OPINIONS OF ECHIDNE OF THE SNAKES, A MINOR GREEK GODDESS. She can be reached at: ECHIDNE-OF-THE-SNAKES.COM

Sunday, August 31, 2008

What Not To Do by Anthony McCarthy 

This Just In: At the Labor Day Weekend party, in mixed company, including young children and your 90-year-old mother, as you are answering the observation by your niece that you have not read her a single word of the Harry Potter cycle this summer, do not suggest as an alternate selection “Sets, Relations and Functions” by Selby and Sweet. At least not unless you enunciate very, very, very clearly.
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The hurricane & women (by Suzie) 

     

       As a former resident of New Orleans, watching the approach of Gustav with horror, I want to remind people about the gendered aspects of disaster. Check out "Women in the Wake of the Storm: Examining the Post-Katrina Realities of the Women of New Orleans and the Gulf Coast," a report published in April by the Institute for Women’s Policy Research. It recommends: 
Make affordable housing a top priority. The safety of women and girls remain in jeopardy with each day that severe housing shortages go unaddressed.
Incorporate women in the rebuilding economy through non-traditional training and enforcement of anti-discrimination laws. ... Providing women training in the skilled and technical trades would help increase their chances of earning a rate of pay that would allow them and their families some level of economic well-being. And buttressing that training with aggressive enforcement of anti-discrimination laws in hiring and pay would help to alleviate some of the difficulties women report in trying to gain access to fuller employment.
Increase the availability and quality of child care and schools.
Address both physical and mental health care needs, especially among the most needy.... Special attention should be given to women and girls whose Katrina experience has included domestic violence or sexual assault ... 
Include a broad representation of women on decision-making bodies  that address disaster recovery, and any future bodies formed for the purpose of pre-disaster planning. 
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Insight Into Psychobabble Review by Anthony McCarthy 

I was going to resist the temptation to mock the Boston Globe’s bi-monthly column “Surprising Insights From The Social Sciences” but, pleeeease.

WHAT IF THERE were no God? That is the title of a new study by psychologists at Northwestern University in Chicago who studied 128 observant Christians with diverse political orientations living around Chicago. In interviews, subjects were asked what their lives would be like without God or religion. The transcribed responses were categorized according to concern for impulse control, societal breakdown, or life fulfillment. Conservative Christians of all backgrounds were more concerned with, while liberal Christians were.

McAdams, D. and Albaugh, M., "What If There Were No God? Politically Conservative and Liberal Christians Imagine Their Lives without Faith," Journal of Research in Personality (forthcoming).

Ah, that item, most rare in psych news reporting, a number. 128, count ‘em, “observant Christians”. Apparently divided in, perhaps, equal halves? So, on the basis of 64 (just guessing) each of “liberals” and “conservatives” we are presented with a basic difference in the psychology of the two groups numbering in their scores of millions.

Conservatives are concerned with “containing their baser instincts and societal decay” liberals are “more concerned that life would lose some of its deep richness and meaning”.

Are we to take from this that liberals are more concerned with their lifestyle and conservatives more interested in preventing societal decay? How could you escape that conclusion? Now, that really jibes with the philosophies of these two groups as manifested in real life doesn’t it. I mean, you just know that conservatives will go for shoring up the common good while liberals always go for looking out for airy-fairy fulfillment.

What in the world does the reported methodology mean? Categorizing transcribed responses for concern for impulse control, societal breakdown or life fulfillment? What does that mean in plain English, never mind whether or not the process used has a shred of scientific verification of its legitimacy?

So, what we have here is a tiny sample size, reporting on what they IMAGINE would be the case about a situation they haven’t experienced and DON’T BELIEVE to be true, in ways that requires the interpretation of the researchers. I'll make believe I don't think they had any kind of bias that could influence their conclusions.

Vague interpretation of what the researchers guess the imaginary responses of people to a situation they haven’t experienced mean. When does this get too tenuous for anyone to take it seriously?

Doesn’t a columnist pretending to act as a science reporter have a higher journalistic responsibility than this?

I am tempted to go into the first blurb too. I’m wondering what kind of scientific verification there is for the validity of the “ psychopathic personality questionnaire” used. If it’s like much of psychological testing, that’s an important question in determining the believability of the results. Why would anyone guess a psychopath would give honest answers to a questionnaire, to begin with, or that psychopaths as a group would give consistent answers. As you can also read, it’s a forthcoming “study” so we’ll just have to wait to see if what the “insight” really reveals.

I’d go into the pseudo-science of the Rorschach and some other widely used psychological tests and the horrific and legally mandated use of those by employers and the judicial system but will wait for another time. Did you know the Rorschach test is derived from an old Viennese parlor game, has dodgy verification and yet, unless they've dumped them since the last time I looked, the Rorschach industry still has a position in the AAAS? And it’s still widely used in clinical practice?
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McCain’s Choice of Palin Proves He Is Unsuited To Be President by Anthony McCarthy 

The media said that Obama’s Vice Presidential choice would constitute his first “presidential act”. He appears to have made a choice after a long process by a team of serious and experienced people. McCain’s choice of Sarah Palin, we are told, appears to be one of his famous “gut decisions”. After months of campaigning on Barack Obama’s alleged lack of experience he chose someone who, of all those mentioned as possible Republican Vice Presidential nominees has the least experience of any. Apparently John McCain believes that her son’s imminent deployment to Iraq constitutes of a record adequate to fill out her military if not foreign policy portfolio. If he really believes that, he has given serious people adequate reason to doubt his mental health

We may be witnessing the tipping point where the Republican establishment goes from calculated cynicism to pillaging nihilism. They have given their nomination to a 72-year-old man with less than a far less than optimal health history who listens to his gut when it tells him that a two-year governor in one of the least populous states, whose major record in government is as the mayor of a town of less than 9,000, should be one of his heartbeats away from the American presidency. I suspect, the media will soon begin declaring parts of Palin’s record and personal history hands off and “old news”, in the way they inevitably do when serious examination of Republicans begins. If that happes we will know. There is only one possible Democratic President between us and the final, decadent end of American democracy.

Barack Obama’s pastor was endlessly used against him in the past year, even though he disavowed his most extreme statements and doesn’t appear to have ever based his political decisions on them. Sarah Palin belongs to a church which is part of a far right cult dangerous enough so the Souther Poverty Law Center monitors them. You wonder what McCain’s gut told him about that.

Sarah Palin is known to have embroiling the Governor’s office and other parts of the Alaska government in her families bitter feud with an ex-brother-in-law. Whether or not the accusations made against him were true - and I haven’t seen his side of it yet- using her position and allowing her husband to use it in an attempt to get him fired from his job as a state trooper shows a complete lack of ground floor judgement. Her part in the firing of the public safety commissioner, apparently over a family matter, could end a political career in many states. And her cooperation with the legislative investigation into her use of power has been less than cooperative, apparently. John McCain should certainly understand the need to maintain the reality as well as the appearance of propriety and transparency in matters involving ethics, given his own history. His wife’s problems should also have given him an appreciation of why it’s a good idea to keep a fire wall between family problems and official duties as a public servant. But his gut overrode his vaunted experience here too.

John McCain has said that he knows nothing about economics and proved it by putting Phil Graham in charge of handling economic issues for his campaign. You would think that the subsequent need to remove him, for the time being, might have taught McCain’s gut a lesson in why someone from a state with an economy rich from extraction industries might not have an appreciation for what it’s like for people in the rest of the country. Palin’s brief experience as governor of Alaska certainly couldn’t provide her with a good idea of what those in non-oil states face. And her odd ideas about that are just beginning to surface. Alaska, with its odd form of oil based, income independent welfare, is certainly atypical of the rest of the United States, even of oil-rich states. Being governor of there is probably about as much a preparation for handling economic issues as being a Senator from there produces ethical and responsible appropriation of public money. I believe that in the coming weeks we will find out that Sarah Palin has some bizarre ideas about economic issues based on what her experience in Alaska’s Republican Party has taught her.

Forget her ideas about the environment, which are as psychotic as the worst of the Bush and Reagan administrations. She might yet become the first overtly pro-extinction president in our history.

One of the often mentioned possible Vice Presidential candidates for McCain was one of my senators, Olympia Snowe. I’m not a fan, having actually watched her career instead of the PR hype. Like that of all “moderate” Republicans her record actually consists of several token shows of independence while being a reliable supporter of whatever retrogressive policies the far-right Republican establishment comes up with most of the time. But I would have to admit that she had experience that would at least make her a credible successor to a Republican president, if he died in office. She wouldn’t be a complete neophyte in foreign policy or have entirely wacky ideas about the state of the environment or the economy. Though her policies would probably be lamentable, they wouldn’t be insane. Several of the other possible Republican Vice Presidential candidates were similarly qualified.

Yet John McCain’s gut told him that Sarah Palin, who embodies the lies his campaign has endlessly bellowed about Barack Obama’s “extremism” and “inexperience” and a person who opposes many of the “moderate” Republican policies that have created the McCain myth, should be handed a more than excellent chance at succeeding him as President of the United States. There is every reason to expect that she will be president if McCain is elected.

That is John McCain’s first “presidential decision”. The issue here isn’t just Sarah Palin’s complete unsuitability for the job of President, or Vice President, it’s also the issue of John McCain’s appalling decision. His first important decision impinging on the presidency of the United States and he has made a totally nutty choice. John McCain is not suitable to be President of the United States, we need ethical, wise and informed leadership not someone who goes with his obviously busted gut.
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Saturday, August 30, 2008

Reflections from Denver - Guest post by Skylanda 

I had meant to throw up a couple more posts from the stands at the Democratic National Convention, but (hey, who knew?!) typing on a PDA is harder than it looks. So instead I’ll finish out with a couple days’ retrospect, a reasonably sized keyboard, and a little more sleep than I’ve had in a week.

I’m not a flag-waving sort, but Thursday night in Denver I waved a flag. In general I don’t believe in the sort of thoughtless, jingoistic patriotism it takes to go swinging any nation‘s cloth around in a crowd. And over the last seven years (two weeks out from the seventh anniversary of 9/11, we are), the idea of patriotism and the act of flag-waving has been so usurped by reactionary idealogues in America that any time I see red bars and white stars on a field of blue, my gut tightens with the heavy anticipation of what hatred or hawkishness is coming down the road.

But they were passing out flags Thursday, before the sun went down, so I took one and dutifully pinholed it on the seat back in front of me in a spot usually reserved for Broncos sports paraphenalia.

The afternoon was long and hot and some of those speeches could have been a might bit shorter (though I can’t help but smirk that the afternoon’s entertainment opened with the Yonder Mountain String Band, a collection of bluegrass-picking stoners from just up the road in Boulder…in a venue just a tad larger than the last outdoor bar I saw them play in). The crowd built throughout the afternoon as the hours-long line outside the stadium (which we had the good foresight to hit up in the early afternoon when it was less than 45 minutes long) slowly poured in to fill the seats. The lesser-knowns spoke first - state party officials and campaign managers, House representatives from Midwestern states, a token panel of undersung war heroes. Then the better-knowns - Howard Dean, the New Mexico governor who keeps pretending toward a presidential bid despite that atrocious semi-mullet he insists on sporting, a local member of venerable Udall political clan. Then Al Gore, who comes off as so terribly more presidential that he ever did during his run for office. Then the six American Voices - men and women from across the country telling their own stories of life under the Bush years - who proved that people you would never expect to have a public voice can talk like elder statesmen and stateswomen in front of eighty-thousand live and another how many millions over the airwaves.

And then, the man himself: Barack Obama. And a thunder of applause that could have brought down mountains. He speaks with the intonation of an old-time preacher and the rhetoric of a classical civil rights leader - more electrifying in person than television or YouTube could ever capture - even to a crowd of tens of thousands and under the watchful eye of snipers that roamed the high points of the perimeter. He commands crowds in a manner that Kerry or Gore never could, and even Clinton (the ex-president, not the ex-candidate) never did until the retrospect of the Bush years made him look a whole lot better than he ever did on his own.


He spoke of hard times in America, and how it speaks to the soul of a nation how we face down, put down, or help up those enduring tough times. He spoke of pragmatics like oil independence, educational investment, and covering the uninsured with health care. He spoke of hope, and of renewal, and of a kind of conciliation that understands political opposition as a force not of mal intent, but a force of those who just don’t get it.

His conciliatory stance is sometimes frustrating, and his command of the issues doesn’t line up precisely with the farther left side of the left wing. He put the word “abortion” out of the spotlight, offering up that eternal thorn in the side of pro-choice rights, the safe, legal, and rare clause: “We may not agree on abortion, but we can agree on reducing the number of unwanted pregnancies in this country.” One has to read between lines to understand that it’s not that Obama may disagree with the right wing on the abortion issue, it’s that he does disagree, with 100% score from NARAL on his pro-choice voting records for 2005, 2006, and 2007. The recent change in the Democratic platform both emphasizes the prevention model and staunchly support Roe v. Wade all at one time - a move designed to make the tent bigger, include a greater constituency, please the breadth of the masses.

Which is all a very mixed blessing. On one hand, I would like to see a candidate who is unafraid to stand up for pro-choice rights without this nebulous couching of the issue in a candy wrapper of palatable concession. On the other hand, losing this election by forcing the abortion issue to the front and center - for a candidate who is palpable and provably pro-choice - does not seem like a wise move for anyone interested in preserving a woman’s right to choose. Perhaps this sort of tactic will widen the door of the democratic party to what is probably a quiet majority in the anti-choice movement - those who would like to see fewer abortions, but who are not so bat-shit crazy as to oppose comprehensive sex education and accessible birth control. Pro-choice services and preventing the need for abortions go well together in every-day practice (just go ask your local Planned Parenthood what they have on the table if you don’t believe me); it is only in politics where they make uncomfortable bedfellows, and maybe an alliance between them can go a ways toward actually solving concrete problems rather than miring us down in ideology and battlefield damage control.

Other topics too got a glossing over; environmental protection got a four-word nod to clean water alone…though in a line-up where Obama was preceded almost directly by resident Democratic party environmental guru Al Gore, it is easy to see why this might have already been said better and more thoroughly that Obama had time for.


But the sustaining issues that drew the party to Obama remained the focus.

Front and center: “For the sake of our economy, our security, and the future of our planet, I will set a clear goal as president: in ten years, we will finally end our dependence on oil from the Middle East.”

Front and center: “As commander-in-chief, I will never hesitate to defend this nation, but I will only send our troops into harm’s way with a clear mission and a sacred commitment to give them the equipment they need and the care and benefits they deserve when they come home.”

Front and center: “Now is the time to keep the promise of affordable, accessible healthcare for every single American.”


Front and center: “Now is the time to finally meet our moral obligation to provide every child a world-class education.”


Front and center: “Now is the time to keep the promise of equal pay for an equal day’s work, because I want my daughters to have exactly the same opportunities as your son.”

Front and center: “America, now is not the time for small plans.”


I looked up to find that flag in my hand, waving among the tens of thousands of others like it. It’s kind of pretty, you know. All primary colors against the midnight black of a moonless summer sky, backlit by the glow of a thousand stadium spotlights, washed in the populist flash of 80,000 Americans and their digital cameras and cell phone cameras, hoping to capture a moment in history.

Promises are just promises, and they are harder to keep than virginity on prom night, but still. This is the kind of America I could wave a flag about. This is the kind of nation that might make me pick up those colors and believe again.


It will take more than showing up on November 4th to make this happen. It will require will, and effort, and the movement of thousands of people to force a new vision of America into being. Especially in the wake of McCain’s half-hearted, media-grabbing nod to putting a woman on the ballot, it is vital that every American who desires something other than four more years of the same put in the time, here and now. Whether Obama lines up perfectly with your ideals or not (and whether you pressed for a Clinton candidacy, as did I), if you’re reading this blog, chances are he’s a hundred-eighty degrees closer to your place on the spectrum than McCain. Between now and election day, promise yourself that you will do just one thing to put Obama and the litany of progressive candidates in office: Register at least one new voter before the October 4th deadline (later in some states). Skip a latte once a week and send the money it would have bought to the coffers of an activist organization - NARAL, even the Democratic party itself, what have you - working to put progressive women and men in national and local office. Call your local precinct and ask them how you can join up and be a part of the effort. Talk to wavering independents in your family; write a letter to your local newspaper.

Be a part of the process. Make your voice heard. The next four years of this nation’s history depends on us.

Cross-posted at my blog, Loose Chicks Sink Ships.

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Fifteen days of blogging for health care reform: Where do we go from here? 

Guest post by Skylanda.

If you’re still with me, fifteen wordy days later, you may feel buried beneath an avalanche of priorities and issues and complexities. Out of a whole heap of information, there is always the lingering question: where do we go from here? What conclusions can we make from all this quagmire of complication and controversy?

So here’s the post-game, the recap, the proverbial twelve steps to health care reform, not so humbly opined from the dozen-plus posts above. Without rehashing the minutiae of detail from every post over the last two weeks, these are the overarching priorities that I believe could make substantative, transformative health care reform a reality in this decade, in this country.

* Single payer health care. Health care is a public good, like roads or schools or national defense, with a unique requirement of portability; it is the obligation of every soul living on our soil to pay into it in the proportion to which he or she is able, in order that he or she may draw out what is needed for the maintenance of their health.

* Structuring reimbursement to best motivate service without compromising quality, with an eye toward equalizing procedural and non-procedural reimbursement and drawing quality providers into the field of primary care.

* Prioritizing funding and services toward maximum gain per dollar spent (especially in considering preventive care versus heroic end-of-life interventions), with the caveat that this does not release us of any obligation to care for the most vulnerable populations among us.

* Minimizing barriers to care for the most at-risk populations in order to prevent costly delays in service associated with neglect of care in those groups.

* Market-based and legislative pressure to bring pharmaceutical research & development in line with the goals of social good, with an emphasis on innovation over continued production of me-too drugs.

* Using evidence-based medicine as a means of exerting cost-control measures. We have the means to know what works, and to know what works at the most efficient price: time to put this to work for us at the individual, system-based, and legislative levels.

* Reforming medical education to emphasize clinical over theoretical focus, humane treatment of trainees, and capping student debt in return for expectation the physicians will make generous but not unreasonable incomes throughout their career.

* Reforming the medical malpractice to systematically emphasize patient safety and create a means of compensating patients harmed by medicine without resorting to the bad-luck lottery of the lawsuit.

* Drawing on the immense portion of the governmental budget and national GDP already dedicated toward health care to reformulate a fifty- to one hundred-year plan to fund, streamline, and maintain a sustainable health care system at a per head investment comparable to that of other developed nations.

* And finally, understanding that health care insecurity is an untenable impingement on the freedom that Americans value so highly, and that health care security divorced from private employment-based insurance is a key to maintaining a healthy, open market for small-scale capitalism to flourish in.

The work of today’s generations - the generations that opt out of health care through their twenties, that shoulder the tab for the nation’s health through their productive years, and that will very likely live to see the useful end of that nested safety blanket known Social Security if we do not steer this ship in a very different direction - the work of this generation is to meld the brilliance of American innovation and ingenuity with the pragmatics of the collective good to form a health care system that none other can parallel. We can do this. It has been eons in coming, and the shoulders of giants are ripe and ready for you to stand on.

You may have been tinkering on this issue for years, or you may new to the playing field. If you have been involved in the push for health care reform for weeks or months or decades: good on you, keeping fighting the good fight. If you step gingerly around the questions of whence to start and who will pay for this and whether you really know enough to put that first toe in the water, understand this: as a famous person once said (and many have since quoted) - if not now, then when? If not you, then who?

It starts with November 4th and every day that comes between now and then. It starts the next time you see your doctor and ask whether he or she considers cost control when prescribing your medications. It starts with a letter to the editor, a call to your state representative next time a health care bill arises. It starts when you tell your story, when you speak up, when you talk out.

It starts now, today, here. With you. Let the work begin.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

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Buying Locally by Anthony McCarthy 

For Phila

A
dusty Saturday morning in August,
The music store in the dilapidated building on Sixth Street,
Looking for the kid’s new instrument,
She’s heard of one there.

Good lord, guitars.
All shapes, ages, some
configurations you can’t believe could work.

You see sparks in her eyes ,
dream colors of post-war chemistry,
and you almost have to pinch yourself awake.
Strange, ancient electrics,
Safe?
The risk of death modulating the frisson of stage fright?
Talk about your performance edge.
Even you, who curse the too-too-solid body,
have got to admit,
they’re really something.

Ancient sliders,
Spirit mediums conjure Commodore Bing in a lea
exiled in a decaying New Hampshire mill town,
depression winter escapes to “Havaii”.
Another points to Opree
A cursive text in red glitter worn.
unreadable, unrestored, Road Show unwashed.
A Nashville palimpsest, though Bangor is closer.
And a ‘one-string’,
Not so designated, but a complete outfit,
with beater and bottle.
The can resonator, sprayed leftover opalescent blue,
like an old pickup by, you hope, a craftsman-scholar-bodywork guy,
Is that Bondo?
“Can’t out funk that,”
You tell the owner.
But he can, he’s got the LP!

Alas, to business.
“This one’s on consignment”, he tells her,
“adjusted the action myself.”
She waits your advice,
That’s why you’re here.
Look down the neck,
“Who can tell in this joint,
nothing straight or level?”
He offers a meter stick,
swallowing your pride,
adjusting your bifocals,
you take it.

“Yeah, looks good.
Only way you can tell is to play it.”
She tries a Sor study, one in A,
Good. Then the Bb,
Bb, the test of all flaws, the limits of resonance.
The bar chords tell all.
She does all right. The action’s good.

She still, wants you to decide,
“’s your money”, you say.
She vacillates,
“Return policy?”,
Flexible, trusts his stock,
and makes the money back on strings and service.
Better to have a customer than a sale
She takes it.

You find an ocarina,
clay, tenth up from about G with chromatics.
Filthy, she can’t believe you put it in your mouth.
“Been here forever, five bucks.”
You can’t top it.


“One-string” : A beaten monochord played with a slide, as recorded on only a couple of legendary dates with the mysterious LA street musician Eddie “One-string” Jones.
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What The Media Would Say If Sarah Palin Had Been Barack Obama’s VP Pick by Anthony McCarthy 

If Barack Obama had crossed party lines and chosen Palin as his VP pick, by now the corporate media would have:

- Gone wild over her Troopergate scandal. They would have said it was an illegal abuse of power that exposed her as a power hungry woman bent on using the power of her office to destroy her ex-brother in law at the behest of her husband who would also be being revealed to be a danger to the republic by his part in it.

This would have revealed her to be:

- A power mad cop hater who ruined the decades long career of Walter Monegan, a dedicated public servant, when he wouldn’t do her bidding in violation of his legal obligations and his code of honor.

- A hypocritical “reformer” engaged in a major cover up of unethical if not illegal abuse of power through Bush-Cheney style attempts to keep evidence from being investigated. Only the names of Bush and Cheney wouldn’t be used to describe it.

- A jumped up, small town mayor who climbed to power over the political corpses of more experienced politicians. They might mention Lady Macbeth. The public relations stock of many discredited Alaskan Republicans would be rescued in the process, their crimes would all but become unmentionable in the cabloid babble and Sunday morning BS sessions.

- Her children’s names and the number of them would be an issue. They would be proof of at the least terminal ickiness if not some serious mental defect. Dowd, alone, would get at least a half dozen of her instantly produced columns from it. Yes, the one with downs syndrome would be fully used against her. Proof of irresponsibility (late parenthood) etc. Her pursuing a career while having and “neglecting” a disabled child would be a major ‘issue’. Though the more august media would report those as a "it's being said" story.

- Obama would be slammed non-stop for putting the United States a heart beat away from the inexperienced hands a flawed, green, small-town mayor. Handing the nuclear codes to the likes of her would be considered treasonable. The media would suddenly rediscover that it really matters who is president.

- Obama would be accused of going for the Jerry Springer vote. Every effort would be made to turn his choice into proof of irresponsibility, negligence, malfeasance and most damaging of all, tackiness. They would call it proof that his reputation as a reformer, a maverick an advocate of women’s rights etc. was a sham.

- Alaska would be as ‘exotic’ as Hawaii. It would go from the rugged frontier to being marginal and dangerous. It’s entire cultural history would be mined to show that having the president’s understudy come from there would endanger the entire world.

- Getting back to her husband. He would be revealed to be the male equivalent of that Hillary Clinton monster created by the media and Jerry Falwell among others. He would be accused of every possible crime up to and including murder of a close friend for political gain. There would be a complete investigation of his and her sexual histories, those would be created for them if nothing concrete was found.

- Every yahoo they could dig up with any connection to her and her family would be put on national TV to make their charge. C-Span would have their representatives on, this would be the US-BS stamp of approval for the legit media to run with every single story they could invent. How much do you want to bet that some oil billionaire wouldn’t start funding that one immediately.

- Oh, they also would say she only got anywhere because she was a woman. They might mention Lady Macbeth.

And that’s only what I can come up with on short notice. You can take any of the Democratic “scandals” of the past thirty years, change the names, make a few minor modifications and I can just about guarantee you’ll see exactly how the media WON’T be covering McCain's Palin choice. They won't even mention his history with younger women.

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Friday, August 29, 2008

McCain/Palin: A Bad Choice For Women 

The divine Snake Goddess asked me to cross-post this, which I put up at my place in response to queries:

I've gotten quite a few e-mails asking what I think of John McCain's choice of Governor Palin for his VP. Here are my initial thoughts.

First, Barack Obama gave an historic speech last night. It was soaring, it was grounded, it was inspirational, it was lethal to the Bush junta, and I was feeling very honored to have lived long enough to get to hear it. And, second, no woman should vote for McCain/Palin. He and she are anti-choice, anti-woman, anti-polar bear, anti-Social Security, neo-cons. They'll give us 16 more years of Bush policies and we can't take even 16 more months.

That said, I disagree with the majority of liberal bloggers (whom I've been able to read so far) who think Palin was a dumb choice. I think she was a smart choice and one that points out that, as I've maintained all along, Biden was a dumb choice. (She was on my short list until she gave birth a few months ago to a child with Downs Syndrome, which I assumed meant that she wouldn't be interested in the job.)

Palin's young, attractive, middle class, a sympathetic figure as the new mother of a child with Downs Syndrome and the mother of an 18 year-old son about to be shipped to Iraq. She hunts and fishes and is married to her childhood sweetheart. She's going to suck up a huge amount of media attention and comparisons to Geraldine Ferraro are going to keep opening wounds in the Democratic Party and give Ferraro, who's had almost as big a problem running off her mouth as does Biden, more air time. Lots of rural, Southern, and working class voters -- the one group that has yet to really warm up to Obama -- are going to like her. I include men from those groups; the large population in the racist and sexist overlap of that Venn Diagram will pick the anti-woman pretty woman over the black man. She undoes some of the damage that being married to a millionairess with a jillion houses has done to McCain. Elections aren't won or lost based on the VP debate, but Biden's going to have a tough time debating her and, if he mistreats her or patronizes her, that could have larger ramifications. Let's hope he's learned something since the days when he treated Anita Hill like the dirt on the bottom of his shoes.

Will she attract some votes from women because she's a woman? As I said above, women should not vote for her. But consider this. If the situation were reversed and Clinton had won after a long and emotional primary battle against Obama and had then chosen Biden for her VP, indicating that she didn't see any need to give African Americans the VP slot, and then McCain had picked an African American VP, would you expect some African Americans to be tempted to vote against Clinton/Biden? I would.

Obama made this problem for himself. If he'd picked Clinton or Siebelius or McCaskill or any of a dozen other good Democratic women for VP, McCain would have picked Romney or Lieberman or some other man. So, once again, if I were advising the Obama campaign, and, Goddess knows, they never listen to me, I'd advise them to find some new and important ways to reach out to women. Endorse the ERA. Announce some early cabinet picks and make them women. Democrats always count on the "women's vote" -- they can't win without it. The difference this time is, they shouldn't continue to take it for granted.
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Fifteen days of blogging for health care reform: The bridge to EPT 

Guest post by Skylanda.

Where the dusty border town of Juarez butts up against the jutting mountains to the north, there is a bridge. On one side of this bridge lies Mexico, and on the other lies the city of El Paso, Texas. A place whose name itself invokes journey, transition, a throughway to greater things: The Passage.

Women on the south side of the river that divides the wealth of the north from the churning poverty and violence of Ciudad Juarez gather to watch and wait. These women walk heavily, bellies swollen with child, often in the night, often alone. When labor pains come fast and hard and strong enough to promise imminent delivery, these women make for the bridge. Border patrol will pick up most of them; if they are picked up short of the bridge, they are transported to a hospital back on the Mexico side to birth their children. If they make the bridge, they are transported to the north side and the babies born of them - born on American ground - become American citizens by right of birth.

This is something of an apocryphal tale. I have never seen this bridge, or met these women, nor can I verify for certain the veracity of these stories. I only hear tell of them from the residents who rotate through the labor & delivery floor there in El Paso. But it is a useful tale, one that silhouettes race and class and gender against the background of globalization as clearly as a nine-month gravid belly silhouettes out, against the desert heat of the borderlands under a moonless August night like tonight, back-lit by a Border Patrol spotlight.

In 1981 a cadre of radical feminist women of color published the anthology titled This Bridge Called My Back. It’s an aptly titled book, and the name came to mind when I first heard about the bridge to EPT. On the backs of these women, the layered complications of globalization are played out. These women bridge nations for their families; their flight during the pain of labor is a valiant attempt (from one perspective; a sneaky ploy from the other perspective) to drag their families into a relative sort of wealth in a manner that their men cannot, nor would they likely be asked to. On their backs intersect every complication of their gender, their minority race, their humanity-defying poverty. In the pangs of labor, outside, on the run, they become the reflection of everything unjust about a stratified world of haves and have-nots, and a mirrored view into the never-dead but ever-ephemeral hope that one day, somehow, life can be better.

The story of these women, when I first heard it, gave me pause to remember what the fight for universal care is about, and what it is not about - what it means to merely operate a universal payment system versus what it means to institute a social movement that pushes toward real social change. It is difficult to imagine - never mind articulate - how universal health care can be a part of that move toward equality and justice, so I’ll take on an easier task: the task of defining the things that universal health care cannot be if it is to play any role in the universalization of human rights.

And so, these are the things that universal health care is not:

Universal health care is not a system that claims to cover every person, but with a benefits package that circumvents one of the single most common services needed by half the adult population. This is why I will not get behind any pro-life candidate who talks out one side of his mouth about abstinence-only education and out of the other about covering the uninsured; if you’re not covering reproductive health services, you are not offering universal coverage.

Universal health care is not a system that reimburses for its covered citizens but leaves hospitals and clinics out in the cold for care of undocumented patients. It’s hard to advocate that the US government pay unlimited health care costs for people crossing borders illegally, but care for people who pick your grapes, clean your office building, and mow your lawn without benefit of legal status has to be covered in some measure. The most marginalized people are also some of the least likely to be able to pay, and the infrastructure that cares for them needs to be maintained as well as the infrastructure for legal, documented workers.

Universal health care is not a system that tackles the price tag of health care without at least some nod to the radical health disparities increasingly apparent in our nation today - why African American women and their babies die in the peripartum period at a rate that stands out like a sore toe compared to the rest of the nation. Why decades of increasing life span has suddenly reversed for women in the poorest mountain states of the south and east. And what the system needs to do to produce equitable care - toward equitable outcomes - for the people most affected by the disparities.

Universal health care is not an excuse to promote nationalism, exclusionary stances, an us-for-us and them-alone policy. If we didn’t want to cope with an influx of undocumented people, we should not have set up the border region as our own personal sweatshop, and we should not have built our agrarian and light-industrial economies on the backs of immigrant labor. The price we pay for being wealthy and well-funded is that our services are desired by those whose resources are so minimal as to be non-existent; we either accept a certain price tag on that privilege, or we decide to drop our care standards to the lowest denominator common to both sides of the border region so that people stop coming across. I would like to suggest that the latter is not an idea any of us would choose to live with.

Universal health care is not a foundation on which to build a healthy class of cannon fodder for the next military incursion into the next hotspot of global tension.

Universal health care is not a means to reinforce a global norm of inequality.

Universal health care is not simply another means to prop up wealth in the world’s core economies on the backs of the poor, the children, and the women of the peripheral economies.

It is up to the ambition of our collective conscience - and the hard work of concrete planning - to imagine up what universal health care can help make of America. I’ll keep my thoughts to myself on this one, and let yours do the work of imagining where a profound move toward taking care of our own might take us.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

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Friday Critter Blogging (by Suzie) 

This is a photo of Elle. Previously, when I posted a photo of a Chihuahua in a bee costume, I had no idea there was a site dedicated to dogs in bee costumes. "Beedogs.com is the premier online repository for pictures of dogs in bee costumes." My favorite part is the verbiage about clicking on the next page, such as: "Your daily intake of beedogs has been critically low. Click here or you will die."
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Gay men & sexism (by Suzie) 



         Like a lot of feminists, I don’t think we’ll ever end discrimination against gay people until we end sexism. For that reason, I’d love to see every LGBT organization educate members about sexism. We need some good old consciousness-raising.
         A lot of gay men are squeamish about behavior marked “feminine.” When one refers to another as Mary or a diva or a girl, it’s usually a putdown, even if a very gentle or humorous one. This reinforces ideas about the proper behavior for men and women.
         Gay culture that elevates muscular, “masculine” men hurts men who are considered effeminate. But it also harms women by once again making the “masculine” superior.
          It’s not enough for gay men to tell me how much they like women since plenty of straight guys say the same thing. As a political ally with gay men, I want them to question their own sexism.

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Fine Music From Minneapolis, Decorah, Cincinnati, Hales Corners, NYC, Independence, Rochester, Dallas, Kirkland, .... by Anthony McCarthy 

The Public Radio radio program Pipe Dreams, which features organ music played in a lot of different places by a lot of different organists, is one of the most reliable opportunities to hear fine performances of unusual music, much of it very new. Since it’s based in Minnesota a lot of the performances are recorded in the middle of the country, a continuing revelation to someone based on the infamously insular East Coast. You can listen to it and find yourself grinning happily to hear the evidence of great musical culture from cities and even states which are associated with high art in no other part of the media.

A good pipe organ and a good player can go a long way towards taking the place of an orchestra in a town. And good, well maintained, organs are more common than you might think. They are certainly less expensive, and so more common, than good orchestras. The culture of organ playing tends towards having good habits of musicianship. I’d imagine it’s due to all that Bach and the historically informed performance practices a concentration in his music tends to foster. It’s a question of honesty and integrity. Once you learn to try and find how one composer said they wanted their music played, you feel an obligation to try and find out how other composers wanted it done. Organists also tend to have a much better ability to control the rhythm of their playing than other instrumentalists, though this isn’t a universally practiced virtue. Anyway, for whatever reason, organists are often very good.

