter to both its own business interests and the sentiments of many customers. (ITT)

It's as good or better explanation as any and it rings true to these ears. Shields concludes:

As the General Motors layoffs are showing us, even though it may make some uncomfortable, a clear case is to be made for universal healthcare in the United States. Simply put, it's an issue of competitiveness. There's a reason GM is cutting thousands of jobs mostly in American factories. The executives will never admit it for political reasons, but the crushing burden of healthcare costs is taking away American jobs. While universal healthcare has long been an interest of the party, it's often pushed to the back, being seen as too controversial. But now that Democrats have seemed to find their footing and the will to fight back, it certainly seems the time has come for bold healthcare proposals supported by obvious economics. This issue should be a no-brainer for Democrats in 2006 and 2008.

But no-brainers are only no-brainers for people with brains. Another paradox.

[Cross-posted at Effect Measure]

Addendum: After posting this I found Paul Krugman has a column on the same topic in today's (11/25/05, p. A35) New York Times. It contains the additional information that Toyota spent only $201 per vehicle in North America and $97 in Japan, compared to over $1500 for GM.

Poli-Sci 101

You know what's really starting to frost my pumpkin? All the chatter I'm picking up from signals intelligence (yup, we monitor radio and TV broadcasts here at Stayin' Alive, to learn what we can about the worldwide idiocy conspiracy), about how the minor difficulties the U.S. has encountered in Iraq force us to assess whether the "idealistic" foreign policy goals of the neo-conservatives, to bring freedom™ and democracy™ to the world, must surrender to Kissingerian realpolitik.

Puh-leeze. The PNAC used the language of "democracy" to refer to the regimes it proposed to install in the Middle East, and they continued to put words about democracy and freedom into the mouth of President Mortimer Snerd after they seized power, but it is obvious what they really meant by the term. The new "democratic" government of Iraq was to be led by a person of their choosing -- specifically, a convicted embezzler who hadn't set foot in Iraq for decades -- and it was proposed that this "democratic" government would be friendly to Israel, would allow the United States to establish permanent military bases on its territory, and would allow U.S. corporations to extract, process and sell its petroleum. Since any government in Iraq that had popular support would do none of those things, it follows that "democracy" to the neo-cons means "regimes friendly to U.S. corporate interests."

We know that the preznit took Economics 101 because he talks about it all the time. Okay, that doesn't prove anything, but he did attend Harvard Business School so he must have at least sat in the back of the class. But it appears he did not take Political Science 101. In that course, you learn that political institutions depend on political culture -- that the expectations, aspirations, and norms people have about political participation, the role of government, loyalty to the state and the nature of the national interest are powerful limiting factors for the form of government.

You can't have a western-style secular democracy if you do not have the requisite political culture. You can't ride in on tanks and say, "Okay folks, now your country is a democracy, and you'd better act democratically or we'll blow you up," and expect results. The neo-cons may be blinded by ideology, but they aren't total idiots. They have always known that perfectly well. Their rhetoric about democracy™ and freedom™ is utterly cynical. The Iraq project was about installing a client regime, nothing else, and it was as Kissingerian as it could possibly be.

The alternative to imperialism, which is the correct label for neo-con policy, is working through international institutions to solve global problems. The U.S. has the world's most powerful economy, at least for now -- although we are squandering our wealth -- and is admired for its cultural achievements and for the ideals that it has lately failed to honor. Those are essential assets that we can use in exercising leadership. Military power, however, does not make for leadership, but for bullying -- which isn't working.

I'm going to be away from Your Internets for a couple of days. If we're lucky, you may hear from Revere. But I'll be back.

It's just one outrage after another

One major reason why there are racial and ethnic disparities in the health care people receive is that the health care workforce -- doctors, nurses, therapists, administrators -- is much less ethnically diverse than the country. Specifically, it's more than 90% anglophone European-American, i.e. white. That means that people who don't happen to be of the dominant culture are likely to have culturally discordant providers, that the culture within hospitals and other provider institutions is monolithic, and that there aren't a lot of people around who speak languages other than English, who understand the lives and worldviews of people who aren't of the dominant culture, who can readily perceive discriminatory and other inappropriate treatment, and who can advocate for cultural competency.

Since the Clinton administration, we've had a national goal to eliminate health disparities by 2010. Well, we sure ain't gonna get there. Diversifying the health care workforce is a key part of the strategy, but evidently the Bush administration isn't staying the course. According to Elena Rios of the National Hispanic Medical Association, "The only Federal Programs to recruit disadvantaged students to all health professions schools are being seriously threatened. The HHS FY06 Budget Bill presented to the Congress last week called for their virtual elimination ($30 million for each last year ---FY 06 budget down to $2million for HCOP, $4 million for AHEC and $20 million for COE). " AHEC=Area Health Education Centers, HCOP=Health Careers Opportunities Program, and COE=Centers of Excellence, i.e. "Centers of Excellence grants assist health professions schools to support programs of excellence in health professions education for minority individuals in allopathic and osteopathic medicine, dentistry and pharmacy and graduate programs in behavioral or mental health (clinical and counseling psychology, clinical social work, marriage and family therapy)."

These are all very important programs that everyone who works in the field of public health and health disparities knows and values. The budget reconciliation bill has yet to pass, as you know, so along with Medicaid and food stamps and all the rest of it, here's one more stand we need to take. NHMA's government affairs page is here. Click on "legislative alerts" on the left side of the page for more info, including an easy way to get a letter to your own Rep.

A commendable example of citizenship

Many people turn regularly to the web site Iraq Coalition Casualty Count, for a comprehensive, up-to-date tally of deaths and injuries in the Iraq war -- or at least as comprehensive a tally as is possible, since Iraqi casualties are not systematically reported. ICCC maintains a database of U.S., U.K., and other coalition forces killed in theater; a compendium of news articles on troops wounded in Iraq; reports of Iraqi civilian deaths and deaths of foreign contractors; hotlinks to the latest news stories out of Iraq and from the home front; and statistical tables and analyses.

It's all drawn from readily accessible public sources but the Pentagon doesn't bother to add it all up. ICCC is an essential document of history, and it's also the place to go to watch the counter click on deaths and injuries in the war. It's at ICCC that the world gathered to watch the thousands column on U.S. military deaths click over to "2," and that's where we'll watch the number go to 2,100 today.

I asked the folks there if they wanted to say anything about who they are and why they do it for this post, but they declined. Fortunately, Ann Varela in the Atlanta Journal-Constitution told the story back in October. Here's a reprint since the A J-C has taken down the original. The site is a volunteer project, done on personal initiative, of Michael White, a computer programmer from Stone Mountain, Georgia, and Patricia Kniesler, a civil engineer from San Francisco. The two met on-line and have never met in person, but they are committed to continuing the collaboration "as long as there are troops dying overseas," even though it is just one more responsibility on top of work and family.

They don't go out of their way to make any political points, they don't try to interpret, they don't comment. They just make a public record. What a surprise, then, that they have received baskets full of angry e-mails. According to the Varela article, these came from supporters of the war who, as we know all too well, think that it is unpatriotic to notice that Americans are being killed in Iraq, and from opponents of the war who wanted more on Iraqi deaths. (I have a feeling those tended to be very different in tone, don't you?) Anyway, U.S. military families have praised the site, and many now contribute links to stories about their loved ones who have been killed or wounded. So I want to say thanks to Michael and Patricia, and the other folks who help them out. You give us hope for our country.

Now this is just getting ridiculous

Okay, so Chimpy wanted to bomb the headquarters of a television network in a friendly country because he didn't like the coverage he was getting, but he let his poodle talk him out of it. That's not surprising, of course it's the sort of thing the big baby would think he could do. By an odd coincidence, although the U.S. never did bomb al Jazeera HQ in Doha, we did bomb their offices in Kabul and Baghdad -- purely by accident of course.

So, the networks in the U.S. cover the story - with understandable, err, delicacy. NBC even covers it! At the end of a long story focusing on how the Brits are busily prosecuting the leaker, we get this throwaway:

Meantime, NBC News analyst Bill Arkin says that while there is no military order to bomb any media outlet, the U.S. Strategic Command in Omaha has been given responsibility for exploiting and disrupting the communications and computer systems of news media outlets worldwide. Arkin says the center of this effort is the Network Attack Support Staff, which while assigned to Stratcom, is headquartered at Ft. Meade, Md.

Meanwhile, I checked the NYWT, the Boston Globule, and all the major networks to see how they're playing the story of Iraq's political leadership in Cairo agreeing that a) there has to be a timetable for U.S. withdrawal, and b) Iraqis have a legitimate right of resistance to foreign occupation, i.e. it's okay to attack U.S. troops. The Globe buried the story in the back pages. Although Salah Nasrawi's AP story leads with the "legitimate right of resistance," the headline was about the timetable. The NYWT ran the timetable story as its front page lead, but didn't get to the right of resistance until after the jump, and then added, gratuitously and on no evidentiary ground, that the statement "stopped short" of condoning attacks on U.S. troops. No it didn't. ABC ran the AP story, and even teased the right of resistance on their front page! But CBS buried it and as far as I can tell, CNN didn't even cover it.

