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.

Fair and Balanced

There was an anti-war demonstration in Boston on Saturday, attended by more than 2,000 people. There were also six (6) -- as in 10 - 4 or 2 x 3 -- counterdemonstrators. The story appeared inside the Boston Globe, in the metro section, on Sunday. But guess what was on the front page? A photograph of one of the counterdemonstrators, waving her "Support our Troops" sign.

Meanwhile, what are our troops up to? According to ABC News, which is nothing but a front for the communistic, terrorist-supporting, America hating Disney Corporation:

Before dawn Monday, Marines backed by jets attacked insurgent positions near the Syrian border, destroying two safe houses believed use by al-Qaida figures, a U.S. statement said. The statement made no mention of casualties, but Associated Press Television News video from the scene showed residents wailing over the bodies of about six people, including at least three children.

At the local hospital, Dr. Ahmed al-Ani claimed 40 Iraqis, including 12 children, were killed in the attack. But the claim could not be independently verified.

APTN footage from the scene showed Iraqi men digging through the rubble of several destroyed concrete buildings with a pitchfork or their hands. In the building of a nearby home, women cried over the bodies of about half a dozen blanket-covered bodies lined up on a floor. Some of the blankets were opened for the camera showing a man and three children.

"At least 20 innocent people were killed by the U.S. warplanes. Why are the Americans killing families? Where are the insurgents?" one middle-aged man told APTN. "We don't see democracy. We just see destruction." He didn't give his name.

That'll teach those ragheads not to threaten our freedoms.

Malpractice

Rosa was frightened. Her little boy Diego was sick again. Diego had asthma, he’d had a positive TB test, he had recurrent ear infections and had been operated on twice to have tubes placed to drain his ears. Two months ago a doctor told her Diego had salmonella, and the clinic had mailed her a letter about it, but she couldn’t read it because it was in English. Now Diego had been up all night with a fever and vomiting, and his ear hurt again. When they came to the clinic, there was no-one to interpret, so Diego’s twelve year old sister Juanita had to do it.

Juanita did her best, but when she tried to translate her mother’s questions, the doctor just ignored her, or wouldn’t even let her speak. Juanita tried to tell the doctor that Rosa was worried about a lump on the baby’s lip, that she wanted to know what the letter said about the salmonella, that Diego had had diarrhea and fever. But the doctor just said the letter was too old to worry about. Then the doctor asked Rosa what Diego took for his asthma, but Juanita didn’t translate the question correctly. The doctor asked how long ago Diego had his last asthma attack but Rosa thought she had asked how often he took medicine for his asthma, and the doctor’s question was never answered. Rosa tried to ask what was wrong with Diego’s ears, and what she should do if he kept vomiting, but her questions were never translated. Then the doctor said to give him Tylenol or Advil, but Juanita told her mother to give him both.

When my colleague Irma Rodriguez interviewed Rosa after the visit, she asked if the family had been back to Puerto Rico to visit. No, said Rosa, nor can we. Why not? “Because the father of the children is hunting us to kill us.” Rosa said she was going to keep on living and fighting for her children, but now they were staying in a homeless shelter. Juanita had seen her father repeatedly beating her mother, and was in psychiatric treatment for post-traumatic stress. But the doctor never learned any of this.

Communication is the most fundamental requirement of medical practice. Taking care of people is not just about biomedical science, although technically precise communication is essential. It depends on mutual trust, rapport, and the exchange of experiences, beliefs and feelings. Facilitating communication across a language barrier is a demanding professional skill. An interpreter must be truly fluent in both languages, but much more than that is required. Interpreters must be conversant with medical concepts and terminology. They must possess special skills for mediating the structural differences among languages and the deeply embedded differences in world view. Interpreters must also have skills to mediate culturally determined expectations about interactions, the physician and patient role, and theories of physiology and disease. Interpreters must meet high ethical standards. They must scrupulously respect confidentiality and avoid injecting their own judgments into an interaction that properly belongs to physician and patient.