In this program of Pipe Dreams which contains performances of all four books of his “Gospel Preludes” William Bolcom points out that organists, unlike some other instrumentalists, tend to buy new music at impressive volume. He said that when one of his Gospel Prelude books would come out his publisher would rush it into print, expecting that music directors at churches would buy them up. He suspected that it was a combination of musical curiosity and adventurousness along with having a budget that needed to be used or it would be cut the next year. The 2007 program presented all of his Gospel Preludes, unless he’s written more since then. The performances on different organs and different organists are excellent and evidence of the geographic dispersal of high art mentioned above.

If you were raised with these hymns you might have pleasant or unpleasant associations with them. I don’t, with a few exceptions. Having been raised an Irish Catholic in a French parish, the hymns aren’t the ones I grew up with. A few I associate with cloying religiosity as presented in movies, though that’s not really a reason to condemn them out of hand. It’s interesting, in the interview with Bolcom that’s interspersed with the pieces, he addresses those associations and his trying to do something with them.

One, probably the most famous one, I hate due to having lived next to an impossible person who played a famous recording of someone crooning it every single day for a year. It was a penitential experience. You’ve heard it a million times yourself. That’s the Gospel Prelude that gives me the most trouble in the way of extraneous associations. Though I think Bolcom’s setting could turn it around for me. His most explicit presentation of the melody, minus the annoying grace notes introduced into the singing tradition, perhaps by that famous recording, is probably the best rendition I’ve heard. The others move me in ways ranging from being knocked off balance and having to find my footing to excitement to wondrous raw experience that escapes reflection. Say what you will, these are not demure, well behaved pieces representing the uptight, self-righteous tradition of protestant hymnody.

The one which made the biggest impression is the last one, the Free Fantasia on O Zion Haste and How Firm a Foundation - if you want to find that one, it starts at about 1:14:00. Listing the technical features that are so marvelous might not help you get more of it, so I won’t go into those. Just say that when Bolcom constructs one of his enormous chords you don’t know what direction they’re going to take off in. The last part when he combines the two melodies, after what I’ll just say is an amazing chord, is stirring.

Perhaps most audacious of all is Bolcom’s citation of Black gospel performance traditions, which he was familiar with from his attendance at an AME church in Seattle in his youth. That took real guts for a white composer in the years he was writing these. It is done with such respect and observance of the dignity and validity of the tradition, with such respect for the substance of its intentions, that I don’t see how anyone could honestly fault it. It’s clear that he loved what he heard enough to really understand its techniques and purpose. Other traditions are cited but not, to my hearing, as often or with such strength. At times I suspect I can hear reference to one of his teachers, Darius Mihaud as well as the culture of the organ in general. With Bolcom, you get worlds, many of them, all in one sitting.

In reference to some of the other pieces posted during this brief return from hiatus, listen to Bolcom talking about the jobs he had while he was a student. Listening to one of the world’s finest living classical composers talking about some of the jobs he’s worked might come as a surprise to some. Musicians won’t be surprised, though.

As I said, Pipe Dreams is one of the few reliable broadcast sources for hearing new and exciting music and old music in fresh, informed performances on the radio. Luckily, they’ve got an archive of past programs and a few CD recordings for sale. I’d recommend sampling quite a bit of it if you are interested. Note that some newer Preludes Bolcom has written on Jewish melodies are included in the program as well as pieces by Virgil Thomson and the rarely heard Gardener Read.
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Thursday, August 28, 2008

Fifteen days of blogging for health care reform: The Road to Denver 

Guest post by Skylanda.

Today’s the day. The speech-givers have speechified, the spinners have had done their spun, the pundits have spoken their punditry. Tonight the man of the hour takes the stage in front of some 70,000 some-odd live and some millions more by television and internet to accept the Democratic nomination.

Like thousands of others, I am in Denver among the revelers and the protesters and the bloggers and the masses and the elite. I come here with a group called Healthcare United and their website is worth a look if health care reform is up your alley.
Sponsored by the two million-strong Service Employees International Union (the largest health care employee union in America), Healthcare United is a newly-formed organization designed to bring together people from all branches of the healthcare field - nurses, pharmacists, psychologists, nursing aides, doctors, and everything in between - to bridge the gap between these workers, start a mutual conversation on how health care reform might look that would account for every level of care, and work toward national goals of reform. The SEIU is the umbrella organization that oversees the Committee of Interns and Residents (CIR) - the union that stepped up when the administration at my residency decided unilaterally to double or triple individual contribution to medical coverage a couple of years ago. The residents unionized; the move to dump increasing costs on one of the most underpaid programs in the western US was halted. Among the points negotiated in the first union contract - alongside the first pay raise in years and caps on insurance premium increases - was a $25,000 patient care fund for the residents to collectively distribute to projects that benefited patients in a system that chronically underfunds hospitals, providers, and patients alike. In so many ways, unionization of the residency program has worked toward improving patient care in my state - though the small but symbolic patient care fund, to the renewed ability to attract quality trainees to a region underserved by every medical specialty from primary care to the most sub-specialized service.

We caravanned two vehicles up to Denver from my neck of the woods - one of the CIR residents and one of the Healthcare United volunteers. Since I got on at the last stop, I hopped on with the nurses and staff of Healthcare United. Between naps (I had been up all night - a crash c-section, a couple of peds admissions…not a terrible night, but no more than an hour of sleep either), I chatted with and quietly talk of what healthcare looks like from their end of the short stick. These stories are always three-pronged: one prong is the patients they see harmed from the stunning holes in the system; another prong is the staff they se
e the harmed from the gaps in safety, in pay, in benefits; and the third prong is the families - usually their own - that inevitably suffer a story or two of harm from underinsurance, the gap between insurance and the required cash contribution to one's care, or lack of access to care altogether. Their tales sounded eerily similar to mine, and I am struck by how little difference there is in our plights despite how different our jobs sometimes our. We did not get to talking about solutions, but I wonder how similar or different those might be too.

In Denver we attended a rally where SEIU advocacy groups - single payer players, health care for all fighers - gathered from all across the nation to speak for health care reform. The afternoon was MC'd by none other than Chuck D (yeah, that Chuck D), and if anyone can tell me how to upload a wave file from my phone to the web, I can stream a live version of Fight the Power - 2008-style - here on this site. It was a surprisingly small (but enthusiastic) crowd for a free concert that also included an appearance by Death Cab for Cutie (are they the living image of Flight of the Conchords, or what?) and local phenomenon Devotchka...but hey, it's a Wednesday afternoon, apparently some people have to work. The speakers ran the range from health care workers to local organizers, and the diversity of speakers spoke to the broad-reaching appeal that Obama brings to the table.
In the evening we gathered at a local watering hole for a standing-room only viewing of the goings on just down the way. The crowd cheered and jeered on cue as if we were front row at the event itself. Much merriment was made, many optimistic views of the future were offered up for hope. The crowd broke up happy and inebriated on the drunken brew of hope. In the back of my mind the words of one of the afternoon's speakers rang through again. On the millions without insurance, children without coverage, elders without access to care, his voice called clear and true...

It is not only wrong, it is a sin, and it is a shame. Wrong, sin, and a shame. Wrong, sin, and a shame...

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals. Please excuse any technical difficulties...I'm writing from a pda from the stands of Invesco stadium - more to come!
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Being Such an Elitist You Won’t be Satisfied Until Everyone is Elite. by Anthony McCarthy 

One of the more irrational ideas that has become commonplace is that a passionate interest in what’s called classical music is a sign of snobbish elitism. Even when someone is advocating the wider encouragement of all classes of people to try classical music, the charge of “elitism” will follow. It’s a funny kind of elitism which insists on the right of all people to have access to high art. You’d think it would be obvious that it represents the exact opposite, radical populism.

Maybe its because there is, in fact, a snob audience for classical music who consider it their property, or at least their exclusive franchise. Anyone who has worked in classical music will have run into them. Some who aren’t musicians imagine that one of the greatest pleasures of being a musician, practicing, is the worst part of it. Actually, speaking for myself, it is the after concert reception that is the most brutal form of torture inflicted on musicians. The snobs who frequent and often are the reason for those events can be some of the most trying and obnoxious people in the world and you have to experience them at a time you are absolutely demolished by the experience of performance.

And there have been artistic snobs within classical music, though almost never have they represented the greatest figures of all, the great composers. Just about every really great composer was familiar with folk and popular music around them. They clearly listened to it and many of them explicitly incorporated it into their music. It’s always been that way, from Dufay to today. Jazz, even before it was jazz, absorbed the attention of composers from Brahms through Schoenberg. Stravinsky would never have composed the music he did if he hadn’t been aware of jazz and there are not many American composers who haven’t been thoroughly immersed in jazz. I’ve hardly ever met a good classical musician who didn’t have the highest respect for the great jazz composers and performers. Jazz composers have also composed very fine “classical” music.

And artists in other genres of music have certainly been interested in classical music, which has often stretched the limits of musical resources farther than their own idioms. Even many pop musicians, sometimes even the most banal of those, have enriched their music by borrowing or stealing from what classical composers have invented. The borrowing back and forth in what is called “country” music goes to the start and finds some of it’s clearest traces in the familiar suites of Bach and other baroque era composers and fiddle tune collections.

Just about to a person, the people I’ve known who have worked in classical music have been from the middle and upper middle class and just about every one has been on the populist side of the left. Some excellent classical musicians have had parents who worked in what would be considered menial jobs, a lot of them worked menial jobs themselves. The disadvantages of not starting out with good teachers due to lack of money is the real limiting factor for many people who would like to work in classical music. Unless people without money have parents interested in music and able to sacrifice and an unusual amount of drive, the disadvantages to them will be a roadblock to their achievement. But advocating that children be provided as good a basic musical education as possible will get you the “elitist” label faster than advocating the use of public money for a kitschy ornament for a little used venue. Isn’t it interesting that advocating tax breaks for the wealthy is unlikely to get someone called an elitist by the media.

You get the feeling that a lot of the pegging of classical music to elitism is done through the ignorance of people who don’t know the first thing about classical music, a lot of whom seem to be in charge of programming at public radio and TV stations. Since most of those I’ve met have been social climbers it’s possible that they deeply want to believe that “serious” classical music is beyond their audience’s attention span.

Or maybe they rely on those marketing surveys which should be banned by statute and charter for any public broadcasting medium. There was one I read about which seems to be responsible for the reduction of public broadcasting’s classical music programing into a manifestation of what Virgil Thomson called “the music appreciation racket”. The results are eternally repeated chestnuts and banal alternative offerings that are offensive because they achieve bathos through boring inoffensiveness. I’ve heard rumors that the disappearance of vocal and original instrument performances from some public radio stations are due to this kind of survey. When’s the last time you heard Bach that wasn’t played on a piano on your local radio station?

I once heard a program director who was outraged when someone said that the purpose of his station was to educate, something that is explicitly stated in their mission statement and, I’d guess, the excuse for the deductibility of donations to them. God help us if someone should learn something new from listing to public radio. Like just about all of what passes as contemporary culture, it’s practice is to confirm existing experiences and stereotypes, not to challenge or overturn them. But that will get me on the pathetic state of the “avant guard” again. “Posterior poseurs in pursuit of patronage”, would be more accurate. So you see that is a topic relevant to a discussion of American public broadcasting.

The descent of the news programming in public broadcasting into establishment babble has matched the destruction of its music programming. I don’t think it’s just a coincidence.

Maybe it’s because I was forced to go to so many of those after concert receptions. I’ve had my elbow rubbed by rich snobs, I’ve had my ear chewed by them. I’ve had to smile and answer them without having heard what they were saying. With few exceptions, I’d rather practice music with a rowdy bunch of public school students. You’re more likely to find someone who’s listening for the first time and having their imagination kindled. The experience I got as a teenager hearing, my first hearing Schoenberg’s Chamber Symphony, the clarinet after the introduction the non-stop compulsion to listen and pay attention to the very end, the amazing audacity and daring of it. The memory of that still raises my hair and makes me know life is worth the effort after more than four decades. It has dragged me out of low spots any number of times. That kind of experience is the birthright of every human being.
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Wednesday, August 27, 2008

Fifteen days of blogging for health care reform: A Primer on the Obama Healthcare Platform 

Guest post by Skylanda.

Tomorrow, in Denver, Barak Obama will take the stage to accept the nomination for the Democratic ticket for presidency. I will be there along with Americans from all over the nation, converging on a mile-high city that could not be more dead center of the country. Not a bad metaphor for Obama: a man who sometimes seems to walk so far above petty politics that even the swift-boaters haven’t had the juice to knee-cap him yet, and who seems to so thoroughly occupy middle-of-the-road America that the progressive left may be wondering - like I am - what exactly happened between his solemn promises of change and renewal.

So it might be a good time to take a moment to look at Obama’s health care platform through the lens of the issues and reforms I’ve brought up over the last two weeks. A thorough but sound-byte summary of the platform is available here, and if you really want to want knock yourself out cold, you can read the whole document in all its multi-page PDF glory here.

First, let’s examine the overarching, definitive issues.

Does he propose a single-payer system? No, frankly, he does not. But he cracks the door to some intriguing possibilities. His opening proposal is for a new national health plan available for all Americans to buy into (yeah, I know - if you could afford it, you’d have bought already). It includes clauses for subsidies to folks who cannot pay outright for this option, and promises affordable premiums, copays, and deductibles. Who would provide this insurance plan? Well, this is a little nebulous, but if you read the finer print, it appears that it would be administered via private insurers who contract to federal government. So: more access, still through individual contributions to private corporations. It has a certain ring to it - you get a certain sense that this might be a slow move toward a central, national system that could evolve into a single payer - and yet it lacks moxie. And it does nothing to address the question of why federal money should be going to private insurers in the first place.

Does he use the magic p-word? “Portability” makes a prominent (double-size header font!) appearance in the language of the Obama platform. Specifically mentioned is the problem of moving job to job, and the proposed answer is that through this new national health plan, you could keep your insurance through those transitions. Not mentioned are any other moments of salient relevance to portability: moving states, turning eighteen, getting divorced, suddenly making enough money to get booted off the Medicaid rolls, or, saying, losing a job altogether. I like that the word has entered the common vocabulary on a national platform; I’m not terribly pleased that the Obama platform would be satisfied with a “portability” that applies to only a fraction of cases in which it is required. A publicly funded system without full portability will incur all the taxpayer cost of a subsidized system without the streamlining benefit of single-payer sourcing - and I fear that this will end up costing more over the long haul than its own benefits are worth.

Does his platform include a provision for free small business from the yoke of paying for employee health insurance? Yes and no. Tax breaks are proposed for those that kick in for their employees health coverage, and small businesses would be exempt from a proposed requirement to tax commercial enterprises that do not offer employee health care. This is a move in a good direction, but it radically fails the fundamental task at hand: firmly and permanently extricating health benefits from employment.

Does he emphasize patient safety as a means of increasing patient confidence and reducing malpractice suits? Yes, and he proposes a steep investment into electronic medical records (though as a separate, not adjunctive, issue to the question of patient safety).

Does he acknowledge the role of prevention and public health? Yes: “Too little is spent on prevention and public health.” Good enough for me.

And then there’s some interesting details…

Investment into “Comparative effectiveness research.” You can read the detail on your own, but the content of what is proposed here already exists in several form - the most well-respected of which is the Cochrane collaboration. If the Obama camp failed to notice its existence (or thinks it can outdo Cochrane), it has another think coming.

“Millions of Americans are uninsured or underinsured because of rising medical costs.” I suppose one does not need a macro-economics lecture wrapped up in campaign promotional material, but statements like this belie a naïvete about the root causes of lack of access - things like a private insurance industry which relies on stock market investment and high interest rates for profitability and raises premiums when those do not come through; a growing disparity between rich and poor; monopolistic practices and obscuring of cost which disallow free choice (that whole “free market“ thing that we love so much in this country) in choosing providers and products; and a whole host of other complications.

Requiring that “providers that participate in the [federally supported plans] utilize proven disease management programs.” Though this sounds like a good, solid prop for evidence-based medicine, the wording raises some hairs on the back of my neck. Proven protocols exist for common and quotidian diseases like diabetes, high blood pressure, and cholesterol. Treatment algorithms are far less established for diseases like cancer (especially the rarer types). Some diseases simply require far more flexibility, ingenuity, and nuance - not a federal mandate that straitjackets them into narrow protocols with compliance enforced by the threat of yanking reimbursement.

And then there’s a few red flags…

Demanding “mandatory coverage of children” without explaining how he plans to enforce that mandate. The paragraph following this edict notes an emphasis on expanding S-CHIP and Medicaid (which both disproportionately cover children) as “critical safety net(s),” but fails to make anything other than a threatening overtures in answering the question of how to mandate insurance for a majority children. What plans do they have for the uninsured child - turn the case over to CYFD, throw the parents in jail for lack of compliance? It is not clear what “mandatory” means in this context. Aaah, the great unfunded mandate: the same no child that was left behind under the Bush education plan would be left behind once again with the Obama health care plan.

Promising comprehensive benefits by citing “maternity health” as one of the covered aspects of the proposed national health care plan. Why not just go and call it what most providers call this sort of stuff: reproductive health. Ah yes, because that might imply that we are going to cover birth control and abortion - two words which make absolutely no appearance on the Obama platform‘s exhaustive leading page. *sigh*

In summary, the Obama platform on health care reform is ambitious and far-reaching, but still far from aligned with the vast majority of points made here over the last couple of weeks. Will I vote for him? Yeah, I will. He’s our man, whether we want him or not, and his vision for health care reform at least leans in a tenable direction. This platform is a starting gate, a flawed and imperfect one, but a place we can work from nonetheless.

As for McCain - because you might be wondering - you can sum up his proposed health care policy in four words, and so I will:

More. of. the. same.

On to Denver…

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

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Tuesday, August 26, 2008

Beauty contest for nuns (by Suzie) 



       I hope to publish a calendar called "Priests: Straight From the Heart," with photos of priests looking as heterosexual as possible. I want to counter the stereotype that they're all gay. I won't dictate what they wear; I just want ones who look like models. 
      I got my inspiration from an Italian priest who is organizing a beauty pageant for nuns to prove they aren't all old and ugly. 
      Update: The priest has scrapped his plans. 

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Fifteen days of blogging for health care reform: Paying the piper 

Guest post by Skylanda.

Today, you’re going to hear something new and different. Today you are going to hear this bleeding heart, tree-hugging, west-coast, San Francisco-born, ivory-tower progressive make a neo-conservative argument. Free market, pay-your-own way, private enterprising, classical neo-liberalism. Hold on to your wallets, we’re going for a ride.

This argument concerns the question that underlies everyone’s hesitation with heath care, no matter what your political orientation: how are we going to pay for it. Covering every child, woman, and man in America is an expensive proposition, and paying for it is the key stumbling block between dreamy idealism and real movement forward toward universal health coverage.

Anyone who wants to answer this question - from the most laissez-faire neo-liberal to the farthest left socialist - needs to understand one thing, and one thing alone: we already are paying for it. No health care economist disputes this one common understanding: Americans pay more - per capita and as a percentage of our gross national product - for health care services than any other industrialized nation. And for that sacrifice, we cover less of our people, we live with the gripping national fear of health care insecurity, we measure out at some piss-poor rankings on standard outcomes measures like infant mortality and childhood nutrition. We pay more money for the great privilege of getting less health.

In other words, Americans are getting the rawest health deal on the block.

That is the bad news. But that bad news is also the seedling that sprouts the sapling of good news on the horizon. The good news is that if dozens of nations with similar wealth profiles to ours are able to squeeze better outcomes out of lesser health investments, that means that there is slack in the system, that we have already dedicated the resources and the means to the accomplish the task, and that providing America with a first-class health care system is merely a means of rearranging that system to fit the circumstance at hand. Simple, yes?

God, however, is in the details, as they say. So here are some of the nuance it behooves us to understand in tackling the dizzying problem of paying for universal health care.

Rationing. If you’re my age, the word might bring to mind propaganda shots of little old Russian ladies standing in line to buy bread just before the fall of the Iron Curtain, with a Reaganesque voiceover decrying the evils of Communism. A little older and you might remember the oil crisis and the self-rationing feat of standing in line for hours to pay for gas. If you’re my parents age, you might remember stamps that gave you the right to buy tires and butter and other household products that were scarce during the war.

Rationing is the hobgoblin under the bed, the Commie in the closet, that is yanked out to be puppetted around every time the prospect of a national health care plan arises. Do you know how long it takes to get an MRI scan in Canada?! - it threatens (and actually, I have no idea at all how long it takes to get an MRI in Canada; I suspect it depends on the same variables that drive wait times here: distance from nearest tertiary care center, relative wealth of the region, staffing issues, and the like). Because in America we use rationing as a strawman to promote the glories of capitalism over the evils of…well, just about everything else, we tend to be blind to the fact that there are actually two forms of rationing - one of which terrifies us to our very core (Commie plot that it is, of course), and one of which we live with so commonly that we fail to notice its sinister existence, the way we forget to notice the sky is blue after too many sunny days.

The first form of rationing - the one that invokes such terror - is rationing by wait time. These are the communist breadlines of old Russia, the gas lines of the 1970s, the apocryphal wait times to get that MRI scan in Canada (it also explains the way you have to put your name on the list now if you want to get a private permit to run the Grand Canyon by river raft some ten to fifteen years into the future - even in the good ol’ USofA, rationing by time has its well-worn time and place). If you stand there long enough, you’ll get your goods. The goods aren’t even necessarily any more expensive for your troubles; you just have to wait for them.

The other means of rationing is by cost - that is, you just raise the price until the right number of buyers drops out, and there you have your trade. This is the absolute fundament of free-market capitalism; a certain quantity of goods is out there, a certain demand is placed on that supply, and the winners are those whose cash and values come into best alignment with the available quantity of desired stuff. This is also what you see modeled in simple Cartesian form in every freshman econ class, with the supply on one axis, the demand on the other axis, and economic efficiency at that magical price where the two meet in the middle (I never saw rationing by time modeled on a two-axis graph - I suppose it‘s possible, but not so much the subject of talk in countries where the free market is the order of the day). This functions well for goods like luxury cars, designer jeans, concert tickets hawked on the day of the show, and artwork; it falters clumsily in the face of health care products which are not optional, and have great social consequence if they are not distributed with some efficiency of manner.

In America, we ration by cost so frequently and so thoroughly that we do not consider it rationing and we get very huffy when anyone implies that it might not be the best means out there to distribute goods like health care. And if we do complain - about, say, the cost of health care - it is not looked on as a reaction to rationing; it is looked on as the free market in action (which it is; it is also a formalized and highly regulated form of distributing limited supplies of goods…that is, rationing). Conversely, we recoil at the very thought of rationing by time, even though rationing by time may actually get services sooner for a large number of people than rationing by cost, because so many people can simply never mount the resources pay for something like an MRI.

The question of rationing by time versus cost is heavily reliant on regional values, and it speaks to the soul of America whether we would rather to continue rationing by cost - which allows quick access for the ever-shrinking numbers of those who can pony up cash (or bill their insurer) - or whether we might start to thinking about rationing by wait time, which equalizes the playing field across a wider socio-economic spectrum. The fact that those making policy usually have insurance (and the quick access it entitles) throws a wrench in any attempt to change this status quo (though insured individuals should remember that this is not a permanent status, rather an ephemeral notion of security that could evaporate tomorrow). Rationing by time does not necessarily mean that every cancer patient is going to wait eight months to see a specialist; a good health care rationing system uses effective triage to work in emergent cases first, then urgent, then routine, with preventive services tracked along a different route. These sorts of systems take planning and rational forethought (as well as continuous adjustment to feedback) to work effectively, but consider the alternative that we have now: a haphazard system where your entry into specialty care is wholly predicated on where you live, what emergency room your ambulance screamed into the night you first got sick, what providers happen to accept what insurance, who your primary doctor happens to know that she or he can pull strings with when time gets alarmingly short, and the like. Rationing by time provides a means to more efficiently utilize services that are today placed without overall regional planning for needs, often with a waste of investment inherent in that sort of decentralized system.

Which brings me to the second point that is vital to understand in the financing of health care:

The inevitability of decreasing returns on investment. Health care is like chocolate cake. The first bite of that cake is good, even fabulous. It satisfies that place in the belly that only chocolate cake can satisfy, it fires off a few dopamine receptors, and for a moment, life ain‘t so bad. The second bite? Also very good, but not quite as fulfilling as the first. By the fourth or fifth bite you’re getting kind of bored, and by the end of the plate, you wish you had stopped a few bites back.

Such is the investment in things like health care (and other public goods like education). If you had been uninsured and get, say, a sudden windfall of $2,000, the first thing you might do is spend a chunk of that money catching up on the pressing health issues that have been bothering you. A hundred fifty bucks to go to the dentist to take care of an aching tooth - money well spent, like that first bite of cake. After that you focus a little more on that gnawing feeling you get in your stomach after you eat, so you go to the doctor, who tells you it’s just severe heartburn and gives you a prescription. You feel better - not quite as much better as when you knocked that first burning priority off your list, but still, better. Next you’re wondering if that ugly twisted toenail could be fixed; it doesn’t really bother you, it’s just unsightly, and it turns out that it costs lots of time and money to fix something like that. You decide to forgo it, because you’ve already blown about five hundred bucks, and you want to spend the rest on a vacation you’ve been putting off, a contribution to your retirement account, and a new bike to replace the one that is breaking down in your garage. The toenail is the middle of that cake, the part you’re still enjoying but not really getting too much out of anymore. On the other hand, you might take that money and hit up a cosmetic dermatologist, who gives you an expensive cream to remedy that embarrassing adult acne and talks you into lasering the hair off your legs (or chest, or back…let’s not discriminate against the boys here) for $350 a shot. It sounds like a good idea at the time, but once the bill comes, you realize that not only is your entire $2000 gone, you now owe another $200 on top of that, and that‘s the end of your vacation and your retirement contribution and your new bike. This is that last bite of cake, the one you kind of wish you’d never eaten.

This model can be extrapolated to nation-wide health expenditure. There are pressing matters that can give great relief if funded: vaccines for children, primary care access, care for life-threatening illnesses, those kinds of things. Then there are secondary matters that are best addressed once those primary matters are covered - advanced care for professional sports injuries, cosmetic issues like acne and braces, etc. The primary issues tend to be (though are not always) mass, cheap interventions; after that, things usually become more costly and individualized. But if you go far enough on down the line, you can continue paying more and more money for incrementally smaller outcomes (let’s call those outcomes “health”) until you are paying so much cash for so little gain in health that it is questionable whether that is still something you want to spend your hard-earned dough on - or, more accurately, what we as a nation want to spend our hard-earned dough on. Not because health isn’t important, but because there are other important things too - roads, schools, social security, clean air and water, national defense - and the national budget (or GDP, or whatever your source of cash) is always going to be a limited resource.

For that reason, it is not necessary nor desirable to purchase an unlimited amount of health, nor does it make sense to spend unlimited funds on health care. It behooves us to plan what portion of our collective wealth we want to spend on this thing called “health” - or what sort of health we want to achieve given the limits of our wealth - and then to determine the most efficient way to reaching that end. Setting open-ended financial boundaries, on the other hand, does not make for sound planning and is not a sustainable means of establishing universal health care.

The year that I moved to Oregon, citizens of the state voted on a ballot measure to provide universal health care for every person within the state borders. It was a lovely thought - it would have paid for everything, for everybody. It set no limits on what would be covered, when, or for whom. It included things like aromatherapy as a covered medical service, despite the dubious benefit of that particular modality for any other purpose than making your nose happy. It was voted down by a resounding margin, something like 70-30 on the nay side. This was a wise move on the part of the voters. The measure included no cost estimates, but pundits and analysts on both sides noted that this kind of coverage for that number of people would exceed the entire state budget every year; no new funding source had been built into the proposed program. Had it passed, it would have failed with the thud of a thousand lead bricks hitting the ground, and it would have been hailed by opponents nationwide as a failure of universal coverage - a nail in the coffin of single-payer health care. For that reason, I can look back and say that I am very glad that, in this case, single-payer coverage did not pass muster.

Which brings me to the third point that I advocate everyone understand about health care financing:

Understanding that good business sense and the profit-making motive are two different things. That there is a very big difference between divorcing the profit motive from the health care industry, and removing good financial sense from the health care industry. Under no circumstances can I advocate the breezy, never-can-care idea that medicine should not be about money. Medicine is about money. Everything is about money. The last time that medical providers acted like they could work without a thought to the financial consequences of their actions, we ended up with a system of capitated HMOs...please, please let us not do that again.

On the other hand, prying our health care system back from profit-making ventures is not going to be an easy maneuver. The health insurance industry is a large and powerful lobbying force, one that gets its digs in every time a state or region starts tinkering around with the idea of single-payer coverage. And whereas pharmaceutical outfits have at least some mutual role in which profit motive operates toward the benefit of people who eventually receive their drugs, I am not sure I can come up with a solid social good provided by for-profit insurers that could not be equally provided by a well-funded single-payer system (aside from providing employment for a literal legion of administrators and bureaucrats along the way).

This is not to say that the free market has no place in health care - on the contrary, single-payer coverage may actually open up choice for consumers by unshackling the lock-down on preferred providers, formularies bargained for convenience instead of efficacy or cost-effectiveness, and regional limits that insurers tend to have over their patients. Moreover, ancillary services (such as imaging centers, laboratories, even clinics themselves) can still operate in the free market under single-payer coverage by providing competitive advantages over each other to attract business in the same manner they do currently. This is one of the main reasons I support single-payer sourcing but not an entire system of government-employed providers: by hybridizing socialism and capitalism, you can squeeze the best out of both without losing the aspects that makes each of them attractive.

So in the context of these three principles (rationing, decreasing returns per increased investment, and good financial planning with or without the profit motive), where is the American health care system now? One, we ration by cost, not by time, for almost every service…though some regions are so strapped for specialty care that we ration by both cost and time - a particularly potent recipe for disaster. Two, we are hugely overspending on health care and yet not even getting that first delicious, satisfying bite of cake out to the entire population. And three, we consistently emphasize profit over any kind of good business sense at all.

Pulling these three forces into alignment is - in this one opinion - key to founding a sustainable, affordable version of universal coverage that Americans can live with and thrive on. And here is the sinking realization that should haunt every American when it comes to health care: we already pay too much for too little. We are getting the rawest end of the deal in the developed world. We now have a choice: we can continue to bury our heads in a very expensive sort of sand and believe that a fractured system with ever-increasing premiums is working to our advantage, or we can start to wonder what would happen if we took all that cash - that enormous chunk of the GDP now wrapped up in health care - set it all into one collective system, redistributed without the skimming of profit or the redundancy of hundreds of parallel systems, and set about planning a rational health system for the next fifty years. Could we do it? It would be one of the toughest, most contentious enterprises America could take on…just a hair less tough and contentious than our current health care system, I would wager.

But, you say, would I have to pay higher taxes?

Well, that’s a good question. I submit that if you are paying insurance premiums in America today, you are subjecting yourself to one of the most ludicrously progressive tax schemes on the planet. You may consider yourself middle class (or otherwise), but the public good known as the nation’s health is resting on your shoulders - not only are you contributing directly to the private pooled premium fund, you are also paying federal taxes to support others on the Medicare-Medicaid axis and a variety of other programs. And if you are not paying health insurance premiums, it’s time to buck up and do your share - in the proportion to which you are able, so that you may draw resources that you require. There is only one way to accomplish this: taxes.

If you worry that only the wealthy, the documented, or the honest will pay their fair share? Well then heck, make it a sales tax - no one walks the American soil without buying something. If you want to ensure that every person stepping foot on American earth deserves their fair share of the health care pie because they contributed their piece, sales tax is probably the most thorough (though probably not the most equitable) way to do it.

And if we paid for single-payer health care out of an increased tax, what would that buy you to make it worth your trouble? You could do away with your health care premiums. Stop wondering if Blue Cross is going to double your deductible this year just for the heck of it, or triple your premium because you just found out that persistent nagging cough is severe asthma, or deny your coverage because you had that condition before your employer switched plans last month. You would buy portability, security, and predictability - ratcheting the stochastic impact of health care costs out of your emergency budget. And if you get what you expect out of a single-payer system, you actually have a voting say in who stays in office to guide the system - unlike your coverage today, where you only have a voice in Blue Cross’ policies if you are a major stockholder. And remember, head for head, every other developed nation in the world - by controlling the profit motive and the redundancy issue - has managed to pull off some form of access that covers more of the population for less cost than we have. We are already paying the piper; now is the time we demand that the piper hand over the goods.

And how do we go about demanding those goods, forcing a system wracked by inertia to start a free-wheeled move in the direction of universal coverage? First there is the regional approach - county by county, city by city, state by state. State-wide universal coverage has been tried to varying degrees of success in a number of territories; New Mexico is among those currently wrestling (thus far unsuccessfully) with how to cover its total (albeit rather small) population within the bounds of a notoriously cash-strapped budget. On a smaller scale, cities like San Francisco and Albuquerque have made grand efforts to carve out havens of access within their boundaries. The pitfall of this approach is obvious: it creates a system more finely fractured than Yugoslavia after the fall of the Iron Curtain. You move ten miles down the road and lose your insurance.

A second tactic is to attempt grand sweeping reform at the national level. This might result in the best outcomes should it succeed, but please remember this was recently tried at the highest levels of power - during the Clinton years - and the plan was killed by political manhandling before it even got a chance to stretch its wings.

Another strategy - this one sneakier and designed to make an end-run around such organized resistance - is to simply pick the most successful federal program and quietly fund and expand its scope until it covers a larger and larger portion of the population. What the free-marketeers fail to mention so often is that we are have an enormous sector of America already on federally funded health insurance. Start adding up the numbers from these programs, and go from there: Medicare. Medicaid (alongside its state-by-state contribution). The VA system. The Indian Health Service. S-CHIP. (If you add every county and local coverage scheme across the nation, you might start to guess that we already have a heavily socialized, but very poorly planned, medical system - but that‘s a digression for another time.) Medicaid is fractured by state, the IHS is limited to tribal members only, and S-CHIP is for childhood coverage. But then there’s Medicare - a nationwide, full-spectrum insurer that (so long as its budget stays on an even keel) doesn’t do such a bad job of funding care for a large number of Americans, albeit usually of a particular age group. If one could slowly expand its population coverage (maybe even combine it with the contribution of the VA’s remarkable system of health care informatics), it is possible to build a system of universal coverage without ever having to do national battle on the gladiatorial field of the congressional floor. The infrastructure is already in place, the bureaucracy already pushing those papers; all we need is the will and the cash.