So let me spell it out. The sovereign Iraqi government says its okay for Iraqis to attack U.S. forces, and that those forces should establish a timetable to leave the country. On the first point, they apparently agree with the preznit -- Bring 'em on! -- but it does kind of make the definition of "victory" in Iraq seem all the more mysterious. Essentially, we seem to be fighting in Iraq in order to stop people from attacking U.S. troops, even though it's perfectly okay with the Iraqi government for them to be doing it. It seems to me that the easiest way to stop that from happening is to leave. Then we will have won, because Iraqis won't be attacking our troops any more. Also, we wouldn't have to bomb any TV networks.

And while we're on the subject . . .

So, as I just said, CDC has given us a checklist to evaluate our state and local public health infrastructure and preparedness, but talk is cheap. According to the APHA newsletter The Nation's Health, the FY 2006 federal budget proposal from the White House cuts funding for state and local emergency preparedness by $130 million. HHS claimed that the reason for the cuts was that the states couldn't absorb their grant funds. The CDC's cooperative agreement with the states previously focused on building infrastructure and capacity, but the new one will focus on measuring the public health system's preparedness.

I'm all for measuring, as you know -- but the purpose of taking measurements is to build.

Making a list, checking it twice . . .

As you ought to know by now, the national pandemic flu preparedness plan -- and our public health emergency preparedness plans in general -- consist largely of:

Local health departments, get ready!

So, it looks like a citizen who wants to know whether to kiss his or her own ass goodbye needs to check up on the state and local health departments. CDC has at least given us checklists for doing that, through the National Public Health Performance Standards Program.

If you click on the link on the left-hand side called "The Instruments," you will find detailed checklists of capabilities and resources against which state and local health departments can be evaluated, based on an inventory of "Ten Essential Services." Emergency preparedness gets fairly short shrift -- it's a sub-sub-category under essential service #2, "Diagnose and investigate health problems and health hazards in the community," where it doesn't even seem to fit very well. But it's there.

The rest of the stuff is also very important. These are useful documents because they at least establish some standards. Now, putting in the resources to assure that those standards are met . . . naah, that would smack of creeping socialism.

Check this out

My old friend Frederick Clarkson and some of his colleagues, including other well-known writers and researchers such as Chip Berlet and Esther Kaplan, who have been vigilant observers and thoughtful critics of the rise of the religious right, have started a web site for learning and discussion about the Christian right and dominionist movements. They represent the common ground of liberal religious and non-religious people, and that means they aren't planning to revisit fundamental civil rights that some religious people oppose. The focus is more political than philosophical, although I expect that distinction will be a bit fuzzy. You can register for free and join the discussions.

The site is called Talk to Action. Here's their statement of purpose:

Talk to Action is a platform for reporting on, learning about, and analyzing and discussing the religious right -- and what to do about it.

There is an editorial framework for this site than that is different than you will find on other major blog sites, so please read this carefully: We are pro-religious equality and pro-separation of church and state. We are prochoice, and we support gay and lesbian civil rights -- including marriage equality. Therefore, debates about the validity of abortion and gay rights are off topic. We understand that some people who share our general concern about the politics of the Christian Right may not agree on all of these matters. That's fine. Anyone who agrees with the general mission of this site is welcome to participate -- but bearing this in mind. It is our intention to take the conversation forward, and not let it be held back by debating what, in our view are or should be, settled matters of human, civil and constitutional rights. Similarly, religious debates are off topic, especially debates between theism and atheism. Finally, we are nonpartisan. While political discussions are welcome, -- even central to the purpose of this site -- we do not wish the site itself to be a platform that is necessarily for or opposed to any particular party.

So give them a look. I suspect many of our readers will want to join in there.

A Step Forward

I've enthralled you all in the past with horrific tales of atrocities in medical interpreting. But I'm not a voice crying in the wilderness. The National Council on Interpreting in Health Care (NCIHC) has developed a code of ethics for medical interpreters and standards of practice.

I haven't had a chance to study these minutely, in my usual Jabert-like quest for damning flaws, but on a brief review they definitely seem to be on the right track. You can read both documents at the NCIHC web site, they're in the 'hot topics' links on the right.

Now that's all well and good, but getting hospitals and other institutions to actually employ interpreters who subscribe to the code of ethics and are qualified under the standards is the next problem. It won't just happen by itself. State health departments, health care consumer organizations, legislators, and individual managers and consumers all have to make sure it does. (I'm not counting on the feds right now. Although the Office of Civil Rights of the U.S. Department of Health and Human Services could play an active role in this, they won't under the present administration.)

Sex and Death

They are probably our greatest preoccupations, and they have something else in common. They are both what I will call meta-evolutionary attributes of living organisms. They are essentially universal not because they favor the survival and reproduction of individuals, but because they favor evolution itself.

Without the ability to share and reshuffle combinations of genes among individuals, a population could scarcely evolve. If a favorable mutation happened to arise in an individual of a purely parthenogentic organism, it would remain with the descendants of that organism only, and no others. It could never be paired with other mutations that might further enhance its favorability. Indeed, it might not even be favorable unless it happened to be matched with some other characteristic that the mother organism lacks, but may be present in other individuals. Prokaryotes -- cells without a nucleus -- can exchange genes in processes not directly related to reproduction, but the eukaryotes evolved the strategy of sexual reproduction and they all use it. Even single-celled protozoans that usually reproduce by simple cell division sometimes create and then fuse haploid cells, i.e. reproduce sexually.

An individual could reproduce more efficiently and certainly, and pass on 100% of its genes, by asexual reproduction. If the idea of "survival of the fittest" meant that evolution rewards success at passing on 100% of an individual's genes, we wouldn't have sex. But that's not what it means. Evolution selects lines of descent over the long term. When we speak of extinct species, we really conflate two very different concepts. Some species indeed have been wiped out without leaving descendants, but in the case of others, their descendants are simply so different from the supposedly "extinct" ancestors that we call them by a different name. But in fact, these extinct species may have been highly successful in evolutionary terms.

So, the dinosaurs, as a class, are not extinct. They are all around us. But they are small, have feathers, and fly. They don't resemble plodding 60 ton grazers, or 10 meter long killing machines with six inch teeth. Even so, the dinosaurs live among us.

Evolution has made us mortal for related reasons. Once organisms have passed on their genes, their continued existence can create problems for their progeny. Ancestors compete with progeny for resources, most fundamentally, and even lock up resources needed by their progeny's (and their own) food sources. Animal carcasses return organic nitrogen to the soil, and make plant growth possible. An immortal species could not evolve, because it could produce few generations before it would completely exhaust its ecological resources. So death may be a misfortune when it comes untimely, but it is programmed by evolution into every sexually reproducing species. In the case of reproduction by division, the very concept of death seems not to apply -- there are now two "daughter" cells, but where is the mother? So we can say that since sex is necessary for multicellular organisms, death is also necessary. Death follows from sex, inevitably.

In the case of humans, because we are social organisms, each of us may have value to our progeny and our cousins' progeny beyond our mere ability to reproduce and nurture our own young. Non-reproducing individuals can be stores of wisdom, have skills and do work which is valuable to the group. So, while salmon die as soon as they spawn, humans are endowed with lifespans that extend well past their reproductive stage. Nevertheless, evolution has struck a balance, at approximately a factor of two. So evolution has also produced a paradox. The individual is programmed to survive, at least long enough to complete its reproductive potential. In us, that programming does not switch off when we are done reproducing. It makes us egocentric, and it makes us fear death. But those impulses have no chance of prevailing.

The fortunate thing for people is that, as social beings, we also have legacies that go far beyond our genes. What we do in life makes a difference for those who follow. We are even remembered, for a generation or two by a relatively small number of people in most cases, or for thousands of years and by billions, in rare cases. But in any event, we continue to matter after our deaths. Can that realization alone be enough to overcome the fear of death, for most people?

No, I don't have a definite opinion about everything

Long time readers may remember that I'm somewhat ambivalent about legitimizing physician-assisted suicide, in part because of an aspect of the issue that is not much considered in the public discussion, specifically the burden it places on physicians. It is easy for me to decide that terminally ill people should be able to choose the time and manner of their own deaths if they wish to -- with the very important proviso that there should be equal access to excellent palliative care, including nursing care, pharmaceutical relief from suffering, social support, and counseling; and very strong assurance that suicide is freely chosen and that there truly is no better option. Limited experience in Oregon and Europe, fortunately, has seemed to show that the people who avail themselves of the option are not poor, disadvantaged, or socially isolated. Rather, they seem to be relatively empowered people for whom everything is being done that can be done.

Of course, people can find ways to take their own lives without the help of a physician. But doctors have technical expertise to make sure they succeed painlessly, and the prescription pad to supply the means. However, many doctors are averse to the idea, fear the responsibility of having to decide on individual cases, or have moral objections to it. They feel uncomfortable about the prospect of a legal and cultural regime in which patients are likely to come to them with requests for assisted suicide, and so physcians are quite divided on this issue.

A rather disturbing case from Switzerland, where assisted suicide is legal, calls attention to these concerns. A German woman approached the organization Dignitas, which assisted terminally ill people in taking their own lives, with a medical report showing she had terminal cirhhosis of the liver. A Dignitas physician gave her a lethal prescription, which she took. It then turned out that the medical report was a fake, which she had obtained from another physician under a pretext, and that she had been depressed but not terminally ill. Upon learning these facts, the physician who had given her the prescription took his own life.