Obviously, children can never meet these requirements. Furthermore, having children interpret places demands on them that may be overwhelming and frightening, and may expose them to inappropriate or upsetting information. A 15 year old girl told us that she was serving as interpreter for her mother, when she found she didn’t understand what the doctor was saying, so they called for a Spanish-speaking secretary to help. “Don’t you understand what they’re telling you?” the secretary asked her. The girl went on, “’No, I said.’ She tells me, ‘They’re telling you’re your mother has,’ some sort of thing, cancer, I don’t know, I was like, ‘No, I don’t understand what you’re saying’ . .. and the lady was just so rude.” Doctors in England have told of a child from India who was traumatized by having to interpret for her family during her brother’s fatal illness.

In California, regulations have been proposed to forbid the use of children as interepreters. Naturally, the hospitals are expected to oppose the regulations. Let me make this absolutely clear:

Having children serve as medical interpreters is medical malpractice, and child abuse. It should be a crime, everywhere.

Evolution Sunday

The cnidarians (formerly called the coelenterates) are a successful animal phylum. They are almost exclusively marine, except for some aquatic representatives of the sub-pylum hydrozoa (hydras). Beachgoers are very familiar with the jellyfish. Corals and sea anenomes are also cnidarians, as are some less familiar creatures.

The cnidarians possess a nerve network, but no brain -- no central processing unit. Unlike the chordates, to which we belong, and the many animal phyla more closely related to us, they have only two embryonic tissue layers, as opposed to our three. They have an important asset belonging to no other phylum, called the nematocyst -- a mechanism in specialized cells that shoots out a stiff thread. In most cases, this thread is a poisonous dart. Nematocysts are typically found in the tentacles which surround cnidarians' mouths, and are used to kill prey which the tentacles then transport to the mouth. But nematocysts also function for adhesion, locomotion, and other purposes.

While we may pity the cnidarians for their lack of a brain, they are at an even greater disadvantage from lack of an anus. We three-layered creatures have a tube running the length of our body cavities. Food enters at one end, is systematically disassembled, and its useful contents assimilated. The dreck eventually exits at the other end. Cnidarians have a much less efficient system. They have only one opening to the digestive cavity. In order to ingest a meal, they must open the door, so that whatever contents are already present may escape, whether or not they are fully digested. When cnidarians swim, the cavity is inevitably distorted and its contents may be expelled. Even less happily, from our idiosyncratic point of view, cnidarian gametes -- sperm and ovae, essentially -- are discharged into the same cavity. To be exchanged with the opposite sex -- or a fellow hermaphrodite -- the gametes must be expelled into the oceanic environment along with lunch.

It's sad that we have so little appreciation for one of our most important assets. It seems an undeserved honor to label Pat Robertson, Jerry Falwell, James Dobson, and their friend in the White House by a name for this essential body part.

Critical Thinking

Commenter Tyler writes, in response to my previous post mentioning Rep. John Boehner, "If you knew anything about the man, you'd know he's fought against Democrat attempts to cut child nutrition programs in his own committee (Education & Workforce). The ignorance of the left never ceases."

Now, I certainly welcome criticism and debate, although I don't welcome gratuitous insults -- I am definitely not ignorant. So I hope Tyler will continue to visit and engage us in discussion here, in a civil and respectful manner.

As for the facts of this matter, the Democrats obviously support spending for child nutrition progams at a higher level than do the Republicans. In fact, Mr. Bush has proposed (again) cutting these programs in the new budget, and the Democrats on Rep. Boehner's committee oppose these reductions. (Subsidized school lunches, the WIC supplemental nutrition program, and some other programs to feed needy kids in homeless shelters, summer camps, etc. are normally wrapped up in a single piece of legislation.) The issue in question was not that Democrats wanted to "cut" these programs. Rather, it had to do with nutritional quality of school lunches. As James Weill, Director of the Food Research and Action Center, testified before the corresponding Senate Committee:

We have to improve the nutrition environment in which children consume the meals and snacks offered in the child nutrition programs. The Secretary of Agriculture should have the authority to control the sale of competitive foods throughout the school from the time school opens in the morning until the end of the last lunch period, in order to ensure as much as reasonably possible the healthfulness of foods offered to children. Other steps to improve health and reduce obesity should be part of this process.