And now to bring it all back around to the place where I started, the neoliberal argument for universal health care. So far, this probably sounds pretty far to the opposite side - all kinds of people-taking-care-of-people, feel-good socialist talk. And it is. But flip it over for a second and take a look at what the burden of the providing insurance does to the free market in America:

Providing private health care benefits to employees saddles businesses - especially small businesses - with a burden so unpredictable, expensive, and bureaucratically top-heavy that it severely impinges the ability of the free market to operate in America today. The current health coverage system does its part to kill the entrepreneurial spirit as people feel locked into secure jobs purely for the health benefits. It imposes a legitimate but ultimately defeat-ist fear of going out and taking the risks needed to start a business, become self-employed, go out on one’s own - all those things that go along with free-style invention and innovation. It restricts the market for labor as people become geographically bounded by their need to maintain a particular insurance policy due to a pre-existing condition, or because one state has more sympathetic laws regarding repossession of personal property in medical bankruptcies (ironically, Texas - a bastion of neo-liberalism - has been repeated cited as a state with laws friendly toward individuals in crisis from the hit of medical bills on their finances…go figure), or because they are afraid to temporarily lose Medicaid coverage for a serious illness in the interim. I defy you to find another force in America that so deeply impinges in the entrepreneurial spirit for so little gain in social good.

It is a strange sort of backwardness in America that we are defiantly against government-sponsored socialism (at least on the surface: I‘d like a show of hands of how many neo-cons are on the Medicare or VA rolls), but we are quite happy to saddle commerce - especially small businesses - with what largely amounts to a social good obligation. I believe the reverse should be true. I believe that the free market should be unburdened of the heavy load of providing health benefits, and that once so unburdened, we may see a re-flowering of what Adam Smith envisioned when we first spoke of the capitalism and the invisible hand a couple centuries ago: a multitude of players, easy entry and exit from the market (a key component of “perfect competition”), a society of self-motivated self-sustaining players who can equally sell their labor to others or work it for themselves, as they so choose. That is capitalism, old-style, old-school, the way the game was meant to be played.

Single payer health care. Socialized medicine. It’s the new capitalism.

Moreover, health care security on the individual level is about that most American value of all: personal freedom. It is about the ability to choose a job that fits your interests and your skills, not your medical needs. It is about being able to quit that job and not worry that you‘re also quitting your best shot at health. It’s about being able to work hard and get that raise without worrying that it will be the straw that breaks the Medicaid threshold without offering any new benefits in return. It is about being able to divorce your spouse and not worry that you are also divorcing your right to be seen by a doctor for your health problems. It is about being able to cross state lines for a better job without leaving your benefits behind. It is about sleeping well at night knowing that a mis-step in front of a bus or a few cancer cells growing in your bones will not mean the capping out of your meager private benefits, repossession of your house, or the long road to permanent poverty.

Universal coverage is about security. It’s about freedom. It’s about time.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.
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Monday, August 25, 2008

Science, The Bubble Reputation And The Scary Fact That Only Good Will Is Going To Save Us by Anthony McCarthy 

Allegra Goodman’s op-ed in Monday’s Boston globe asks an odd question, “Why do we distrust scientists”. It’s a question I’ve been asked in many variations and temperatures of accusation, in the second person as a result of things I’ve posted here, as recently as this week. I don’t think it’s a valid question, put that way. Not that people don’t “distrust scientists”, they do. But, it’s just that there is no category “scientists” which is treated with uniform distrust or suspicion by an equivalent, unvaried “we”. If she had said “Why do we distrust science,” it would be an absurd question on its face.

Distrust or skeptical suspension of trust is an intrinsic part of what scientists are supposed to do. They’re supposed to seek verification before they consider work in their field to be reliable. They aren’t supposed to take the word of their colleagues on faith. But, like any other human activity, scientists have a success rate in practicing what they preach that falls way sort of 100%.

Skepticism is routinely suspended for practical reasons. You can’t read everything, you can’t verify everything you need to accept in order to just get on with things. Short of standing still, that ideal can’t be practiced.

And you often just accept things because of the reputation of people asserting them, everyone does that all the time. And there is the tendency to believe something just because you want it to be so, because you like the person saying it or you like what they are supposed to represent or because it props up your personal preferences. And many people, certainly including scientists, reject research on the basis of it offending some aspect of their personal preference. Much of the popular history of science creates drama based solely on the resultant wrestling matches and personal struggle created by this widespread phenomenon. Experience leads me to believe that most of the acceptance of science and much of the rejection of it is based on anything but personal verification of claims.

And scientists can be some of the most exigent, sometimes vicious and notably unfair critics of the work of their colleagues.

And what is true of people who make their living in science goes even more for people without the training to understand the original assertions, never mind supporting evidence or critiques of them. People constantly accept all kinds of science on faith. You don’t even have to be the type of science reporter who couldn’t calculate a probability or detect a break in a line of logic to do that.

The idea that “science” doesn’t enjoy the highest repute of just about any human activity today is most clearly and ironically contradicted by the “Intelligent Design” industry. It’s been pointed out here, before, that people wishing to confirm their religious or other metaphysical beliefs with science are giving science the greatest possible creedal reverence. They yearn for their beliefs to enjoy the repute of science, they want their religious beliefs to have the functional certainty of science. They are as human in demanding their personal preferences enjoy what they unconsciously admit is the unquestionable status routinely granted to “science”, which is just as routinely insisted on by some materialist devotees of scientism.

But in doing that they pay science a compliment that it can’t accept honestly. They want science, which is equipped only to study the natural universe, to make the supernatural its subject. You can’t turn a god into a subject without diminishing what you define as being god. You can’t make a god subject to natural laws, which can only exist within limits, without implying that god is limited by them. If god is not limited in such a way, science wouldn’t be able to make an approach, in any part. To assert the use of science to study the supernatural is to claim the supernatural as a part of the physical universe. It is to accept, tacitly, the assertions of materialists. You would think religious people would gladly, joyously embrace that the deity they believe in is not in any part subject to the human invention of science. Yet they, themselves, insist on chaining their god within the confines such laws of the universe as we limited beings have the power to discover them.

So, you see, even the enemies of science respect science more than you would think they would ever want to. Would that they realized that. And also that materialists who assert their ability to use science to study what was beyond its competence would also stop pretending what cannot be. It’s impossible to quantify which group are the more clearly irrational in their pretensions.

Science doesn’t also just enjoy the suspension of skepticism and necessary acknowledgment of its fundamental limitations, it also enjoys a form of reverential sanctity.

What jumped out of Goodman’s piece most was the seemingly unconscious removal of science from the sordid context in which an impressive amount of it is done. She mentions two scientists by name, Bruce Ivins, the suspected anthrax murderer and Stephen Hatfil, who has been pretty well vindicated as a victim of a smear by the government and the press. But nowhere in her article does she mention who they worked for. The military.

Some of the most be sainted figures in science have been weaponeers, those in various countries who produced atomic weapons, conventional munitions, biological and chemical weapons, etc. It’s astounding how often people assert that science is a beacon of light, the hope of humanity, the blameless, chaste pursuit of knowledge. It’s incredible how people involved with full knowledge of the purpose of their work, to kill more people in more efficient and easily effected ways, are given a place on a pedestal previously reserved for religious icons and anointed princes.

Quite often when the connection between science and the resultant military and industrial uses it was commissioned for is mentioned, the blame for that is quickly and loudly placed on engineers and other Beta level techies. It’s as if those most nearly omniscient scientists had no idea how their money from the DOD was intended to be spent in the first place. How can you talk about Bruce Ivins without acknowledging who he was working for and the ultimate use to which his research could easily have been put by his patrons? If he did send the anthrax through the mail, how could anyone suspect him of some diabolical innovation unknown to the people who were working with it.

I used to be a science romantic in that way. My mother has a degree in the biological sciences and other members of my family work in science. We were taught to respect science from the earliest years. And I do respect science and those who do it, but not universally and not removed from the context in which it is made manifest in practical reality. In other words, I put science on an equal footing with the rest of human life. I don’t think it’s an illuminating beacon, a talisman of purity or an Ariadne’s thread out of the labyrinth of death. It is a human activity, conducted by humans, within our species limitations of perception and our species, perhaps, biologically limited ability to address the universe. It is human activity carried out by individuals and entire communities which are as fully heir to human folly and villainy as religion or the arts, or politics or, especially, the sordid machinations of university and corporate departments.

The fact is that those who have made evil use of science aren’t routinely expelled from the cannon or even their positions of honor, prestige and influence. I recall reading a figure of scientific sanctity* once complained that even the odious Edward Teller wasn’t paid the respect due a physicist of his stature. Considering his history of scientific politics and back stabbing, you have to appreciate the size of the ethical disconnect in such an assertion.

It is an open question whether the science for the purpose of saving the biosphere, life and the human species will outstrip the science which is so widely used to destroy them. The assertion that “science might save us” is not even an unambiguous inference you can make from the available evidence. I don’t believe the contention is anymore than romantic and automatic piety of the kind that used to be the reserve of religion. “Science” seen this way is wishful thinking, the deus ex machina that will save us from ourselves even as we use science to destroy ourselves.

Science doesn’t provide the self-denial, self-sacrifice and empathy for other living beings which will be necessary to save the planet. It doesn’t contain them in sufficient quantities to make scientists notably less immoral than lesser mortals.

If the species is going to make it, those and other virtues will need to be practiced by a universally potent majority of humans. People holding those values might use science in the way that technology is taken to be the tool of science by the apologists of science. We will need science in order to save ourselves. Science is the most potent means of understanding and manipulating the physical universe we have. But without the governance of those scientifically unverifiable virtues overriding self-interest, self-service and indifference, science will serve other purposes. In fact it, like most other human activities, largely does now.

* Will provide the name as soon as I can locate an online citation.
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Fifteen days of blogging for health care reform: Status iatrogenicus 

Guest post by Skylanda.

Many, many moons ago, a man came to the emergency department. He was older, suffering a raft of chronic medical problems, and now short of breath - so short of breath he could hardly pace out the length of his ER cubicle without stopping to rest in ragged gasping heaves. The ER doctors began working him up and called upon the admitting service to get him a bed in the hospital.

In the ER they took an x-ray, which showed lungs wet with pulmonary edema - fluid backed up behind a failing heart. They drew a wide variety of labs, and while these cooked upstairs, suspicion grew that this man might have thrown a clot from one of his sluggish leg veins into his lungs. A chest CT was ordered with appropriate haste, and IV contrast was injected into his veins to better elucidate his pathology in the scanner. Somewhere, somehow, a call did not get made. A number, shy and timid, sat quietly in the online medical records, but did not get shouted across the halls to the ED doctor, the admitting doctor, or the radiology tech who wheeled the man down for the scan. The number was the patient’s creatinine, a direct reflection of his kidney function. The number was resoundingly high, indicating that some kind of kidney failure was at work, driving the fluid overload that was backing up into his lungs and impairing oxygen exchange to his blood. That number would have told any one of the doctors, nurses, or techs involved that this man should not have IV contrast dye administered to his veins; IV contrast dye is toxic to stressed kidneys, and can drive them over into permanent failure. He received the dye, and was subsequently admitted to the hospital for an extended stay for his severely compromised kidneys.

Those following his case could identify at least half a dozen possible reasons why his kidneys were failing before he even arrived at the emergency room, and every one of them was the result of combined self-inflicted misery and some kind of medical intervention. Top among the usual suspects were one of several medications he was on that can cause acute renal failure; he was prescribed these medications by health professionals, for certain, but they were prescribed for life-threatening chronic and acute conditions that were largely the result of lifestyle diseases. Also contributing were his chronic conditions themselves, two of which cause kidney failure over the long term. And then he arrived at the emergency department and was ordered up a test that was entirely appropriate for his less-than-stable condition, and then he received it even though it would have been halted if the lab put the ER on notice that his kidneys were not fully functional, or had the ER been proactive about rechecking the labs.

So a mistake is made in the delivery of care that deviates from the standard of that care. Of that we are certain. Harm, on the other hand, is a more nebulous concept. Was he harmed? Hard to tell; his kidneys were already in florid failure. Was the harm done worth the risk of the CT exam, which ruled out a potentially life-threatening condition? Hard to tell; the test was negative, but we weren’t going to know that until it was completed. If you were a jury hearing this case, would you award a sum of money to a gentleman who had already shot his chance at good kidney function by leaving chronic conditions uncontrolled despite repeated attempts at management? Or would you side against the hospital for a gross misstep in the management of this patient even in the absence of evidence of direct harm to him?

I outline this story - which roughly parallels one that I saw at a distance quite some time ago now - because the ambiguity is similar in nearly every malpractice case I have ever been close enough to know any kind of detail of. Everyone once in a while, something grossly negligent happens, and someone healthy gets irrevocably and obviously harmed. But usually, malpractices cases look like this one: the cause of bad outcomes is multifactorial, the case for harm not entirely clear. Lots of dicey details in the middle.

Malpractice - and malpractice reform - is a touchy subject. No matter what one’s political bias at the outset, close involvement with the medical field almost always causes a hard gear shift in one’s thinking about malpractice once one is in the target scope of the malpractice beast. It is said that most doctors trained today will, statistically speaking, be sued at least once in their career - and for some like neurosurgeons, the rate of lawsuits can be calculated on a per year average (ie. they will be sued an average of every two years, or twice per year, or the like). Something does not quite jive about this scenario: either there are a whole hell of a lot of harm out there, or people have some wildly unsupportable expectations of the medical industry, or both. Probably both.

The first thing to acknowledge - openly and honestly - is that medicine does indeed cause harm. In the year 2000 the National Institutes of Health published an alarming report aptly (and graciously) named To Err Is Human, documenting the stark patterns of error and harm in American medical institutions. The report is worth perusing; it is both sobering and bearing some beacons of hope, as such whistle-blowing documents usually are.

Most of this harm is unintentional, difficult to avoid, and part of the risk of undergoing treatment for conditions that do need treating. Medications have side effects, hospitals are notorious sites of drug-resistant infection even under the best of hygienic circumstances, every procedure has a risk and a documented failure rate. Layered on top of that is the alterable variable of human error caused by fatigue, mismanagement, under-staffing, lack of training or supervision, lack of system checks, negligence, and just plain old human fallibility. And finally, there is just a limit to what medicine can do to fix the human body, and a limited knowledge of where we go right, where we go wrong, and where are rightly obligated to do better given limited knowledge and resources.

The complication in medical malpractice is figuring out which cases fall into the middle category…because as much as it may be one of life‘s hard knocks to suffer bad outcomes, this alone is not cause for medical malpractice. Being alive has with it the inherent risk of suddenly not being alive any more (or being alive but in a much altered state), and you only get to collect cold hard cash for your troubles if you can prove that a bad outcome was the fault of another person - not the result of bad health, not a reasonably expected outcome of treatment, not a quirk of fate, but someone’s fault.

Proving harm is notoriously hard to do, and it engenders an industry whose sole mission is less to find and elucidate the truth than to spin information just enough in one or another direction that a judge or jury finds a particular way. Courts of law have never proven particularly apt at sorting out scientific truth (just asked the two hundred men and women freed from jail so far after The Innocence Project demanded that DNA evidence be brought to bear in challenging their convictions), and there is no reason to think that malpractice claims heard before a lay jury will consistently and accurately reflect who suffered actual harm and who merely suffered bad outcomes. (There is also the question of compensation for potential harm…when Vioxx was pulled off the market, I saw a number of discussions online and in newspapers of how people might go about putting in claims for harm simply for having taken the drug without experiencing the side effects that it was yanked off the market for; it is a uniquely American habit to ask for compensation for harm that has not happened, and it’s one of the quirks of the medical profession that makes it difficult at times to feel empathy for the malpractice industry.)

Moreover, it is often difficult to ascertain who is at fault for harm done. For example: a patient is given a dose of insulin units ten times the prescribed dose, experiences severe low blood sugar, seizes, and sustains hypoxic brain damage. The nurse who gave the insulin holds up a barely legible order sheet and reads off the dose (say, “100 u“) she gave, which looks like what is written on the orders. The ordering physician asks what kind of idiot would administer such an enormous dose of insulin without thinking first, as of course the order said “10.0 u.” The nursing supervisor bitterly adds that floor staff would have time to re-check orders if they were not routinely short three nurses per floor due to poor management and high turnover at the administrative level. The administration asks in return if the nurses have any idea what it’s like to try to run a hospital in a state so strapped for cash that the only tertiary care center for hundred of miles around has to divert patients to rural care centers because it can’t pay for staffing while hospital beds sit empty. A progressive state senator adds an op-ed piece in the newspaper noting that the voters of the state routinely turn down bonds that would increase funding to schools and public hospitals. Who do you sue? Who will pay? And most of all, if the patient wins a $10 million law suit, does this diversion of funds help or hinder the reforms needed to ensure that this same problem never happen to another patient again?

Part of this quagmire is the question of personal versus systemic responsibility for error. Individual sources of error occur when a doctor or nurse fails (or refuses) to follow protocol, shows gross incompetence, or acts negligently toward a patient; in my experience, these are relatively rare occurrences. Conversely, systemic approaches to error acknowledge that people are fallible beings, and that error is inevitable unless the whole system is built with a mind to minimize error through checks, rechecks, and constant monitoring built into the system to catch error before it does harm. Medicine has been slow to build in systemic approaches to preventing error - slower, for example, than the avionics industry, which pioneered the systematic approach to preventing accidents. Within medicine, certain specialties such as anesthesiology have taken on the strict methodological approach and have been rewarded with rapid gains in safety over short years, with concomitant gains in patient trust (though this works for a large predictable, algorithmic practice like anesthesiology, it is less helpful in more unpredictable fields of medicine…especially obstetrics, where observational studies are easy to accomplish but randomized controlled trials are difficult: no one, after all, wants to experiment on pregnant women).

The error I mentioned above, for example, should never happen in an American hospital today. Several years back, studies were done that identified about a dozen very common sources of miscommunication between written error and medication administration; doctors are now strictly disallowed from writing “trailing zeros” (ie. the zero after the decimal point) and the shorthand “u” for “units” (which looks too much like “cc” - the equivalent of a milliliter - when written by a fast and tired hand) on orders, and these forbidden orders are posted everywhere is hospitals all over the country. These rules are easy on me - I never practiced medicine when they were allowed - but tougher on providers who wrote “10.0 u” for decades and suddenly have to go rewrite orders every time a nurse catches this shorthand.

Handwriting of any sort is the source of so much error that it is questionable whether handwriting has a place in the modern medical institution (and while doctors traditionally have atrocious handwriting, really: I challenge anyone to take a random sample of the population, have them write the same general thing several times a day under severe time pressure, and see what sort of result you get from them), but medicine as a whole has been very slow to engage the sort of technological infrastructure that even your local post office has had for years. Some argue good reason for this: electronic medical records (EMRs) are like credit records - the more digitized, the easier the access for folks with nefarious intent, whether that be the nosy medical assistant or the picky life insurer who would like to deny your policy. Health information is sensitive to a degree beyond even financial information, and current technology far from guarantees the security of either. But that is largely a superficial excuse; really, EMRs are expensive and hard to introduce to a notoriously stodgy old profession.

Ironically, the most comprehensive EMR out there comes from a most unexpected source: the US government. The Veterans Administration hospitals uniformly use an EMR (called CPRS) so advanced that one wonders how it ever came from a behemoth bureaucracy like the American military-industrial complex (they do exert their bureaucratic prowess by making sure it takes half a dozen passwords - which randomly expire in the middle of the night - to get into it, but that’s a different problem altogether). CPRS allows you to see every note ever written about a patient since its inception, enter notes by typing or dictation, access patient data from other centers in the VA system directly, and enter orders directly from a vast array of pre-set menus. The learning curve is short and steep (and sometimes painful), but once you master it, it is hard to return to the messy hybrid systems of most other hospitals. It cuts costs by allowing you to see what tests have been run and instantly accessing the results, preventing repeated exams just because faxed copies of results would be too long coming. It allows for rapid assessment of vast quantities of searchable information.

Most salient for patient safety, however, is the direct entry of orders. To order medications, providers choose from an enormous menu of choices - drugs, common doses, routes of administration. Any pre-set order can be overridden should the provider decide they want an unusual quantity or unusual route, but these overrides have to be done manually. You have to think about it first. You are forced to notice that you are doing something out of the ordinary.

You might think this is shocking, that people providing your health care don’t have every drug dose memorized in their vast bank of knowledge. Well, on the commonly prescribed drugs, we usually do. But sometimes, we’re terribly tired (remember, those thirty hour shifts…some time try remembering your own kid’s birth date after you’ve been up thirty hours at a stretch). And sometimes we are on specialty services prescribing drugs that are brand new to us. And those vast banks of knowledge - they are built with training, they are not inherent, and if you check into any teaching hospital, you will probably have trainees working on your case (if you check in in July, you will have trainees who are mere days out of medical school). And sometimes, we just make mistakes - thinking of one thing, writing another. It’s a funny thing that way, we’re human too. Sophisticated electronic ordering systems cut out whole layers of potential error.

Most hospitals have some form of EMRs, but their weakness are legion. They are not searchable; they archive data too soon; they are not compatible with the main outpatient clinics the hospital interfaces with; half the information is still found on paper floor charts. And most of all, they do not allow for direct provider entry of orders, losing the one salient detail that makes EMRs so useful for improving patient safety. It is my contention that the VA’s CPRS system should be made available and expanded to every hospital in the nation. That is not a popular assertion (especially with the myriad vendors who sell expensive second-rate EMR products), but there it is. Someone already invented that wheel, and the free market has so far done a shoddy job of reinventing a better one. Can I prove the VA hospitals provide better, safer service to their clients than your average private or university hospital because of their EMR? No, I don’t have that data in front or me, nor am I sure it exists. But at the least I can tell you that no mistakes are made there due to doctors’ shoddy handwriting (and I can tell you that in the VA hospitals, I can see double my efficiency in seeing patients because I spend so much less time wrestling the dual paper-electronic system typical of most other hospitals).

But no matter how many preventive protocols are in place, no matter what system checks you implement (safety lists before surgery, double verification of blood types before transfusions, that “x” you get on your knee before they do surgery so that you don’t get the wrong leg operated on), errors will happen. You can reduce them to their most minimal number, but harm will occur somewhere - it’s the nature of the game. So what do we do when someone is harmed?

Right now, of course, we either do nothing, or we call a lawyer and file a malpractice suit. And I am of the firm belief that neither of these options are particularly efficient or fair means of compensating people for harm done by bad medicine. On one hand, calling a lawyer starts you down a road of gambles that would catch the keen eye of compulsive betters. But - you might argue - malpractice lawyers often work on commission, charging only a portion of potential eventual winnings. True that, but upfront fees are not the only cost; since it usually takes malpractice suits months to years to actually go to court or settle, you actually invest a heavy part of your life (hours, days, weeks…never mind your emotional wellbeing) into the process…something I would argue is far more valuable than upfront attorney’s fees.

On the other hand, you can do nothing, which is what most victims of medical harm do. These people receive nothing for their troubles, and often personally absorb the cost of the disability associated with that harm.

As such malpractice suits are a bad-luck lottery in which many people are hurt to provide a very few with a big hurt, big harm jackpot. Though everyone may get a righteous buzz when a particularly egregious example of harm is met with a proportionately dramatic comeuppance, this comes at the expense of dozens of victims receiving nothing but the big blow off for their pains. There is nothing just about this system from any angle I can think of.

There are other means out there of compensating victims of medical harms; one has even been tried in America. This is the National Vaccine Injury Compensation Program (VICP). Acknowledging that if you inject every kid in America with any substance at least a few are going to have some kind of problem with it (leaving aside autism because I simple refuse to open that can o’worms here), this fund was established as a “no-fault alternative to the traditional tort system for resolving vaccine injury claims that provides compensation to people found to be injured by certain vaccines.” Except for a few highly publicized autism controversies, this has largely kept vaccines out of the courts; people take a small risk with vaccines for the public good, and if some harm comes of it, they are compensated without having to engage in the legal roulette game that is the malpractice courts. The supply of vaccines remains stable, the data stream helps monitor true patterns of problems with the vaccines, and people who truly experience adverse effects are shuttled into compensatory programs rather than being left out in the cold or forced to invest years into trying to pry justice out of a very tight-lipped system. It’s not perfect, but it works. This type of approach could be applied to other areas of low-level medical harm - not the sorts of harm that occurs when a homeless person is let to die on the floor of an urban ER, but the sort that occurs when the details are ambiguous and the line between the risk of being alive and the risk of being in a hospital turns grey and obscure. Maybe we could keep a large portion of cases out of the courts, save people the risk of an extended and draining settlement process, extend the safety net for those harmed by medicine that is intended to heal.

Overall though, broad-arching reforms are needed to bring malpractice into line with the values of healing and care provision that medicine needs to be able to offer across the board. These are what I would offer up; yours may vary wildly; feel free to discuss.

* Institution of systematic safety protocols (including EMRs) to reduce medical harm, including a scorched-earth approach to eliminating all “never events” - the term given to errors so egregious (eg. operating on the wrong person, or the wrong side of the body) that they should never happen.

* Medical malpractice-specific tort reform. Monetary settlements should cover lost work time, lost potential income, medical and rehabilitation costs, and some limited sum (say, a quarter million dollars) for the nebulous concept known as “pain and suffering.” But the large, deep-pocket, punitive settlements out there for damages for these kinds things cause a reverberating effect on the ability of providers to afford malpractice premiums and go on providing care. Unlimited medical malpractice settlements impinge on the public good in a way than settlements against, say, polluters do not, and they should be subject to a different set of rules than other tort claims.

* Publicly funded malpractice coverage, especially in areas of physician shortage and where historically problematic malpractice environments has caused staffing and recruitment issues.

* Monitoring of quality and improvement through non-punitive means. Quality control incentives are a notoriously double-edged sword, often punishing institutions for accepting tough cases and motivating them to deny care for people who are difficult to cajole into good outcomes - the chronically ill, the homeless, the poor (this is known among cynics as the “No Child Left Behind“ effect). Troubled hospitals should receive focused help and programmatic improvement efforts, not punitive threats to funding in response to their issues.

* Planned and systematic compensation for victims of medical harm, along the VICP model. This should include a universal policy of halting billing of patients (and families of patients) whose cases have been flagged as having been profoundly harmed by some kind of medical error.

In conclusion, we might go back to the incident I started this post. The error was caught within minutes, giving the raft of doctors involved some time to start corrective measures before the ultimate damage was done. The patient was informed, a pre-emptive call was made to the ever-so-euphemistically named “risk management” department. That I know of, no complaint was ever filed, no malpractice claim was ever made against the hospital or the doctors involved. I checked in on the patient’s electronic chart a couple years after the case; his kidney function never recovered fully, and surgeons had scheduled him for a vascular shunt - he would soon be receiving dialysis. In his case, the line between error and harm, between acceptable risk and unacceptable damage, between outcomes of his own doing and outcomes of an inflicted nature, was a shaded and obscured region indeed.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

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Sunday, August 24, 2008

Gladly Ripping Up My Ticket For The Wayback Machine by Anthony McCarthy 

It was during NPR’s report from Prague, recounting the events of 1968, that my creeping suspicions came together. Someone might be hoping to get a benefit from the usually concentrated looks back at events of that bitterly divisive year coming up to the election in November.

They reported that, as opposed to the American media, the people who went through the Soviet invasion that ended the Prague Spring showed little interest in dredging up the history. They seem to be more interested in the present. Could there be a feeling that the Czechs are negligent to not stir up that pot again for this anniversary year, concentrating on their present? You can imagine some listeners to NPR feeling nostalgic, remembering what they were up to as the tanks rolled in. Perhaps the people there are looking for ways to avoid repeating the past, sitting right on top of it right now, as it is.

Put that together with the 1948 style coverage of the Russian intervention in Georgia in our media. God help us if this the beginning of a rerun of the next fifty awful years. The superficiality of the coverage here has not shown an improvement on the press that ushered in the cold war and the red scare. You could have gotten through much of the coverage without knowing that it’s a long standing division over parts of the country which largely want out of Georgia and into Russia. There was an effective partition going back a long way and our boy in Georgia isn’t exactly smelling of roses over his handling of it this year. Maybe since he didn’t exactly get that shelling the breakaway provinces would be an invitation to Russia to intervene, the finest heads talking in New York, Washington and Atlanta bureaus might not have gotten it either. Add putting the phonied-up missile shield in Poland and you wonder if a second go-round of the Cuban crisis might not be the results. Only, we have a No-John-Kennedy sitting in the White House this time.


Then there is the planned Reenactment of Chicago 1968 Encampment. I haven’t looked too much at the effort to recreate that political bloodbath for the left, but don’t see anything good about it. Unless you happen to be a Nixon Republican, who were the direct beneficiaries of the original event.

Having experienced first hand the rage and frustration over the Vietnam War, the stalled civil-rights movement and the assassinations that year, and felt the anger of the response to seeing the police riot in Chicago, I have to report that the demonstrations around the Democratic Convention didn’t accomplish anything to make the world a better place. Political demonstrations that end up reinforcing their opposition’s hold on power, what could be stupider? Risking a rerun hoping for a better result, perhaps?

Of course, people who inadvertantly helped make Nixon president might not have fully appreciated what was to come. Some can be forgiven their shortsightedness and bad planning, though I’ll never forgive those for who it was entirely a question of their bruised egos. We don’t even have to rehash the various cults of personality on the left, though. There have been forty years of resultant bad policies stemming from the Nixon presidency and the Republican ascendancy ushered in by the left’s fragmentation in 1968, to look at dispassionately and to learn from.

Maybe the underlying issue is the difference between history and antiquities, looking at the past in order to try to understand the present as opposed to trying to experience the past, something that is impossible and so really only produces let’s pretend. The reality of those of us who were active in the anti-war movement was that we were all trying to get out of what was a real-life nightmare that led to even worse things in the years that followed. Who in their right minds going through 1968 would want to reexperience that?

Some of us learned from how the media covered us in 1968, a lot haven’t, apparently. What good will come of giving new images of flakiness and irrational chaos to TV networks which are infinitely less interested in pretending to accuracy and fairness than the decidedly pro-Republican networks of that year? There was some attempt at the appearance of objectivity back then, as they were blatantly supporting Nixon.

Experience shows that trying to use the failed tactics of the past now will produce similar results. Doing it because it just feels good is an indulgence for those removed from the resulting reaction. The number of those involved in bringing about Chicago 1968 who brushed the dirt off and went on to become Republicans is as much a part of the story as the misguided nostalgia for the event itself.

Having started out that year supporting the Robert Kennedy of 1968* but in the end having to support Humphrey wasn’t a great experience. But there is absolutely no reason to believe that the U.S. involvement in Vietnam wouldn’t have ended faster under him than it did under Nixon. Kissinger would likely not have played his evil part in a Humphrey administration, just for starters. William Rehnquist wouldn’t have become a justice of the Supreme Court. Those and countless other differences would have shaped the realities we have today. If we’re going to indulge our imaginations, trying to imagine the possible results of choices Humphrey would have made might get us a lot farther than reliving the mistakes that got us where we are now. We don’t live in a theme museum, we live in what we really get. People really end up dead here, they don’t get up and shower the ersatz blood off before going to supper with your friends.

* Robert Kennedy’s evolution during his public career carries a lot of lessons about learning from some really terrible mistakes and swallowing pride.
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Fifteen days of blogging for health care reform: Burden of debt 

Guest post by Skylanda.

Not long ago, I was cruising along the highway at about 75 miles an hour (hey, it’s a rural state, that’s not even speeding here). I was headed north to sign some papers; after innumerable years on a student budget (four undergraduate years, a couple more to the premed classes I hadn’t taken the first time around, four years of medical school, and a year to complete my masters in public health), I finally had a solid resident income. I somehow managed to wangle a mortgage out of the messiest era in history to lock down a line of credit, and I was buying me a house.


The sign at the roadside was for a casino. This is Indian country, brightly lit casinos cling to the highways and byways like hummingbirds on honeysuckle. The billboard glittered and flashed and promised - wow! - a half million dollar jackpot. Top prize! Some lucky soul will take it home!

A pit opened in my stomach and I almost turned around and called the whole thing off. Half a million dollars, I realized…if I signed those papers, half a million dollars would no longer pay off - nay, not even come close to paying off - the total dollar amount I owed to the world at large for the enormous debts I had accrued over the last five years.

I kept driving. I signed those papers. I am now thirty-three years old and the proud owner of two-thirds of a million dollars of accumulated debt. Far, far less than half of which is tied up in that real estate deal.

Four years of medical school, one year of graduate school to obtain a masters in public health. Fifty-something thousand a year, add on five years’ worth of accumulated interest (capitalized twice when I lost eligibility for deferral due to quirks of the federal loan program), and you have my total school debt: three hundred thousand dollars. When those loans skid into repayment two years from now, they will cost me about three thousand dollars a month to service - that’s thirty-six thousand dollars a year in loan payments alone, more than my entire take-home pay as a resident last year.

In some ways, I struggled. The vast bulk of those loans contributed directly to tuition; the living expenses portion of my student loans put me within about 150% of the poverty level after you subtracted unavoidable school expenses from the checks cut to us every three months. By then my parents had their hands full with other financial obligations and could not by any means put me through medical school; nor did I have a partner to share expenses with. My home state boasts all notoriously competitive medical schools, and though I was accepted to several schools throughout the country, I would have paid private school or out-of-state tuition at all of them - and so I just chose the one that best suited my needs.

In other ways, I was lucky. I have no debt from my undergraduate years, thanks to parents who were both generous and able to support me through those years. My medical education coincided with historic interest rate lows, and I have the majority of those debts locked in at rates that would make you drool (and here’s my public service announcement for the day: if you have unconsolidated federal student loans out there, talk to the Direct Loan people now). I had a lucrative contract job leftover from my former career that I could squeeze into vacations and off rotations, and if I was willing to work eighty-hour weeks while my classmates were playing on their off time, I could pull down a reasonable income. And that I did, pulling in roughly $40,000 in real income over five years; I figure it like this: I came out of medical school no savings at all and living frugally most of that time…if I had not worked that contract job, I would be $40,000 in the hole on credit card debt just to stay even.

Three hundred grand debt from student loans alone, thirty five years old by the time I start making a full physician’s salary, no retirement in the bank, a couple of toes in the dicey-est investment in the market today (real estate, that is), and that’s what I’ve got. So if you ask me if doctors - especially primary care doctors - make too much money, I might just have to say no.