While this is a highly unusual event -- one out of hundreds of suicides that Dignitas has assisted -- it certainly should give us pause. It might be argued that the physician who gave her the false medical report was most to blame, but that is beside the point. I still feel that we should proceed very cautiously with proposals in this area, and that at the least, very carefully designed safeguards are needed. The Oregon experience has appeared to be alright so far, but it is still very limited. When I posted about this issue before I asked for comments, but didn't get any. I understand -- it's a tough one, and as I say, I'm not sure how I feel about it myself. But I'd still like to know what others think. (In polls, most people do support it, but that's not enough reason to go ahead, in my view.)

Looting

As has been widely discussed in the corporate media, a major setback to stability and reconstruction in Iraq was the widespread looting that followed the U.S. invasion. Until this week, however, when they were forced to take notice by criminal indictments, the media in the U.S. largely ignored the biggest looters of all: that is the Coalition Provisional Authority appointed by Emperor Chimpoleon the First, and the mostly U.S. corporations with which it did business.

The British charity Medact issues regular reports on the state of public health in Iraq. The criminality of the Bush administration is, unavoidably, a big part of the story. The Summer 2005 report (PDF) includes the following information:

Growing Evidence of Corruption
‘If you take US $10 million from the US government and sub the job out to Iraqi businesses for US $250,000, is that business, or is it corruption?’
Ed Kubba, American-Iraqi Chamber of Commerce

At the time of the last Medact report on Iraq there were rumours and accusations that there had been gross corruption and a lack of transparency within the Coalition Provisional Authority (CPA). These have since been confirmed. Stuart Bowen, Special Inspector General for Iraq Reconstruction, reported to Congress at the end of January that inadequate CPA controls meant that there was no assurance that $8.8bn from the Development Fund for Iraq (DFI) had been used, as mandated by Security Council resolution 1483, ‘to meet the humanitarian needs of the Iraqi people, for the economic reconstruction and repair of Iraq’s infrastructure, for the continued disarmament of Iraq, for the costs of Iraqi civilian administration, and for other purposes benefiting the people of Iraq’. The DFI is Iraqi money, mostly revenue from oil sales, and $8.8bn is equivalent to almost 10 years of Ministry of Health spending at current (2004) levels. [emphasis added]

In other words, the United States invaded Iraq, installed a colonial regime, and set about stealing the oil wealth of the Iraqi people. The report goes on to say that under the CPA, the same work was subcontracted five or six times and was still profitable -- in other words, a long chain of middlemen simply pocketed the money before a remnant made it down to people who may have actually done work. The so-called "Office of Reconstruction and Humanitarian Assistance" was supervised by the U.S. military. As the report says, "ORHA were inexperienced. Furthermore, military involvement blurs the line between the military and the reconstruction efforts, narrowing the humanitarian space and making life more dangerous for the humanitarian agencies." Things got no better after the so-called "handover of sovereignty" and the January elections. Western NGOs are seeing no results from spending. The U.S. pledged $32 building for Iraqi reconstruction in 2003 but apparently has approved less than a half billion in spending so far, and spent almost nothing. International funds that have been spent have gone in substantial part to administrators based in Amman and Washington.

Here's a case study:

One of the major contracts in the health sector was awarded by USAID to Abt Associates.* USAID audited Abt and found that only 40% of the work achieved its intended output. Incomplete work included a household survey, a primary healthcare quality improvement programme and a facilities database. There were serious delays in the delivery of 600 kits containing essential equipment such as stethoscopes and blood pressure cuffs to primary health centres (PHCs). However, since the contract had expired by the time the audit was published, the report concludes that “there is little that can be done with regards to the activities and unachieved outputs.”

Among the consequences:

1. Only 54% of Iraqi households have access to safe water.
2. 36% of households have "unimproved" toilets -- i.e., they use buckets or open pit latrines.
3. 23% of children age 6 to 59 months suffer from chronic malnutrition; 8% are acutely malnourished
4. 9% of children under five had had diarrhea in the two weeks before a survey
5. Four of Baghdad's hospitals do not have safe drinking water, and 60% of toilets in hospitals do not work. One hospital had sewage backed up into the basement. Five did not have refrigeration facilities. Half the hospitals did not have disinfectant solution in stock.
6. There is almost no public health expertise in Iraq, no training is available in public health, and there are no plans to fund any
7. There are no effective health information or disease surveillance systems in Iraq
8. Community based mental health services are nearly non-existent

Etc. The report covers the debate about the civilian death toll and reviews the security situation, and discusses various other subjects. It's only 8 pages long, but it crams a lot in.

Mission Accomplished.

* Medact has it as "ABT Associates" but that is a common error, which I have corrected. They appear to be referring to Abt Associates, based in Cambridge, Massachusetts, which is named after the founder Clark Abt, who should get a vowel. Redacted 1:45 pm.

Burning issues

The Pentagon, after first denying that the U.S. used white phosphorus as a weapon in Fallujah, was finally forced to admit the truth. But, they claim, it is not a chemical weapon and anyway they only used it against enemy combatants (a newly discovered class of non-human beings). Italian journalists revealed this particular truth, of course, as the U.S. corporate media covers the war largely by channeling Central Command press briefings.

Now, as far as I'm concerned, there is no meaningful distinction between burning people and blowing them up or shooting them. In the process of attacking people with explosives, you often end up burning them anyway. White phosphorus is obviously a chemical, but then again so is TNT. So what?

But most people perceive something uniquely horrific in white phosphorus, which clings to the body and burns its way in, sometimes killing people just from the unendurable pain. In the Vietnam war, the U.S. used napalm, which is jellied gasoline, to burn huts and whole villages, just as it uses white phosphorus today to burn people out of urban dwellings in Iraq. Then as now, they claimed to be targeting only enemy combatants, and not civilians, but apart from the fundamental difficulty of making that distinction at all in a guerilla warfare context, you obviously don't know who is inside a building until after you burn the people out.

What you may not know is that the igniting agent in napalm was nothing other than white phosphorus, and it burned its way into Vietnamese flesh just as it burns into Iraqi flesh. One of the most powerful reasons that Americans finally turned against the war in Vietnam was that the corporate media back then chose to show us the pictures. I'm not going to put this one on the front page, even though it was on the front page of the New York Times, but I'm sure you have already seen it. The little girl, named Kim Phuc, was hiding in a pagoda with other children when the Americans dropped napalm on them. The photographer who took the picture took her to a hospital, where she spent months in a coma. You'll be glad to know that she survived and now works for the United Nations. Most napalmed Vietnamese weren't as lucky.

Maybe if the corporate media would show us the pictures of the real war in Iraq, we'd leave.

Addendum: Here is a link to Dahr Jamail's Fallujah photo album, which I just found out about.

And here is The Independent's story about the white phosphorus issue, which is approximately 20 times more informative than the 2 paragraphs in the NYWT.

Ladies and Gentlemen . . .

the President of the United States, John Forbes Kerry.

One good way to stay alive . . .

... is to drive and ride in comparatively safe vehicles. If you're buying a car, make sure you get good gas mileage, and also make sure it's as safe as it can be.

Our friend Ben Kelley of the Public Health Advocacy Institute has sent a link to their new automobile hazards information site. Much of the site is for researchers and wonks, but they have a page for consumers that you should definitely check out before you head out to dicker with the guy in the lemon yellow blazer and checkered pants. There are a bunch of informative links, and click the link at the bottom for a complete listing of makes and models with their summary safety ratings. Note, as we posted a while back, that the large SUVs tend to have moderate to high rollover risk.

But their goals are broader than just helping you buy a car. According to Ben:

Our aim is to provide access for the public to a growing number of key source documents that put motor vehicle hazard control into its historical perspective. . . .Motor vehicle crash injury prevention is a prime example of public health needs that require legal interventions in the legislative, regulatory and judicial arenas. Increasing the effectiveness of efforts by the world of law to help achieve public health goals is a principal mission of the Public Health Advocacy Institute.

Sounds good to me.

Activism Alert

First of all, the criminal Republican budget cutting bill was temporarily withdrawn, as we noted last Thursday. But it isn't dead, and we still need to kill it. Rather than re-invent the wheel, I direct you to Revere's post on this, where he gives the handy-dandy link to APHA's site where they will conveniently let you communicate to your member of Congress that you don't want to cut health care for disabled and elderly poor people, and make low-wage workers go hungry, in order to partially offset more tax cuts for obscenely rich people. Got that?

Now, on another front, and I'm sorry I'm a little bit late with this, an FDA advisory committee is considering restrictions on direct to consumer advertising of prescription drugs. The public hearing happened a couple of weeks ago, but it's not too late to submit comments. According to a petition signed by more than 200 medical school faculty members:

Prescription drug advertising pressures health professionals to prescribe particular medications, and often the ones that may be less effective and more expensive and dangerous. This intrudes in the relationship between medical professionals and patients, and disrupts the therapeutic process. It takes up valuable time to explain to patients why they may have been misled by the drug advertisements they have seen.