Boehnert opposed giving the Secretary this authority. In the new legislation, local schools are required to develop their own "wellness" programs, but there will be no federal standards for the content or quality of these programs, or the quality of school meals. It is likely, obviously, that local school districts will often be ineffective at getting junk food out of their schools. To portray this dispute as an effort by Democrats to "cut" child nutrition programs seems fundamentally, ahh, disingenuous, shall we say?

It's no surprise that Boehnert would take this position. While he receives the largest share of campaign funding from the financial industry, he is a significant beneficiary of campaign funding from the Food and Beverage Industry ($8,375 in 2005-6); Food Production and Sales ($11,520); Retail Sales (including convenience stores -- $8,500); and, interestingly though perhaps off topic, Alcoholic Beverages ($17,000). More important than his personal campaign fundraising, no doubt, is Boehnert's role as a major fundraiser for Republican causes in general -- he has his own PAC -- and as a K Street power broker. According to Jonathan Kaplan writing in The Hill:

Rep. John Boehner (R-Ohio), a likely candidate for a position in the House Republican leadership if former Majority Leader Tom DeLay (R-Texas) does not return, has assembled a loyal and effective network of lobbyists.
Boehner formed his alliances on K Street when he served as chairman of the GOP conference from 1995 to 1998, when his portfolio included working with lobbyists on K Street.

“He was a policy traffic cop for the business community,” one of Boehner’s allies said. “When [former Rep. J.C.] Watts [Okla.] won [the election for conference chairman], DeLay, in the whip position, vacuumed in the policy and business outreach. He added staff and translated business outreach into votes, which is something [Missouri Rep.] Roy [Blunt] is doing now.”

Many GOP sources say Boehner would receive strong support from his so-called K Street Cabinet if he decides to run for another leadership post. He is considered a strong contender to become majority leader or speaker if DeLay, who is under indictment on charges of conspiracy and money laundering in Texas, does not return to his post or if Speaker Dennis Hastert (R-Ill.) retires in 2008.

The sources add that Boehner would likely be able to count on strong support in either case from these lobbyists:

• Bruce Gates of Washington Council Ernst & Young, whose wife, Joyce, served as Boehner’s administrative assistant.

• Henry Gandy of the Duberstein Group.

• Michael Boland and Peter Madigan of Johnson, Madigan, Peck, Boland and Stewart.

• James Boland of Sundquist Anthony, who is Michael Boland’s brother.

• Robert Schellhas of Citibank.

• John Fish of Reynolds American.

• Marc Lampkin of Quinn Gillespie & Associates.

• Barry Jackson, a senior adviser to White House Deputy Chief of Staff Karl Rove.

• Gary Andres of the Dutko Group.

• Nicholas Calio of Citibank.

• Dirk Van Dongen of the National Association of Wholesaler Distributors.

“It’s a pretty broad-based orbit and relationships of people who saw him as a rising star when he was just a junior member,” said a senior GOP lobbyist close to Boehner.

Gates and Gandy hosted the first of the now-famous warehouse parties that have become regular features of Republican national conventions and are referred to as “the Boehner parties.” The first was in 1996 in San Diego.

While many lawmakers use Washington’s button-down restaurants to host fundraisers, Boehner and his allies prefer the more relaxing Cantina Marina, a bar and restaurant noted for its Gulf Coast and Cajun fare, located on the Potomac waterfront in Georgetown, several of the lobbyists said.

Each August, Boehner diligently raises money for members of his Education and the Workforce Committee, GOP challengers and vulnerable incumbents; this summer the beneficiary was Rep. Cathy McMorris (R-Wash.).

And, as for my other characterizations, Boehner is a vocal backer of the Iraq war and of increased military spending; of Social Security privatization (and simultaneously, and opponent of protections for small investors); and of yet more tax cuts for the wealthy.

It is, unfortunately, a common practice of the political right to fundamentally misrepresent the policy positions and actions of their opponents. For example, Max Cleland and other Democratic Senators were attacked for opposing the president's efforts to "protect the homeland" because they advocated for employees of the new Department of Homeland Security to be covered by civil service protections.

Tyler, there may well be arguments on both sides of the dispute over school lunches, but you fundamentally mischaracterized it. And you cannot deny that Boehnert, in his role on the Agriculture Committee, is trying to cut funding for food stamps, even as more and more Americans are going hungry, which is what I posted about in the first place. Do you care to defend that? I'll be happy to discuss it.