Debt is only one reason that doctors expect to be compensated a certain way. Another is the soul-sucking vortex of the residency years. Until you’ve lived a medical or surgical internship, you can’t really compare it; it destroys marriages, sparks mental illnesses, invokes ulcers and bouts of depression and vague hints of personality pathologies in even the most stable and competent people. In 2003, residents nationwide were put under work hours limitations for the first time - eighty hours a week no more than thirty hours at a time, can you imagine the luxury (luxury, I say, because prior to that, hours worked by residents were totally unlimited). During my intern year, I ran roughshod over these hard-and-fast “rules” with alarming regularity; my department made it clear that so long as they did not get caught at it, they did not care. The week I broke a hundred hours I calculated my hourly take-home pay for those seven days: $6.68. I could probably double that wage at Starbucks.

And then there is the fatigue, that bone-aching tired than never leaves you, so tired you can’t even conjure up a yawn anymore, so tired that sleep no longer helps. Because there is no universally validated scale to measure fatigue, imaginative means have been invented to measure this otherwise very subjective parameter; one study standardized fatigue on a scale of blood alcohol level equivalents, and compared residents after a thirty-hour call shift unfavorably to a blood alcohol beyond the legal limit of .08%. During my intern year, I woke up behind the wheel of my car at stoplights, wrote and submitted admission notes so asleep I didn‘t recognize them the next morning because my eyes were closed and flitting around the inside of my eyelids in the throes of REM sleep as I was typing them, lit my kitchen ablaze after a scheduling glitch forced me to fire off two thirty hour shifts with only a seven-hour sleep between them, stopped eating because I fared better through on-call nights if I didn‘t hit that hard downswing in energy after dinner. I lost twenty-five pounds in three months; people I didn’t know asked me in the grocery store if I was alright. Fatigue makes you learn what it means to hate irrationally, it’s the closest most people in modern industrialized nations come to engaging their most primal needs; you have no idea how much you would give for something as simple as sleep until you have done several months back-to-back staying up all night every fourth night.

So let’s see a show of hands of people who would, under any circumstance, choose to let a doctor (in training, no less) who is in their twenty-eighth hour without sleep for the second time that week take care of your urgent problem - your heart attack, your critically low blood sugar, your c-section. Anybody…anybody?

The work-hours regulations were born in New York state after a particularly notorious case of harm from an overtired, overworked resident; the dead victim was no different than a hundred other victims of exhausted residents, except that Libby Zion was the daughter of a local lawyer and journalist, who had the voice and the wherewithal and the bewilderment to ask in a very public voice why we needed impaired doctors taking care of critical patients. Nearly two decades years passed before New York’s pioneering (and meager) regulations were extended into the national work hours limitations, and even these are under continual fire (one notorious controversy surrounds conflicting data on medical floors - where resident hour limitations have consistently shown improved patient safety - and surgical floors, where the data has not shown improvement; though much hoo-hawing has been made over this paradoxical discovery, anyone who spends time with residents knows that the policy of yanking accreditation for programs in violation of the work-hours rules means that surgical residents are under great pressure to simply lie about their hours…and that is all I will say in a public forum on that matter).

I rotated through a hospital in Britain during my fourth year of medical school. One afternoon I asked the wild-eyed, bushy-haired Irish attending physician if I might show up early the following morning to see my patients before we started rounds as a group at the ripe hour of nine am and thus be better prepared to present their problems. He fixed a jaundiced eye on me and said, only half in jest, “You Americans, we know about your habits…you all think something very important happens before the sun rises, that if you’re not here every moment of the day you’ll miss out, you want to start the morning earlier and earlier. Well, we don’t want your over-eager, overachieving ways here, you will keep that to yourself thank you very much…you will arrive at nine am and not a minute earlier!” I heeded his stern warning and dutifully slept in til 8 am the following day. In Britain, you see, trainee doctors are limited to more or less sixty hours per week. Somehow, they turn out world-class physicians, not unlike American physicians. Somehow, they do it without the soul-sucking demand of the eighty-plus hour work week.

One way they do it is to start medical training earlier, and stretch it out longer. British medical student go to high school one year longer than Americans, but start medical school right after that. Medical school is also one year longer, and then begins a rather extended period of post-graduate training. It is hard to compare the two system because chronologically they are so different, but one thing is clear: they both turn out good doctors, and one does it without asking its acolytes to bow to the god of the 80-hour work week. (As a side note, there is some serious grumbling about reform of the content of the US medical curriculum; the first licensing exam is heavily biased toward non-clinical material, a raft of detailed information that students are forced to memorize then promptly forget after they past the test, which forces medical schools to spin their wheels the first two years on topics of limited use to a practicing doctor. It is questionable whether - in a world where clinical knowledge is expanding exponentially - we still need such an emphasis on a classical education where the detail of theory is emphasized to the exclusion of practical clinical material. This is unlikely to change any time soon, but the time spent rememorizing and forgetting the Krebs cycle certainly contributes to the frenetic pace of learning required later on if one is to master the practice of medicine in the limited time allowed by an American medical education.)

You cannot pay people enough to make up for what they endure during the typical residency in America - especially surgeons, who endure five or more years of it, and who are largely at the mercy of unlimited work hours despite clumsy efforts to the contrary. Cash is all we offer doctors in return for those years of their lives (other old-fashioned notions like renown and universal respect are largely phenomena of the past), and that cash has to compensate not only for the sucking vortex of the residency years, but also for the enormous debt and interest that medical students accrue.

As such, expected payment over a lifetime necessarily has a profound impact on how medical students choose their future careers. Many choose by following their passion alone, but many have multiple areas of interest and make the final decision on which promises a quicker loan payoff, a better guarantee of a reasonable age of retirement, a promise that their investment in their education would not have been better spent on a computer sciences BS capped off by a two-year MBA (which, frankly, is what I would tell any 18 year-old to do if they professed an interest in going into medicine purely for the money - there are quicker, easier, and far less painful ways of making a buck, let me tell you).

Why is this of interest to you? Because there is profound and growing crisis in the staffing of primary care services in this country, and because the increased reliance on specialist services is one of the driving factors behind increasing medical costs. In some ways, this is a region-specific phenomenon; in my adopted home state of New Mexico, for example, every specialty under the sun is in grave demand, from family medicine to dermatology, and whole agencies have been set up to recruit all sorts of doctors to all sorts of regions. But in many areas, recruitment into primary care is suffering from the growing emphasis on specialist care, care that costs more to provide without clear evidence of improved outcomes per dollar spent.

So how can one balance my two assertions above - that we cannot pay doctors (especially in certain specialties) enough for the tortuous training they endure and the debt they acquire, and that we cannot afford to continue to pay certain specialties as much as we are paying them now? First, we can reform the medical education system to treat trainees in manner more akin to the way patients expect to be treated: humanely, with respect to human limitations, and with the idea that residents are not an limitless pool of cheap labor that hospitals might otherwise have to pay a real attending physician a real salary for. And in return we can ask that once they graduate, they not expect to command limitless sums of cash for their troubles. These reforms might have to include starting medical school earlier, with less undergraduate training (a tactic already in place at a handful of US institutions that combine undergraduate and medical school into a single six-year program); reorienting the emphasis away from basic sciences and toward more clinically useful practices earlier on to lighten the load later; and offering longer residencies in exchange for reduced hours. These reforms might also have to include giving residents a voice at the planning table; unionization of trainees at my particular residency proved to be a rapid and potent means of improving working conditions and benefits, and the improvement in those conditions visibly cascades back down into patient care.

Second, keep a lid on medical education costs. The prohibitive cost of medical school not only has a profound effect on specialty choice at the end of school, it also has a prohibitive effect on the diversity of students who enter medical school. It takes a solidly middle class outlook to believe the fanciful notion that a $60k per year outlay will ever pay itself off, and for potential students who do not arrive with significant family support, living on student loans well into one‘s twenties (or even thirties) is still a struggle. Any hope of maintaining diversity in the medical profession will rely heavily on keeping the doors open to medical education, and that means keeping some kind of cap on the ever-expanding cost of attending school. We subsidize every other form of education in this country, and medical education should continue to be no exception.

Third, we can restructure reimbursement away from the current emphasis on high pay for procedures and low pay for the kind of work that primary care doctors do - medication management, counseling, dealing with the problems of life. Small procedures that take ten minutes (and no greater skill or capital input) often reimburse at ridiculously higher rates than an hour spent attempting to get a diabetic’s blood sugar under control - though the latter may have a far greater impact on the patient’s morbidity and mortality over the duration - for no greater reason than mere custom. Careers should pay in proportion to the training they require and the benefits they provide, not arbitrary notions of the importance of procedures over non-procedural services. (Britain - one of the most notoriously socialist of the European medical systems, where doctors are actually employees of the state - recently used a classical market-based approach to try to solve their crisis in primary care: faced with a dearth of GPs and a rapidly aging population, they simply offered to pay them enough that the profession all of sudden became lucrative again.)

As for me, I chose family medicine over my other more lucrative areas of interest because of the philosophy of service and the wide-ranging skill it would provide me. Except for the days when I sit down to calculate how many hundreds of dollars of interest are accruing on my loans each month, I don’t regret it. I know a few folks who have no student loans; they are the ones who will go wherever they want to work, who will go abroad and blow a few months volunteering with Doctors Without Borders after residency ends, who have the choice to work at the lower end of the pay scale for community clinics instead of counting every penny toward that debt pay-down, who can feel righteous about their choice to work for lower pay because they don’t need to make those $3k a month loan payments. I’m not one of those people; my every choice for the next ten years will be driven, necessarily, by money. Ironically, I went into primary care despite the money, and because of that, money will drive my every decision until that last penny of debt is paid off.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.
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Saturday, August 23, 2008

A Summer Night in 1958 

Dinah Washington: All of Me.

Catch her fooling around with the vibes during the break. She looks like she knows what she’s doing to me.
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Fifteen days of blogging for health care reform: Down on the pharm 

Guest post by Skylanda...and sorry folks, this is a long one!

A virile sixty-ish male chucks a football through a tire swing, raises a couple of fists in victory, and manhandles his comely wife; the final voiceover lists headache, flushing, dizziness, rash, cognitive dissonance, sudden loss of conscience, and pernicious priapism as possible unintended consequences of the little blue pill that made this moment possible. I might have just made up the side effects, but you’ve seen the ads.

If you’re old enough to remember ten years back or more, you remember a time when pharmaceutical ads did not appear on television. These ads first appeared around 1996, when changes in FDA regulations began allowing direct marketing of pharmaceuticals to consumers, bypassing the expertise of your doctor and asking you as the patient to approach your provider and ask for medication that might benefit you. Pharmaceutical peddlers now go to a lot of trouble to make sure that you know their brand names as you know the brand of your kid’s cereal: they debut ads during Superbowls, they hire ex-presidential candidates to plug drugs for conditions that no one wanted to talk about in public a year earlier (Bob Dole wants you to know that Bob Dole has trouble with his wee wee, says Bob Dole).

Among the most eye-browing raising ads I ever saw for a pharmaceutical product was for Procrit, an extraordinarily expensive injection used to drag red blood cell counts up in anemic chemotherapy patients, those with end-stage renal disease, and those doping for high altitude sports. The former patients are usually managed closely by specialists who keep an eye on issues like this, so unless you are trying to get yourself kicked off the Tour de France, this is probably not something you need to ask your doctor for. Nevertheless, these ads are more or less asking you to call up your doctor and request yourself what roughly amounts to a chemotherapy drug (Patients, ask your doctor if adriamycin is right for you today! …sorry, geek humor…move along…nothing to see here…)

The opening of the advertising for pharmaceuticals was ostensibly done equally in the name of the free market and in the name of full patient education. And indeed, there is some equalizing factor poured into the mix when you as a patient find out that there are six roughly equal allergy medications on the market instead of the one marginally effective one that your doctor has been prescribing you for ten years simply because it is the one that he or she is comfortable with. The concurrent explosion of direct-to-consumer advertising and the arrival of the world wide web have contributed to a double-edged sword for doctors: a generation of patients that is perhaps the best-informed in history, and the enormous headache of trying to sift through the raft of misleading misinformation that is now at every patient’s fingertips.

Aside from direct advertising, pharmaceutical companies have more insidious ways of inserting their buy! buy! buy! message into the public consciousness. Gone are the halcyon days of all-expense-paid golfing trips to the Bahamas to hear a one-hour lecture on the newest heart drug, but pharmaceutical money still pays its way into physicians’ minds in a variety of ways. Drug companies buy their way into trainees’ heads by providing food for required lunchtime lectures in return for a few minutes of air time on their latest product. They sponsor professional conferences, which for small states and less lucrative specialties like mine, could not happen without some commercial support (ironically, in family medicine, these conferences are often the site of ragged ongoing debate about the issues du jour surrounding affordable health care and - always - the role of drug pricing in that affordability). They litter the hallways with cheap pens, clocks, and other products bearing the flashy logo of their expensive wares. You would think that future doctors and practicing doctors wouldn’t sell out quite so cheap, but this is an awful large outlay of funds across the nation for these efforts; something must be working.

Most controversial of all is the provision of free sample drugs to clinics. Ostensibly, this is charity: who can nay-say free drugs? But by providing free drugs as a start-up pack, pharmaceuticals hope to buy patient-doctor loyalty to that brand, and this is often the case - and it is important to note that only patented, on-brand drugs are given out for free (no one runs around in fancy suits with branded pens and clocks pedaling drugs that cost four dollars a month). A patient is started on, for example, a cholesterol medication out of the doctor’s free sample closet, and once the samples run out, the patients transitions to paying for the medication at full price because it works and they are comfortable with it and they know the brand. You can see how this does not work at all as a charity for uninsured patients, it only works as a come-on for insured patients. You’ve probably seen this tactic before; it’s called “First one’s free!” and - not to be too prejudicial or anything - it’s also used by the guy selling heroin a block down the street from your local high school.

It is for all these reasons that some institutions - often at the behest of medical students and residents - have started to boot the pharmaceutical companies out of their clinics, their mailbox, their lunchrooms, and their drug closets. The integrity of education is at stake, they argue, as is the integrity of their ability to treat patients without this ultimately costly interference. The American Medical Student Association’s Pharm Free campaign has successfully spearheaded the movement to drive the pharmaceutical companies out of several major university hospitals, and is gunning for more. (Of note, some community-oriented providers have made interesting compromises with pharmaceuticals to continue providing expensive drugs without compromising patient priorities. Both community clinics I have worked in within New Mexico have had a policy of allowing pharmaceutical companies to hawk their wares and leave samples, but only those with whom the clinic has established means of continuing uninsured patients on those expensive drugs through corporate-sponsored patient assistance programs, which give a certain number of prescriptions out for free each year as a charity write-off for the drug company. Why the pharmaceutical companies even bother with these clinics, I cannot imagine - perhaps the hope that one day these patients will receive paying Medicare benefits? - but nevertheless, there it is.)

So the move is afoot to boot the pharm companies from places they should not be sticking their noses, to reclaim a less biased territory for training new doctors, and to control costs. This is a universal good, yes?

Well, it may be more complicated than that. Drug innovation is a mighty expensive enterprise. It depends who you ask (and what their motivation is for cooking the numbers in any given direction), but from the moment a drug is first thought up to the time the first commercial batch is sold off the assembly line, the total cost of developing a new drug is somewhere between $75 million and $800 million dollars. This can include versions of the drug that are canned early on because of safety or efficacy failures - expenses which biotech companies routinely swallow as a cost of doing business, which is part of why it is so hard to say exactly how much a new drug costs to get to market. And every drug that does reach the market risks being yanked later (amidst a raft of lawsuits) due to unforeseen safety problems…even a blockbuster like Vioxx. With that kind of up-front investment required of pharm companies to keep the conveyor belt of innovation moving, it requires some powerful motivation to keep the pipeline open. That motivation is known as profit. There is a danger to impinging too deeply on pharm profit, and that danger is that we slow the pipeline for innovation into advances that may be life-altering or life-saving down the road. What is the use in inventing drugs that no one can afford?, you might ask, and that is indeed the balance that has to be struck: keeping the pipeline open, but in a means that at least a useful critical mass of people can afford.

It is also useful at this point to widen out the scope of this discussion to a more global scale, to understand the role of the US market in the drug trade (the legal drug trade, that is) around the world. And for that, we have to go back in history a few years, to a very different time and place.

That place is New Hampshire, around 1944, in a town called Bretton Woods. The Allied victory was starting to look like a sure thing, and the representatives of the future victors gathered quietly to start planning for what that victory would look like. Galvanized with the understanding that punitive measures against the loser nations (especially Germany) after World War I largely sparked the disastrous build-up toward World War II in Europe, these planners sought to employ the lessons of the 1920s and 1930s toward building a better world. You’ve probably never heard of Bretton Woods, but you’ve certainly heard of at least one of the global institutions that were born or consolidated that summer in New Hampshire: the International Bank for Reconstruction & Development (later the World Bank), the International Monetary Fund, the General Agreement on Tariffs and Trade (GATT), and the United Nations, which had its roots in the post-WWI League of Nations and was formalized in the spring of the following year. Together these formed the logistical underpinning of the Marshall Plan, perhaps the most ambitious (and arguably the most successful) program ever undertaken to promote peace and prosperity in the world to date; in a couple of decades, western Europe was transformed from a zone of constant conflict and cyclical spasms of poverty into the wealthy and relatively peaceable place we know it as today.

Among these institutions, the one you are least likely to have heard of is GATT. The GATT treaty was designed to create a forum for breaking down trade barriers that had both hindered free movement of goods and people and also encouraged the kind of regional Balkanization that historically sparked wars throughout Europe. When GATT was originated, its founders probably had no idea the sort of contentiousness and riots would one day be fomented in its name wherever its representatives gathered, for what started as GATT eventually morphed into its heir child, the World Trade Organzation.

A full discussion of the WTO and its controversies is entirely beyond the scope of this post, but the role of pharmaceuticals in that morass serves as both an example and a parable of globalization and its complications. And the best place to go to study the globalization of the pharmaceutical industry is the Indian subcontinent. In 1970, India’s populist government passed a law that no pharmaceutical compound could be patented within its borders (patents, incidentally, are nation-by-nation protection; the WTO tries to enforce world-wide patents, but has no legal authority to do so, and can only attempt to wangle compliance through economic pressure on member nations); a nascent industry was born in generic knock-offs of costly medicines patented in industrial nations, unhindered by any legal ramifications of this sort of intellectual piracy. But in 1995, India joined the WTO and was given 10 years to comply with intellectual property rules (known as TRIPS - “Trade Related Aspects of Intellectual Property Rights” in one of the clumsiest excuses for an acronymn ever invented) and cut out the business of knocking off expensive drugs invented in other countries. The intervening ten years saw some profound advances in the treatment of cancer, AIDS, and other devastating diseases, and the dust is still settling on the nuances of which patents are enforceable in the massive Indian pharmaceutical business (some drugs were patented before 1995 but not marketed til later; others receive exemptions from WTO patent rules for their life-saving public health properties; the gritty details go on and on).

The moral right of Indian generic pharmaceutical producers to knock off patent medicines is a tricky one. On one hand, India has a burgeoning population to take care of, and its pharmaceutical industry has traditionally also been a prime source of drugs for developing nations that do not have infrastructure to produce their own nor the cash to buy them on the global market from legitimate producers. On the other hand, lopping a billion or so of the increasingly wealthy Indian people out of the profit-making market for any given drug is liable to put such a crimp on expected revenues that it may hinder motivation for new drugs to be sent down the pipeline in first world countries, when corporations know that these drugs can be knocked off the moment they start coming down the production line. Patent rights may still to this day be threatened on newly marketed drugs because many compounds are patented years before they are proven to be at all useful; this was the driving logic behind the Gleevec decision (which allowed generic versions of a very expensive cancer drug in India), of which I wrote extensively two years ago in this very forum.

Which brings us back to the role of the US market in global drug development. We all know that Americans pay more for the same drugs, no matter how many variables you adjust, than any other nation in the world. Sometimes on an exponential scale. While pricing out drugs in a number of nations for the masters thesis I wrote on TB pharmaceuticals, I stumbled across a policy paper out of the British National Health Service that unequivocably declared that the antibiotic Avelox - at some two pounds per pill - was far too expensive to consider as a first-line drug for any known condition. In translating that number through the exchange rate, I generously doubled two pounds to four dollars (to account for our ghastly exchange rate at the moment) and looked up the price per pill at Walgreen’s: ten bucks a pill. Two and a half times a number that the British medical authorities had deemed too ridiculously expensive to consider for routine use. Avelox is on formulary at the hospital where I work now; not a day goes that we don’t have someone on the inpatient service taking this drug. The mind does boggle.

We pay for prescription drugs at a rate that would impress your local cocaine pusher. We do it because we can, we do it because we’ve been pushed into it, we do it because we have such an obscured system that the only people who actually know the true retail price of a drug are those who are paying out of pocket without insurance coverage. And when we get fed up with it, we get sneaky and order our prescriptions from Canada or India or Mexico and feel like we’ve just got the deal of the century over it (and on that note, here’s today’s PSA: order drugs from Canada, fine, that’s a developed nation with drug standards similar to our own; but caveat emptor if you order medications from developing nations, including India - serious questions of purity, efficacy, and even content have arisen, especially in batches sent abroad to unsuspecting and well-paying foreign buyers). But if you start to strand out the threads of the story, you’ll find that it is not only the pharmaceutical companies that are parasiting off the American consumer; in a very real way, drug consumers in other nations aren’t just getting a better deal than American patients, they are quite literally freeloading off Americans who pay full price for medication. And here’s why:

When a multinational pharmaceutical corporation looks at a promising compound and calculates the plausible return on investment if they take that compound into trials, part of that profit projection comes from bloated, high-roller drug costs in the good ol’ USofA. A large part. If you removed the American portion of that profit margin (or just tightened its belt by a good notch), you would be looking at a far thinner profile. Investment into patent drugs sits heavily on the American consumer; you may eat your shirt every time you pay a hundred bucks for a month’s worth of one drug, but come on, revel in it: you’re ensuring the next generation of cancer cures, blood pressure controllers, and cholesterol fighters in a way that consumers throughout the rest of the world are not contributing so much.

If only the truth were so clear-cut as that murky road home, eh? But of course there is one more twist. And that twist is that the pharmaceutical pipeline is not necessarily as responsive to consumer needs - even the very American consumer that feeds it money-hungry maw - as we might like it to be. You would like to see a safer, more effective treatment for cancer this year; what you get instead is yet another cholesterol drug, in the same class as a half dozen other cholesterol drugs, that is one atom different and costs ten times more than those that have gone generic for no provable increased benefit. You want to a new class of antiretrovirals - AIDS drugs - to see the market this decade; what you get is a blood pressure drug in the same class as ten other blood pressure drugs…again, for an increased price, with little increased benefit. How on earth do you get anyone to buy this stuff - same product, higher price - you might ask? Well, go back to the beginning of this wordy diatribe…advertising, accessing young doctors at their places of training, building brand loyalty through free sampling, obscuring the true cost by filtering it through the insurance industry. The cycle is vicious indeed.

So where do we go from here? We can’t single-handedly redirect corporate funds to socially worthy drugs over yet another branded me-too blood pressure drug, or reform the WTO stance on patent medications (although throwing rocks at WTO conventions seems popular enough world-wide to make an Olympic sport of it). But remarkably, this is an area where patients as individuals do have a marked bit of control. You buy this stuff, you are a market force. Here’s how you can use your dollars to effect this issue.

First of all, the next time a doctor prescribes you a medication, you have the right (you might get a little annoyance in return - but still, you have the right) to ask these questions: Is this the cheapest effective drug for my condition? Are there generic alternatives that are equally effective? If I am being prescribed an expensive medication in a class where there are cheaper alternatives, why is that? You may get a legitimate answer to this last question: because you had side effects to the cheaper alternatives that we tried, remember?; because your condition is severe enough that we go for broke with the absolute best in the class; because the expensive medication happens to be on your insurance provider’s formulary, while a less expensive one is not; because there is no cheaper effective alternative. But many times, there is no good answer, and the next right answer is: There is no good reason why; let’s try a cheaper alternative instead.

Second, you can understand that pharmacies are a market like any other, and that drug prices vary wildly between them. Call around next time you get a prescription and ask how much it will cost before you fill it, even if your insurance will cover it; the answer may surprise you (when I was between insurance plans once, I paid $18 for prescription eye drops that I later found out I could get for $4 down the street…I‘m not talking about fifty cents, I‘m talking about a four-fold price difference). Part (but not all) of this variation is wrapped up in the four-dollar prescription programs at Walmart, Target, K-Mart, and a few chain groceries like Smiths. Far be it for me to gives props to the vortex of social ills that is Walmart, but credit where credit is due: Walmart initiated the four-dollar pharmaceutical plan a couple years ago to provide a month‘s worth of certain generic prescription drugs at a fixed price (a couple hundred different medications at last count), and the others scrambled to follow suit. Walmart surely crunched some heavy numbers before establishing this policy, some numbers that ensure market share and profitability and competitive edge over the mom-and-pop pharmacies that you would love to support instead of the globe-eating big-box chain, but still: gotta give some credit for affordability, transparency of cost, and ease of accessing their list.

Third, you can refuse (unless there is good reason to do otherwise) to buy expensive, new-generation medications for which there is an older, cheaper equivalent. Market forces allow the continued arrival of me-too drugs, and as consumers, we can just refuse to buy them unless there is some pressing reason to do so. Your single purchase won’t re-shape the market, but if as a whole nation we start refusing to buy me-too drugs at inflated prices, the incentive to continue investing in them (instead of in truly innovative and necessary classes of drugs) will dry up.

But eventually we have to tackle the core idea of the how much we are willing to pay for truly spectacular new drugs - cancer cures, HIV treatments, and the like. These will continue to filter down the pipeline to us if we are willing to pay for them - but the price is steep. The top tag I’ve seen cited on a medication is a whomping $100,000 per year for Avastin, a drug which chokes off the blood supply to breast and colon cancers. These drugs arrive because of market forces, and it is entirely possible that we have other priorities that are more important - such as covering all diabetics with drugs that we already know to save lives. Maybe we don’t need a pipeline of new drugs bad enough to pay what we are being asked to pay for them. Maybe innovation should slow a bit to accommodate a market that cannot handle this kind of expense. Maybe the inflated pharmaceutical market needs to accept a slow-down before it hits the kind of skids the similarly inflated mortgage market just took in the gut.

Or perhaps we can work collectively to cap prices while maintaining incentive, by means like trading government or university funding for caps on prices (the former is already in effect, the latter has not generally been demanded yet), or allowing increased patent times in return for limits on prices or guaranteed supplies to patients who cannot pay.

There is no one answer, no victorious football-through-the-tireswing to mark a successful remedy to the question of balancing drugs and prices in America and throughout the world. What we have is a big, snarly, expensive problem. What we need are thoughtful, balanced, comprehensive solutions. And those are never easy to come by.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.
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Friday, August 22, 2008

Bound and gagged (by Suzie) 



           From an interview with Jewel Staite, who plays Dr. Keller in the sci-fi TV show Stargate Atlantis: 
So I understand that Dr. Keller gets tied up in the woods in like every other episode of Stargate. What's up with that?
Yeah, I don't know what that's about. In season four, I was kidnapped and bound and gagged. This year, it's happened to me twice so far. And I just read yet another script where I am again bound and gagged… .
Is there a site somewhere where they're charging five dollars a minute? Is it a fetish thing?
Maybe that's what it is. … And it's the same writer every time that writes the episode where I'm being kidnapped. Maybe he likes seeing me dragged through the woods. I don't know what's going on. And you know what? I don't question it. I guess. At least he's writing for me.
          Since he’s not writing for me, here’s a question: If Dr. Keller were a man, would there be as many scenes of him bound and gagged? ETA: Maybe so! Please see the comments. 
          Update: Stargate Atlantis has been canceled.

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Fifteen days of blogging for health care reform: End of the road 

Guest post by Skylanda.

Several months ago, I was admitting a gentleman to the general medicine floor of the university hospital. Per protocol, I gave him our standard speech about how we don’t expect him to drop over dead during this admission, but in case he did, we needed to know in advance if he would like us to make all attempts at resuscitation or let him to die peacefully. I promise, the speech came out a good deal more gently than that; the first time an intern has to ask this it usually feels awkward, but after a several dozen times, you get down a speech that you feel comfortable with, that patients don’t recoil in horror to, and you make it part of your routine admission. It’s quite far from the weirdest thing we do every day, believe me (rectal exams: now there‘s one of the weirdest things we do every day).

“Well,” this gentleman said thoughtfully, “I guess you can bring me back. Just so long as they don’t keep me alive like a vegetable or something. I just don’t want to be a burden on anyone.

This a guy who was being admitted for the sixth time in as many months for one of those diseases you develop by following a particular lifestyle. He had been abstaining from his vice of choice for some number of weeks, and had been asymptomatic of the disease it had been causing, but that evening something had provoked him to hit up one of the local houses of marginal repute. He sat down at a slot machine, he indulged, he landed on our floor via ambulance an hour later, groaning in pain and wondering if this was the event that was finally going to get him.

His response was not new; you might have thought it - or said it - yourself if you’d been asked the question. But it brings up the question: what does it mean to be a burden? Who is a burden on the system? More aptly, is any one of us not a burden on the system? What do we do with those who cost so much for individual care that we are forced to consider the financial consequences of that care on the larger picture - that is, the health we cannot provide to others because of the gross expenditure we are pouring into one person?

There is much rhetoric around the idea of being a burden, or of not wanting to become one. Most of this comes from healthy able-bodied people who do not actually have to face down the question - now, today - of whether or not they want their own burdensome self taken off the human map. Much of this rhetoric is sanctimonious in nature: “I would never want to live like that,” it says of the disabled body or ill body; “Kill me if I ever need a machine to help me breathe, or a tube to help me eat,” it threatens. This rhetoric makes movies like Million Dollar Baby; it creates Jerry Lewis telethons where the disabled are reified as hapless children incapable of anything but receiving your benevolent charity; it finds tragedy in disability, and redemption in a throw-yourself-on-the-fire-for-the-greater-good stance from the disabled, who usually have zero interest in throwing themselves on fires for the comfort of others. It inspires a hypervigilant but entirely necessary form of activism known as the disability rights movement, spearheaded by people with precisely those conditions who have decided that indeed, they would not like to be invited to die just because they require a tube to eat or a wheelchair to move about the world in.

But let’s back up a second. What does it mean to be a burden? On one hand, you could define a “burden” as someone who requires so much individual care that it profoundly disrupts the lives of the people around them, reorienting entire families around the care of a sick member. Financially, you could call a “burden” anyone who draws more off the health care system than they pay into it. The popular rhetoric on this topic would have you believe that the follow groups are the most frequent offenders in the category of “burdens” on the system: Illegal immigrants. Those who frequently visit the emergency room instead of accessing primary care. Severely disabled people. Uninsured patients who don‘t pay their hospital bills. People who smoke. People who don’t eat right and don’t exercise. Drinkers. Drug addicts. Fat people.

I beg to differ with that rhetoric. I argue that just about every last one of us is a burden on the system. There are many reasons why, and here is the first: because at the current cost of medical services, any of us who use any quantity of medical services in a given year - even those of us paying out the nose to maintain private insurance premiums - are likely using more resources than we are paying in. In one particular year of medical school - when I was grousing about paying cash out of student loan funds (which I will be repaying, with interest, for the next thirty years) for a group health insurance plan, I was treated for two benign conditions: chronic migraines, and an allergic reaction to a skin infection that required a long course of powerful antibiotics overseen by a dermatologist. Nothing profound, nothing terribly out of the ordinary. But unless my insurance company was bargaining far lower prices than were showing up my billing summaries, those alone racked up costs in excess of my total premiums. There I am: a burden on society. Few but the healthiest people won’t suddenly rack up costs in excess of their contribution even with just a couple of routine conditions - this is one reason (among myriad others) why premiums go up every year but never seem to quite catch up.

The second way most people become a burden on the system is by outliving their own health. You can be the most good eatin’, clean livin’, regular exercising’ guy or gal on the block, but eventually something is going to get you. And unless that something kills you dead (say, a full frontal bus wreck or a drop-dead cardiac arrest) before you have any chance to haul your rear end into your local health care provider, it doesn’t matter how old you got to be before that bad stuff caught up with you: you too are now a burden on society.

This is the dirty little secret of the public health world we like to call the “prevention paradox”: that good preventive care saves money now, but it generally does not save money in the long run. Here is why: people who stay healthy live longer and take incrementally more out of the system year by year using those preventive and routine services than someone who dies younger. And eventually, all those healthy people will get old, and they will die of something; in the months just before they do just that, they will - on average - run up some astronomical medical bills that short circuit all the savings they accrued over all those long years of good health.

The irony of course is that we spend ungodly sums of money in America to keep people alive during the time of their lives when they are least likely to benefit. Where we hedge about vaccinations for children and click a mouse to donate one hundredth of a free mammogram to a middle-aged adult, we seem quite happy to hurl sums worthy of the national defense budget into stretching life out another month or two when the writing is so clearly on the wall. Bang per buck, keeping a ninety year-old alive for another three months at the cost of four hospital stays does not make near as much sense as getting the whole population to ninety as healthy and happy as can do. You better enjoy those last six months - hospitalizations, crises, dialysis, adult diapers, and all - because they will cost you (or, that is, cost the collective us) some hundreds of thousands of dollars to drag that end heroically out to the last possible second.

And since we are all playing a part in this all-consuming system suck together, it is time to dispense of the notion of who is a bigger burden than whom else. Your contribution to the insurance pool - assuming you do pay insurance premiums - is a poor marginal quantity compared to what you will in all likelihood one day draw off of it. The leg you stand on when feeling self-righteous about your contribution over the contribution of the illegal alien who picks your grapes, or the guy down the street who is that much fatter than you, or the kid with cerebral palsy who needs monthly health maintenance, or the smoker next door, is an ephemeral and illusory source of self-righteousness indeed. Promoting health for the sake of quality of life, controlling cost along the way, and doing some serious soul searching about our emphasis on end-of-life heroics over end-of-life comfort…these are the things that diverge the pathway of “burden” from the pathway of reasonable cost. Not whether you pay your premiums or not, not whether you were born in the country or not, not whether you use a wheelchair, and not whether your BMI fits between the numbers 20.1 and 24.9. Thusfar, the most of us can wear that scarlet B for “burden” without standing out from any kind of crowd.

As for the gentleman I admitted to the hospital that night, he survived just fine to be a burden for another day. Good for him.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.
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When Men Not Only Let Their Hangups Show But Hang Them For Display Themselves by Anthony McCarthy 

What is this about, anyway?