Prescription drug advertising is not educational. It is inherently misleading because it features emotive imagery and omits crucial information about drugs and their proper use, as well as about side effects and contraindications that can be found on the full FDA-approved label. Drug companies have an inherent and irredeemable financial conflict-of-interest which drives them to exaggerate the positive and minimize the negative qualities of their own products.

If you want to add your voice, Commercial Alert has made it easy. Go there and check it out.

Remember, you read it here first . . .

Well, I doubt that's true, but at least you might have read it here a few days ago. The 9/11 Commission, having submitted its half-assed report, decided to stay in business as the 9/11 Public Discourse Project, and maybe they've reconstituted their anatomy.

Chair Thomas Kean told a news conference that the administration hasn't done diddly about what president Chimpy and his opponent John Kerry agreed was the biggest national security concern -- nuclear weapons falling into the hands of terrorists. The administration has neglected the problem of proliferation -- yes yes, they've rattled the saber at Iran and they keep yacking about North Korea, but this goes much deeper. The administration has undermined the non-proliferation treaty by refusing to pursue disarmament, and of course all those Russian nukes are still there under uncertain conditions of security.

When I wrote about this last week, it didn't seem to stir up much interest. So here's the short version:

a) It is highly unlikely that any non-state actors currently possess a nuclear explosive device, in spite of what you might read on NewsMax.
b) It could happen in the future. A tactical-size nuclear weapon exploded at 16th and H street, NW, Washington DC, would wipe out the White House and Executive Office Buildings, the Treasury Department headquarters, the OAS headquarters and PAHO, several consulates, George Washington University, the southern Dupont Circle neighborhood and Farragut Square, quite possibly start a firestorm that would devour much of Georgetown, and a lot of other stuff I don't have time to mention. But the way to get serious about this is to restore the international credibility of the U.S. and work with Russia and the other nuclear powers on disarmament, non-proliferation, and security of nuclear materials.

Oh yeah -- that includes Israel which we need to stop pretending doesn't have 100 nuclear weapons. There is no reason for Iran to stop pursuing nuclear capability if Israel won't agree to disarm. Just sayin'.

Old news: we have a very large problem

Some in the corporate media have finally recognized that the neo-con cabal in power is probably not good for business in the long run after all. Yes, it eliminated regulations in the public interest that they found limiting to their ability to rake in the bucks, it slashed the taxes of their wealthy owners and megamillionaire news readers, and it gave them the splendid little war they wanted so badly. Wars pull eyeballs to TV sets and sell newspapers, the first Gulf War was a bonanza for them, and they were obviously eager to have another.

But now there is this little issue of the long-term decline of the United States. Here we are in hock up to our eyeballs, hemmorhaging billions of dollars and burning out our military in a pointless, hopeless disaster of a colonial war, our physical and social infrastructure deteriorating, more and more dependent on totalitarian regimes that despise us for the petroleum lifeblood of our economy, our society fundamentally fractured, completely unprepared for potentially catastrophic environmental challenges. Of these multiple crises, some were a long time in the making to be sure but ignored or exacerbated by the present regime, others are largely or entirely of its making.

Yet the most corrupt, incompetent, dishonest presidential administration in U.S. history is still in power, and will be for more than three years. That is more than enough time for them to finish the job of sending the nation onto a permanent path of disastrous decline. The Resident has no clue of the folly of the past five years. Instead, he just grows ever more vulgar in the conduct of his office -- which scarcely seems possible -- most recently using the solemn national occasion of Veterans Day to stand before a military audience and equate dissent with treason.

So, while the corporate media have finally started to panic about the catastrophe they have helped to create, they have yet to acknowledge their own complicity, and have barely begun to reform their ways. Here is a very telling example. This Times editorial is fearless in denouncing the lies that led us into war, but it completely ignores the newspaper's own essential complicity. And however strongly worded this editorial, the news pages of the Times continue to re-transmit administration lies without correction.

The fundamental corruption of journalism in the U.S. remains unacknowledged and unaddressed. The content producers -- I won't even call them journalists or reporters or editors -- do not see it as their job to determine the truth and tell it to the people. The see their job, at best, as re-transmitting the versions of reality provided by competing powerful groups. I say at best, because most of the time, they just act as amplifiers for the single, most powerful party. We still see news stories every day which consist of nothing but statements of opinion or outright lies by the Resident or his closest associates, frequently under a cloak of anonymity. Political hacks go on the Sunday talk shows and spout lies, completely unchallenged by the moderators. If some prominent Democratic politician happens to say something on the same day which contradicts the lie, it may be reported, but the medium makes no effort to tell us that one story is the truth and the other is not.

I've said it before. Reality has a liberal bias. This will be true so long as the conservative party in power continues to base its rule on a foundation of lies. Journalistic integrity means telling the truth, even if it disfavors the party in power. That's fair and balanced.

Not getting what you pay for

Back in the old days when I was famous, I used to go around and talk about health care reform before various audiences, including out on Cape Cod every summer where the vacationing crowd tended to include a lot of doctors and their fledgling doctor offspring. (Yup, it runs in families.) After I got done explaining why we need universal, comprehensive, single payer national health care, I'd always get a raised hand and a whiny objection about how "Here in the U.S., we have the highest quality health care in the world."

I had plenty of snappy answers back then (such as, how is it high quality if 15% of the people can't get any primary care, and how come we don't live as long and aren't as healthy as the people in those low quality countries?) but now I've got another one. Folks over at my beloved Commonwealth Fund (Blogger ethics alert: they give me money, but depressingly little), surveyed relatively sick people in six affluent countries, five of them English speaking because I guess they didn't have time to learn French or Norwegian.

Anyhow, here in the U S of A we do okay on some things like communicating risk and discharge planning, at least based on patient self-reports (although these are not good sources of info on risk communication, since if they failed to communicate adequately, you wouldn't know it, right?). However, when it comes to screwing up, We're Number One!

Fifteen percent of U.S. respondents said they were the ungrateful beneficiaries of a medical mistake, tied with Canada for the top spot. We won "Given the wrong medication or the wrong dose" hands down, at 13%, with Australia, Canada and Germany tied for second at 10%, so we are alone in first place for having people experience some kind of error. For those who experienced and error, we also won runner up for the Cover Your Ass award, with 75% not being told about the error by their doctors. (Germany actually won that one at 83%.)

We win the prize for getting the wrong results from a lab test in a runaway (10% vs. 7% for runner up Canada), and we nudge out Canada 16% to 15% for delays in getting results from an abnormal lab test.

Now, I don't know how reliable these self-reports are in telling us the number of errors that actually happen. Much of the time, people probably don't even know that they were the victim of a medical error, and on the other hand people may decide that an error happened just because they are unhappy with the results. Sometimes doctors have to go with the percentages and being wrong isn't exactly the same thing as making a mistake. Still, folks who are served by the highest cost, fanciest, highest tech, most razzle dazzle health care system in the world are also perceiving it as not the highest quality, but the lowest, among these particular wealthy countries. That has to mean something.

A gram of prevention

I didn't get a chance to post this morning because I had to go and have my doctor pull a significant chunk of Douglas fir out of my left hand, where I had embedded it on Saturday while handling lumber. There was no way I could pull that thing out without anesthetic. He swabbed the area liberally with antiseptic, numbed it with a couple of shots, and even so it hurt like hell when he dug it out but at least it's over with. Then he gave me a tetanus shot. It's a little weird typing with half of my left hand numb but I take it I'm coming through okay.

This is just one more reason why our governor's plan to make low income people buy crappy health insurance with high co-pays and deductibles is not the best idea. People with that kind of insurance would have had to pay something like, oh, a hundred bucks for the "surgical procedure," which is an awful lot when you work at the counter in the doughnut shop, which means you probably won't do it, which means your splinter might end up with an infection requiring intravenous antibiotics and you might even get septic shock, who knows. Fortunately, at that point you've used up your deductible and the insurance kicks in. Seems kind of wasteful though, doesn't it?

Riding back to the office, I wound up on the homeless schizophrenic train. It appears that some program or other at a community health center on the subway line had just gotten out. Maybe they meet in the morning for a support group or something and now they were heading for a downtown mission that has a free lunch. These guys have pretty good health insurance actually -- MassHealth, our Medicaid program, is pretty comprehensive although they did largely eliminate dental benefits a while back. (There's talk of restoring them.) However, health insurance doesn't do anything about the rest of their needs.

We had a big progressive movement back in the Dukakis administration to close the snakepit mental hospitals and move the seriously mentally ill into supported community housing. They did part A, which was great -- it saved the state a bunch of money. Somehow they never got around to part B, however. So now people with severe mental illness are sleeping at the Pine Street Inn or a cardboard box, in between brief bouts of hospitalization or, just as often, imprisonment. Yup, what with mandatory sentencing and no instititutional alternatives, our prisons are warehousing large numbers of people with psychoses, for crimes like drug possession, shoplifting, vandalism, etc. It costs about $36,000 a year to imprison somebody in Massachusetts, which would pay for a pretty decent group home. Go figger.