The Back Pages

What with all the excitement lately, you have to turn a few pages to find out about unimportant stuff like the federal budget, but just so you know, the House Agriculture Committee yesterday voted to take food stamps away from 300,000 people, which would also have the effect of taking subsidized school lunches away from 40,000 kids.

As Rep. John Boehner (R. Ohio) put it: "The fact is, our country is going broke. We're spending money we don't have and passing it onto our kids, and at some point, somebody's going to have to say, 'Enough's enough."

Right Mr. Congressman, we're passing that debt on to our kids -- at least the ones who live long enough and are productive enough to have to pay it, because we didn't starve them when they were five years old. (The government also reported yesterday that the number of people who can't afford to buy a sufficient diet rose last year to 38.2 million, that's 12 percent of Americans. Thanks to Libby Quaid of the AP for putting this particular two and two together.)

So I'm gonna say it. Enough's enough. Let's stop spending $5 billion a week to defend the Shiite side in the Iraqi civil war that we started. Let's stop getting our young men and women killed and maimed in the process. Let's stop spending money on useless and dangerous projects like ballistic missile defense and biological weapons research. Let's stop building bridges to nowhere, and endlessly cutting taxes on the wealthiest Americans. And let's throw these greedy, lying, war mongering hypocrites like John Boehner out of office. Enough's enough.

Okay, I'm out of here until Sunday.

Indictment

Then there's the small matter of mass murder. That would be 2009 dead American soldiers and marines (as of this minute), 97 dead from the UK, 102 soldiers from various countries in the Coalition of the Billing, 60 journalists (that we know of), 276 "contractors" (that we know of -- mostly mercenaries).

And oh yeah, something between 40,000 and 120,000 dead Iraqis, depending on who you ask, but hey, who's counting? And we definitely aren't counting the starving children. Anyway, death is a small price to pay for being liberated.

But I guess all that is not a crime.

Culture of Life, Installment 323

What you can't read in North America

Back to my day job . . .

A couple of quick hits from the new JAMA:

1. I wrote a couple of months back about European studies that called into question whether routine screening mammography really reduces the breast cancer death rate, at least for women not at high risk. A new analysis commissioned by the National Cancer Institute finds that screening has contributed substantially to the decline in breast cancer deaths in the U.S. Caveats still remain: most lesions found by screening are benign, and you have to go through all the sturm und drang. Probably something like 30% of cancerous lesions wouldn't have gone on to cause clinically significant disease, but you have to go through surgery and chemo anyway because the docs can't tell the difference. But most women will probably decide it's worth it for the survival benefit. Still, talk it over, make up your own mind.
2. Is this really a major problem, or more "War on Drugs" hype? Some burn specialists in rural areas are saying that the number of people burned in home meth lab accidents is straining their resources and forcing them to ship innocent victims of house fires out of the county. But David Duncan, a research consultant, says "There are just not enough [meth lab explosions] to cause a national problem for burn centers. . . . And while meth lab cooks are not likely to have insurance coverage, their numbers are tiny compared ot the millions of people losing Medicaid coverage or working for companies cutting back on health coverage." Right on. (Reporting by Mike Mitka.)
3. Quackery: There's a mass marketing campaign -- totally illegal, as a matter of fact -- for Human Growth Hormone as an anti-aging elixir. Fuggedaboudit. Not only does it not work, and cost hundreds of dollars a month, it causes joint pain, muscle aches, edema, probably diabetes and, oh yeah, maybe breast cancer. Vile scum, that's what they are -- many of them M.D.s. (Commentary by Thomas Perls, Neal Reisman, and Jay Olshansky.) I recommend Quackwatch, even though some of my friends will think the proprietor, Stephen Barrett M.D., suffers from excessive orthodoxy. Maybe so, but you need to hear his point of view.

There's more of interest, but that's enough for one post.

Parenting of the Rich and Famous

After my class last night I stopped off at the local watering hole for some dinner, and the World Serious was on. Poppy and Babs were at the game, and of course the Fox cameras kept caressing them lovingly.

They were having a Grand Old Time! They didn't have a care in the world, they were as happy as hogs in slop, and Babs had an extra bucket of potato peels and apple cores. At first I thought, "That's a little odd," then I realized -- they're happy to watch Junior stepping in it.