Maybe you already knew but I gladly acknowledge my spotty education had left me ignorant of “truck nuts” until a friend told me about them yesterday. For those of you who are as behind the times as I am, they are simulated testicles in a scrotum meant to be hung below the trailer hitch of a truck. Self awareness isn’t high among the attributes of the macho mind but this is too obviously weird to miss.

When he first told me, I thought my friend was pulling my, uh, leg. Then I looked it up and found out that it, seriously, is going on. And until I read deeply on the subject I hadn’t suspected it was a mature cultural expression complete with artistic evolution, esthetic nuance and moral ramifications.

* There are two major differences between the 1st Generation AND the 2nd Generation of Truck Balls developed by BullsBalls.com.

* The Original 2nd Generation Balls are 2" shorter and have the hole through the side rather than front to back like the 1st Generation Balls. (top hanger type)

* This 2nd Generation Balls * Lock-and-Chain Mounting System was designed primarily for ALL trucks (1/2, 3/4 and 1 tons) with the 2" x 2" hitch receiver tube on the truck. Simply wrap the chain around the hitch receiver tube, snug it up and lock it in place, rotating the brass lock up on top out of sight. (no tools required)

# This slightly shorter length also works well for vehicles OTHER than 1/2, 3/4 and 1 ton trucks, such as suvs, cars, quads & bikes.

# 2nd Generation Balls are shorter and lighter, however they have not lost the hefty, fullness of the O r i g i n a l 1st Generation Bulls Balls and Big Boy Nuts.

# Our 2nd Generation chain balls allow more ways to hang AND they remain swinging even when pulling a trailer, also this design prevents the negative look of flippity flopping of the nuts at higher speeds. They simply float nicely as the air pushes them gently up and back.

# Also with the hanging chain and padlock ( included ) they are much more secure from impromptu theft. At least the bad guys have to bring a pair of " Bolt Cutters."

Yes, that unsightly flippity flopping at higher speeds is just so off putting. No doubt we can all appreciate that the “hefty, fullness of the Original” was retained in the second generation. You appreciate that they’re fairly redolent with quality. Standards to rival those of many Olympic sporting events. It’s nice to see that there’s one part of the Bush economy that isn’t lagging, drooping or cutting back.

A quick google of the them will show they are sold in many colors, including brass and other metallic colors. The message of those is probably self explanatory. If I could make an critical point, the symbolism might be a bit muddled on the blue ones.

Who is supposed to admire these things? Women, either lesbian or straight? I don’t think the right sound to express the idea that a woman would find these alluring can be produced by the human vocal apparatus. Eeeew! doesn’t get to the start of it. One hopes that it isn’t gay men who are supposed to find this attractive, at least this gay man hopes not. If either straight women or gay men could be attracted to intimacy by these, I despair of humanity.

That leaves only one segment of the possible audience and the thought of straight men hanging these for the admiration of other straight men, the implications of which are too twisted to follow. As my friend said, men are buying them and crawling under their trucks to install them, so this isn’t an unconsidered act. What does it mean? It’s not Yosemite Sam on a mud flap. Anyone care to speculate?
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Thursday, August 21, 2008

Fifteen days of blogging for health care reform: Health care reimbursement - a (hopefully) not too boring primer on a (usually) dry as dust topic 

Guest post by Skylanda.

Ever wondered how your doctor gets paid? It’s not something that most patients put much thought into, beyond a cursory glance at the vehicles parked in the physician parking lot and the realization that you’ll probably never drive a car quite like those. But it’s a rather germane - and always understated - topic when it comes to understand how your doctor treats you, and how satisfied you’re going to be with that care, and how reimbursement fits with the total health care reform package.

In reimbursement for medical services, individual doctors (and other direct service providers such as nurse practitioners and physician assistants) can be divided into roughly two camps. The first camp gets paid for the stuff they do. This is called the “fee for service” model; in retail, they call this “working on commission.” In a metaphorical sense, the fee-for-service doctors are the rough equivalent of the used car salesman: they gotta move volume in order to take home a paycheck, and their paycheck is predicated on how many patients they see in a day or a week or a month. The advantage of this system is that doctors who work under it are motivated toward efficiency - people need to be seen, they have carrot and stick driving them to see people. The disadvantage is one you’ve probably seen: if you need more time with a doctor than that fifteen minute appointment allows, you’re gonna rub someone the wrong way. Every doctor who runs their own business operates more or less under this model, as do a whole lot of others who work as employees of larger corporations. Doctors like it because they usually have some flexibility to balance their financial goals against the style in which they prefer to practice; they dislike it because they are always under the gun to produce, and there is a direct hit to their wallet if they choose to provide more personable, time-consuming care.

On the opposing side you have salaried providers. The opposite of fee-for-service providers, these are paid the same no matter what they produce. The advantage is that they can take as much time with each patient as they darn well please; the disadvantage is that functionally, they have no real motivation to do anything at all. These then are the post office workers of the medical profession: you know, you go into the post office, there’s a line of fourteen people, and only two of the four employees are working, and only at a snail’s pace…because, ya know, they get paid for their eight hours no matter what customer service they crank out in the interim. Doctors like this because they don’t get punished for caring to spend time with their patients; they dislike it because inevitably there’s a couple of freeloaders around the office who make the same amount of money for doing half the work, seeing half the patients, taking half the call.

In reality, aside from small private practices, most employed physicians are paid on some hybrid system - part used car salesman, part postal worker, with more tweaks and turns and nuances than you can imagine. Many employers pay a reasonable base salary with incremental upgrades for increased billable services. Some will start doctors at a guaranteed salary to help build a client base, then switch them to a fee-for-service model after a given number of years. A large body of work has been produced on the topic of how to best squeeze a balance of efficient, caring work out of doctors, and much of it would find a far better home in the psychological rather than the economic literature.

Now let’s widen out the picture a little bit a how an entire organization - a hospital, an insurance company, an HMO - organizes billing structures. Similar to how we pay doctors, organizations too can bill on a per-service basis: your hospital takes out one gallbladder, you bill BlueCross/BlueShield for one gallbladder removal. (Insurers can muck of the scene by cutting deals with third parties too - for example, an insurer can cut a deal with a pharmaceutical company to place a particular product on their preferred formulary: the insurer tells doctors which drug to prescribe or which surgical instruments to buy, and in return, the insurer gets a bulk rate on the drug or the equipment; the functional result of this twist is that an insured patient - if they can sort out the Babel-esque complications of their bills - may end up with a lower bottom line than an uninsured patient who gets stuck with the whole thing themselves.)

From an America-centric perspective, the simplest fee-for-service model had been the norm since, oh, approximately the beginning of time (one leech applied for one gold sheckel, thank you very much) until, oh, approximately the mid-1980s or so. And then along came capitation.

First, back up a little bit. By the 1980s or so, a crisis was starting to brew in medical financing. Everything was becoming more expensive, and no one knew quite how to pay for it. The source of the expense was multifold. Over-capitalization and technological advance was one cause; imaging technologies like like CT scanners and MRIs were just coming online, advanced surgical equipment was being patented, drugs to revolutionize cancer and chronic disease management were headed down the pipeline at breakneck speed and wallet-breaking prices. The lack of any inherent cost-control measures was another - doctors merely did what they wanted, billed for it, and got paid, without any thought to systemic effects of their practice. Burgeoning malpractice also played a role, as defensive medicine is also expensive medicine. As insurers struggled to cover the ever-expanding bills, a new system stepped in that promised to put an end to the overspending and lack of accountability: the HMO.

Though you may not know it, “capitation” is why you hate HMOs; the bad taste around the name lingers even though the concept has largely gone the way of other large, flightless birds. “Capitation” means “per head,” and under this new system, practices were given lump sums to per person (that is, per head) to take care of its enrolled patients. I’m making up the numbers, but here’s an example: Main Street Clinic contracts with Hometown HMO; for every patient insured by Hometown that signs up with the clinic, the clinic receives $5000 per year to cover all expenses, whether that patient shows up once, never, or twice a week for the duration. The pooled funds should cover no-cost patients (eg. healthy young men who almost never visit the doctor) and high-cost patients (older diabetics with multiple hospitalizations annually) alike, and any leftover cash at the end of the year belongs to the clinic to keep as profit. Should the cost of caring for those patients exceed the lump per-head sum, well, that’s the clinic’s problem.

You can see where the problems begin. The clinic is going to prefer young, healthy clients and may turn away high-risk patients before they even sign up. Providers at the clinic are under pressure to cut corners and provide sub-par service to save money - possibly for profit, but maybe just to stay afloat if their patient mix is not optimal. In the early years, this seemed like such a good idea that many practices did sign up (so much cash! up front! we can finally buy that CT scanner we‘ve been wanting!), and many of those failed when they realized how direly they underestimated the cost of caring for patients as doctors still practiced under the devil-may-care-for-what-this-costs habit. Later on, only providers with rather dubious practices still had any interest in capitated plans at all, so patients limited to cheaper capitated HMOs had little choice but go with less-than-ideal providers. (Please note: the word ‘capitation’ simply means “per head,” and has been used within health care finance to mean other things at other times; in this setting, it refers to paying a provider a flat fee per patient to take total care of that person.)

Capitation is not commonly used anymore - anything that predatory eventually eats its own flesh - but its arrival occasioned some of the worst excesses of the for-profit health care market and set the scene for the ongoing crisis in health coverage today. Concepts like “pre-existing condition” and low lifetime caps on benefits were born during those years and have not quite lived out their life expectancy just yet. Moreover, this was the era when Americans truly - and rightly - came to believe that health care security was a largely ephemeral notion.

So then, what does this all have to do with you? For one, the manner in which a health system reimburses its providers (both individual doctors and institutions) is a salient factor in how satisfied its customers are. If you got the big brush-off the last time you went to see your doctor, it may be that you happened on one jerky guy or gal with an MD (or DO), or it may be that you’re seeing the under-the-gun results of an individual who would love to sit for an hour and chat about your diet and your health maintenance and your life stressors, but can’t because of the circumstance of his or her employment.

Second, the parenthetical manner in which insurers bargain with providers means that it is very difficult to ascertain what sort of cash actually gets paid for what; this is not a surprise if you have ever been hospitalized and actually tried to read the bill afterwards. Moreover, there is an inherent issue of justice at stake here: when insurers can bargain down their payments because of their status as a bulk customer, but uninsured individuals cannot, the poorest and most vulnerable actually end up paying more for the exact same health care services than the wealthier and better insured - giving a sinister new meaning to the concept of the regressive tax.

Third, the lack of transparency in what you (or your insurer, should you be so lucky) is actually paying for contributes to an atmosphere of inevitable mystery and unpleasant surprises, where the provider is in total control of the cost and the patient is obligated to pay whatever is asked of them or billed to them at a later date. Have you ever asked the awkward question of what an appointment is going to cost? Or seen a charge list posted in a medical office like a menu at the deli counter? Or been able to calculate a side-by-side comparison of your costs at this medical office versus that, as you would do before you bought a washing machine or car?

In medical economics, there is a phenomenon called the “moral hazard”: this is what happens when a patient buys more health care goods (medicines, visits to the doctors, what have you) on the recommendation of the provider than the patient would buy on their own if they had all the information the expert had before them. Say you have marginally high cholesterol; your doctor recommends a fancy new drug which works great for your condition, but if you were as expert as he, you might also know that a six-month trial of diet and exercise modification, followed by a cheaper older drug if necessary, would be just as good. But you don’t know that because you didn’t go to medical school: moral hazard.

The “moral hazard” phenomenon is supposed to refer to the quantity of goods purchased (did you take that fancy new cholesterol medication or just go with the diet and exercise), but I believe it also applies to the cost of those goods: when the cost of health care is hidden from the patient until the bill arrives two months later, that patient does not have full rights to accept or refuse a given cost of care, or go elsewhere for care, or exercise their right to a free market approach.

Some innovative strategies have been proposed to increase the transparency of a deliberately opaque system, and interestingly, a return to the two-gold-sheckels-for-one-leech approach has turned out to be popular: cash-only clinics. This doesn’t work for expensive hospital stays, of course, but doctors and patients alike give high marks to clinics where you pay your bill, at the front desk, based on a deli-counter menu of fees for services, and then you’re done with the matter. It’s cheaper (no $30k/year staff in the back to bill insurers), it’s simpler, and it creates an aura of open-ness and honesty between the provider and the patient. Cash-for-service clinics plus catastrophic coverage for unexpected disasters could go a long way toward satisfying some currently unhappy customers. It is limited by the ability of patients to pay up front, but then, every system has it’s limitations.

But this does nothing to address that thorny question of the relative injustice of charging uninsured patients more than insured patients at the hospital or clinic door. This is going to be an unpopular stance with many interested parties, but I’ll just say it: this has got to stop. Period. Legally, at some point, someone has to grow the cojones to step up to the insurers and the hospitals and legislate an end to a dual system in which poorer patients are charged more than wealthier patients for the same services. It’s not that complicated, really: institute a legal mandate that an institution cannot charge an uninsured patient for any admission, drug, procedure, etc more than they are charging for the lowest bargained bulk rate.

So this is my over-simplified, understated, over-generalized prescription for improving health care billing and reimbursement schemes:

1. Design reimbursement systems that combine efficiency with effective patient care. No one is sure of the best way to go about this, but history has definitely given us a few good lessons on how not to. Heed those lessons.

2. End the unfair skew in billing of health services toward uninsured patients.

3. Increase the transparency of medical costs and billing, so that people know - upfront, before they accept services - how much they will be charged and what they will be receiving for their cash. This is a key crossroads where justice and the free market share a common seat at the table; it’s time to give a nod to both.

A few places to start, before the real work of health care reform begins.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.
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There is No Right To Deceive The People. By Anthony McCarthy 

2. The media.

Watching the string of horrible presidents from Reagan to Bush II, criminals in all three branches of the Federal and many state governments, illegal military actions, invasions and massive theft, the casual and systematic corruption in local governments and school districts, a decision became unavoidable. I could continue to pretend the protections insuring the health of democracy, assumed to exist in American law and society, were effective for their purpose. Or I could believe the evidence all around that those have failed catastrophically.

There was no choice. The traditionally cited protections of democracy, the Constitution, the judiciary, representative government and the media have produced the results we see now. The greatest of those failures, corrupting the very base of democracy, has been the media. It can honestly be called the “free press” now only if sarcasm is the intent.

In a period during which the media have enjoyed just about complete lack of restriction on their content, freedom from any obligation to serve the public or to provide accurate information fairly, and have also enjoyed a level of saturation into our lives to an extent never before possible, the ignorance of the American People about the most basic and essential aspects of life, is conclusive evidence of negligence and malfeasance. The media has abnegated their part in assuring our freedom.

They gleefully and smugly celebrate the ignorance of the American People in short news features about polling which shows a majority more informed of the personal lives of the short-lived celebrities they present ad nauseam, but can’t name their own representative to Congress or identify the Bill of Rights when it is read to them. They didn’t ask what part the media played in this ignorance, though they take up many times more hours of our lives than compulsory schooling does. With the opportunity to inform The People, their choice has been to optimize their own profits and propagandize in favor of corrupt politicians who will ensure their further profit. Facts or lies, it doesn’t matter as long as The People are bamboozled to their benefit and our eyes delivered to their advertisers.

This situation calls into question the theoretical reason for the freedom of the press. Why provide them with it if an ignorant army of voters and discouraged non-voters, ensuring bad government, is the predictable result? Freedom of the press has to be given a thorough look. The various things unwisely bundled under that umbrella need to be separated and inspected for usefulness to the emergency of a democracy at risk of dying through negligence.

Rights held by individual people are possessed by the fact of their birth. Those rights are inherent to every person and are inalienable. The only justifiable reason to abridge the exercise of those rights is if the individual uses them to deprive other people of the exercise of their rights.

Corporations and associations aren’t born, they are created by agreements and contracts. These corporations exist to magnify the power of the individuals who form them. Their purpose is generally to supercede the state of being an individual, to gain the individuals forming them more power to do something than they would be able to without the corporation. Corporations don’t possess natural rights, they were given what rights they are alleged to hold by some of the worst Supreme Court rulings, unenumerated innovations never protested by the “original intent” con game. Without stipulating the legitimacy of that fiction, I will ask if the rights held by corporations don’t, at the very least, carry the same limitations as those held by individuals who use them to deny others their rights? I will also ask if differences in the power of those granted those artifical rights doesn’t require equally powerful restrictions of their exercise, as a matter of regulating the dangers resulting from inequality of effectiveness and motivation. Doesn’t the very fact that a corporation is formed to concentrate and magnify power to acquire and influence require equally strong regulation of their tendency to use that for ends that serve their private gain, as opposed to the public’s benefit?

Why should the press, as a corporate entity, be granted those rights mentioned in the constitution? The traditional answer is that a free people must be informed to keep their freedom. They have to have a sufficient grasp of real life to make good decisions both in their personal lives and as citizens participating in democracy. Those choices aren’t interchangeable preferences like what brand of hand soap you buy. It makes a real difference if The People get it right or wrong. The press is granted the right to serve that non-optional requirement, to provide accurate information for The People so we can protect our freedom and ourselves.

What if the press doesn’t keep its part of the bargain? Which ours has not. What if the press becomes the enemy of democracy and equality, if it subverts the existence of an informed populace? As ours does. Can that press remain free? Can it truly be free.

If our history continues, I believe that one of its lessons will be that when the press freely gives up its responsibility to inform The People, their choice is actually to give up their ability to publish freely what doesn’t serve the despots that eventually result from The Peoples’ uninformed decisions. We The People won’t have to abridge the freedom of the press, the press will provide those who will do it as a matter of course.

It is a natural right for an individual to publish their words and ideas, such as we writers for this blog are engaged in. It is an extension of free speech and if the words do not deprive others of their rights the exercise of those rights cannot be limited justly . But even the biggest blog, unamplified by the commercial media in the way that Matt Drudge regularly is, has a limited effect on the political life of the country. Amplification makes all the difference in the political effect of any part of the press.

There is an absurd presumption that the amplification of words by money and the media it buys doesn’t fundamentally change the nature of the press. This is a pretense we can’t afford after witnessing the selling of the Iraq invasion, the stolen election of 2000 and myriad other betrayals of democracy by the press. Corporate media isn’t a guarantee of democracy and freedom, their use has proven that they are the harbingers of despotism in service to wealth. “More speech” is a snappy slogan when it’s a difference between five hundred more words posted on an obscure blog or two hundred words fed to millions through the TV and radio. The medium matters. The Founders had no idea that the kind of mass media around today could exist, they had no idea of a “press” dominated by corporations that can swamp their tiny competitors at will, effectively blacklisting any ideas they choose through ignoring or distorting them in an effort to negate their effect.

With the experience of the modern, mass media, and corporate concentration of the most effective parts of the media, it is clear that “the press” is able to be as much a danger to democracy and civil liberties as it is a guarantor of liberty when it is diverse and diversely held.

Taken in aggregate, the media in the United States is a device to disable the ability of The People to cast an informed vote. Through lies, bias, distortion, propaganda, distraction and demoralization, the media is guilty of corruption of voters and potential voters in the United States. The exceptions, mostly in print, are, at best, of scanty importance to the issue of self-governance. The rest, commercial and allegedly public and non-profit, are guilty of a list of crimes against democracy.

You cannot also serve both democracy and Mammon. You will always serve one and hate the other. The corporate media serves Mammon.
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Wednesday, August 20, 2008

The People Are the Ultimate Place to File an Appeal and Make Our Case. by Anthony McCarthy 

1. Religion

The questions of maintaining a secular government in an overwhelmingly religious country aren’t going to be finally settled to anyone’s liking. The best that can be attained are temporary, shifting and variable lines separating the state from various groups which attempt to use it’s power to establish their domination. On our side of those lines are people and groups trying to prevent the others from using the state to run everyone else over. It has been the situation for the entire period during which the secular Constitution has been in effect. The results have been regional variations and local ones. The attempts of the mid-20th century to enforce non-establishment across the country had some success during a period of Democratic control of the federal government, during the period of Republican control it has been in retreat. Republicans have blatantly used the issue of religion and it has worked for them. It worked very well for them.

There is simply no way to enforce the non-establishment provisions of the Constitution on voters. Arguing whether or not that should be true is entirely futile. Voters, themselves, decide if their part in the most basic level of government will or will not be on the basis of a religious test. Voters are not bound in their decision by any of the provisions of the non-establishment clause and the no-test clause anymore than they are the several Civil Rights amendments. Those voters who want to will use their vote to put people into power who are willing to breach the wall of separation in direct violation of their oaths of office*. Those unscrupulous office holders will then have the power to appoint equally unscrupulous members of various courts, including the Supreme Court. The Republican Party has based a good part of its success on the cynical and highly selective use of “christians” of a kind unwedded to an egalitarian democracy and individual freedom. Would that Democrats of the past had been wiser in forming a coalition among various groups to thwart their success instead of insisting that the question had been settled.**

Today we are in the situation where the federal courts we unwisely depended on to protect our liberties, not only don’t do that, they are in the forefront of tearing down the Wall of Separation. It should be no surprise that a court which is increasingly destroying the most fundamental feature of democracy, the ability of people to cast a vote, would have no trouble destroying other aspects of an egalitarian, democratic government. We must give up the myth that the Constitution, which exists only within the interpretation the present day courts impose on it, is any substitute for direct, continuing political involvement. Direct political involvement always ends in trying to convince a winning margin of the voters to your point of view.

In the appeal to the voters it has to be remembered that we only need the margin of victory in any election, we don’t need to convince the entire population of the wisdom of our position. But you must also remember that the people we do need to convert to the cause will be religious believers, most of them self-defined as Christians. That has been a fact for the entire history of the United States, it is a fact that we operate under today. Antagonizing them will not get us anywhere anymore than depending on the present day Supreme Court will. Considering the history of the Supreme Court, the Warren Court, which you can still just catch in your rear view mirror, as it rapidly vanishes into the horizon, should be considered a fluke. We are living in a different world than that one.

I am an absolutist in the question of the Separation of Church and State but I am an absolutist-realist. In our politics, down here where we really live, to insist that it has ever been a settled matter is to ignore most of our history. If we want to defend The Wall of Separation our only secure tool is not the courts, it is The People, in all their diversity and at times their perversity. It has to always be remembered that The People, the final and most basic part of a democratic government, are the only secure guarantee of any part of our liberty and freedom. And you can’t force them to vote any particular way by Supreme Court order or through legal doctrine. You have to do it by appealing to their sense of justice and fairness and by pointing out the benefits of keeping the government out of religion. One way to do that is to point out it also protects them from unwelcome meddling in their religious beliefs, by competing religious groups.

Christianity, if that is the attempt to follow the teachings attributed to Jesus, never lost more than when it became an established religion, of Rome and then various other countries and nations. The earliest Jesus tradition, as described in Acts, was radically egalitarian for its time and it was overwhelmingly concerned with the welfare of the poor. That tradition never died out, though it was never dominant within the sphere within which Christianity existed. With establishment came a religious establishment and establishments tend towards their maintenance and enrichment. With establishment also came an ossification of the spirit into creedal statements as a means of enforcing uniformity. It isn’t any accident that some of the earliest ones were as a result of imperial command. Some of what was come up with would certainly have come as a complete surprise to the earliest members of the Jesus tradition, those who actually knew him.

The charade that goes by the name “christianity” in the American media has more to do with the imperial religion of a totalitarian monarchy than it does the teachings of the destitute Jewish peasant they claim is the son of God. I hold that today’s liberal Christianity is far better at following the teachings of Jesus than fundamentalists have any intention of attempting. I don’t think those teachings as understood within liberal Christianity are inconsistent with a real democracy or with the agenda of the left in general. One of the most basic tenets of religious liberalism is that people get to decide for themselves what they believe and do, so long as they don’t abridge the rights of others to do the same. As a non-Christian, I would have no concern for my freedom under a government dominated by liberals of any Christian churches and traditions. I believe they would most likely appoint judges who would protect personal freedom. Though with judges, the part of the federal government most remote from The People, it’s always something of a gamble.

Arguing these civic religious issues is a more effective means of fighting a corporate-state empire than insisting on what clearly has been a losing political, and so, ultimately, a losing legal position. Contending with “christian” fundamentalism on the basis of their complete non-observance of the justice teachings of the man they pretend is their Messiah, that’s messy, it’s hard. Many will turn up their noses at the prospect of the fight. And it’s fraught with problems. But so is democracy. Appealing to people on the margin of the groups wanting to destroy the Wall of Separation, those who might be convinced to join us, will be more successful than insisting on absolutist positions. You won’t be able to convince them in any language but the one they speak. If you aren’t willing to do that on the basis of some abstract principle, the fundamentalists don’t share that scruple.

Our politicians make some of the most careful observations of the political reality in which they either win elections or get out of politics. They have no choice but to work with the country as it really is.

* Is there a better example of the wisdom of Jesus teaching against the taking of oaths than Republican politicians promising to uphold the secular Constitution?

** The reliance on the courts instead of relying on convincing The People is at the heart of the problem. That reliance made the left lazy and over secure. You would think that watching the post Warren court systematically destroying our liberties for most of the last four decades would cure us from that complaisance. The first step in overcoming it is remembering how those courts are appointed and remembering that when the Supreme Court makes a decision against freedom and democracy, The People are the ultimate place to file an appeal and make our case. That is a fact Democrats ignored and Republicans remembered, to our loss.
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Fifteen days of blogging for health care reform: Overuse, underuse, barriers, and compliance 

Guest post by Skylanda.

There are a few folks out there who overuse the medical system. Every emergency department has its “frequent fliers,” and every clinic has its quota of personality disorders on the rolls that require an individualized level of energy that could otherwise fulfill the needs of ten patients in the same time span. These people are often the bane of primary care and emergent care facilities alike, they are a vortex of resource suckage (and if they were stable enough to stay enrolled in a billable insurance plan, they wouldn’t be causing your practice so much grief). But in all honesty, they are usually people with very large problems. Those problems may be occurring entirely above the brainstem, but nevertheless: large problems. Thus need lots of help.

There is another type of overuser, one that no one takes to task for their affect on the total medical system: the user of boutique clinics, unnecessary specialty services, and excessive cosmetic commodities. These people pay - usually straight out of pocket - for the privilege, so we usually don’t get huffy with them for altering the landscape of medical economics in such a way that the limited number of doctors in the nation get pulled to doing things other than providing general care for actual medical problems. This is a mutual harm for sure - doctors who choose lucrative Botox practices over low-income community clinics certainly have their own free will in sustaining this market - but nevertheless: very easy to blame the mentally ill self-medicating narcotic addict for overusing the ED. Very rare to blame the wrinkle-free six-time Botox patient for their role in the dearth of primary care providers, even though on a market-level scale the relationship is hard to miss.

From an economics perspective, you could say that an “overuser” is someone who draws more on the system than is necessary to accrue the most maximal level of benefits per dollar spent. Put that in yer calculator and smoke it. Something is very inefficient, for example, when a person - any person - hits up the emergency department more than once a month, unless that is one clumsy person. Something is also very maladjusted when a cadre of providers is yanked out of the low-pay business of providing primary care and into the high-pay business of catering to people with an excess of time and money on their hands.

But if there are over-users, does that mean there are people on the other side: under-users? You can ask ten providers and get ten thoughtful answers to this question, but from a social justice perspective, the answer is - without a doubt - yes. From an economics perspective, I would argue that the answer is also an unequivocal yes.

For the sake of simplicity, let’s define an under-user in this manner: an under-user is a person who costs the system more when they fail to utilize health care. This is the homeless person who does not make it to a local clinic to get simple treatment for a foot ulcer from sleeping upright on the street, and thus ends up getting scraped unconscious off the park sidewalk a week later and dumped on the emergency room with a bloodstream infection - at an exorbitant, avoidable cost. This is the poorly controlled diabetic who skimps on insulin to pay the electrical bill, only to end up on dialysis because of the consequences of their years of high blood sugar. This is the uninsured construction worker who ignores that shooting pain because he can’t afford not to work, only to end up on long-term disability from continually re-injuring a wrist that could have been fixed permanently if addressed right away. This is the heroin-addicted street person who was hacking up blood in a shelter for a month before anyone noticed that every cough brought up aerosolized whiffs of tuberculosis bacteria. No matter who ends up footing those bills, the whole lot of us would be better off if the care were done earlier, on the cheap, and to the benefit of the individual in question.

There are a myriad of reasons why people underuse medical resources, but the big ones are obvious: Can’t afford it. Don’t have insurance. Could qualify for public coverage, but don’t have the wherewithal to navigate the system. Don’t speak the language. Don’t have transportation. Don’t feel welcome. Aren’t welcome. Have been turned away before. Can’t take time off work. Have a violent partner that won’t allow it. You have your own imagine - feel free to add your own to that list.

The system as we currently know is designed to throw up as many barriers as possible to the class of folks who we could call “under-users.” We have clinics that are only open during business hours; we make sure that if you don’t fill out this piece of paperwork by that date, you fall off the Medicaid rolls for at least such and said number of months; we place facilities where it convenient for developers and physicians, not where it is most inconvenient for people who need it most (the medical school in Oregon, for example, is so far removed from town - perched on a height aptly known as Pill Hill - that a common reason I saw cited for patients no-showing to appointments was simply that they could afford the bus fare from poorer parts of town).

Several years ago, in another state, I watched a debate rage over five dollars. Five dollars per month: the amount that the state suggested asking of every enrolled Medicaid member to maintain their status with the program. Its intent was to force the Medicaid enrollees to buck up and contribute to their care. Indeed, there is a fair amount of evidence that having patients pay for part of their care - even a nominal sum like five dollars - contributes positively to how seriously they take the advice they get, how likely they are to comply with physician recommendations. After all, if you paid for it, you’re more likely to pursue your money’s worth. But the behavior of rational, middle-class consumers in regards to a nominal fee has no bearing on the effect of attaching fees to people who simply cannot pay those fees or do not have the wherewithal to locate the local bureaucracy to whom they must be paid, monthly and on time.

When the policy passed and a five-dollar monthly “premium” was attached to Medicaid enrollees, the net immediate effect was to boot the poorest and most vulnerable patients - those already most likely to be under-users - right off the rolls. In the short term, it cut costs by cutting coverage to a whole sector of the population; in the long term, those cut off the Medicaid rolls will cost the state (and the local hospitals that swallow the cost of charity care) eons more in time, money, and human health by putting up one more barrier between the most vulnerable people and the one source of coverage they qualify for. All for five bucks a month.

The right wing, wouldn’t you know it, likes to put a morality spin on this issue. The rhetoric at the time was all bootstrap and welfare queen: If these people can’t even bother to come up with five bucks a month - and who can’t come up with that - why should we bother to keep giving them free healthcare handouts? An ounce of imagination and a droplet of empathy should put that question to rest, but in case that is lacking, let’s go back to good, sound finances: because it costs us more in the long-term to deny coverage over five bucks a month, that’s why. Medical problems do not go away unless the person who has them ups and dies on you; they merely get worse - and more expensive - until they are treated or debilitating or fatal. And if those medical problems happen to be contagious? All the more reason to get on them now rather than wait until they spin out of the margins of society and into the core of people that actually seem to matter.

It is for these reasons that any comprehensive health care reform must have built into the system a means of reducing barriers to care for the people most prone to getting locked out of the system. First and foremost, this means nixing this morality rhetoric out of the debate; whether or not you believe in bootstrapping has zero regard on whether a homeless man with TB should have to come up with five bucks before someone figures out what he’s got and makes damn well sure he doesn’t pass it on. Whether or not you believe in scapegoating welfare queens has nothing to do with the financial difference between treating a simmering case of diabetes and letting that case go until the body it is developing in loses its kidney function and ends up on the public dollar for dialysis three times a week.

Second, this means that the characteristics and demographics of people most likely to get locked out of the system need to be identified, and those people need to be exempted from the sorts of petty penny-grabbing fees and bureaucratic hoop-jumping that form barriers to care. These barriers include but are not limited to: nominal monthly premiums to stay on the Medicaid rolls; copays at the point of service; inflexible paperwork and deadlines that cause people to be booted off Medicaid if they turn in a signature a couple days late or can’t provide proof of address when indeed have no address. These demographics include but are not limited to: homeless individuals and families, unemployed heads of household and their children, people undergoing treatment for chemical addiction (or heck, throw in those who merely should be undergoing treatment but aren’t yet), the disabled and chronically ill who have trouble accessing the bureaucratic arm of the health care infrastructure due to transportation issues, the developmentally disabled, those with profound mental illness, women and children living in shelters to escape violent partners, and other groups with similar impairments to full access. These are people who you do not want falling off the Medicaid rolls and losing their only access to care, who are prone to becoming the expensive sorts of under-users that eventually cost the system dollars on pennies further down the line. Sanctimonious rhetoric about bootstrapping and personal responsibility aside, regular unfettered access to care is a necessary (though not adequate) safeguard against pointless and costly delays and medical care for these demographic groups.

Paul Farmer - the demi-god of international medicine - has said some inflammatory things in his time, and this may be one of the more calmly understated of those quotes:

"Throughout the world," he writes, "those least likely to comply are those least able to comply."

If we want to demand compliance from the people that we like to label as social problems - that addicts attend treatment, that the mentally ill take their antipsychotics, that the homeless quit with that annoying habit of slumping over on the street and dying while we with homes and shoes and places to be are trying to walk where they lie across the sidewalk - the absolute minimal obligation from those in power is to remove all unnecessary barriers to accessing care.

The five-dollar Medicaid premium? Piece of cake, swipe of the bureaucratic pen and it‘s gone - cheaper in fact to eradicate it than to pay a cadre of bureaucrats to push the paperwork required to collect it. Now then, establishing trust between these individuals and a system that has routinely failed them such that they actually access that care when necessary and appropriate? That, my friends, is what is known as a challenge.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.
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Tuesday, August 19, 2008

Goodbye To All That 

Somebody buy Barack Obama this book. I have a feeling that he needs it.

“Question with boldness even the existence of a god.”--Thomas Jefferson.

“Religious bondage shackles and debilitates the mind.”--James Madison

“I doubt of Revelation itself.”--Benjamin Franklin

“My own mind is my church.”--Thomas Paine

The religious right is gaining enormous power in the United States, thanks to a well-organized, media-savvy movement with powerful friends in high places. Yet many Americans—both observant and secular—are alarmed by this trend, especially by efforts to erase the boundary between church and state, re-making the United States into a theocracy.

But most Americans lack the tools for arguing with the religious right, especially when fundamentalist conservatives claim their positions originated with the Framers of the Constitution. Until now. . . .

Did you know that:

• The Constitution contains not one reference to a deity--on purpose?

• Jefferson’s original draft of the Declaration of Independence did not mention “endowed by the Creator”?

• “In God We Trust” was not on our currency, and “Under God” was not the U.S. motto, until the McCarthy-ite 1950s?