On Religion, again

Regular readers know that I am not religious. I don't readily accept labels for myself, because I don't choose what to believe based on membership in a group. I make up my own mind. While it is quite clear to me that God, as conceived by all the popular religions, does not exist, just calling me an atheist doesn't explain what I believe. That just tells you something I don't believe. It is fair to call me a humanist, if by that you mean that I wish to be a champion of humanity, that I view the welfare of our species and the fulfillment of our potential as the essential guiding principal, and that I turn to our own human resources of reason, senses, and feeling as the source of truth. But the term humanist means different things to different people, and humanists don't have a church, or a doctrine, or a scripture. So there are lots of people who are called humanists, or who call themselves humanists, who differ from me on basic issues.

Being the kind of humanist that I am, I respect and admire human accomplishments and human sentiments, on the whole. Of course, I object to many human works, for example fascism and war. What I mean is that I respect human capabilities and potentials and that there is much to be admired among the many ways in which humans have created social order and resolved conflicts. So it is with religion. I respect and admire much about religious belief, religious community, religiously inspired beneficence, art, music, literature. I love Mozart's Coronation Mass and Mahalia Jackson's singing. As a youth,I was profoundly influenced by the life and work of Martin Luther King, Jr. I was inspired and guided by my uncle, an Episcopal minister, and his sermons in church. One of my early political heroes was Father Robert Drinan. I own a signed copy of his latest book, on human rights, and I was very grateful that I had the chance to tell him in person what his leadership against the Vietnam war had meant to me.

So, do I wish for religion to go away? Religion actually has several functions in human life and society. Religious congregations provide people with community, and in our complex urban society that is an essential function for many people who would find themselves isolated and lonely without it. Religious ritual is soothing for many people, and religious myths and explanations provide comfort in times of sorrow and adversity. Religion most often supports the social order, though at times it has provided an alternative and to the prevailing order, has opposed it, has even fomented revolution. The more general way to describe this function is that religious denominations are social organizations which structure the social relations, beliefs and actions of their adherents, whether in alliance with the political order or in opposition. Religion provides codes for behavior, in other words it is an instrument of social control. Religion provides explanations for puzzling questions. Religion has other functions but I will stop there for now.

Because I respect people, I respect their religious beliefs, even though I disagree with them. Religious people should not resent that because, after all, they disagree with each other. Orthodox Jews, Southern Baptists, and Catholics disagree with each other just as profoundly as they do with me. So I don't see why it is any worse to be an atheist, and yet I often hear from religious people that it is somehow offensive or disrespectful for me to state and defend my opinion that God does not exist. I have the same right to my beliefs as they do.

I do not despise religion, and I am not hostile to religious people. I do believe that religion is obsolete. Just as we no longer try to cure infectious diseases by bloodletting, or allow ourselves to be ruled by hereditary monarchs, we no longer need religion to order society, tell us how to behave or what to aspire to, and above all, we do not need religion to explain reality. We have much better ways. Reality now yields to our scientific inquiry. It is out there to be discovered. What a wondrous liberation that is! And now we find that the universe we have discovered with our senses and our reason is vastly more grand and wondrous than anything the writers of scripture, or the crabbed and cramped thinkers in the Southern Baptist Convention, ever imagined.

As for ethics, they come from within. They are a part of us, and the explanation for that is evolution. Essential to our successful adaptation is that we are highly social beings, and so evolution has equipped us to live together and work together. That's our nature. Human nature. And I'm with the home team.

Political Strategery

With Chimpy's approval rating almost as low as his IQ, and the Congressional Republicans heading toward liquid helium territory, they've decided to shore up their base -- specifically, it appears, the all-important pro-torture movement, which spans a broad segment of the American public from Alan Dershowitz to Dennis Rader. It is something of a mystery why the right to torture is non-negotiable for President Cheney, minor demons Lott and Hastert, and president Mortimer Snerd, but there it is.

While they may not have found the winning coalition with that one, politics is also tough for those of us who want to do what's right and establish universal, comprehensive national health care here, just like they have in civilized nations. The problem is that the public interest is diffuse. The vast majority of Americans would benefit, but they aren't spending their blood and treasure to get it. On the other hand, drug companies, for-profit hospital and nursing home chains, and insurance companies will fight to the death to stop it, and they have plenty of money to spend and no scruples whatever. Doctors are divided, depending on whether their top priority is making every possible dollar to buy the biggest possible sailboat; or keeping people healthy, healing the sick, and comforting the afflicted. Consequently the AMA -- which used to be the most powerful opponent of reform, at least that's progress -- is now on the sidelines.

So here's my pitch. The only way to win this is to have an active, mobilized, organized citizenry. If there's a coalition for health care reform in your state, join it, give money, go to meetings. Check out Community Catalyst (see the sidebar), tell your friends, and write and call your representatives in Congress and your state legislators. Give money to progressive candidates, just like the followers of the Anti-Christ, Pat Robertson, give. If you want to save your ass, get off of it.

Lecture over. I'm in the wilderness again until Sunday.

From Our Friends at Community Catalyst

House Votes are Happening Today, Nov.10, 2005!!!
November 10, 2005

Dear Medicaid Advocate:
IT IS NOT TOO LATE TO CALL THE HOUSE!!

* Keep the pressure on-call your members of Congress again TODAY and oppose the cuts to Medicaid.

* Yesterday you may have received alerts indicating that we had lost-but the Republicans are bluffing. They do not have the votes and your calls are still very important.

* The key message remains: Vote no on the House budget bill. It would impose deep cuts in Medicaid eligibility, benefits and out-of-pocket costs that will deny health coverage and affordable care to children, people with disabilities and seniors. The House budget will hurt millions of Americans and increase the deficit, while rewarding the wealthy few with tax cuts.

Use the toll free number provided by American Friends Service Committee to contact your Representative: 1- 800-426- 8073

* Ask the switchboard to connect you to your Representative.

Addendum: Budget bill withdrawn as of about 4:30 -- the Republican leadership couldn't pass it!

Sorta, kinda, maybe a disease

Without going through all of the philosophical tangles, diseases have various kind of existence. There are the definitely really real diseases, like kidney stones or tooth decay. These are unambiguous physical entities that just about everybody would rather not have. Then there are diseases in which we don't feel there's anything wrong until a doctor tells us to worry, like high LDL cholesterol. There are other diseases we aren't actually sure constitute specific physical states or processes or single entities, even though there are a lot of people out there who have similar clusters of complaints, such as fibromyalgia and chronic fatigue syndrome.

Then there are mental disorders such as one of our all-time favorite topics here, Attention Deficit Hyperactivity Disorder. The diagnostic criteria for this disease include the following kinds of observations:

Often fails to give attention to details or makes careless mistakes in school work, work or other activities;

Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort . . . ;

Often loses things necessary for tasks or activities;

Etc. Then there's another set of criteria -- either one will do, there are two ways you can have this disease:

Often fidgets with hands or feet or squirms in seat;

Often runs about or climbs excessively in situations in which it is inappropriate;

Is often "on the go" or often acts as if "driven by a motor";

Etc. I don't know about you, but it appears that I have the first version of the disease, at least by most Thursdays, and I tend to get the second version during baseball season. I'm not sure how often is "often" enough though.

Children who are diagnosed with this disease are usually prescribed amphetamines, which are also sold illegally on the street to addicts.

CDC has recently released results of a study based on the National Survey of Children's Health, done in 2003. It turns out that a child's chances of having this disease are 8.6% if the parents speak English, and 1.3% if they don't. The chances are 8.1% for children who have health insurance, and 4.9% if they don't. More than 11% of children in Alabama have the disease, but only about 5% of children in Colorado. (Must be that bracing mountain air.) So this is a disease which is caused by having English speaking parents, having health insurance, and living in a humid climate. Weird etiology, I must say.

Ka-boom

I wasn't going to write about this, because it's disconcerting and I'm not sure I have anything to add, but recent developments compel me to comment.

As long-time readers know, I am firmly of the opinion that putting chemical and most biological weapons in a category called Weapons of Mass Destruction™ is deceptive and propagandistic. Nerve gas and non-contagious pathogens such as anthrax spores are not inherently more "massively destructive" than high explosives -- in some ways less so. It is not a worse fate to be killed by nerve gas than it is to be blown to pieces by a 500 pound bomb, and it is actually easier to defend against. Contagious diseases such as smallpox indeed could cause mass destruction, but they don't make good weapons under most plausible circumstances. I won't go into all that now.

But nuclear weapons are indeed in a different category. I've written about proliferation and disarmament -- the problems surrounding states possessing nuclear weapons. But there is also this troubling issue colloquially known as Loose Nukes. Just google that phrase and you'll come up with a ton of stuff, leading off with various documentaries done by corporate media and PBS over the years, and thence descending from the speculative through the dubious to the wacko.

When the Soviet Union collapsed, its military establishment fell into disarray. Soldiers went unpaid, many deserted their posts, and nuclear weapons scientists and technicians were also out of work. Security at nuclear weapons sites deteriorated, sometimes to the point of non-existence, and there were huge temptations to sell nuclear materials. There were several incidents in the first half of the 1990s of people attempting to smuggle radioactive materials out of the former Soviet Union through Eastern Europe. When many attempts are uncovered, one must assume that others were successful. These incidents stopped in the mid-1990s, but a likely explanation is that smugglers decided it would be easier to go through central and southwest Asia than through Europe.