Babs was thinking, "If I had a pearl necklace for every time we've had to pull that boy's lazy, smug, dumbshit sorry ass out of the deep doo doo . . . It got so tiresome, I was growing pimples on my beautiful mind. Well he's on his own this time, we aren't loaning him five bucks for a shoeshine. We're just drinking martinis for lunch now, sitting on the front porch watching the sailboat races. His uncle Dick can't help him either, he's swimming in the doo doo himself. Which is also just fine by me. I never could stand the way that man talks with his jaw clenched, such a sourpuss.

Anyhow, maybe this will finally ram some sense and some respect through Junior's concrete cranium, but frankly, at this point, I don't give a rat's ass."

At least that's how it appeared to me, but I only saw a bit of video of people I've never met. Maybe Dr. Frist has a better diagnosis.

Yes there is good news

Just so y'all know I'm reality based, rather than a constitutional depressive, let us all take note that the aspiring king and his court are indeed severely weakened. They've caved on suspending the Davis-Bacon prevailing wage law in the hurricane zone, and they've caved on developing new generation nuclear weapons -- tactical so-called "bunker buster" bombs designed for first use.

Much to their credit, CBS News not only has a well written story on this, but an interactive primer on nuclear weapons and nuclear dangers in the modern world. (Click the "interactive" links in the left side bar.)

Now, do we have a chance to stop the Congress from passing yet more tax cuts for the wealthy while taking health care, housing, and fuel assistance from the poor?

This is from our friends at Community Catalyst: (They had a call in day on Oct. 18 but it's not too late, these issues are still in play.)

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Katrina Survivors Need Medicaid
Medicaid must not be cut!

The tragedy on the gulf coast has affected thousands of African American and low-income residents who depended on Medicaid and other programs, such as food stamps and subsidized housing. They will need emergency assistance to meet their immediate needs and to rebuild their lives. Emergency Medicaid is the best way to make sure that survivors have ready access to the full complement of physical, mental health and long term care supports and services they may need over the coming months, and that Medicaid can easily and efficiently provide, no matter where survivors are temporarily living.

"Ensuring that these individuals get access to health care, wherever they are, is our biggest issue," said Dr. Fred Cerise, who heads Louisiana's Department of Health and Hospitals. Tribune,September 14, 2005.



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Set Congress's Priorities Straight!
Call Capitol Hill and tell your Senators and Representatives not to cut life saving health care services Katrina hurricane survivors need. Let them know you oppose cutting Medicaid, Foodstamps and other vital programs to pay for for the hurricane relief.
A new bipartisan proposal, supported by Senators Grassley and Baucus as well as members of Congress from the states hit by the hurricane, would immediately provide Medicaid coverage to low-income Katrina survivors. However, this proposal has been blocked by the Bush administration, and further delays immediate aid to Katrina stricken areas.

In this time of need, the Administration opposes paying 100 percent of the cost of coverage and administration, and expects each state to foot all or part of the bill. The Administration has made even more dangerous proposals:

Even more cuts! In response to the increasing cost of the Katrina damage, Congress may cut even more deeply! The House has already delayed the FY 2006 budget reconciliation and has set a higher target for cuts to programs such as Medicaid, Food stamps and other vital services.
States are on their own! Refusing to financially support states for Katrina relief leaves states vulnerable and may lead to further state cuts in Medicaid, denying benefits and coverage to those who rely on the program.
The poor are punished and the wealthy are rewarded! Federal tax breaks for the "well-off and well connected" are hurting middle and low income people. But plans to pass more breaks for the wealthy are proposed in the budget. This will result in more cuts of vital services that we all need, especially those who are vulnerable. Stopping the tax cuts for just one year would be more than enough to pay for the entire costs of Katrina/Rita recovery.

What we can do:

Call your Senators and Representatives and tell them that these cuts are devastating and unacceptable! Instead of cutting much needed life saving programs, Congress should:

Call on Majority Leader Frist to bring Grassley- Baucus up for a vote now: Each day that passes, more lives are put at risk. This legislation should be enacted on an emergency basis as soon as possible. People from the disaster areas have been forced to wait for help for too long.
Not make cuts in the FY2006 Budget to life saving programs such as Medicaid. Cost-savings in Medicaid that do not hurt beneficiaries are possible through prescription drug pricing reform. However, this should be done separately from the budget proposal to make sure savings help stabilize Medicaid.
Not increase tax breaks for the wealthy while middle and low income people are struggling to make ends meet.