• The 15th-century Roman Catholic Church considered abortion moral?

• The Treaty of Tripoli--initiated by George Washington and signed into law by John Adams--declares: “The United States of America is not in any sense founded on the Christian Religion”?

• James Madison, “father of the Constitution,” denounced the presence of chaplains in Congress--and in the armed forces--as unconstitutional?

• Lincoln’s first drafts of The Emancipation Proclamation and Gettysburg Address made no mention of any deity?

In Fighting Words, Robin Morgan has assembled a toolkit for arguing, a verbal karate guide: a lively, accessible, eye-opening collection revealing what the framers (and other leading Americans) really believed—in their own words. She resurrects the Founders as the revolutionaries they were: “A hodgepodge of freethinkers, Deists, agnostics, Christians, atheists, Freemasons—and radicals.

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The hurricane that wasn't (by Suzie) 



       You should never go shopping on an empty stomach -- or the day before a hurricane hits. 
       I braved the grocery store Monday, after taking stock of my cupboard, only to find one can of mushroom soup and another of cranberries, left over from Thanksgiving.
      Later, as I filled containers with water, I sang to my Chihuahua: "Wasn't that a mighty storm? Wasn't that a mighty storm in the morning, well? Wasn't that a mighty storm that blew all the Chihuahuas away?"* I like to personalize songs for her.
      Staff at my apartment complex posted notices on all the doors that read: "REMAIN CALM," along with other helpful tips, such as: Get out. 
      Tropical Storm Fay made landfall in Florida again today, without ever reaching hurricane status. I'm glad I didn't have to huddle in the bathroom (no exterior walls), surrounded by canned goods.
       
*Folk song about the Galveston storm in 1900.
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Fifteen days of blogging for health care reform: The opt-out crisis 

Guest post by Skylanda.

I was a sophomore in college, abroad, studying marine biology on a beach in Mexico, when my parents called me up to tell me my father was retiring. He wasn’t entirely too young for it, but neither was he quite old enough to qualify for Medicare. But he had worked long years of hard hours, and they chose together to enjoy the next couple of decades at a reduced income rather than merely endure through them with plenty of money. They were very lucky, and planned extraordinarily well; they will live out retirement with a level of wealth few Americans past the boomer generation will be able to expect.

And so, at age nineteen, like middle-class post-teens all over the nation, I got booted off my parents’ cozy medical insurance plan and out into the nebulous world of the marginally insured. They did their best by me for a year or two; they qualified for COBRA, and since I was in college, I qualified too. They quietly paid premiums that - had I had any idea what they cost - I would have refused their generosity for: some three hundred dollars or so a month for a perfectly healthy, low-risk teenager - at the time, I was paying less than that in rent. The only contribution they asked of me was that my father - ever the academic at heart - routinely quizzed me on the expanded meaning of the acronymn COBRA; to this day, I can still reel it off the top of my head: Consolidated Omnibus Budget Reconciliation Act. Of 1986, by the way. But eventually their COBRA coverage ran out too, and they could no longer afford me anyhow, and so I became uninsured.

This did not make me comfortable. I was never an unhealthy kid, but when I did get sick, it was always the weird stuff. I used go nearly anaphylactic to poison oak, and had been on steroids twice for it. In my first year of college half of my face froze up for a month, and I was diagnosed with Bell’s palsy - a sometimes reversible neurological condition that usually affects septugenarian diabetics. I had migraines and a persistent winter cough that turned out to be undiagnosed asthma. We all have a medical oddity or two brewing somewhere in our corporeal selves.

I searched for insurance, in earnest at first. I tried to find organizations to join to gain the advantage of group rates, looked into catastrophic coverage only, considered the university-sponsored insurance until I realized that I would pay through the nose for a plan that would cover about a quarter to a third of the daily cost if I ever did have to be hospitalized. I identified half a dozen sources of free care in the city (by then I had moved to San Francisco), including the clinic I volunteered at to provide free care to other uninsured patients. Every six months or so I would get on a kick about it, make a few dozen phone calls, search the then-burgeoning internet, give it a good try. After a week or so without success I’d give up again, buried in possibilities and paperwork but no actual insurance on the table. Eventually, when I went to work offshore, I signed up for a dirt-cheap maiming insurance policy (I kid you not, that’s what it was called): one million dollars cash if I was physically injured so badly I couldn’t work anymore. That’s the best it got until I started medical school and was forced to pay for health insurance out of my student loan funds. Three years passed during which I had no medical coverage at all.

For the generations known as “X” and “Y”, this is not an unfamiliar story. Most of my friends went uninsured for some period of time, some by choice and some because they could not find or afford coverage. For the most part, it’s a gamble, but a fairly safe one. I was young, healthy, strong, in excellent shape for the most part (putting my thirty-ish self to shame now), and unless I was struck down by a bus or a pernicious cancer, I wouldn’t be drawing as much off an insurance policy every year as I would be paying into it. If I had tried harder, I probably could have found something.

But I didn’t. Like many healthy young people, I faced some barriers, I gave it a good but not Olympic try, and then I opted out.

It worked for me. The worst upshot I faced was a foot fungus that raged out of control - gross, but far from dire in consequence. For the vast majority of the young, healthy, middle-class opt-outs, the outcome is similar: you skimp on insurance for a couple of years, you save yourself some money. Your career picks up, you get a job with benefits, by your mid-twenties you leave those uninsured years behind relatively unscathed.

Let’s set aside for a moment the disastrous consequence for the unlucky few opt-outs who get sick enough to go to the emergency department - even once - without insurance (mostly because the reverberating effect of a single ER bill on credit, savings, and ability to access future care for years down the line is topic for an entire other post). This is about the effect of opt-outs who successfully navigate the uninsured years without incident.

Let’s consider who they are: the opt-outs are the young and healthy. They pay into the system and draw very little out - particularly young men, who aren’t obligated to yearly visits by the need for prescription contraception and generally don‘t like visiting doctors. They form the low-risk end of total risk pool - in general, their premiums support the care of people other than themselves. No wonder so many maintain a certain disinterest in paying ever-increase premiums on services they rarely use: in an individualistic, every-person-for-themselves system, opting out is both feasible and reasonable.

In a sustainable, collective health care system, opting out is neither feasible nor reasonable. Everyone who lives long enough will eventually reach the age where they draw more benefits than they contribute in cash, and as long as the general pool of funds is maintained by a flow of people from all demographics, it’s a relatively stable system. But everyone has to contribute at any given point in time to maintain the system - young, old, sick, healthy, in the relative proportions that they are able - in precisely the manner that Social Security has historically functioned. If only the people that need health services are asked to pay into the pool, premiums become exorbitant; if you pay your own insurance premiums these days, you don’t need me to tell you this.

In America today, we’re watching the collision of two inexorable forces: the aging of the baby boomers out of their working years, and the normalization of the opt-out phenomenon among the young and healthy. The astronomical rise in premiums - twice the rate of inflation in recent years - can be attributed to a multitude of phenomenon, but this is one of them: at a time when a large proportion of the population is drawing heavier and heavier services, the young and healthy are contributing less and less to the risk pool. Not necessarily because they don’t want to (because really, who wants be to uninsured?), but because barriers are so high to entry into the pool. There is nowhere good this path can go.

The solution is thorny but obvious: we need to start treating health coverage like the public good that it is. Even private insurance works on a pooled risk basis, so that illness in the general population directly affects my premiums, even though I’m (still) a (relatively) healthy young person. Every person needs to contribute in the proportion that they are able, such that when the day comes, they will be able to draw what the need from the system. You cannot force people to buy health insurance (really, ask the couple of states that have tried), but you can use the good old IRS - from which no American can simply opt out - to collect, funnel, and redistribute funds through a single-payer system. Through taxes, everyone can be asked to contribute - in the proportion to which they are able, with the right to draw out the goods that they come to need - the same way that we way do for every other public good: education, roads, the national defense. We don’t question that it works - with all the requisite bumps in the road - for those collective efforts.

And if the thought of higher taxes makes you cringe just to hear the words, remember this: you’re either already paying those exorbitant premiums, or someday you will be, or someday you’re going to get one whomping medical bill that will make you wish you were only paying those premiums...eventually, one of these (or both, or all) will happen to virtually every one of us. Whether we choose to pay that into a sustainable collective system or a crashing individualist system…ah, that is the crux of the issue. And that is a topic for another post entirely.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

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Pills of Great Price by Anthony McCarthy 

One of the fun gross-out facts of natural science a couple of decades back was the observation that in some preying mantis species, insufficiently careful males would die for love. You remember. The male would carefully, hesitantly approach the female. When he got close enough she’d pull off his head and eat it while his decapitated body jumped her bones. To the ....... spine tingling delight of many and, one suspects, the erectile dysfunction of some, the ways of nature were revealed to an avid public. I recall hearing it mentioned in some bit of nervous, male, anti-feminist bluster somewhere or other. Maybe it explains the rise of Rush Limbaugh.

You get used to filtering out commercials during the evening news but once in a while one breaks through your defenses. At the tail end of a Levitra commercial Sunday they included sudden deafness as a reported side effect. Sudden deafness now joins the list of announced effects of taking whoopie pills, which already include seeing blue and inconvenient, hours long, priapus. To anyone aspiring to enjoy the erectile state of a 16-year-old, the last one should come as no surprise. That is if their long-term memory of one of the more embarrassing parts of being an adolescent male is still intact.

There are so many sides to this, the lax standards of drug approval in the aftermath of neo-classical economics, the direct promotion of dangerous drugs to the public - thanks to the idiocy of a Supreme Court more wedded to legal theory than observation of real life, etc. But the most interesting question is how far geezers, themselves, are willing to go to achieve rock hard erections into their late senescence. Would they accept having their head fall off, one wonders? Would they miss it? I’ve got to listen more closely tonight to hear if death is a reported side effect of aphro-geeziacs, by name or not. The answer may have already been reported.

I won’t extend this parallel to the mating habits of the Mantidae and risk adding to the performance anxiety which is the root of the issue. And some readers of this blog might still have to get through breakfast.
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Monday, August 18, 2008

Remember. And, If You Cannot Remember, Invent 

Hurrah! I can post!



Max Daschu explains how women have been left out of history.


We can, of course, either remember our history or, in Monique Witting's words, invent our history. Daschu opts for "remembering." And expanding our vision of power helps.

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Safety, racism and guilt (by Suzie) 



         This is related to what I posted Friday about women’s safety vs. men’s feelings. I want to go back to a well-known anecdote about Obama’s grandmother, Madelyn Dunham. In his memoir, he wrote about her being so upset by an aggressive panhandler that she didn’t want to take the bus to work. His grandfather accused her of being scared of the panhandler because he was black. Obama talked to family friend Frank Davis, a journalist and poet.
Davis told the teenager that his grandmother was correct to feel scared because she understood African-Americans "have a reason to hate."
          In Obama’s speech on race, he said his grandmother “once confessed her fear of black men who passed by her on the street.”
         Did she fear any black man who passed her on the street? Is it possible that she would have been wary of any man, no matter his race, who pursued her for money?
        First Obama, then others, have discussed his grandmother’s fears to illustrate attitudes about race. But her fears also speak to the harassment women (of all colors) face on the street and in public transportation. 
         I understand that it’s incendiary to talk about white women and black men. I’m not saying white women should fear black men more than white men. In regard to violence, women are more likely to be victims of men of their own race whom they know than they are of a stranger of another race. Nevertheless, if a woman (of any color) is afraid of a guy on the street, I think she has the right to be heard. Also, if a woman (of any color) has no problem taking precautions against a strange white guy, she should feel free to do the same when confronted by a man of color.
          This dovetails with a fascinating series I’ve mentioned before in which a writer for the Cleveland Plain Dealer talks about many issues connected to her rape, including race. Joanna Connors is white; the rapist was black. She encountered him in a theater, and he was the only other person there.
I ignored my instinct not to trust a stranger, because the stranger was young and black, and I did not want to look like a racist white woman who automatically does not trust young black men.  If he had been white? I'm not sure -- but I think I would have left. 
          In another situation, a white woman might have trusted a white man, and still gotten raped. Or, a woman of color might have trusted a man of color. Or, she might not have wanted to look afraid in front of a white man. You can complicate the scenario with different ethnicities or different rationales, such as a woman needing to do her job. No matter what, women who get raped may still feel shame in a society that second-guesses their decisions. Connors continues:
        The rape made me fear black men I did not know, especially young black men. I hated this fear. I tried to reason my way out of it, and I spent a lot of my time in therapy trying to overcome it.
          Finally, a psychologist asked me the obvious, common-sense question: "But do you also fear and avoid strange white men?"
           My answer was yes, of course. The difference was that fearing white men did not make me feel bad about myself. It did not make me feel like a closet racist. It did not bring me shame.
          As in the previous post, I’m not saying women have to live in fear of, or distrust, all men all the time. Nor am I saying that whites should not examine their feelings about race. What I’m saying is: As progressives, let’s not forget women when we talk about civil liberties. 

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Fifteen days of blogging for health care reform: Unfunded mandates 

Guest post by Skylanda.

The arrival of my intern class at the university hospital was occasioned by the opening of the brand spanking new emergency department. I never had the pleasure - or the horror - of seeing the old department, though its mythology remains. Occupied beds lining the hallways, bleeding patients begging as you passed anonymously on your way to find the one you were assigned to admit, and dingy, always dingy in those old war stories. No, by the time I arrived and rotated through there on the first month of the academic year, the old one was shut and gutted, and the sparkling new ED was up and open and running at such a constipated pace that most nights we had half a dozen beds moving patients, a dozen or so beds in each wing housing admitted patients waiting for real rooms upstairs, and nothing to do but twiddle our thumbs while some forty to sixty patients lay triaged but unseen in the waiting room. Except for a few Friday nights when the frenetic shuffle between the ambulance docks, the resuscitation bays, and the trauma-surgery ICU kept the whole lot of us running, it made for an eerily quiet month in the busiest emergency department in the state.


On one of the quieter nights, I got an earful out of one of the ED attendings. The topic was universal health care; the tone was at a low yell. I didn’t ask about it because I know better than to talk politics at work - someone else set off the spark, I was just in the line of sight when he started to breath fire.

“What do you think,” some poor, unsuspecting resident rotating from another department asked, “are you for or against universal health care?”

“We already HAVE a system of socialized medicine in this damn country,” the attending snarled back, all afire all of a sudden, “people just refuse to f’ing admit it.

I thought for a moment before contributing anything to a clearly sensitive topic, then I ventured forth. “You mean things like Medicare?” I asked and then ducked back. People over 65 and enrolled tribe members under the Indian Health Service are often cited as the only two demographics in the US with entitled access to health care - that is, they have it and cannot lose it through change in circumstance; the former was the first one into my head and out of my mouth.

“No,” he said tightly. “The emergency room. Look around you. How many of these people can pay? How many will pay? How many handed you a fake name and a social security number that doesn't exist because they can't afford to have this bill coming to their residence, if they even have a place they call a residence? But we take care of them anyway. Not that we wouldn't if we did have the choice, but we are mandated to. The great unfunded - and unspoken - mandate of the American health care system. Anyone who cannot pay comes to us. You primary care people can turn them away, but we cannot. No one pays for this, no one reimburses us for this, we eat most of these bills, if we‘re lucky the billable visits covers the write-offs in any given year. And if something goes wrong, they can sue us even though no one has paid us a dime for the time and effort spent on their care. We already HAVE socialized medicine in the US. We just need to start acting like we have it, and start f’ing paying for it.

We digested this for a moment while he went back to scribbling orders. But he wasn‘t done just yet.

“You know about EMTALA, right?”

Oh yes, EMTALA: The Emergency Medical Treatment and Active Labor Act. This is the law that mandates that anyone who is hurt or in labor can show up to almost any ED and has the right to be seen by a provider, no matter if they can pay or not (not that this stops private hospitals from owning ambulance companies and directing their fleet to triage their cargo to various hospital, including or not including their own, based on their gestalt assessment of the patient's ability to pay). It always seemed to me - as it probably seems to most - that emergency departments, merely by their nature, have some kind of cosmic obligation to treat emergencies. But this is not the case. There is actually an American law that states that all emergency departments - at least all those who receive any reimbursement from the Medicare/Medicaid axis - must triage, stabilize, and at least transfer to an appropriate facility (if not treat in house) anyone who presents ill, injured, or in labor. Without this law, you can bet that certain emergency departments would not accept certain patients…of that you can be certain.

EMTALA, it turns out, is a mixed blessing for the uninsured and underinsured folks of America. On one hand, it provides the final and definitive safety net for those without any other means of access to health care. You can be undocumented, on the lam from a felony charge, hopped up on meth, without a cent to your name (and believe me, this constellation of demographic niceties is not a rare story at the university ED), and if you walk into any almost emergency department in America, they have to address your chest pain, your diabetes, your stab wound, your disease du jour. EMTALA is what stands between care and disaster for a large number of American citizens and others living and working inside our borders.

EMTALA is also - in my opinion - one of the primary stumbling blocks between America and concrete health care reform. However noble in intent, it is entirely possible that without EMTALA, pressure would have mounted so high on the health care system from so many quarters by now (from so many people dying, being turned away from the ER doors with no insurance) that something would have had to give. The stitching on real safety nets might have begun. No one can say for sure, of course - Americans are breath-taking in our ability to bury heads in sands when tough but feasible answers are available to nasty problems - but EMTALA has become both a curse and godsend to every uninsured person in the country. If worst comes to worst, the ER always has to take you. It makes us all sleep a little better at night. And because we all sleep a little better at night, we don't bother to get up the next morning and do something concrete to solve the problem of lack of health care access.

Would I revoke EMTALA now? No, of course not - the ferrets are already loose in the chicken house, it would do far more harm than good. But if I could go back two decades to the year that EMTALA was passed - to a time when the health care crisis was just peaking around the corner and not brewing in forty million-plus American homes - I might have thought twice and hard about whether it was such a good idea. By providing half a safety net full of holes, we have put off the weaving of a strong social fabric to take care of the nation‘s health.

The attending’s diatribe ended with a declaration that he already provides universal health coverage, and that it is just up to America to start ponying up the cash for the services we demand of his profession. Moreover, wider coverage would prevent the sort of drain-clogging ER crowds that drive doctors trained in the medical heroics of trauma and resuscitation to spend their time fixing primary care issues that cost a pennies on the dollar to treat in clinic versus the emergency department. Universal coverage would empty the ERs of the earaches and the bellyaches and the headaches and leave way for the car crashes and the heart attacks and the knife wounds - the things that ERs were built to handle, the things that ER docs were born to revel in.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.

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Sunday, August 17, 2008

Fifteen days of blogging for health care reform: OHP - a bold experiment in systematic reform 

Guest post by Skylanda.

Local newspapers are a funny thing - half pulpy fiber ready-made for the recycling bin, half pure insight into the local ways and goods. When I first moved to Oregon several years back, I picked up the local rag one day, intending to peruse the real estate and rentals section. The front page caught my eye; on it was a lengthy list of medical conditions, some five hundred or so altogether. Somewhere on the list - probably around number three hundred or so - was a line break. I scrutinized it for some time, but couldn’t discern the connotation even behind the accompanying article. It took me several years of pre-clinical and then clinical experience to fully appreciate what I saw on the front page of the paper that day.

The list of medical conditions was the condensed essence of the state Medicaid program, known about town as the Oregon Health Plan (OHP). There is much myth - and much detail - about OHP that is somewhat lost on me, so any Oregonians out there who care to correct me are invited up front to do so. But the gist of it, as I understand it, goes like this.

Years back - before the lean years, when Oregon was still enjoying the spill-over of the tech boom in California - a group of reform-minded physicians and other supporters started a bold experiment in health care reform. The charge was led a lanky, cowboy boot-clad, bolo tie-wearing governor who goes by the name of Kitzhaber. Kitzhaber was an ER doctor in his first incarnation, before he got into politics. This crowd got federal exemption from the standard Medicaid rules, and went about creating a new system on which a model of universal coverage could be built. It was built on a series of assumptions, something like this:

The first premise is that the coverage offered should occur in a hierarchy, and that that hierarchy should be 100% transparent. These folks claimed - boldly, I emphasize again - that all available medical treatments could be given numerical value based on a set of parameters that come down to, essentially, health bang per health buck. There are, for example, cheap treatments that result in major health gained - things like vaccinations and drugs to control diabetes; these things top the list. Then there are cheap treatments for only marginal health gain (oh, let‘s say, acupuncture), and expensive treatments for large health gain (how about: chemotherapy for cancer); these get mixed up in the middle. Finally, there are expensive treatments for little health gain, and these go at the bottom of the list (the most notorious of these was treatment for pancreatic cancer - expensive, painful, almost useless, most people die of the disease no matter what you do for them). You can use health surveillance data to then multiply each list entry by a) the number of people who get that condition each year, and b) how much it costs to treat each one of those people. You can keep a running total in the next column, and if you know your total Medicaid budget for the year, you can draw a line through the list where your running total equals your Medicaid budget. You cover the conditions above the line, deny the conditions below the line, and voila, you have achieved maximum health available per dollars you have to spend.

Although I suspect it involved a little more math than I give credit for, perhaps.

The genius of this tactic is the transparency - that the list was run in the paper every year (maybe still is, I don’t know…Oregonians, want to chime in on that?). Don’t like it? Think it’s heinous that coverage is denied to little Susie just because her condition fell two notches below the line? Fine. Pressure your representatives for more dedicated Medicaid funding from the state and federal pools next year. It’s the opposite of the CIA’s black-line discretionary budget: you know exactly what your tax dollars are buying, and if you don‘t like it, you‘re welcome to involve your own bad self in the political process and push to change it.

The second premise - which you may have already noted above - is that the decisions on which to base the list are to be based in clinically sound data and guidelines. In the parlance of modern medicine, they are to be “evidence based.” This tactic means that the ranking of the list was based on available data, not on what is popular at the moment, what the pharmaceutical reps are pushing, or what is the hottest new experimental procedure. This also caused some consternation - partly because not everything medical people do is evidence-based under the best of circumstance, and partly because no kind of experimental treatment is covered at all (though this is not atypical of any insurance plan). Nevertheless, there it is.

This also leads to the third premise: that the medication formulary associated with this plan should also be evidence based, with a firm emphasis on cost control. Functionally, this means that if two drugs perform the same in trials, the cheaper one goes on the formulary and the more expensive is not covered unless there is some compelling reason why the patient cannot tolerate the cheap one (formularies are usually based on which drug company cut which deal with which insurance company and/or hospital, making them profoundless useless outside of their immediate context). This was among the most useful tools produced by the OHP folks, and doctors here and there around the nation picked up the OHP formulary for informal use in their own practice because it was so pointed and effective in weeding out pharmaceutical advertising from actual evidence. I used it not because I had many OHP patients (by the time I came around, OHP was flailing badly, and most my patients were either privately insured or uninsured), but because it was the easiest way to find a drug in a given class that a poor patient was most likely going to be able to pay for.

The final premise that made OHP such a unique experiment in medical coverage was the role of the list itself. Medicaid is designed to cover poor people (Medicare, remember, is designed to cover retired people); the definition of “poor” often moves to accommodate a given state’s Medicaid budget. In some states, you have to be so dirt poor that if you work so much as a few hours a week, you’re off the Medicaid rolls. The crux of the OHP experiment was to shift the mode of cost control from trimming people from the rolls to trimming the health care package itself. The standard metaphor they used went like this: when your local county elementary education budget gets cut by 10%, no one throws 10% of the kids out of school - they merely cut 10% of services: teachers, aides, school lunches, whatever. It’s not ideal, but even in the worst of circumstances, as a society we agree that you do not cut people out of that particular service; you can cut the service package, but you cut it the same for all parties. And so should be health care: when the inevitable budget crisis comes reaming through your front door, you do not cut people off the Medicaid rolls; you cut services, you cut the package offered, so that the total group of people is still covered.

And this is the place where revolutions happen. Though this is the norm in every other industrialized nation, it is an alien concept here, one that needs metaphors and explanations and justifications. But the crux is this: we take care of ours. Even in lean times, when they’ve trimmed the fat and are now cutting down to bone, we’re all in this equally, together, getting the same goods, receiving the same package, facing the same limitations, even if we‘re just talking about the subset of us on Medicaid. It’s just that little tweak of this thing called justice. It ain’t perfect, but wow, it’s a bold shot, isn’t it?

That was then, back in the mid-1990s or so. I moved to Oregon a couple years after the tech bust, when state budgets on the west coast were doing the rough equivalent of the gymnastics that the mortgage industry is performing now. Whereas providers rushed to sign on OHP patients in the early days, reimbursement for services had fallen so sharply that it had become hard to find providers who weren’t refusing patients at the door. This doesn’t speak well of all providers, but you can’t entirely blame them: you cannot maintain a business pulling in less cash per patient than it costs to rent the building you house your office in for that chunk of time; the world just doesn’t work like that. When I left the state, the program was sinking rapidly and no one was quite sure how to fix it, short of a mass infusion of cash that didn’t seem to be materializing.

Meanwhile, Kitzhaber’s term limits ended his governorship and he left office the year I moved up there; he and his cadre went on to found the Center for Evidence-Based Policy, a think-tank dedicated to continuing the pursuit of the basic values of OHP: cost-effective, health-effective medicine. Medicine, that is, that buys health.

Far from a requiem, the precepts of the OHP should serve as a model for nation-wide reform. Transparency, evidence-based practice, cost-effective choices mandated first when all other parameters are equal. And the move toward policy that gives at least a tiny little nod to that stubborn, hard-to-kill beast we call justice.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.
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What Do You Know, You Can Get People To Agree With Themselves by Anthony McCarthy 

Or, Do these guys ever listen to themselves?

In this mornings Boston Globe in yet another psych-ridden look at a story in the news, the “Clark Rockefeller” riddle, is this piece of vital information:

These subtle cues, Pentland emphasizes, are difficult to fake - he calls them "honest signals." But Bailenson and Yee's work suggests that the cues don't have to be subtle to work: most of their subjects didn't notice that they were being mimicked, even as they were proceeding to bond with the digital figure on the screen in front of them.

To earn someone's trust, in other words, even rather blatant aping can do the trick. One of the landmark studies on influence was done in 1965 by the Ohio State psychologist Timothy Brock. In it, shoppers at a paint store were approached by a research assistant who offered them advice on what type of paint to choose. He told half of the shoppers he approached that he had recently bought the same amount of paint that they were looking to buy, he told the other half he had bought a different amount.

By and large, the first group took his advice, and the second did not. Something as trivial as buying the same-sized bucket of paint, Brock argued, can forge a bond with a total stranger.

I had to read this at least four times to believe I was really reading this in the masthead article in a prestigious section of a major newspaper. I thought it was incipient dementia at first.

Apparently it takes a “landmark study” for psychology to understand that if a store clerk tells you he did what you wanted to do you’re likely to do what you wanted to do. And if he tells you he didn’t do what you wanted to do, you’re likely to do what you wanted to do. In short, people tend to do what they want to do.

Apparently this piece of obviously counterintuitive wisdom is impressive enough to be used in the Boston Globe Ideas Section forty-three years after it was published.

I’m tempted to look it up the ancient study to check to look if they controlled for:

- people who tried to estimate how much paint they would need and the methods they used,

- how many of the buyers just went into the store and guessed,

- whether or not they were trying to cover a darker color with a lighter color,

you know, the kinds of things real people think about when they’re painting something. In the small samples typical of studies of this type, even a few people taking these kinds of things into account might give entirely different results. But I’m on a very tight schedule. If you know the study, please tell us.

I’ve got a hunch that too much dependence on psychology is a sure sign of a lazy reporter, the Boston Globe Ideas section would be a good place to look for evidence.


II. No Joke

You might also read the letter by the executive director of public and member communications of the American Psychological Association, denying that it has done little to keep its members from actively participating in the Bush regime’s use of torture. Contrast it with this news article by Tania deLuzuriaga in another place in today’s Globe.

This issue, brought to new prominence by Jane Mayer and especially her reporting on the role of Martin Seligman in relation to the torture scandal. It’s tempting to be sarcastic about his protestations that his lecture to the incipient torture team was turned on its head and that his torturing dogs was for the greater good but that might risk turning this into a joke. It’s no joke.

What did Seligman think they were asking him for? I don’t believe he couldn’t have guessed that his lecture and the dog torturing experiment was very likely to be used to plan a program of torture in the year after 9-11. If he’s that naive you wonder what his lifetime in psychology has taught him about the way people think. A highschool history student looking at the darker side of the 20th century for a term paper would likely have guessed better. But then, I think history has a better track record for getting that kind of thing right, than psychology has. I also don’t trust people who torture animals for the greater good.

III.

And finally, a very rare and skeptical look at the use of imaging in studying behavior by Jonah Lehrer.

"There are so many bad brain imaging studies, it's hard to believe," says Nikos K. Logothetis, director of the Max Planck Institute for Biological Cybernetics in Germany. "Too many of these experiments are being done by people who, unfortunately, don't really understand what the technology can and cannot do."

Logothetis and others believe that much of the misuse stems from the visual nature of the data. One study, by researchers at Colorado State University, showed that simply giving neuroscience students images from an fMRI machine, even if the images were redundant or irrelevant, made the students significantly more likely to find the data credible. According to Paul Bloom, a psychologist at Yale, this is because fMRI "has all the trappings of work with great lab-cred: big, expensive, and potentially dangerous machines, hospitals and medical centers, and a lot of people in white coats."

The data looks rigorous - it has the veneer of cutting-edge science - and people assume it's valid, even when the reasoning is shoddy.

"You can't just put people in a scanner and ask them whatever question you want," Logothetis says. "Many of these [fMRI] papers are such oversimplifications of what's happening in the brain as to be worthless."


Update:

A
n e-mail objects most strenuously by to my jibe about the vintage psych study above.

First, what is there about being deceived by the accused con-man “Clark Rockefeller” and the experience of being psychologically manipulated by a psych student posing as a store clerk in an Ohio paint store in 1965 which makes the latter intuitively relevant to the former? What does the study of 1965 authoritatively add to the intellectual investigation of the bizarre news story? Please forgive me if I assert that the more rational assumption is that the study has nothing to tell us about it.

The two attempts at deception are insufficiently similar, to start with. The possible motives would seem to be entirely unlike. The people attempting the manipulation are hardly alike and the subjects almost certainly as unlike, though that would be an entirely undefined variable in the comparison. The fact is that “Rockefeller” is suspected of a decades long, geographically vast and complex range of deceptions, perhaps, including killing. The “clerks” in the paint store were certainly not doing it for the same reasons. They probably just wanted to get their degree.

We know the subjects in the study wanted to buy some paint, we have no idea of what range of motives the people who fell for “Rockefeller” under his various names and guises may have had or if those deceived by him shared anything else in common. There is no reasonable reason to suspect that the situations have any real life similarities that would make resulting claims linking them to have sufficient reliability to be considered science or journalism.

About the paint store study, let me pose just two possible scenarios to you.

You are a woman who has painted a heck of a lot of things. You are a very experienced painter who has taken the time and made the effort to come up with what experience leads you to believe is a good estimate of what you need to buy. You go into a store and see a younger man (somehow I’ve got the feeling that all the psych students were probably males, though I don’t know that*) who says that he bought a similar amount of paint. He proposes a brand of paint you have had good results with in the past, so you buy it. It might have been one you were considering buying anyway.

Another scenario. Assume you are an experienced painter who has made an estimate and the kid says he bought twice as much paint. You might be on your guard for being sold too much paint, maybe someone did that to you in the past. You know the kind of paint he tells you is not what you need. You might think the kid doesn’t know what he’s talking about. You don’t take his “advice”. If he tells you he bought less than you know you’ll need, you would also think he doesn’t know what he’s talking about. Maybe you decide to shop for paint elsewhere.

The ages of the customers and the “clerks” would have just about certainly been an issue for many of the customers. At least the ages could be objectively verified, many of the other issues couldn’t.

The people who walked into that paint store might have represented any range and combination of variations on the two scenarios proposed above, and there could have been other issues relevant to the choice that was made. Maybe the kid looked like a favorite nephew or one you think is a snot nosed brat. I wonder if there is any reason to believe that the customers were all sufficiently alike to assume they would have belonged in the set conceived of in the study other than the convenience of the researcher.

Would the motivations of two people either buying (or not buying) what the clerk recommended be the same action, representing the same motivation? I doubt it. I believe their motives would have been vastly different, perhaps no two truly alike.

How large a sample would you need to take all the possible relevant issues into account? What kinds of equations would have covered all these possible issues? How would they tabulate the results?

If these are problems of sufficient complexity so as to be a insurmountable problem for psychological researchers that might be unfortunate. It doesn’t make them irrelevant. Not if discovering reality is the goal. As seen in the rest of my morning post, decades old studies can have horrible real life impacts.

People working in journalism who make the improbable assumption that these “studies” are relevant to their reporting of the news are guilty of multiple journalistic sins. Just the facts. The verified facts, supported by two independent sources. Anything else isn’t news.

* You wonder what the possible effect of having a female “clerk” advising a customer on paint would have had on the choices made in 1965. I don’t know about Ohio but do suspect that it would have been very unusual in most places in 1965 to have a female clerk in most hardware departments. You wonder at the difference in gender between “clerk” and customer. And you wonder about the various responses to that among customers of the same gender. How can you account for those contributors to the ultimate choice. And you wonder what the relevant social changes would do to the applicability of the “findings” four decades later.

I can’t tell you, just that I think they’re probably important.
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Saturday, August 16, 2008

Get Who’s Calling Obama “Exotic” By Anthony McCarthy 

You aren’t surprised. The Republican Party is going for the racist vote, as they always do. The effort of their soundboard, the media, to make Obama’s vacation trip to Hawaii an “exotic” location is clearly part of a campaign to whip up white racists. Visiting his infirm grandmother in the one of the 50 great states she lives apparently ranks lower in strangeness levels than The Bush Crime Family buying a massive estate in Paraguay*. Visiting an old grandmother is more sinister than buying a large chunk of a country famous as a haven for WWII era war criminals. Our media seem to be populated by folk too innocent of modern life to notice that Crawford del Sud would make a good refuge from indictments crimes against humanity or to shelter from those who might, someday, try to recover the billions plundered from the taxpayers of the United States.

Hearing the “exotic” line recited by Cokie Roberts last Mondy has to rank up there with Sally Quinn on marital propriety. There is no one more exotic than Cokie Roberts, whose family left New Orleans, a perfectly normal city, to morph into the most alien life form, the DC insider. Her brother’s a DC lobbyist, her husband, another DC media pod person. The talking heads are service droid mannequins more believable as Sci-fi Channel filler than as sources of information about life in the United States.