Radioactive materials could be used to make a so-called radiation dispersion device or "dirty bomb," but it is unlikely that a non-state actor could manufacture a nuclear explosive weapon. If a sophisticated terrorist group could obtain enough highly enriched uranium, it seems marginally plausible to some people that it could make a bomb, but of much greater concern would be diversion of a working device from the Soviet arsenal. Soviet -- and now Russian -- so-called strategic nuclear weapons are believed to have fail-safe devices, such that they cannot be detonated without codes possessed only by certain Russian military personnel. But the Soviet/Russian arsenal also includes many battlefield nuclear weapons -- artillery shells -- which may lack such protections. These are not very bulky and could have been sold on the black market. They have relatively small yields, probably 10 kilotons or less, but that isn't very much smaller than the Hiroshima bomb. The Russians claim that they have accounted for all of their weapons but there is no particular reason to believe them.

Lately, of course, the Russian military has greatly restored its competence. The U.S. has even provided some funding and worked with the Russians to improve the security of the Russian arsenal. But there was a window during which one or more nuclear weapons could have gotten into the hands of criminals or terrorists.

As time goes on and nothing nightmarish happens, worry about this tends to fade, but now we have a spate of claims promoted by the wing-nut media -- Newsmax and World News Daily -- to the effect that loose nukes are out there. On Monday, the EPA, on no evident occasion, proposed new rules to raise the levels of radioactive contamination at which land and buildings could be re-occupied following a nuclear explosion.

It's easy to see why there would be a right-wing interest in promoting this fear. It provides a classic "ticking bomb" scenario which can be used to justify further erosion of civil liberties and the policy of torture. Fearmongering has proved effective in the past in driving up the White House Occupant's popularity, although it is beginning to get a little strained to claim, on the one hand, that the Monkey God is the best person to keep us safe, but on the other hand that after five years of his wise and heaven-blessed leadership, we aren't safe after all. Still, they keep trying to work the trick since they don't have much of an act left.

If some bad guys do have a nuclear weapon, we have to ask, "What are they waiting for?" There are plausible answers to that -- they're arranging to smuggle it into the U.S. (or Russia, if it's in Chechnya), or perhaps Iraq (a nuclear explosion in the Green Zone would put an end to the U.S. project there, for certain), and they obviously would want to be very certain of success. But at this point it seems highly doubtful. It is not clear that any sufficiently sophisticated network even exists that could keep such a secret and plot to exploit it. The global jihad movement is disorganized, rag-tag, and amateurish, though certainly capable of depraved violence.

I think that what we really need to worry about is the future possibility of a nuclear weapon falling into irresponsible hands, and that is still about non-proliferation and disarmament. We need to commit to the disarmament provisions of the non-proliferation treaty, and cajole the other nuclear powers to do the same. The world will not take non-proliferation seriously as long as some countries are permitted to possess nuclear weapons, either officially, or with a wink and a nod as in the case of Israel. As long as nuclear weapons exist, the risk of catastrophe that they represent is unacceptable.

The Mailbag

I hope you don't think it's easy coming up with material every day. So thanks to C. Corax for this tip. It seems that some international organizations we're supposed to admire, in the name of conserving wilderness areas, are helping to push indigenous people's off of their lands. It's long been my view that one of the highest priorities for our future has to be making it possible for people to live sustainably on the land. Indigenous people must be partners in conservation; casting them as the problem is outrageous. (And if anybody wants to tell another side of this story, feel free.)

And, from a reader who wishes to remain anonymous but who probably should be writing this blog instead of me, this from the Washington Post. We've long taken comfort in the idea that even though they can outsource computer programming, customer service and shoe manufacturing to Asia, medical care has to stay home, along with all those high paying jobs. Well, as I've pointed out earlier, the radiologist who reads your MRI or CT Scan is quite likely in India. Now, Blue Cross/Blue Shield in southern California is sending people to Tijuana for cheaper medical care. That won't work in Iowa, but I have heard of people travelling on their own initiative to as far away as South Africa for surgery, in order to save money.

Meanwhile, the Arab princes are sending their family members here for expensive procedures, which they evidently assume must be better than what they would get in Qatar (probably not so). Many academic medical centers have large marketing departments devoted to bringing in wealthy foreigners who will pay top dollar -- even as uninsured Americans go without. I don't know where all this leads, but it does complicate our thinking about the future of health care in the U.S.

It will be difficult to find a volunteer, I'm afraid.

Sorry, provenance unkown. Can anybody give us a credit line?

One step forward and two steps back?

I don't know how much attention it's getting in Peoria, but the game is afoot here in the People's Republic to reduce the number of people without health insurance, maybe even to something like zero. This has been tried before, back when Michael Dukakis was Governor, and the strategy then was broadly similar to the Democratic strategy now: require employers to cover their employees. Then as now, there were built-in "cliffs": cut-off points in numbers of employees at which the mandate kicked in or became more onerous. I forget the details from the late unlamented Dukakis plan but I described them for the current plan a few days ago.

Meanwhile our present Republican governor wants to create a minimalist policy, with high deductibles and co-payments and limited benefits, and require people to buy it. He figures it will be relatively cheap, maybe a couple of hundred dollars a month. Then he'll close down our so-called "free care pool," which is financed by a surcharge on insurance premiums and used to pay to keep the uninsured poor from bleeding to death in hospital doorways, and use it to subsidize the cost of the crappy insurance for low-income people. The idea is that the "free care" money will no longer be needed once everyone is covered.

There's a commonality between the plans because not everybody works full time, obviously, and the 5% payroll tax on small businesses don't provide insurance in the Democratic plan is equivalent to very crappy insurance at best. Note that whether the employer opts to pay the tax, or buy the insurance, it's coming mostly out of workers' pay, not the boss's profit, which in most small businesses is not much by the way. One reason I know this is because I used to manage one. (See Hometown Homeland Security.)

Creating a crappy insurance policy and forcing people to buy it with what otherwise would have been their rent money appears to be the big new "liberal" idea. Stuart Altman, who I know and certainly respect, defends the crappy insurance concept:

I do believe that advocates for comprehensive healthcare are actually hurting the poor, even though they say they are helping the poor, because we have made it so expensive that no one can afford it.

Ahh, no Stuart, you have fallen into the bottomless pit of assumption. Your remark makes sense only if we presume that any redistribution of resources from rich to poor is impossible. And as Dr. Altman knows better than anyone, and has advocated throughout his professional life, the only way to really control health care spending is to establish universal, comprehensive insurance and then make socially responsible decisions about how to allocate limited resources -- as every other affluent country does. Apparently he has thrown in the towel, which is terribly sad.

Anyhow, two people who really know which end is up on all this are Alan Sager and Deborah Socolar at the Boston University School of Public Health Health Reform Program. They deconstruct the crappy insurance solution here. (This link still seems to work as of Monday November 7, but it's a Boston Globe archive story so it may shut down soon.)

I know, I know, doing any better may be politically unrealistic, don't let the good be the enemy of the slightly less horrible, maybe incremental change will lead to better things later, yadda yadda yadda. How about this: let's wrest the country away from the corporate fat cats, the insurance companies, the drug companies, the hospital chains, and their lobbyists. Let's have a second American Revolution.

Ptolemaic Economics

If you happen to take Economics 101 (apparently the preznit's favorite course, he talks about it all the time), the pedagogical procedure goes like this. The instructor will present a list of assumptions about how markets work, then he (or maybe 5% of the time she) will go on to spin elaborate theories based on these assumptions. These edifices of logic will prove that "free markets" allocate resources efficiently, produce the greatest possible "utility," maximize welfare, etc.

But then along come various pests from the looney left who point out that the assumptions are contrary to reality. Rather than set out to build a new theory based on truth, economists add epicycles to their theories -- theoretical superstructures to try to make predictions of the theory to resemble observable reality. They never quite succeed so they add epicycles to the epicycles.

Maybe they should give up and admit that the entire edifice of modern economics is no different from Ptolemaic astronomy. It is a false description of the world. The planets do not go around the earth, and the costs and benefits of market activity are not captured in the transactions between the parties. The heavenly bodies are not embedded in crystal spheres, and information is never perfect but limited and usually unequal. The stars are not fixed in a firmament and sellers and buyers are frequently not willing but compelled. The planets are not immaculate shining spheres but cratered balls of rock or swirling gases that shine by the reflected light of the sun. There is usually not equal market power between sellers and buyers but rather enormous asymmetry. Providers, not consumers, generate a substantial portion of demand. Labor is not merely a commodity sold by the worker, but is intrinsic to the worker's social position and enjoyment of life. And so on.

Economics is a vast edifice of bullshit erected on a foundation of sand. It isn't a science at all, even though the economists decided to start giving themselves a phony Nobel Prize to try to convince the world otherwise. It is the most ideological, most tendentious, and least scientific of the disciplines of social inquiry. It's time for the Copernicus of economics to emerge. Let's start over.

Living on the edge, but still taking up way too much space

In my checkered youth, I was at one time a community organizer in Philadelphia. I worked in black and white neighborhoods -- and believe me, the city was completely segregated. I was an exotic sight in North Phillie, but I never felt unwelcome there. In the poor white neighborhood of Fishtown, however, I felt like an extraterrestrial.

