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First of all, the criminal Republican budget cutting bill was temporarily withdrawn, as we noted last Thursday.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.

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.