One of the more important aspects of this campaign of racism is whether or not white people, especially those in “the heartland”, will be played for chumps as the Republican racial strategy wishes them to be. You would think that people who live in the mid-west would be tired of that role, especially as many of them are fully as progressive and sophisticated as anyone who works on either coast. I’ve known many people from states that start with an I who are more enlightened than any member of insider Washington and New York City. I’d be hard pressed to think of a mid-westerner I’ve known who isn’t more aware of real life than anyone who gets asked to yack on the cabloids. People in the mid-west aren’t consigned by fate to assume roles in perpetual I-Hop commercials. They should punch anyone who tries to force them into that square in the mush and in the only way they will stop it, by overturning the corporate establishment that creates these roles for them.

Obama’s campaign must point out how insulting and condescending those Republican campaigns are to the people who live in the fabled “heartland”. I’ll bet there are millions of white mid-westerners who are just waiting for evidence that they are not eternally consigned to the role constructed for them by snobs in the media and publishing elites over the past century*.

The announcement by the Census Bureau that the United States will be white minority about the middle of the century makes me wonder if it isn’t part of the effort by the Bush Regime to scare white people. But that’s one of the problems with this kind of thing, once you get used to seeing it used, you get suspicious of everything. Doesn’t mean your suspicions are wrong, unfortunately.

* The first elected government in Paraguay in about sixty years is in serious trouble with next to no notice given by those obsessing about Georgia’s defacto partition. The timing in Paraguay seems a bit too convenient to me. We will know after the election if the Bush compound there was conceived as a continuation of that dark history. Call me suspicious if you want to. More about the situation in Georgia later in the week.

** The real history of the “heartlands” reveals a much more sophisticated and complex reality that is never told in the corporate media. Mid-western progressives, progressive populists and radicals have a rich history to reference and promote. I’d be proud if New England had a record to match it.
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Fifteen days of blogging for health care reform: An argument for single-payer health care 

Guest post by Skylanda.

One day, several months ago, a little boy appeared at the pediatric urgent care clinic I was assigned to on rotation. He and his parents had been shipped upstairs to us after the emergency department triaged his concerns and determined they had little to offer him. He was not sick, but he could not wait to be seen. The ED dumped him - unceremoniously but appropriately - into the hands of the peds department, and I picked up his chart.

The child was a type I diabetic. This is childhood diabetes, the kind that comes on suddenly, is no fault of the patient‘s lifestyle or diet preferences, and requires lifelong injections of insulin. In the days before insulin was available, these kids regularly died of the acute complications of high blood sugar, a condition called diabetic ketoacidosis or DKA. Around the turn of the century, someone discovered that if you starve these kids to within a few calories of death, they last longer in a skeletal form (whether that discovery was a blessing or a curse is up for argument). But today we have insulin and syringes to administer it with, and machines to check blood sugar, and lancets and test strip papers to help monitor and direct daily insulin dosing. With these resources, these kids do well. Without them, their blood glucose runs high within hours, and soon their electrolytes swing wildly out of control; without treatment, DKA can be rapidly fatal.

This child did not have DKA. This child had well-controlled, tightly-monitored, appropriately managed type I diabetes. He also had Medicaid coverage in another state and a dwindling supply of insulin and assorted supplies.

His family - they explained in more Spanish than English - had moved from the next state to the north because his father was a manual laborer (legal and documented, second or third generation in the US); the faltering construction business had left him finding little work, and so they packed up a car and moved to be closer to a larger family network that could help with childcare and housing while the parents looked for more stable work - family values in action, I thought to myself. They had spoken to social workers before leaving the state regarding the boy’s coverage, and left those meetings convinced they would be covered by Medicaid in New Mexico when they arrived. They were mistaken. When they went to a pharmacy to refill a month’s supply of supplies, they were presented with a bill for $800, which they could not pay, and so they left the pharmacy without. The supplies of insulin dwindled; the mother was halving the boy’s doses to make it last longer, and giving fewer injections to save needles. The seal on the last bottle of insulin was broken on the morning they finally came to the ER, out of options, out of insulin, out of time.

Now in the hands of myself as a resident and the attending physician who supervised me, we began the search for some means of acquiring the goods. The social workers were called, and we put our heads together. First we thought to get presumptive approval for the child to get in-state Medicaid, which would cover the bill immediately…but no, one cannot have Medicaid in two states, and it takes several weeks to cancel one, and the next cannot be approved before the first is canceled; this would take a month at minimum to accomplish. We considered any source of insulin within the hospital grounds; with the number of pharmaceutical companies prowling the campus, there had to be a cache somewhere…no dice, the endocrinology departments had no sample vials, and knew of no one else who did either. I called the pharmacy that filled their last prescription and asked if they would ship out of state; they would not. I called a pharmacy chain that I knew from back home had a policy of shipping out of state for free; this service was not available at the franchises we might have used. I called the first pharmacy again and had them agree to transfer the prescription to a branch at the state line, where the family could drive and pick it up; but the family did not have gas money for the four-hour drive north and then the same length back, and they were dubious that their geriatric car would survive the journey anyhow. I called the sole peds endocrinologist on staff and begged, pleaded, cajoled for any solution.

“Hospitalize the boy,” she said. “If you can’t find that child some insulin, that’s your only option.”

At the end of the day, we did not hospitalize this kid. The social workers got the state Medicaid office on the phone, got special dispensation to extend dual coverage until his coverage in the former state could be revoked, and we sent the family out late in the afternoon with a prescription for the month’s supplies that probably required no more than a $15 co-pay.

All it took was roughly six hours of my time, the combined efforts of two social workers, and the periodic attention of my attending who could only shake her head and offer wan encouragement along the way.

Lest anyone think that I’m just complaining about a bad day at work, here is the crux of the issue. A resident physician like myself is paid in the neighborhood of $40k a year. If I waste a day providing social work services to one healthy child instead of seeing a dozen other sick children with bill-able problems, the government subsidies that pay for resident salaries just threw away about $150. The social workers probably make a little less than I do, and they both worked on the problem about half-time all that day, so throw down another $120 for their time. My attending - at full physician’s salary - had to check in a dozen times throughout the day, so let’s chuck in another $100 on her behalf. The parents were unemployed, but if they had been working, they would have been pulled out to spend the day at our clinic while we sorted out the mess. Someone at the state capitol fielded the case and pushed the paperwork; add another few dollars. And so on.

If you total the cost of what it took to get this child’s medications, I would estimate it at $500, bare minimum. Probably more around $1000 or so in people-time and lost resources that could have gone to other areas of need. Had we run out of options and been forced to hospitalize the kid solely to give routine insulin shots, the cost would have run more around $5000 and up.

All this for a child who was insured, covered, and not sick.

And this is the true cost of a fractured health care system. There is no reason under the sun why a federally-funded system like Medicaid should be so state-specific that a child crossing the state line should lose coverage and - moreover - be ineligible for coverage in the next state. There is no earthly reason why doctors’ hour-by-hour salaries should be spent fixing social work problems, but if you ask around any primary care clinic, you’ll find that few doctors can avoid playing this role - for which we are untrained, unqualified, and overpaid to the point of gross waste.

This point was hammered home when I transitioned to a new clinic several months later. There the social workers lead off with an afternoon of orientation to the programs from which we residents could obtain coverage for our patients, at a community health center where the vast majority have no insurance and no money. The array of programs is astonishing, and in some ways, heartening: Title X, BCC, Project Access…even some of the names ring idealistic and true. But they are dirty rags on a seeping wound - it takes hours to memorize which programs cover which services (paid time, you bet), the salaries of several social workers to sign patients up for the appropriate ones, the combined mental efforts of dozens of people to puzzle piece together some kind of health care from the dizzying complexity of charities, government agencies, and private entities that offer incremental coverage.

This sort of waste, redundancy, and inefficiency is quite likely one of the main reasons why Americans pay more for health care per capita than any other industrial nation, but receive less “health” for their cash. And this forms the backbone of the argument for single-payer coverage: one payer, to whom all care providers bill - not as employees, but in the same manner that care providers now bill insurance companies. Eliminate the need for multiple billing and coding systems, multiple lists of who covers what procedure, multiple formularies of who can get which drug, multiple layers of bureaucracy - one for each and every payer source under the sun.

This is a matter of some controversy, of course - not just among the cacophony of insurance lobbyist and like, but among the health care reform movement. There are pragmatists out there who believe in covering people, now, in any manner, at whatever cost to the long-term goals of health reform. They have a point. While we bicker over how we cover whom, people are hurting and dying for lack of coverage. This faction sees the fragmented mosaic approach not as ideal, but good enough for now; they see the single-payer model as too ideal, too far away to count on, too elitist to serve people who need life-giving services now.

But there is a flip side, which is that any system that does not unify the basic payment scheme across the nation is inevitably going to bog down in its own weight. It will bog me down in tracking down insulin for an ostensibly insured little boy, it will bog clinics down in the need to hire social workers at $30-40k per year for the sheer purpose of figuring out who to sign up for which programs, it will bury itself under its own bureaucracy. The fragmented, mosaic approach is what we have now, and it is not working.

So here is today’s argument (and there are many, many others) for single-payer health care: portability. Portability is the idea that your coverage goes with you. You do not lose it by crossing state lines, changing jobs, becoming unemployed, turning eighteen, getting that raise that finally breaks the Medicaid threshold and makes you only wish you were back to minimum wage again. There is only one way to create true, universal portability of health insurance, and that is to have one single entity paying for it.

A true solution is worth working for. That solution can take many forms in the detail, but unless it eliminates the geographical and bureaucratic fragmentation endemic to our current system, it is not a real solution. Single payer health care - without it, every other reform is merely a finger in the dike, a bandaid on a spurting artery.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.
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The Soporific Values of PBS by Anthony McCarthy 

Sitting with a convalescent a number of evenings, I was reminded just how god-awful PBS entertainment programming has become. Foyles War? Inspector Lindley*? On our local affiliate they’re showing Miss Marple. If there have been more than two series of Miss Marple made to please what they condescendingly believe the American audience wants, please point it out so it can be avoided.

Is there Brit kitsch so bad that they won’t show it on some Yank public TV station? And where is the American produced stuff they were promising us a while ago? Has anyone seen anything produced in America for PBS in fresh memory? Wait. Cancel that. Do we need a clone of CSI dressed in tweed and elbow patches?

While sitting through one piece of Brit trash recently, I was reminded of a tiresome joke repeated on one of the blogs a few months back about Canadian TV shows and their superior quality. It’s supposed to be ironic, trouble is, its not. Living where I do, I’ve seen a bit of Canadian stuff over the years, a lot of it back when I used to get the French language station out of Quebec. Some of it is garbage, but some is better than what you’re going to see here unless you buy it. Omerta, for example, or the wonderful English language series, Slings and Arrows**.

Slings and Arrows would be especially appropriate since its theme is a theater company that went through the motions for years, producing correct and boring productions of Shakespear and a bloated and incompetent bureaucracy more interested in sucking after funding than in fulfilling their stated purpose. You get the feeling that PBS and its affiliates wouldn’t be especially eager to explore that theme. Maybe they should notice that the incompetent financial manager has an easier job of selling the stuff when the hack-work artistic director dies and the content of their production gets shaken up.

Theater - including film, however shown - has the chance to tell about life. They have the words and actions to do that. An instrumental musician who deals mostly in abstractions, can get blown away when hearing what a single singer and piano player can do during a recital. It can change the way you see life. It rarely happens, though when it does it makes you certain that it is a useful activity. But it has to be the right singer, the right pianist and the right program of songs. Luckily, the songs, like the plays and scripts, already exist. There are writers and composers who aren’t just going through the motions, they’re generally the ones with a small audience. There are writers who are doing their part against all odds.

With the luxury of using the medium of reality, you wonder why anyone would settle on doing absolutely nothing with it at such great cost for so many years. You can understand people paying for junk if it has some novelty value or spectacle, though nothing gets older faster. That’s what fads are all about. But when a public TV system depends on those who will pay to see the same old junk and new junk of rapidly deteriorating quality, it’s already down the drain. Other than Moyers in the news and less than a handful of other news and history relates shows, PBS and public TV works against its purpose to exist.

Note: By the way, anyone else who is tempted to produce yet another mini-series glorifying Elizabeth I or the rest of her blood thirsty family should read William Cobbett’s THE HISTORY OF THE PROTESTANT REFORMATION IN ENGLAND AND IRELAND first. But for the rest of us, Cobbett’s History is a good antidote to that mildewed line of docu-drama. Note that Cobbett was, himself, a protestant.

When you cut through the establishment propaganda, the Tudor’s destruction of the medieval social support network in order to plunder it and buy support might go a long way to understanding what’s been so rotten about the Anglo-American system. They come off as sort of like the Bush Crime Family with a somewhat better record in arts patronage.

His defense of Mary as the least blood soaked and most beneficent of the Tudors and Stuarts are an interesting change from the line of lies and propaganda that started during her family’s reign and which will probably continue in the fall line up on PBS. Cobbett’s list of the hypocrisies and crimes of “That prince of hypocrites” Thomas Cranmer will come as a real shock to a lot of people brought up to their knowledge of history by PBS. Loved Glenda Jackson but Elizabeth I was no Glenda Jackson.

* That how it’s spelled? I was tempted to look it up but the effort isn’t worth it.

** The writing was great, the actors great. The three major roles played by Martha Burns, Paul Gross and Stephen Ouimette are especially good. Movies and plays about theater people are usually terrible but this series was great.

I probably shouldn’t mention it, but someone has posted the first season on You Tube.
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Friday, August 15, 2008

Guest post by Skylanda: Fifteen days of blogging for health care reform 

I am a physician. To be more specific, I am a resident, in my second year of training in a rural family practice track. I live and breath health care, more hours than I live any other part of my life. Ask any resident, they will quite likely tell you something very similar.

Doctors battle out the flaws and foibles of the American health care system every day. No matter what their opinion on the solution, few will disagree that we indeed have a problem in this country. Some will tell you we need more free marketeering, less government interference; others lean to the far opposite side, demanding reform toward single payer coverage or even a government-run health care system that directly manages health care workers as its own employees. But find me a doctor in this country who thinks there is nothing direly wrong with health care in America today, and I will find you a chicken who hatches pink bunnies out of its eggs - that is, a rare bird indeed.

At the same time, few physicians are immune to some personal ensnarement of the health care crisis in America. We straddle two sides of the fence - we are providers, but we are also consumers, and our relative wealth provides only thin insulation from the same traps and pitfalls that plague the rest of the nation. Just out of college, in the midst of the turn-of-the-millennium tech bust, I took a job that required heavy manual labor on offshore construction rigs; I was uninsured, working on subcontracts among union crews of merchant marines, and I was without a hint of worker’s comp coverage - it was simply understood among us contractors that if we were ever injured offshore, the first call would be made to lawyers to start talking settlements, because there would be no other way to pay a medical bill proportionate to the risks to life and limb we took on those rigs. My older sister, meanwhile, waited out ten years without health insurance, during which time a minor (and treatable) skin condition blossomed into inflammation and scarring so severe that it impairs her ability to walk, write, even provide fingerprints required by new employers; by the time she obtained insurance, the condition had become entrenched and largely irreversible. Two years ago, my brother’s school-age child came down with a complicated case of leukemia less than a month after he returned from a year-long tour in Iraq with the National Guard; though her epic hospital stay was graciously covered by the combined taxpayer efforts of Tricare and Medicaid, he now has to closely balance his potential income with Medicaid limits lest his chronically ill and entirely uninsurable daughter lose her only source of insurance eligibility.

These are not sob stories and they are not meant to gain any particular sympathy for a few rough years in my family tree; these are entirely typical stories in America in 2008 (and I don‘t doubt that readers here could share a litany just like them). Few families outside of the shrinking and ever-more-distant elite cannot tell similar stories: grandparents hospitalized for conditions that could have been prevented by medications they were prescribed but could not afford, bankruptcies filed as a last-resort means of coping with unpayable medical bills, choices made between health care and food, health care and education, health care and mortgage payments.

Nor can one pretend any longer that the crisis in health care coverage and access is at all limited to the poorest corners of the social strata. There is nothing acceptable - morally, economically, or otherwise - about a wealthy, industrialized nation leaving any portion of the populace without access to care, but when such problems are limited to the most marginalized people, we can at least pretend that we are on our way to vanquishing the problem, chasing it into darker and darker corners, moving toward something better and brighter. This pretense has no business existing any longer. Extinguish the notion, right now, that we are not losing a fight, in this nation, in this very moment, to the burden of ever-growing numbers of the uninsured, the under-insured, the improperly insured, and people simply pushed so far to the margins that access to care comes only at the door of the emergency room - a door exponentially more expensive than that of your local five-star hotel. Some forty-something million of the former, some uncountable number of the latter, growing every day.

Echidne has graciously provided several of us guest bloggers a platform on which to speak during these next two weeks, and this is auspicious timing indeed. In my adopted state of New Mexico, the governor has called a special session to force the legislature to start addressing this issue of broadening health coverage; at the end of the month, Barak Obama will accept the nomination for the democratic presidential ticket, bringing new hope - and renewed cynicism - to the health care reform table and the litany of other progressive issues. During these two weeks, my contribution to Echidne’s blog will be a series of posts from this one insider’s perspective - and there are as many insider’s perspectives as there are doctors, nurses, hospital administrators, biotech developers, patients, and the like - on some of the key issues and developments that shape and hinder health care reform in America today.

Times are ripe indeed for a profound push toward reform, as they have been ripe and then fallen short before, time and again. But like an addict who quits their cigarettes fourteen times before the quitting takes, one of these times, reform will take hold. The shape of that reform, the effect it will have on the diversity of issues that shape health in America, its inclusive or exclusive nature - those remain to be seen. Stay tuned.

Cross-posted at my blog, Loose Chicks Sink Ships. Please note that all references to patients have been altered and/or fictionalized to protect the identity of those individuals.
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The United States of Feminists (by Suzie) 



         Feminists are not a state authority. We don’t have an army, police, courts, judges or executioners. We rarely, if ever, commit violence against our political opponents.
         I just wanted to clear that up, after last Friday’s lengthy arguments. One argument was that feminists who cannot imagine forgiving an alleged ally who abused a woman were akin to Stalinists who held trials with no chance of acquittal. If I choose not to forgive a man, he can still have a fine life. I have restricted him only in his dealings with me. I haven’t executed him or sent him to Siberia.
         This argument is related to the use of “feminazis,” in which we're compared to Nazis because we’re … what? extreme and militant? Not militant in the sense of being violent, of course, but too aggressive. In case anyone is confused, feminist armies have not invaded other countries, nor are we committing genocide against men.
        Some feminists talk of a war on women, or women living in occupied territory. If it’s false to compare feminists to the state, isn’t it equally wrong to compare men to the state? I don’t think so because men predominate in the top rungs of the government, military, media, religion, etc. Men do have much more control over state policy and actions.
        Another argument from last week's post was that some feminists presume men to be guilty until proven innocent, which flies in the face of our jurisprudence. False. The presumption of innocence is a right in U.S. criminal trials, but it doesn’t apply throughout the criminal justice system. If police presumed everyone to be innocent, they’d never make any arrests.
        A related argument is that feminists are stereotyping men if they distrust a man until he proves to be OK. Although I’m sure they exist, I can’t name a feminist who thinks all men are intrinsically bad. We understand some men are great, but we know men disproportionately commit crimes against women, and we cannot always predict who will do what. We have a right to try to lessen our personal risk. 
       Of course, this isn't just feminists. A conservative woman might not open the door to a man she doesn't know.
        Our society sends mixed messages. Some men are hurt and angry if they aren’t trusted. On the other hand, women can be blamed if they trust a man who then abuses them. People may ask: "Why did you go over to his house if you hardly knew him?" "Why did you get in his car?" “Why did you open your door?” These attitudes have a long history in which women are expected to guard themselves from men, or to allow other men, such as their fathers or husbands, to guard them.
        Another argument is that women are gender profiling, like racial profiling. But we're not the police, pulling over drivers, or transportation officials, keeping people from boarding planes, just because they're men. By not opening my front door, or by locking my car door, or by meeting a man I don’t know in a public place, I’m not curtailing anyone’s rights. I'm a person in a less-powerful group protecting myself against the group with more privileges.      
        The bottom line on all of these arguments is that men’s feelings are more important than women’s rights. 
        
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Thursday, August 14, 2008

Vacation! 



Ah. Blessed vacation. For me, anyway. I'm going to be on vacation from today until the end of August. In the meantime you will be entertained and educated by my gracious and charming and smart guest bloggers: Anthony McCarthy, Bleustocking, Hecate, Phila, Skylanda and Suzie (in alphabetical order). My sincere and heartfelt thanks to all of you guest bloggers.

Now, where are those flippers and that beach ball?

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Never Again Going to Give The “News” The Benefit of the Doubt by Anthony McCarthy 

During this personal hiatus, I’ve been trying to do something about the old writing style. Again. One of the things stressed by those who have thought about the form of effective advocacy is how to place information in a written story for maximum persuasive effect. Not burring the lead idea is high among those. Putting the most important information in the very beginning of the piece is just about universally advocated for written material.

But what about other parts of structuring information to inform? How can you decide when they are doing that and not, in fact, advocating a subjective opinion? And what about the different opportunities and requirements for effective view point promotion on the radio or TV? You can assume a much smaller number of words, to start with, but you probably can count on them all being audible, if not heard. People don’t change the page when listening to the news as opposed to reading the paper.

I got interested in this last week when, during its alleged hard new headlines, I heard a story on NPR that started out to be about Obama’s position on an issue but during which his voice wasn’t heard and none of his words were quoted. However, they did manage to quote McCain and to have a clip of a Republican STATE SENATOR(!) opining on what was alleged to be Obama’s position. You’d think the least they could do was use Obama’s own words or even a position paper, but that was held to be less important in a story about Obama’s stand on an issue than what a Republican State Senator had to say about it.

Funny, once you notice it, you hear that kind of clear bias practice all over the place. Characterizations of Obama’s positions are given, motives ascribed to him based on those characterizations, even alleged campaign strategies “reported” (without verification from the campaign) but the actual quotes and voices are those of Republicans. And, mind you, this is in the alleged reporting sections of alleged news programs, not the vastly longer time given to “analysis” during which are mired all manner of speculation and dispund. Hey, if the venerable NPR gets away with that kind of practice, why should the seamier organs of the media be expected to remain chaste?

And yet they wonder why people are abandoning the traditional news in favor of online sources. At least people on the blogs don’t pretend to be practicing objective reporting while they are advocating a side, certainly not pretending it’s news. At least not in such large numbers.

They want people to trust them, they can cut this kind of crap to start with.
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Weight & health (by Suzie) 



         I count fat as a feminist issue because there are so many messages in society that pressure girls and women to be as skinny as possible. That’s why I was happy to see this article, which says:
A new study suggests that a surprising number of overweight people - about half - have normal blood pressure and cholesterol levels, while an equally startling number of trim people suffer from some of the ills associated with obesity.
         Unfortunately, the article began with the idea that only “trim people” “can look great in a swimsuit.”
         My mother, who was “trim” into her 80s, had high cholesterol and died of a heart attack. Thanks to genetics, I had high cholesterol even when I was thin. I wish more people understood that thinness does not guarantee health.

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In the 21st Century 



Nations don't invade other nations. That's what John McCain said about the Russian invasion of Georgia. Now, he could have meant the statement as a positive one, meaning that nations don't indeed invade other nations now that the time stamp starts the century with a "2". If so, he was wrong, and a simple counterexample is the U.S. invasion of Iraq.

Or he could have meant it as a normative statement, arguing that nations shouldn't invade other nations in our current era. If so, was he as outspoken against the earlier U.S. invasion of Iraq? I don't recall that.

Yes, all this is boring and about something trivial. I'm just trying to fill the enormous gap that exists in the media triviality account balances when it comes to McCain. Obama we get a lot about, from Maureen Dowd onwards. But poor McCain? Isn't he interesting enough for some trivia scandals?

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Wednesday, August 13, 2008

Two Takes 



On the new Democratic platform about reproductive choice. First, Digby sees a fundie touch in the developments. Second, Linda Hirshman sees the development as good for women's reproductive rights.

I'm too tired to chime in but some of you are probably not.

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What Is That Smell? 



Here we go again:

While several factors can send a woman swooning, including big brains and brawn, body odor can be critical in the final decision, the researchers say. That's because beneath a woman's flowery fragrance or a guy's musk the body sends out aromatic molecules that indicate genetic compatibility.

Major histocompatibility complex (MHC) genes are involved in immune response and other functions, and the best mates are those that have different MHC smells than you. The new study reveals, however, that when women are on the pill they prefer guys with matching MHC odors.

Best mates? What sort of research is this based on? What is the frequency distribution of these smells in the general population?

And do the guys prefer different MHC smells from their own? Do the parents apply these rules in societies where marriages are arranged? What about those cultures which favored cousin marriages? How often have women had the chance to pick their own mates?

Here's more on the study:

Past studies have suggested couples with dissimilar MHC genes are more satisfied and more likely to be faithful to a mate. And the opposite is also true with matchng-MHC couples showing less satisfaction and more wandering eyes.

"Not only could MHC-similarity in couples lead to fertility problems," said lead researcher Stewart Craig Roberts, an evolutionary psychologist at the University of Newcastle in England, "but it could ultimately lead to the breakdown of relationships when women stop using the contraceptive pill, as odor perception plays a significant role in maintaining attraction to partners."

Sexy scents

The study involved about 100 women, aged 18 to 35, who chose which of six male body-odor samples they preferred. They were tested at the start of the study when none of the participants were taking contraceptive pills and three months later after 40 of the women had started taking the pill more than two months prior.

For the non-pill users, results didn't show a significant preference for similar or dissimilar MHC odors. When women started taking birth control, their odor preferences changed. These women were much more likely than non-pill users to prefer MHC-similar odors.

Well, it could be interesting that the smell preferences of some of the women on the pill changed. But note that the women not on the pill apparently didn't express a preference for dissimilar MHC odors. Doesn't that sorta affect the basic thesis and all the speculation that follows?

And what is "much more likely" in that study? How many of the pill users changed their preferences?

Pardon me for sounding suspicious, but it's hard to take the evidence of "past studies" completely seriously because those studies were in this same field of evolutionary psychology, looking for the same kind of stuff, and often popularized with the same extreme language.
----
Via feministpeacenetwork.org.

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Oh My! You People are Exotic! 



Most of the presidential campaign coverage makes me vomit. The part which is all about Barack Obama somehow being too uppity or too foreign or a secret mole for the Islamofascists. If the so-called liberal media in fact was at all liberal it would also cover similar silly stories about John McCain. About his famous temper (well, those stories might even be legitimate), for instance and about the eight houses he owns. Having eight houses sounds really exotic, uppity and foreign to me.

But nope. All we get is up-close-and-personal stories about only one of the candidates. I'm really tired of them. Tell us at least if Obama used to collect stamps.

All this is in honor of Cokie Roberts who criticized Obama taking a vacation in Hawaii as exotic. Even though Obama's granny lives there and even though Hawaii is part of the United States of America. It's so utterly silly a statement that it must be a feed from the secret wingnut headquarters. Pick your role, Cokie: Either you are silly or you are a secret mole of the Wingnutofascists.

Well, the Hawaiians didn't take well to being called exotic (via Eschaton).

This gives me an excellent opportunity to point out that all you American readers look and sound exotic to me. I remember those wolf-teeth in early television programs (every American guy in the shows had them). And jello desserts! Heh.

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Tuesday, August 12, 2008

What Women Have Mouths For 



Not for speaking or eating, according to Rush Limbaugh. Those mouths are for blowjobs.

And women should shut up and suck. If that sounds gross, don't blame me. Blame our little friend Rush, because that's what this long ramble means when translated into plain language:

LIMBAUGH: Well, it's -- I mean, at some point, at some point, you gotta exhibit maturity and restraint. You know, and I do that constantly. But -- well, I don't -- look, let me see if I can run you through this and get you to think what I'm thinking without my actually saying it. That might be a pretty big talent if I could do that -- make you think what I'm going to say without my having to say it, therefore if anybody gets in trouble for saying it, you say it.

We know -- we've been told that Elizabeth Edwards is smarter than John Edwards. That's part of the puff pieces on them that we've seen. Ergo, if Elizabeth Edwards is smarter than John Edwards, is it likely that she thinks she knows better than he does what his speeches ought to contain and what kind of things he ought to be doing strategy-wise in the campaign? If she is smarter than he is, could it have been her decision to keep going with the campaign? In other words, could it be that she doesn't shut up? Now, that's as far as I'm going to go.

Well, you're -- Snerdley says he's missing something. If you're missing it, you're going to have to provide it. What are you missing? Mm-hmm, mm-hmm.

I can't close the loop on it. I can't close the loop on it. I'm on -- you know, I'm in a little quicksand already today talking about how the chicks are giving us boring pictures of the female athletes from the Olympics. Because I know -- you -- the diversity crowd's going to be upset. They're going to -- "Ooh, do you mean the Olympics are just so you guys can ogle wom--" Yes, because we do not care to watch 'em compete. But back to Elizabeth and the Breck Girl.

I'm sorry, my friends, I just -- I can't. It just seems to me that Edwards might be attracted to a woman whose mouth did something other than talk.

[...]

LIMBAUGH: OK, we're back. Ladies and gentleman, my theory that I just explained to you about why -- you know, what could have John Edwards' motivations been to have the affair with Rielle Hunter, given his wife is smarter than he is and probably nagging him a lot about doing this, and he found somebody that did something with her mouth other than talk. I think I can back this up from her.

We have a sound bite. This is February 2007. She was on the tabloid show Extra. And this is what she said. Listen very carefully.

HUNTER [audio clip]: The whole experience was life-altering for me. One of the great things about John Edwards is that he's so open and willing to try new things and do things in new ways.

LIMBAUGH: "Open to new things." Folks, it is what it is. You get mad at me for bringing the truth to you, but it is what it is.

Note that the premise of his whole thesis is missing, because he has no information about the blowjob habits of the two women discussed here. He's simply assuming those, because our little Rush really, really hates smart women who are something more than animated sex aids.

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Life Imitating Art? 



Well, sort of. The events at the Olympic opening ceremonies in China appear to have imitated Terry Pratchett's fantasy book Maskerade:

A 7-year-old Chinese girl was not good-looking enough for the Olympics opening ceremony, so another little girl with a pixie smile lip-synched "Ode to the Motherland," a ceremony official said — the latest example of the lengths Beijing took for a perfect start to the Summer Games.

If you are unfamiliar with Pratchett's funny science-fiction-cum-fantasy books you are in for a treat. The Maskerade might not be a bad one to begin with. It's a story about the opera (and, as usual for Pratchett, also a story about us ridiculous human beings). A young witch (never mind that part for the purposes of this post) called Agnes has a wonderful voice and wants to become an opera singer. Her voice qualifies her but her body does not, being too hefty. Thus, Perdita (as Agnes wishes to be called) sings from the wings while a pretty little thing lip-syncs on the stage.

Of course neither role is much fun. One woman doesn't sing well enough, the other doesn't look cute enough. Now apply that storyline to reality and replace grown women with little girls. Two of them got their dreams squashed there.

But of course the final result was fantastic. In both senses of the term.

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Writing About Medical Research Findings 



Here's an odd thing: Two reports about the same breast cancer recurrence study were published today. One of them begins like this:

Even early-stage breast cancer patients who complete five years of drug treatment have a significant risk for relapsing, new research shows.

The study included patients treated at Houston's M.D. Anderson Cancer Center between 1985 and 2001 who were cancer-free five years after initial treatment with surgery or surgery and radiation.

The other one, discussing the very same study, begins like this:

WASHINGTON (Reuters) - Women who survive breast cancer for five years after treatment have a relatively low risk of the disease recurring, according to a U.S. study published on Tuesday.

Is the glass half empty or half full? What is it about these write-ups that chose to go either positive or negative? The actual information in the stories is roughly the same, except for the selected emotional tilt.

More generally, I'm not sure what "recurrence" means in the sense of a lot of time passing after breast cancer treatment. Couldn't the new cancer be a totally new one? I doubt that surviving breast cancer means that the woman is then somehow guaranteed a zero risk of it in the future, but I may be confused about that issue.

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Monday, August 11, 2008

Let's All Hold Hands So We Can't Punch Each Other 



Communitarianism is an interesting political ideology. The first time I heard the word I rather liked it, because it seemed to stand for all sorts of goody-two-shoes values and I love those values. Communitarians want all of us to work for the common good, you see, and that's quite wonderful.

But then I got a few books on the topic from the library and felt sort of let down. One of those books was by Amitai Etzione, one of the big names in communitarianism. Whether it was his book or one of the others I read I can't remember, but one of the books had a long chapter on all the bad things about feminism, including the idea that because women in the past were banned from jobs they did the important charity work instead. Now that many women work for money nobody is doing that important charity and therefore the past might have been a better time for the community. Surprisingly, the chapter had nothing about charity being a task which men, too, could practice.

This whole treatment made me uncomfortable, because it appeared to construct "the community" as somehow not including the women whose free labor was perhaps semi-forced into charitable uses. It also has that odd flavor of communitarianism as the kind of barn-raising where the communitarian prophet tells other people to raise the barn while he sits back and has a beer or two. I've known people like that in the real life, by the way. They're very keen on community efforts and it may take some time to realize that the efforts are to be made by others.

To return to the topic at hand (or, rather, to stay on the topic), I got the feeling that many communitarians want other people to have good unselfish values while they themselves continue working as professors or whatever they do for money. It's a neat trick, that one, because the only way you can really be a selfish communitarian is by leading the movement. Or so I think.

What brought this rant on? Some time ago I read a Huffington Post piece by Etzione on how Obama really is a communitarian:

The nature of communitarianism is best illustrated by contrasting it with identity politics, the rejection of which is both a major theme of Obama's campaign, and is symbolized by his post-racial biography and personhood. Identity politics build on what differentiates us from one another: our racial or ethnic origins; our sexual orientations; our separate past social histories. Identity politics led to attempts to form a 'rainbow' coalition, composed of various groups who considered themselves victimized -- against the declining white, male majority. Other forms of identity politics pitted citizens against immigrants. Some of the more radical versions of multiculturalism also contributed to this kind of divisive politics.

...

A revival of the American community requires us to spend much less of our energy and resources on fighting one another, and invest much more of it in the common good, in those goods that serve one and all. Hence, Obama seeks not only social justice for the poor, but decent work at decent wages for one and all; he harps less on the uninsured, and seeks a health care system that will encompass all Americans; he is as open to those with a strong faith as he is to those who embrace secular humanism.