Almost everyone in Fishtown claimed to be a conservative, and expressed scathing contempt for liberals. So what were some of their conservative ideas? This was the time of the Arab oil embargo and (gasp!) gasoline at a dollar a gallon. Many of Fishtown's rabid conservatives advocated nationalizing the oil companies. Other popular conservative ideas included government sponsored health care, a higher minimum wage, stopping the developers who were deliberately creating blight so they could buy up large tracts for upscale development, massive investments in public transportation (the Kensington Ave. trolley was a foretaste of hell), cleaning up the air pollution -- all kinds of radical right wing ideas. They were mostly Catholic and went to church, but I can't remember anybody giving a shit about abortion or keeping people on life support.

Now, actual real conservatives have an iron grip over all three branches of the federal government. In public opinion polls, many more people label themselves conservative than label themselves liberal. But a majority of people also tell pollsters that they are willing to pay more taxes to protect the environment, improve the schools, and do other good things; that they want universal health care; that they want curbs on development to protect communities and the environment; that they favor keeping Roe v. Wade (that one's not even close -- 65% to 29%). 82% of Americans opposed intervention in the Terri Schiavo case by the Congress and King George. In other words that particular maneuver was less popular than legalized wife beating. And oh yeah -- the majority favor sensible regulation of gun ownership.

Now, back when I was knocking on doors in Fishtown the gay rights movement was just emerging and nobody was talking about gay marriage. I'm sure the Fishtowners would have opposed it had it come up. So score one for a position more associated with conservatism. But looking at the scoreboard, it's pretty clear that the supposedly democratically elected government is generally sharply opposed to the majority of voters on important issues of public policy.

What's going on? I confess I have left out the most important issue that the good people of Fishtown were worried about. In their own words, it was the niggers. They were all on welfare, and they were taking all the jobs. (That's right, I often got that in consecutive sentences. And by the way, I would estimate that 1/4 of the households in Fishtown consisted of single mothers on welfare, or disability pensioners.) They were going to push us into the river. They don't keep up their own communities -- why some of them moved in over in Kensington a couple of years ago and inside of a year, half the houses on the block were abandoned. (Oh yeah, that's their fault.) The nearest high school was dropping plaster on the kids heads, and there was a proposal to build a new high school in Fishtown, but the people were against it, unanimously. Why? Because black kids might have walked through the neighborhood on their way to school.

Frank Rizzo, the racist neo-Nazi mayor, was very popular in Fishtown. Now you know why.

Politics is complex. The right has cobbled together a coalition of minorities -- people who are willing to trade off issues that aren't terribly important to them for ones they really care about. Wall Street financial barons and corporate executives want low taxes on high incomes, minimal environmental and safety regulation, low wages and minimal protections for workers, and they have plenty of money to put into political campaigns. Most of them think the religious right consists of ignorant lunatics, but they're happy to scoop up the wacko vote for candidates who will favor the rich. The mass media, of course, are part of the corporate establishment and naturally favor its interests. Religious zealots may be in a minority, but they volunteer for political campaigns, give what little they have, and vote as a bloc. So that's an important part of the story.

But it is racism that makes it all possible. It is largely because of racism that we have such an underdeveloped social infrastructure compared with western Europe and Canada. Racism has divided the working class, and made the white majority mistrust social programs which they have been persuaded somehow favor the other at their expense. It is racism, and nothing else, that led to the ascendancy of the Republican Party in the states of the confederacy, once the Democrats embraced the Civil Rights Movement and resolved the contradiction between their role as the party of the Old South and the party of the urban north. It is racism, ultimately, that underlies the tendency of white Americans who hold liberal views on issues to label themselves as conservatives. Racism is still the central problem in this country. It still is. Yes it is.

Putting the Public in Public Health

Okay, I didn't see any Reveres at the conference yesterday, the reason being, it was inhabited almost exclusively by state public health department officials, and the Reveres are academics. The third sector in public health is communities, as represented and empowered (to whatever extent they are, which usually isn't very much) by community based organizations. I am a very unusual beast, having a foot in all three worlds, which makes me tripedal and hence an extraterrestrial.

Anyhow, talking to the assembled multitudes (of about 18) about emergency communication to special populations (see below), I noted that the "plan" for this in most states, as in all other areas of public health emergency preparedness, consists of some exhortations to municipal boards of health to figure out what to do about it. (Viz. the preznit's pandemic flu preparedness plan.) Props to the pathetically tiny state of Rhode Island, however, for actually trying to come up with solutions to this problem.

The Department of Health of the pocket Hercules of states has come up with agreements with local radio stations (of which there are ever fewer as radio studios increasingly consist of a locked room containing a computer that transmits national programming) to run announcements in multiple languages; ditto with the major Providence fishwrapper; and agreements with pharmacy chains to post announcements in the locally relevant languages in their windows. They are also translating sections of the "bug book" -- the state health department's basic manual on the various infectious diseases (kind of like the firefighters hazardous materials manual) into 8 languages, for distribution to local boards of health to be in turn distributed to the communities.

There are some limitations to these strategies and difficulties in implementing them. It seems unlikely that people who don't read English will buy the Providence Journal or tune in to NPR or the hip hop station in the first place -- although their kids might alert them to listen, and bilingual people who read the paper could tear out the announcement and share it with their neighbors. But there's no guarantee that people will trust what they read or hear, or understand it. DoH tried contracting with a minority CBO for a pilot project in which they were to use various strategies -- phone trees, doorknocking, computer phone blasts -- to reach 500 families. Apparently it didn't go real well, but they are planning to try again, with closer involvement with a different CBO.

It seems almost too obvious to point out, but the solution to this problem is that public health authorities need to have close involvement with community based organizations on an ongoing basis, routinely, before there is any emergency. I don't know about your state, but in Massachusetts this used to be the style. My own agency had state contracts for health education and health promotion with specific content in breast and cervical cancer, diabetes, HIV, mosquito borne diseases, etc., but that's been scaled back or eliminated. We had a growing community health movement in which the state trained and supported Community Health Workers to do comprehensive health education and outreach. It still exists, but it's been starved during the recent Republican administrations.

I did a survey several years back which targeted Latina women 40 and older, regarding screening mammography, and other health and health care topics. To pilot test it, I went to a meeting of our breast and cervical cancer peer educators, in an apartmentin a public housing development in North Dorchester. There were probably 15 women there, all Spanish speaking, who responded to our draft survey and had a lively discussion with us about the survey and the topics that it covered. If there had been an emergency back then, whether it was pandemic flu or anything else, we could have mobilized those women. We could have gotten them to a meeting within a few hours, given them orientation and instructions, and sent them out to pass the word to their neighbors. They could have told us what they thought folks wouldn't understand or would have trouble believing or doing, and helped us find solutions. We can't do that any more because the state pulled the plug on the program.

There's a lot more to public health infrastructure than hospitals and stockpiles and disease surveillance systems. We need to build and rebuild community public health organizations and networks. Yes it costs money but it's a lot cheaper than occupying Iraq.

Hometown Homeland Security

As a youth (not that I am no longer) I worked for the guy who had the concessions at the town beaches. You know -- hot dogs, hamburgers, fried dough pizza, soda, snow cones -- pick your poison. We'd operate with the outside doors hooked open, but as the health regulations required, we had screen doors. Not that they were any deterrent to the flies, but still.

So along comes the fire inspector. "All doors must open out," he tells Wally. Now think about it. (That is assuming that, unlike a fire inspector, you possess the power of thought.) We're in there in the morning doing prep work, in the evening cleaning up, in the winter doing maintenance. Both doors are closed. You can't open the door. You are trapped. You cannot open the screen door, because the outside door is in the way. You cannot reach the doorknob to open the outside door, because the screen door is in the way. The fire inspector did not care. "Here it is in the regs, Section 7, paragraph 14, sub-paragraph b. All doors must open out."

So Wally remodeled to make all the doors open out, then he cut the corners of the screens to make flaps so you could reach the outside doorknobs. If the health inspector had seen that, he would have made Wally repair it, in which case . . .

But enough of bashing Big Government. I'm off the a conference today, where who knows, I may bump into a Revere or two. I will talk, among other profound and wondrous topics, about emergency communication with "special populations." Those are people who, for one reason or another, it's hard to get the word out to, such as about how to go to the emergency dispensing site (see below). Examples are people with limited English, socially marginalized people, and societal dropouts (you know who you are), people who for historical and/or cultural reasons are inclined to think you are full of crap (Hey! Could I be a special population?), insular communities, etc. I'll let you know what I have to say about this once I figure out what it is, which hopefully will be before my presentation, rather than after.

Catch you later.

Boy Scout Motto, Part II

Okay, it's fine to keep working on developing new vaccine manufacturing technology so that we might one day be able to turn around the manufacture of adequate vaccine supplies in time to meaningfully reduce the impact of an influenza pandemic -- one day being 2010 or later. It's largely feckless to stockpile tamiflu and try to buy some of the current, experimental H5N1 vaccine. $251 million to help other countries detect and contain outbreaks is a good idea, but not nearly enough. That's the president's pandemic flu plan, except for one more item: $644 million to ensure that all levels of government are prepared for an outbreak. That sounds good. What does it mean?