What do I have to add?

Nothing original, I'm afraid, but I feel I ought to say something.

The corporate media and the "opposition" party have long had definitive, fully public evidence of a horrific crime. A small group of top administration officials -- the president, vice-president, secretary of defense, and some of their confidants -- decided to make war on Iraq, probably even before the Bush administration took office. Acting in secret, they set out to manufacture a casus belli, conspiring with a convicted embezzler who they intended to install as president of "liberated" Iraq, and, among other "journalists," a New York Times reporter. Oh yeah, British Prime Minster Tony Blair and some of his cabinet ministers were in on the conspiracy. Meanwhile, they allowed the foreign policy apparatus to go through the motions of normal functioning, as a distraction to the press and public, although the conclusion was fixed long ago. They even chose to ignore the extensive planning done by the state department for the contingency of a post-war Iraq, simply because it wasn't a part of their conspiracy.

As for the devastating consequences of this crime -- the cost to Iraq, to the United States, to the world -- I won't belabor the obvious. How very disturbing it is that there was no prospect of bringing any of the conspirators to account until a prosecutor was appointed to investigate a relatively minor, certainly peripheral action in furtherance of the conspiracy. The Democratic Party has largely supported the conspiracy, including its most prominent prospective presidential candidates; the corporate media have criticized it mildly but have certainly not chosen to regard it as a crime of any sort, let alone treason and mass murder. The majority of commentators given access to the mass media regard the specific crime under official investigation as a trivial technicality, and disparage the prosecutor as overzealous.

Fortunately, a good portion of the citizenry feels otherwise. We have been betrayed by our leaders. Perhaps they will finally feel our anger.

Is Pooster's Fork, Wyoming, ready for the big one?

With all the bureaucratic reorganizing, redirection of public health funding, and presidential and vice presidential squealing and yapping about bioterrorism, you probably figure we've made major progress in preparing for possible epidemics. Yeah yeah, it probably won't be "bioterrorism," but just a natural event such as pandemic flu or a more novel infection, but the necessary infrastructure and plans are about the same, right?

Maybe, I dunno. But just as a reality check, this is what the national bioterrorism (and/or infectious disease emergency) plan consists of: templates and checklists, that state health departments post on their web sites, for cities and towns to follow. It all falls on your local Board of Selectment and Commissioner of Health -- the guy who inspects the hamburger stands to make sure the screen doors are intact.

These researchers pretended to be nurses or citizens, and they called the hotline number of various local public health agencies, reporting what appeared to be cases of bubonic plague, anthrax, smallpox, etc. Fewer than half of the agencies met the federal guideline of responding within thirty minutes. Some of them didn't get back to the caller for more than an hour and four did not return calls at all. Three of them didn't call back after being called five times.

Once they did manage to reach a responsible party, responses varied:

Respondents varied widely in their handling of simulated cases. Several action officers asked relevant questions about the location of the patient and about clinical details, but in several cases the responses were troubling. For example, among respondents presented with a case report from an emergency department physician of a patient presenting with “pustules on the face, arms, and legs with lesions in the same stage of development,” none suggested isolation of the patient or advised the caller to use personal protective equipment. Similarly, when presented with a case consistent with botulism, one action officer responded, “You’re right, it does sound like botulism. I wouldn’t worry too much if I were you.” In response to classic symptoms of bubonic plague, the action officer told the caller not to worry and to “go back to bed” because no similar cases had been reported that day.

I'm going to write quite a bit more about this general subject in coming days (and check out Effect Measure as well on this), but this will get us started. We need to be engaged with our local governments, big city or small town, if we want to make sure we're ready. The top down approach is not working.

Is this what I wanted to be when I grew up?

Since Haloscan seems to be down for a while, this is probably a good time for me to talk a bit about my actual research. For whatever reason -- I need a vacation? I'm just too modest? -- I haven't talked about it a lot here, but I study physician-patient relationships and communication. I used to say that I focus on language and culture as factors in the above, but now I've decided that's like saying I focus on building techniques as a factor in construction methods. All doctor-patient communication is cross-cultural and bilingual.