I don't think Obama is a communitarian in the Etzione mold, actually. But notice something odd about that quote: The focus on "the common good" that Etzione advocates is great. But he's not saying anything at all about the fact that what "the common good" is might be under great dispute by different groups in the society. Instead, his statement assumes that question to be already solved in some odd way and that solution to assume that no particular group in the community is at all advantaged or required to contribute more than other groups because of that.

An extreme example might make my criticism fairer: If communitarianism had been applied in the slavery era of this country, what would its message have been? That both the slaves and the free citizens should just work together without always focusing on identity politics?

I'm not actually opposed to many communitarian values, but the juxtaposition of those with "identity politics" makes me grit my teeth. The kind of communitarianism that Etzione advocates is too easily just a defense of the current status quo in the distributions of income and power, empty in specific details about what it tries to accomplish and far too amenable to a conservative interpretation.

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Stoning And The Odd Epidemic of Honor Killings 



It is certainly a form of extreme torture, a horrible way to die. You may be glad to hear, therefore, that Iran appears to have suspended the use of stoning.

More generally, stoning people to death for adultery is still legal in quite a few places. Most of those killed that way are women. Why? Here's one possible answer:

Women constitute nearly all those condemned to death by stoning. Why? Because discriminatory laws and customs almost always assign more guilt to women than to men in any manner of action that is seen as violating 'norms' of sexual behaviour, especially any instance of alleged sexual relations outside marriage (zina). Men are entitled to marry more than one woman and can use this justification for sex outside marriage. They are also more mobile and can more easily escape punishment.

This quote comes from the stop-stoning.org. The same page discusses honor killings:

According to the UN Special Rapporteur on Extrajudicial, Summary and Arbitrary Executions, so-called 'honour killings' (or rather, dishonourable killings of women) have occurred in countries as diverse as Bangladesh, Brazil, Ecuador, Egypt, India, Israel, Italy, Jordan, Morocco, Pakistan, Sweden, Turkey, Uganda and the United Kingdom.

That is a very odd way of putting it, that "have occurred in countries as diverse as." It's not the case that suddenly Italians or Swedes, say, have decided to adopt the custom of honor killings. The custom was imported to those countries with immigrants who already had it, and we should be able to state that.

The website is probably just trying to make the point that honor killings should be of concern to people all over the world. But I dislike the veils drawn over the cultural nature of the problem.

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McCain The Pro-Lifer? McCain The Pro-Choicer? 



Sarah Blustein has written an investigative piece about John McCain's views on women's reproductive rights. A snippet:

According to one poll, about half of all women voters backing McCain said they were pro-choice, including 36 percent who say they strongly support Roe. More importantly, these women voters think that McCain might agree with them on abortion. The same research found that "more than seven in ten pro-choice McCain supporters ... have yet to learn that McCain's position on abortion is directly at odds with their own." And the issue is not that they don't care. One June poll found that, when Democratic women voters in twelve battleground states learned McCain's position on abortion, Obama gained twelve points among them.

McCain's views may matter especially to Hillary Clinton supporters, many of whom are pro-choice; according to syndicated columnist Froma Harrop, "[T]hey'll want to know this: Would McCain stock the Supreme Court with foes of Roe v. Wade?" But, she writes, "The answer is unclear but probably 'no.' While McCain has positioned himself as 'pro-life' during this campaign, his statements over the years show considerable latitude on the issue."

That, however, is simply not true. There is no "latitude" in McCain's position on abortion. Interviews with dozens of people who have dealt with him on the issue--pro-choice and pro-life activists, Hill staffers, McCain confidants, pollsters, and staffers--along with a two-and-a-half-decade-long perfectly anti-abortion voting record, make that clear. And his record on related issues, like contraception, is no better. "I think it is outrageous that people give him a pass, as they gave George W. Bush a pass," reflects Feldt. "John McCain will be that and worse."

Read the whole article for a better understanding of McCain's position. My impression is that he really doesn't care about the issue at all on a personal level, doesn't follow it, doesn't know much about it, and will vote on the issues solely based on political expediency. The latter means that a president McCain would certainly do whatever the pro-lifers want him to do. Anyone who expects him not to try to squash Roe v. Wade lives in a different place. One where the sky is pink and sausages grow on trees.

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Sunday, August 10, 2008

Saturday Night Music on a Sunday Night 

Sometimes you just have to have cimbolom music

Lakatos Erno Cimbolom Band

Kálmán Balogh & The Gypsy Cimbalom Band in Chicag
o


Posted by A.M.
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In The Olympic Spirit 






I wish to present a picture from my family files. This guy participated in one of the early Olympics and you can figure out that he was a long-distance runner, just based on the body type.

I like the outfit.

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Saturday, August 09, 2008

Is “Duty” A Dirty Word? by Anthony McCarthy 

Or just a corrupted virtue?

In the decay of our imperial culture, words are primary aspects of the general corruption of thought and language in service of privilege. Theft and usurpation by the rich have to be called something, after all, they will not only be noticed and discussed, in order to effect them, defend them and, ultimately, to render them unillegal, words must be used. The corrupt actions have to be talked about in order to do them and to defend them but they can’t be called what they are. The malignant actions have to be glossed over if not disguised in order to make them seem to fit into the role of virtues, or at least benign entities.*

And the opposite happens too. Whatever inhibits theft and corruption can’t be called by its rightful name. Misidentification of virtues is, if anything, an even more pressing problem for the systematic and universal corruption of life. Nothing can be allowed to get in the way of acquisition and the amassing of wealth by the wealthy and nothing endangers the most successful branch of organized crime like the old-fashioned, named virtues. No words have been more vandalized and twisted by liars in service to the crooks of the ruling class than those dealing with morality. Duty is divorced from morality and turned into an opportunistic citation of conventionalized role playing. Listening to the media or the Bush regime talk about duty in the context of today’s military adventures is to experience a truly pornographic gut punch.

We live in a country in which the language of morality and moral indignation are twisted and stretched to the point where corruption is called reform and personal morality is deformed into mild guilt over eating chocolate and a highly selective, unlikely and baldly hypocritical moral indignation over the private sex lives of Democratic politicians.** And that’s only the most easily taken form of it. When given lip service at all, moral duty is transfigured into that kind of ABC-Disney film of corn sweetener that renders just about anything it covers emetic and pathogenic.

For others, outside of the military, the idea of duty seems to be particularly corrupted as has the idea of actual moral responsibility in general. On one hand, these necessities of a civil society have been mostly deformed into impossible burdens for unarmed civil servants, guaranteeing their failure. It would be interesting to consider how much of the corruption of the civil service is generated by that intentional sandbagging. On the other hand, these burdens for the highest of those, in the judiciary and elected office***have been considerably relaxed from past ethical requirements.

For the general population, duty and moral responsibility are to be seen as pathologies and harmful inhibitions to be discarded, character defects and signs of personal weakness, with the exception of those mentioned in the second paragraph above. In recent pop-psych the resultant inhibitions were held responsible for the increase in cancer rates. Those limiting the frivolous and irrational consumption of vendible junk and the borrowing to service that consumption have been suppressed until just recently. The patriotic duty to buy and borrow is a truly bizarre concept.

While there are exceptions to this, I think it is more the rule that moral duty, the obligation to put the needs of other people and living beings over our personal desires and whims, the obligation to face and tell even the unprofitable truth, the obligation to protect the weak and unable over the strong and powerful, are despised and derided in our late stage empire. Those who try to systematically practice these unfashionable virtues are seen as chumps or derided as anal retentive kill joys. On the blogs it is often met with the order to “lighten up”, or some equivalent admonition.

Any ideas on this?

* I suggested once that words used like that be called “Millerisms” after Judith Miller.

** eg. Sally Quinn on Bill Clinton’s sex life. The racial and gender differences in the definition and application of morality are ever present too and deserving of continued treatment.

*** There are few ideas as stress worn by flexing than “Conflict of interest”, especially in the context of the upper reaches of the judiciary and Senate that confirms them.

Note: This was written before the invasion of privacy in yesterday’s news. Note the difference in media handling between the Edwards scandal, involving private business, and McCain’s relationship with a lobbyist who was doing business before his committee.
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Georgia's Lost Territories (by Phila) 

Danger Room has some background on the conflict in Georgia:
Since 2002, the U.S. military has been providing Georgia with a serious amount of military assistance, beginning with the Georgia Train and Equip Program in 2002....

When I returned to Krtsanisi in early 2006, the place had been transformed into a model base. It even had a sparkling new KBR-style dining facility. The Georgian troops were smartly decked out in U.S.-style uniforms; they were preparing for a troop rotation in Iraq.

Officially, SSOP was supposed to prepare Georgians for service in Iraq. But Georgian trainees I spoke to in 2006 at the Krtsanisi training range saw things a bit differently. A female sergeant told me: “This training is incredibly important for us, because we want to take back Georgia’s lost territories.”
There's more here:
As Sergei Shamba, the foreign affairs minister of Abkhazia, told me in 2006: “The Georgians are euphoric because they have been equipped, trained, that they have gained military experience in Iraq. It feeds this revanchist mood… How can South Ossetia be demilitarized, when all of Georgia is bristling with weaponry, and it’s only an hour’s ride by tank from Tbilisi to Tskhinvali?”

One of the U.S. military trainers put it to me a bit more bluntly. “We’re giving them the knife,” he said. “Will they use it?”
Perhaps so, since all Georgian troops are leaving Iraq:
Georgia will withdraw its entire 2,000-strong military contingent from Iraq within the next three days to join the fighting in the breakaway province of South Ossetia, a senior Georgian military official said Saturday...The US military has agreed to help with the logistics of the Georgian redeployment, Maisuradze added...

Last year, the Georgians raised the number of troops in Iraq from 850 to 2,000 at a time when most non-American contingents were cutting back — a move that won them points with US commanders.
Sounds like a tense situation. But I'm more worried about larger issues, like whether John Edwards' infidelity will rob Obama of the moral authority he'd need to carpet-bomb Tehran.
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Friday, August 08, 2008

Online dating (by Suzie) 



         Anyone who needs reminding that people can be anyone they want to be on the Internet should try online dating. If I ever do it again, shoot me I need to put in my profile: "I enjoy investigating. Do not contact me if you have something to hide."
        One man had a long history of hiring women to act as his girlfriends, called the “girlfriend experience” in prostitution. After we broke up, I thought of sending him an invoice.
         Then there was the man who had to leave his job as a high-school teacher (and his marriage) because he wanted to continue a relationship with a 17-year-old in his class, even after her mother had taken out a restraining order. Last I heard, he was getting a degree in counseling.
          Women also lie to men, of course. But this isn't a battle of the sexes in which both teams are equal and the playing field is level. Women who lie can hurt feelings and waste time. But a lying woman is not as likely to be dangerous to a man as vice versa.  
         I dislike that most men are looking for younger women. A WaPo article says many women now want younger men. This is the hook of the article, which goes on to acknowledge that men want younger women, which is dog-bites-man.
         The article describes eHarmony: “… members are matched according to a psychological profile and personality characteristics.” I was matched with men who had nothing in common with me other than we were all carbon-based life forms.
         One site asks about your politics. Because “sort-of-radical feminist” wasn’t an option, I put “very liberal.” I quickly learned that many men read “very liberal” as “easy” or “kinky.” I had to explain to “very conservative” guys that I would never have sex with them because I was very liberal.
         In hopes of finding other progressives, I signed up at Act for Love, “the largest matchmaking site for Democratic singles.” The slogan “take action, get action” should have tipped me off that this was not the place for me. (As a feminist, I really, really don't want a man who is taking political action in hopes of getting laid.)
          In one profile, I made the mistake of answering honestly the question:  “What are you reading?” I was reading feminist philosopher Sandra Bartky’s “Femininity and Domination,” which I highly recommend. Surprisingly, I did not attract philosophers.
          Any day now, I’m becoming a political lesbian, I swear.

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Ani DiFranco as teacher (by Suzie) 

  

        For those who have trouble understanding the anger or fear that some women feel, in regard to sexual abuse, please read the lyrics to “Parameters” and “Hide ’n Seek.” I can’t find any audio or video, but the words are powerful enough on their own. As she says in another song, "Feminism ain't about equality. It's about reprieve." 

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Feminist men (by Suzie) 



        Can any man say he’s a feminist? Should women accept what he says without question? Is a feminist man who does something bad to a woman worse than a Joe Shmoe who does the same thing?
        The answer: If Camille Paglia can call herself a feminist, anyone can. There’s no credentialing committee. I’m sure people can become feminists by mail, without any actual study.
        Second question: Of course, people have the right to question anyone’s credibility as a feminist. In fact, it’s a minor sport. I give women more benefit of the doubt, sort of like extra credit for experience in the field.
        One complication is the different definitions of feminism. But this is more than a question of semantics. Because of the Kyle Paynes of the world, women should always have the right to question a man’s feminism. I’m not saying male feminists are suspect, but for our own safety, we have the right to ask questions whenever we have doubts.
Kyle Payne was a rape crisis advocate, women’s studies student, and resident advisor at his university. While “looking after” an unconscious drunk student in his care, he undid her shirt and took a photograph and video of her breast.
         This comes from Lauredhel, who has gathered other comments on him. The description above is what Payne has acknowledged in a plea agreement, in which assault charges were dropped. Payne also inspired various posts in the 61st Carnival of Feminists. There are a number of sites that discuss men and feminism in general. Some good ones, such as XY, can be found in this recent Twisty thread.
         To answer the third question: Yeah, I think Payne is worse than some other guy who did the same crime because he makes it harder for women to trust male allies. 
         ETA a second time: A colleague didn't think I should mention a commenter by screen name and so, I have deleted that passage. 
     
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Thursday, August 07, 2008

Mutterings and Stutterings 



Josh Marshall has posted a video compilation of McCain's bloopers. The campaign must be hard work and I understand that the candidates must "misspeak" just because of fatigue. But I'm still a little bit concerned about the number of various types of errors McCain has made.

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Tacky Tactics 



Are often suggested on the comments threads of political blogs. For instance, when the wingnuts attack Michelle Obama, the frequent recommendation I read on liberal blog threads is to counter the attack by going after Cindy McCain. It's as if the wives of the presidential candidates are part of their husbands' private property and therefore a fair target in the campaign battles. You know, like trying to destroy the artillery units of an opposing army. But spouses are not artillery units.

I'm aware of the American political tradition here and also of the fuzzy line between public and private roles of, say, the presidential candidates' wives, and I'm often worried about possibly crossing that line inappropriately in my own writing. But I'd say that character assassinations of the candidates' family members certainly cross that line. Inappropriately.

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Today's Deep, Deep Thought 



It's about certain types of comments on the Internet, especially on YouTube and it's by the Onion:

"We are blessed to be living in an age when we have a global communications network in which idiots, assholes, and total and complete wastes of fucking human life alike can come together to give instant feedback in an unfettered and unmonitored online environment," Mylenek said. "What better way to take advantage of this incredible technology than to log onto the Internet and insult a complete stranger?"


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Wednesday, August 06, 2008

Buffalo Chips and John McCain 



Funny how memes are created in the media. It's mostly the right-wing memes that seem to stick in that so-called liberal media. Even the progressive/liberal blogs spend much of their time refuting the right-wing memes instead of making up new ones and on the whole that helps the memes to stick more. Sad, is it not? Also the reason why today's topics are whether Obama is too arrogant or too inexperienced and young. And all the time the alternative topic of McCain being too out-of-touch and too old just sits there, like an invisible elephant on your living-room couch. We "libral demon rats" have avoided the easy schtick of ageism but nothing of the sort holds back the right-wing meme machine. So now we can discuss Obama's age but not McCain's age.

Here's my offer for a nice meme about McCain which has nothing to do with his age: He wants his wife to participate in a beauty pageant of this sort:





This is the Buffalo Chips beauty pageant at least a year ago, having to do with bikers and biker chicks and consisting of various things, including pretend fellatio of a banana. John McCain would like his wife Cindy to participate in a similar pageant:

On Monday, John McCain appeared at the Sturgis Motorcycle Rally, a veteran-friendly event that featured Kid Rock, Def Leppard, REO Speedwagon (?!) and a biker beauty pageant called "Miss Buffalo Chip" that the presumptive presidential nominee may or may not have known featured topless women.

"I encouraged Cindy to compete," he told the crowd. "I told her [that] with a little luck, she could be the only woman to serve as both the first lady and Miss Buffalo Chip."







Now to parse this all: It's obviously McCain's attempt to make a joke and I'm pretty sure that he didn't know Cindy would have to suck a banana in that competition.

But note that he didn't bother to find out anything about the pageant beforehand and he hasn't bothered to apologize for his statements afterwards, or at least I found no mention of such an apology. Yet he was violating family values in a way which I'd think the fundamentalist right would deplore, as a minimum, and he was also telling us in no uncertain terms that respect towards women is not high on his pyramid of values. Anything to get a cheap laugh beats that.

Here's the fascinating aspect of all this: Imagine what would have happened if Barack Obama had cracked this joke about Michelle? Or if Hillary Clinton had earlier offered Bill Clinton as a participant in some semi-naked hunk competition? The media treats McCain as if he was fragile and above all criticism. Even something as juicy as this story gets no traction as a meme.



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Guys On The Pill 






Is that ever going to be the norm? A piece in Time discusses the reasons why we should all be quite pessimistic about the likelihood of a male contraceptive pill or injection or something of the sort. To create a safe and effective form of male-controlled birth control (other than the condom) is tricky for both scientific reason and cultural reasons. The latter have to do with both the assumption that not enough men are interested in having access to medical male-controlled birth control and that women wouldn't trust men to take care of contraception in the first place, unless they can see it happening with their own eyes (as is the case with the condom).

The Time article also mentions the high costs of developing new forms of birth control. If the market just isn't there the costs are not justified. But is the market there or not? I can see the reluctance of anyone (including us women) to possibly mess with the health of their bodies just for the sake of birth control. But many women do exactly that, and one might think that men might also be willing to do so because of the many advantages that control has.

As examples of those advantages one might mention the ability of a man to take over contraception when his partner can't tolerate the pill or uterine devices and when the couple doesn't like or trust condoms. But perhaps more importantly, a man cannot be the "victim" of paternity suits after one-night stands if he used good birth control himself. I would think that the Men's Rights Activists would be loud and vociferous in their demands for better male contraceptives. Wouldn't you?

If it is indeed true that the market for the male pill, say, is insufficiently large, the reason might be the simple fact that we already have the female pill. There is less need in general for additional forms of contraception. But note that the recent Bush administration attempts to equate the birth control pill and the intra-uterine devices with abortion might change that comfortable status quo. A male pill would do the prevention inside the male body and no stretch of pro-life imagination could make that into abortion!

Wouldn't it be weird if that was what made the male birth control pill a reality?

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Tuesday, August 05, 2008

From My Self-Promotion Files: Do Women Have An Inner Glass Ceiling? 



You might like to read what I have to say about the scarcity of women in American politics. I worked very hard for the piece, by the way, even going out and playing girl reporter.

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Peace and Punditry 






Picture from Scarlet. More here.


Wouldn't peace be nice right about now? We could then focus on arguing about all the nitty-gritty stuff, such as rebuilding the dangerous infrastructure of this country. Of course Banana Republics require a dangerous infrastructure and as a Banana Republic seems to be on the plank of the Republican Party as the future of this country I guess that we won't see those bridges fixed. Could someone tell me, please, how much work has been done since last summer's bridge collapse? And how much money has been spent in Iraq during the same time frame?

On the other hand of the scales of victory, there is a new Kentucky Fried Chicken store in Fallujah.* So the troops can come home now and start fixing the bridges, right? I love being a naive goddess.

Naive goddesses don't understand why the coverage of the presidential campaigns is like this:





For those who can't watch the video, the pundits go on about how saintly McCain is and how much he is isolated from what really matters which is discussing Obama's arrogance (who does he think he is?) and his use of the race card and how all that was created by the meanies in McCain's campaign while McCain was just being all honorable and stuff.
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* The store appears to be an unauthorized knockoff, not part of KFC.

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One Day in the Life of Alexander Solzhenitsyn 



I wonder if he would have selected his last day for a book with that title? I'm ripping off his famous One Day in the Life of Ivan Denisovich, of course, a book which captured the odd taste of happiness as extremely relative. As anyone who has been very ill knows, a small reduction in the symptoms can give you the highest high of your life. Similarly, Ivan Denisovich could be happy in his horrible prison experience, because on that particular day there was just a little bit more bread, a little bit more time, a little bit more independence.

Or so I recall that book. I read Solzhenitsyn pretty early in my life, around the age of fifteen. Indeed, my first book essay at school was on the Cancer Ward. I loved writing about death and the gloominess and so on, and the teacher was a bit concerned until he got to the end of the essay which had an ode to the victorious human spirit. So that was all right.

Much has been written about the political meaning of Solzhenitsyn recently and a lot less about his actual talents in writing. His message about the horrors of Soviet communism struck a cord with his co-patriots and obviously with the other side in the Cold War, and his currency soared high. Later the reverse happened, because Solzhenitsyn's forced exile in the West revealed his hatred of the West and because he decided to become a fundamentalist Russian Orthodox on his return to Russia after the fall of the Soviet Union.

These political waves may have brought him first too high and then too low. I tend to think of his actual literary merits as somewhere in the middle. We shall see what the future will say about them. At least he doesn't have to worry about being now forgotten for his gender. (I just had to turn this all into a feminist discussion,didn't I?)

Knowing the opinions of a living author always makes the enjoyment of her or his work more difficult, especially if those opinions are unpleasant. It's a little like being invited to see a wonderful artistic piece of furniture in the context of the workshop. There it stands, beautiful, but surrounded by sawdust and bits of lumber and tools all helter-skelter and the smell of varnish and paint remover and dust everywhere. It's hard not to look at the room instead of the furniture, and it's probably true that the state of the workshop does tell us something about how carefully and well the piece was made. But mostly we'd prefer to see the final work of art against some more neutral background.

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Monday, August 04, 2008

From Austen to Dowd 



The most recent Maureen Dowd column is called "Mr. Darcy Comes Courting." It employs Jane Austen's Pride and Prejudice as the pattern into which Obama's election campaign is to be fitted. Yes, you guessed it: Barack Obama is Mr. Darcy. Who is Elizabeth Bennet, then? That's a tad unclear.

Dowd ends up arguing that the United States is Elizabeth, but most of the column is spent on berating Hillary Clinton, the women who voted for her, working class women and American women in general. That's Dowd's usual m.o. and somehow based on the idea that she might, after all, not be a woman herself. Good luck with getting the guys to accept her honorary guyness.

I shouldn't be writing about Dowd's misuse of Jane Austen's book. Molly Ivors has put together an excellent literary response, but I would still like to say a few small words about this bit from Dowd:

The odd thing is that Obama bears a distinct resemblance to the most cherished hero in chick-lit history. The senator is a modern incarnation of the clever, haughty, reserved and fastidious Mr. Darcy.

Jane Austen belongs to the history of chick-lit? Only if you are willing to see Rembrandt or da Vinci or Rubens as the forerunner of your family snapshots. Note, by the way, that this is not in any sense intended to demean the writers of chick-lit (if such a genre really exists in the first place); only to point out that Jane Austen was one of the few great geniuses of the English language and that her books are not about love-and-marriage anymore than Rembrandt's paintings are about trying to take photographs before photography was invented.

Here's an interesting question: Does Maureen Dowd herself write the kind of chick-lit she deplores? I rather suspect so, given her obsession of turning everything about politics into a teenage drama, replete with cheerleaders and burly guys playing football and rather nasty geeks who shouldn't get the girls. All this made me Google what else she may have said about Jane Austen and chick-list. This is what I found in a 2007 column titled "Heels Over Hemingway", a piece deploring the omnipresence of chick-lit, its pink covers turning bookstores into a sea of pink in which the testicle-driven Important Classics are drowning:

Suddenly I was swimming in pink. I turned frantically from display table to display table, but I couldn't find a novel without a pink cover. I was accosted by a sisterhood of cartoon women, sexy string beans in minis and stilettos, fashionably dashing about book covers with the requisite urban props — lattes, books, purses, shopping bags, guns and, most critically, a diamond ring.

Was it a Valentine's Day special?

No, I realized with growing alarm, chick lit was no longer a niche. It had staged a coup of the literature shelves. Hot babes had shimmied into the grizzled old boys' club, the land of Conrad, Faulkner and Maugham. The store was possessed with the devil spawn of "The Devil Wears Prada." The blood-red high heel ending in a devil's pitchfork on the cover of the Lauren Weisberger best seller might as well be driving a stake through the heart of the classics.

I even found Sylvia Plath's "The Bell Jar" with chick-lit pretty-in-pink lettering.

"Penis lit versus Venus lit," said my friend Leon Wieseltier, the literary editor of The New Republic, who was with me. "An unacceptable choice."

"Looking for Mr. Goodbunny" by Kathleen O'Reilly sits atop George Orwell's "1984." "Mine Are Spectacular!" by Janice Kaplan and Lynn Schnurnberger hovers over "Ulysses." Sophie Kinsella's "Shopaholic" series cuddles up to Rudyard Kipling.

Even Will Shakespeare is buffeted by rampaging 30-year-old heroines, each one frantically trying to get their guy or figure out if he's the right guy, or if he meant what he said, or if he should be with them instead of their BFF or cousin, or if he'll come back, or if she'll end up stuck home alone eating Häagen-Dazs and watching "CSI" and "Sex and the City" reruns.

Weirdly enough, Dowd in that column warns us all from confusing chick-lit with Jane Austen's love-and-marriage stories. I guess she has changed her mind about that.

But do you spot something else fascinating about those paragraphs I quoted? Do you spot one of the oldest tricks in the tool kits of us propagandists? Suppose that I wanted to make the reverse argument from Dowd's point. How would I accomplish that?

I'd pile the books in a bookstore into two imaginary piles, one consisting of Lady Murasake's The Tale of Genji, the books by the Bronte sisters, Jane Austen, Virginia Woolf and so on and the other consisting of potboilers written by guys: books all about killing other guys and about having sex with lots of women, with a few military cartoons and Superman stories thrown in. Then I'd compare what's in the two piles and conclude that bookstores are drowning all the important classics written by women in this horrible sea of testosterone, whatever its color might be. And that's the trick Dowd uses except in reverse: She compares the best of male authors with female authors from a genre that she dislikes.

Time now for a very different literary metaphor, one having to do with Charlie Brown, Lucy and the football. For those of you not familiar with this cartoon, Lucy repeatedly holds a football for Charlie Brown to kick, but every time she lifts the ball up at the last moment, causing poor Charlie to fall back after kicking into air.

Charlie never learns the lesson not to kick. Now replace Lucy with Maureen Dowd and Charlie with me and what do you get? A setup where every stupid column written by Dowd elicits an angry response from me, and that's exactly what the New York Times wants from their opinion columnists: The loonier the better! Bring them all in: Brooks, Kristol and Dowd! They can always be trusted to say something vile and nasty about womankind and that's how we like it here at the Gray Lady.

No wonder that Maureen Dowd as Lucy is one of their favorite girls. Just see how many people e-mail Dowd's columns to each other. Sadly, most of them probably feel like Charlie Brown, wishing that they could stop reading the dratted thing.

Sigh. Let's return to the idea of applying Pride and Prejudice to this election campaign, if we must. Who in the book is John McCain? Dowd suggests the wily Wickham, but I think a much closer model would be Mr. Collins, the boring and calculating clergyman with friends in high places. He was even quite a maverick, easily switching to a different woman when Elizabeth Bennet refused his courting.

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Saturday, August 02, 2008

My Day So Far (by Phila) 

I woke early, just like my hypervigilant ancestors did back in the Pleistocene. I considered getting out of bed, but then I realized that I ought to read for a while. After all, being able to display a wider range of knowledge than the next fellow could very well enhance my reproductive fitness.

I spent a pleasant hour with Baron Corvo's The Desire and Pursuit of the Whole, which he wrote in 1909 in order to advertise his health and virility to the wealthy dowagers of Venice. Afterwards, I decided to go downstairs and see how things stood on the Internet. While it may seem to you like a medium of communication, I see it as a battlefield. Yes, a battlefield! For it is there that I go to overawe my male rivals, and dazzle those members of the fair sex who strike me as adequate receptacles for my precious seed.

As usual, the conflict was ferocious. Supporters of Barack Obama sought to improve their chances of passing on their genes by defeating supporters of John McCain, who were hoping that associating themselves with a powerful, aggressive male would help them to attract mates. I waded boldly into the fray; with my help, the tide was soon turned, and McCain's supporters retreated as quickly as a frigate bird with an undersized chest pouch. A pleasant stirring in my groin told me I had done well.

My wife was tending to the garden, meanwhile...just as one would expect, given the typical division of labor among our ancestors. (I think she may have spent a little time on the Internet too, but if so, it was probably just to get tips on gardening, or knitting, or the menstrual cycle.) After making a mental note to knock her up, I turned my attention to the world of Science.

And that's how I learned that Geoffrey Miller of the University of New Mexico has solved the riddle of music (and, in so doing, made himself that much more appealing to prospective sex partners).

Here's how the whole business works:
[W]hy do we find musicians and singers so attractive? Looking at things from a biological point of view, we would normally expect women to be attracted to men with qualities that indicate good genes that can be passed on to her children or those that show he can look after a family, like a wad of cash for instance. Music doesn't seem to serve any practical purpose.

Musical ability, along with other creative skills, are rather like a human version of the peacock's tail; something that has no survival value, but has evolved precisely because it is found attractive by the opposite sex.
The gist of it is, men became creative in order to attract women. Women, by contrast, have learned to dabble a bit in the arts "because the ones that could entertain their men could keep them around to help raise the kids."

You'd think that'd be the last word on the subject. But male rivalry is as endlessly productive in science as it is in every other civilized endeavor, and so Miller has already been elbowed aside by John Manning of the University of Central Lancashire, who claims that "men who make lots of good music make lots of sperm" (thanks to testosterone), and that women accordingly flock to them like flies to dogshit.

If you question the logic here, consider these statistics, which certainly didn't come out of nowhere:
If men can advertise their prowess through music then we'd expect a lot more men than women to be making it. Manning points out that in a sample of more than 7,000 jazz, rock and classical albums, there were ten times as many male as female musicians.

Classical orchestras also show a preponderance of male musicians, but when Manning and a colleague looked at the gender ratio of the audience it was a different story. Those sitting closest to the orchestra during performances were much more likely to be female than male, lending support to the idea that the music might be serving some mate advertising function.
If experience is any guide, I may be taken to task for presenting too crude a picture of Evolutionary Psychology. But I think I have a long, long way to go before I'm as crude as some of its professional advocates.
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The Stranded and the Mobile (by Phila) 

An article in the Toronto Star argues that rising airline costs could signal the start of "a new, global class divide between the stranded and the mobile."
In Europe's late medieval period, the labouring masses rarely travelled further than a few dozen miles from where they were born. For them, travel was dangerous, onerous and slow.

But wealthy aristocrats travelled far and wide in the name of diplomacy, meeting leaders from other countries and extending their power and influence.
Of course, such a divide already exists, since air travel has always been beyond the means of countless people around the globe. The article's analogy between the late Medieval laboring class and the "U.S. leisure travel market" is problematic at best, as is its conflation of homeowners in Newfoundland with "the masses." But it's apparently preferable to discussing currently existing forms of strandedness, many of which are on display in countries that the leisure travel market advertises as escapes from the pressures of modern life.

To the limited extent that this reference to the late Medieval period is anything more than shorthand for some vague, ahistorical idea of privation, it's applicable to a sort of life that's not only being lived all around us, but is often held up as exemplary of progress away from poverty. In Sao Paolo, Brazil, shoppers take helicopters to department stores in order to avoid slum dwellers (whose opportunities are greater than ever, thanks to globalization). In China, the poor are being hidden behind makeshift walls, in deference to the aesthetic delicacy of leisure travelers. And here in the USA, we're contemplating building a border wall to restrict the mobility of migrants who are desperate enough to cross the Sonoran desert on foot (despite their excellent chances for advancement in post-NAFTA maquiladoras).

If anything, the attempt to draw some sort of equivalence between reduced access to air travel among the North American middle class and actual abject poverty is suggestive of the detachment from real suffering that was supposedly typical of Medieval aristocrats. Being forced to take a train or a ship instead of an airplane may involve hardships of one sort or another, but it's not the same thing as being "stranded," nor is it necessarily dangerous or onerous. And yet, we're encouraged to view people who have these options and others as "casualties" (but not, unlike the average ghetto dweller, of some inherent self-destructiveness in their culture):
If we are on the brink of a shift toward the local economies and lifestyles long advocated by antiglobalization activists, the transition will not be without casualties.
We'll just have to throw 'em on the pile, I guess.
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Mania Contradicens (by Phila) 

After responding to a dramatic decline in the population of cactus ferruginous pygmy owls by removing them from the Endangered Species List, and addressing the question of pesticide overuse by canceling the only government program that tracked it, the Bush Administration turns its gimlet eye on the problem of overfishing...and concludes that we need to give the fishing industry power to override the National Environmental Policy Act.
As written, the Bush administration’s proposed rule would undermine NEPA by severely limiting the public’s right to participate in fishery management decisions and even shutting out the public from future participation if they don’t weigh in during the initial round of public comments. It would also allow regional fishery management councils to control environmental reviews. Many of these councils are dominated by fishing interests and have mismanaged our oceans for decades. Additionally, the proposal gives fishery managers the power to make fishing decisions without adequately considering the impacts on other components of ocean ecosystems such as sea turtles, seals, corals, and other precious ocean life.
You can comment on the proposed NEPA rule here.
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Friday, August 01, 2008

Politics & the golden rule (by Suzie) 



         After the UU church shootings, Echidne and others discussed conservative media that fan the flames of political hatred. The question arose: If liberals don’t fight fire with fire, what do we do instead?
        As a journalist, I grew disgusted with colleagues who wanted to make issues black or white, with no grays. They presented “both sides,” not a multiplicity of views. The worst examples were on the op-ed pages.
        Simple is easier to do than complex. Plus, simplistic and outrageous stuff sells. As long as the public buys it, people will sell it.
        I like that Echidne is more likely to raise questions. Her civility stands out in a blogosphere where anger and ridicule rule. I don't want liberals to stoop to the level of the conservatives who say hateful things and twist facts. If we do right, will this change those doing wrong? I’m sort of doubtful, but I still want us to do right.
         I want to apply the golden rule to politics. (Not as a rule, but a guideline.) If I object to people demonizing me, then I better think twice about demonizing them.
        If I employ a certain strategy, I can’t complain about that strategy if it's used against me. For example, I’m happy to boycott most of talk radio and its sponsors. But I have to understand that conservatives also run boycotts of media that they consider harmful. I can