According to the NYWT:

According to a draft . . . obtained recently by the New York Times, the nation is woefully ill prepared for a flu pandemic. Were one to occur, it says, hospitals would be overwhelmed, riots would engulf vaccination clinics, and even power and food would be in short supply. The draft does not specify how troops would be used and who would be in charge under various circumstances. . . .Administration officials have said that such operational decisions will be made in the coming months through cooperation among cabinet secretaries.

In other words, there is no plan. Like Seinfeld, the plan is about nothing.

I've written about this before, but I'll remind you. The existing infectious disease emergency plan for the U.S. consists of something called the National Strategic Stockpile. Obviously, it doesn't have any bird flu vaccine or Tamiflu in it now, but presumably the idea is to buy some. When an outbreak occurs, materiel from the stockpile can theoretically be delivered anywhere in the country within 24 hours. Then what happens?

It is the responsibility of local boards of health to actually dispense it. Every city, town and hamlet is supposed to have a plan in place to set up dispensing sites, capable of processing 5,000 people per day. They are supposed to have enough sites to process their entire population in two days, and then on day three go out and do the shut-ins and riff raff. Processing includes a medical evaluation to triage people for whom vaccine (or whatever) is counterindicated, and identify people who may already be infected and ship them off to the hospital. Your local board of health -- which spends all of its time normally inspecting restaurants to make sure they aren't storing cleaning supplies on a shelf above one where food is stored -- is supposed to have all of this ready to go by the time the stuff shows up from the stockpile, including communicating to the public where to go and what to do, in all of the languages spoken in the area of course. Now, if all 10,000 people happen to show up on Day One, instead of half of them waiting till Day Two like they're supposed to; and if the people don't happen to distribute themselves evenly among the various sites but too many of them show up at one place; and if somebody happens to think that his kids should go to the front of the line even though somebody else disagrees; and if there turns out not to be enough parking at the local middle school for 3,000 cars and the people who get there first can't get out because they're blocked in, whereas half of the staff that's supposed to do the processing can't get in; and it actually takes longer than one day to process 5,000 people (hmm, do you think it might?) and there aren't any toilets and there's nothing to eat and there isn't any water and some people who show up indeed do have the flu but the ambulances can't even get in or out and it wouldn't matter if they could because the hospital has people lying in the parking lot . . .

That's the plan. Fortunately, there is a very good chance that your town hasn't done squat, because nobody is really making them do anything anyway and most of them haven't gotten a dime to spend on it. Who knows, some of them may even have figured out that it's completely nuts.

So now we're going to spend $644 million to actually figure something out. Eventually.

The Boy Scout motto

So the CinC claims to have read a book (hah!) about the 1918 flu pandemic, which made him realize that maybe he needed to think about emergency preparedness in terms other than suspending the Fourth and Fifth Amendments, setting up an international network of torture centers, and declaring martial law.

It appears, for a change, that he has decided to actually believe some scientists. His plan involves investing in new methods of manufacturing vaccine in cell cultures instead of chicken eggs -- a good idea, previously advocated here, but it won't come to fruition for another five years at best.

He also wants to limit liability for vaccine manufacturers, claiming that it is fear of lawsuits which have driven companies out of the business. The Pharmaceutical Manufacturers Association, by way of their former Congressional catamite and now Executive Director Billy Tauzin, applauds the move.

Not really. As Paul Offit, writing in the May/June issue of Health Affairs, explains:

During the past fifty years, the number of pharmaceutical companies making vaccines has decreased dramatically, and those that still make vaccines have reduced resources to make new ones. Pharmaceutical companies are gradually abandoning vaccines because the research, development, testing, and manufacture of vaccines are expensive and because the market to sell vaccines is much smaller than the market for other drug products. Congressional action could assure both a steady supply of existing vaccines and the promise of vaccines for the future.

The cost of liability insurance is part of the cost of selling vaccines, of course, and irresponsible plaintiff's lawyers, such as the despicable Robert Kennedy Junior, have contributed to the problem by bringing lawsuits based on bogus science. (Yes, it happens.) These suits, even if they are without merit, can be expensive to defend. On the other hand, there have been real instances of defective vaccines, or vaccines marketed with insufficient safety testing, in which lawsuits were merited. Liability is a cost of making all pharmaceutical products, and it exists for good reasons. The problem with vaccines is not that there is anything special about the liability risk associated with them, but that the market for them is small.

And why is the market small? Doesn't everybody get a shot? Yes, but that's exactly the problem -- they get one or two, and in most cases, never another for the rest of their lives. People may get an influenza shot every year, but it's always a different one, so it's comparatively expensive to manufacture, while there is strong political pressure to keep the cost down. Drug companies would much rather make pills for chronic conditions that don't cure people, but that have to be taken for a long time, preferably until death do us part. That's why they love cholesterol and blood pressure medications, allergy meds, heartburn meds, and psych meds. They aren't terribly interested in antibiotics, which you might take for ten days. In other words, the drug companies want us to be sick, they don't particularly want to keep us healthy or cure us, unless the cure is very expensive (as in cancer chemotherapy). Vaccination, by the way, is also not profitable for physicians and clinics, who receive very low reimbursement, often below the cost of administration.

Offit's recommendations (sorry, subscription only) put a minor emphasis on liability. There is already a federal program to limit companies' exposure in the case of childhood vaccines, the National Childhood Vaccine Injury Compensation Program, which has worked pretty well. He recommends expanding it to cover adult vaccines as well, and making it harder for plaintiffs to opt out and sue, rather than accepting the standard compensation.

But more important, he recommends beefing up the federal Vaccines for Children program, which purchases vaccines for uninsured kids and is the largest single purchaser of vaccines in the U.S. It underpays, and creates a functional cap on prices. He also urges finding ways to get public and private insurers to raise their reimbursement rates for vaccines. Finally, he urges more public investment in vaccine R&D. But all that requires spending money, which we don't have, because we have bigger prioties like abolishing the death tax and killing people in Iraq.

Next: Actual, reality based emergency preparedness, and the "plan."

Give 'em hell, Harry!

Nads!

It's a river of blood and a few hundred billion dollars too late, but it's happening.

The relationship between health care spending and boat payments

Our good friend Rexroth's Daughter, being fairly new in her town, recently picked a dentist out of the yellow pages. She didn't particularly like his style, but what she also didn't like was that he removed a crown to fill a cavity, and only then did he happen to mention that, oh yeah, you'll need a new crown, at the very least, but I recommend an implant. She had him put on a temporary crown. After various further travails, he tried refusing to replace the crown and forcing her to get an implant.

Now, you may have read that the preznit and the Republicans in congress, led by "doctor" Bill Frist, want to "control health care costs" by largely doing away with insurance, letting us save up for medical care in tax advantaged savings accounts, and then buying health care with our own dollars. We'll then be "empowered consumers" and presumably spending will go down because we'll be reluctant to blow what little is in our accounts, ergo we'll make wise choices.

Sadly, no. (Props to the copyright holder.) We don't decide whether what we we really need is to stop drinking so much Red Bull, or get a brain transplant: our doctor tells us. And even though we all know that doctors are 100% people of integrity, motivated solely by altruism, who would gladly take a vow of poverty and dress in sackcloth, innumerable studies have shown that they shape their treatment recommendations according to financial incentives, i.e., what's in it for them. Ask a surgeon if you need surgery, and guess what the answer will be, at least if he's got a boat payment due.

This is called Provider Induced Demand. It radically violates one of the many counterfactual assumptions that underly the theory they teach you in Economics 101, which is also the snake oil they peddle on Capitol Hill. Or, to ineptly and artlessly shift metaphors, a vast edifice of bullshit erected on a foundation of sand.

Perverse Incentives

Sorry, It's nothing kinky. It's the policy wonk's term for the undesired and unintended effects of taxes and regulations. Efforts are underway here in the People's Republic to achieve universal health care insurance. You can read all about it -- well, not all, actually, but something -- in the Boston NYT Stepsister.

House Speaker Sal DiMasi wants to impose a 5% payroll tax on firms with 10-99 workers that don't provide insurance for their employees, and 7% on firms with more than 100 workers. This money would be used to expand Medicaid and offer a subsidized product to low-income people who don't qualify for Medicaid. But people would be required to buy it.

A lot of my friends aren't going to like what I am about to say, but here at Stayin' Alive, we are without fear or favor. This is a bad idea, at least as it now stands. Where is that 5 or 7% payroll tax money going to come from? It's going to come from workers' pay -- where else? And the workers who don't currently have employer-provided insurance are low wage workers. They need health care, sure, but they also need shelter and groceries. Then there are the two "cliffs," at 10 and 100 workers. A Mom and Pop enterprise with 9 workers is going to do whatever it can not to hire that 10th worker, and ditto with a small business with 99 workers. This isn't some tendentious argument of greedy business owners -- it's obviously true.

We need universal, comprehensive, health care, yes. Preferably, for a number of excellent reasons that I don't have time to go into here, national and single-payer health care. (Very briefly though, the Massachusetts proposal, as currently structured, won't create sufficient levers for controlling costs.) But just as important, it needs to be progressively financed.

The reason people don't have health insurance is because they can't afford it. Forcing people to buy what they can't afford is not social progress.