It might be said that communication is the most important clinical skill. Certainly it is the skill that is used the most. A typical physician visit - or medical encounter, as some would have it - is occupied with almost continuous speech, mostly in the form of what we call a conversation -- a back and forth exchange of utterances between two people. This is not very much like the conversations we have with our friends, family members, co-workers, lovers, or anybody else, for that matter. These are highly ritualized, asymmetrical encounters that are powerfully shaped by cultural tradition, the way in which physicians are socialized and trained, our previous socialization and experience of medical encounters, the instrumental goals of the visit, time constraints, legal requirements, inequality in possession of information and social status, and other factors. As complex as they are to describe and understand, they are often as critically important. Their success or failure can mean health or illness, life or death, and even if nothing that dramatic is at stake in a particular instance, they can greatly affect how we feel -- whether we are reassured, anxious or even terrified, satisfied, frustrated, guilty, proud . . .

There is an immense literature on this subject. There are many instrumental purposes for MD/PT communication, obviously -- diagnosis, treatment decision making, emotional support, personal relationship building. The funding I have right now happens to concern the objective of motivating behavioral change, and more specifically achieving better adherence by patients to prescribed medication regimens, but the work I'm doing is much more broadly applicable. Here is a link to a review just this week of how people think about this issue, which includes some concepts similar to ones I am working with.

What I am trying to bring to the party is a new way of characterizing and analyzing conversation based on an idea in sociolinguistics called Speech Act Theory. You'll notice in the BMJ article concepts such as informing, open questioning, directing, etc. These are rudimentary representations of Speech Acts -- specific kinds of social resources that are exchanged in conversation. Representatives (statements of fact about the world), Expressives (assertions about one's inner reality), Questions of various kinds (which place a social obligation on the interlocutor to respond), Directives (intended to influence the interlocutor's behavior, whether in the form of mandates or suggestions), Commissives (promises and official acts affecting one's status), Praise and Insults, Affective exchanges, Social Ritual, Conversation Management, and others. These are properties of speech in all languages, and they are only loosely and inconsistently related to grammar and syntax.

One can define a completed speech act as a unit, called an utterance, classify it as a speech act, and then classify it according to topic -- what is being discussed. In this way, we develop a rich and revealing quantitative description of an interaction. We are developing computer software to facilitate the coding process.

Where this all leads, I hope, is to a convincing way of consistently characterizing and understanding interaction processes, and the amount and quality of information and other social resources that passes between physicians and patients. We can relate this to outcomes -- such as better medication adherence, patient satisfaction, informed decision making, etc. -- and to inputs such as physician training and other interventions.

It probably sounds rather arcane and boring. One of the great difficulties in social science is in linking levels of analysis. Critical discussion of systems such as the medical institution and public health infrastructure, policy analysis -- these macrosociological fields are usually more exciting than the minutiae of individual encounters. But they are connected. Medicine is hierarchical, unequal, embedded in the our unequal society and shaped, in the U.S., by our powerfully individualistic cultural norms. All of this manifests in the particular.

Anyhow, it's dirty work, but somebody has to do it.

Bankruptcy

This is unbe-fucking-lievable. Former Florida Senator Connie Mack, Chairman of the tax "reform" panel, is interviewed by the New York Times Magazine. He's wants to eliminate the estate tax -- it's so unfair -- and he says there's no way there's going to be any tax increase. The following ensues:

Q. Well, the U.S. government has to get money from somewhere. As a two-term former Republican senator from Florida, where do you suggest we get money from?

A. What money?

Q. The money to run this country.

A. We'll borrow it.

Q. I never understand where all this money comes from. When the president says we need another $200 billion for Katrina repairs, does he just go and borrow it from the Saudis?

A. In a sense, we do. Maybe the Chinese.

Q. Is that fair to our children? If we keep borrowing at this level, won't the Arabs or the Chinese eventually own this country?

A. I am not worried about that. We are a huge country producing enormous assets day in and day out. We have great strength, and we have always adjusted to difficulties that faced us, and we will continue to do so.

Really. This is not satire.