Friday, February 28, 2014

Left, Right, Center

For Ronald Reagan, most questions were simple, and there was a clear answer.  Likely, he was significantly in the grip of dementia even during his first term, and for many demented patients there is often a wonderful clarity; the world and it's contradictions becomes simple, and clear. For Mr. Reagan, the answer to all problems of poverty and lives lived and wasted struggling with economic deprivation was simple: The free market solves all problems. Should we bring the resources of the government to bear on the problem of health care? Let the market bring its ruthless efficiency to the health care system and provide the best, most innovative solutions to the lack of health care for the poor, the unaffordability of basic care for the struggling middle class, but do not allow the government to dictate solutions in health care because the scariest ten words in the English language are: "I'm from the government and I'm here to help you."  That was a very catchy line.  It implied Mr. Reagan had confidence in his audience to see the joke.  It became the anthem for the Tea Party, Rush Limbaugh and the far right. It had clarity.

The problem was, it was the essence of facile. It seemed so simple, it had to be wrong. And it was.

Free markets, the profit motive work are potent forces, but where in America is there a really free market?  Certainly not in health care. 

What Mr. Reagan's supporters mean by "free market" is allowing rich and powerful corporations who got to be rich and powerful with government help, like the railroads, the oil companies, the drug companies, to be allowed, by protection of law, to crush all real threats to their supremacy, once they had achieved a position of advantage.

On the other hand, Karl Marx's idea of government as the ultimate planner and force of justice has no clear model of success. The collapse of the Soviet Union was predicted by that brilliant examination of its practical weaknesses in Orwell's Animal Farm. Communists, socialists never successfully answered Orwell's argument.  

In fact, socialized medicine in England, Germany and France has worked much better than the American patchwork quilt of medical care. Obamacare, has, for all we know, improved healthcare for large numbers of people, but there is little in the free, competitive media to document this. 

There are certain public endeavors which simply are not amenable to the profit motive. Health care is certainly the most obvious example, but national defense, space exploration, water management, power distribution and infrastructure, like bridges, roads and air traffic control are areas where the profit motive may simply be antithetical to the business at hand: The public good in these instances is simply not served by the drive toward profit.

The problem is, nobody has yet come up with a catchy little line for the failure of the profit motive. 

The closest thing is Upton Sinclair's line, "It is difficult to make a man understand something, if his salary depends on his not understanding it."

Sunday, February 16, 2014

Military Uniforms: The Virtues of Humility

Dig the stripes on the pants
 Whenever the Chief of Medicine walked on the ward, a junior medical resident ran ahead of him and told all the interns, residents and medical students to pull on their white jackets. Ordinarily, these jackets were left hanging about on the backs of chairs or thrown on counter tops. In those days only surgeons wore scrubs; at The New York Hospital, housestaff (interns and residents) in the Department of Medicine wore white tunics with a blue New York Hospital patch on the left shoulder and white pants with the same patch near the beltline. After twenty hours on call, most of the tunics and pants were stained with blood, urine, vomit, stool and presumably, the sight of troops on the line looking disheveled  and stained would be offensive to the delicate sensitivities of the Chairman of the Department of Medicine.  
We didn't much care what the Chairman thought. He didn't know any of our names. He was not a clinician. He had worked in laboratories most of his career, was British and he did not make rounds with the interns and residents the way the chairmen of Neurology, Gynecology or Surgery did. What would he have had to say about a patient who presented with a fever or pulmonary edema?  He appeared on the ward rarely, and usually because some distinguished, that is, wealthy person had been admitted. 
Looking at the get ups of the current chiefs of staff of the Army, Air Force and Navy, The Phantom wonders what all those gizmos are supposed to say about the guy wearing them. 
Consider Ulysses S. Grant, commander in chief of the greatest American army in our greatest war, a war in which more Americans were killed than all other wars in our history combined.  Pretty simple uniform. 
Grant had once, as a young lieutenant ridden into town in a fancy uniform and was ridiculed by a stable boy for putting on airs. Grant never dressed up much after that experience, preferring a private's blouse to wear around camp. He didn't need a lot of shiny hardware to command respect. 
One wonders what the current get ups say about the compensatory psychology of our current commanders. If they need all those merit badges, do they really command respect?
Look Ma! I'm an Eagle Scout.


Tuesday, February 11, 2014

Obamacare: Slouching Toward Britannia

Yesterday, the Obama administration announced yet another fix to the nascent Obamacare healthcare program--this time delaying the requirement that businesses of a certain size, defined by the number of employees, could delay paying for health care coverage for their employees.

This can be seen as part of the normal process of government: A regulation is promulgated; affected parties complain, seek a redress of grievances and are accommodated. It works this way with farm legislation, with requirements for increased gas efficiency from auto makers--you name it.

But, in a larger sense, this is really a reflection of a basic flaw in thinking. Republicans, libertarians, conservatives of all stripes categorically rejected the idea that health care is an enterprise, a responsibility which belongs with the people or with its elected government. Healthcare, to Republicans/T party loonies/libertarians is a commercial venture, and is most efficient and best provided when the profit motive drives efficiency and innovation. 

President Obama and his party had no chance of getting even the first step of health care reform had they not conceded this point. What Obama was able to sign into law was a health insurance industry resuscitation act--a law which provided millions more customers for the health insurance industry.

Mad Dog, getting crustier and more ossified with each passing month, has long groused that America, when it comes to health care, is only now just catching up to where Great Britain was over 40 years ago.  When Mad Dog found himself in London as a fourth year medical student doing an elective, he was shocked and dismissive about what he saw as a second rate medical care system.  Patients were admitted to hospital and never seen by their primary care practitioners. Patients were cared for by hospital based physicians, who then returned the patients to their local general practitioners, with a report. 

When Mad Dog asked these patients when they expected their own doctors would be coming into the hospital to write their admission orders, the patients reacted in confusion. "What? You mean Dr. Jones? Why would he come here? He'll see me after I'm home."  

In America, the line was you wanted, nay, you needed to see the doctor who knows you best when you are in trouble, when you get sick enough to be admitted to the hospital. This was an article of faith among American physicians. Not seeing your own patient when he was admitted to the hospital smacked of "abandonment." It was part of that strong bond between doctor and patient. He is MY patient. I must arrive on my white charger and direct his care, protect him, defend him and be sure I steer him through the dangerous shoals of the American hospital.

It turned out, of course, this was a lovely story, but it was sentimental and not the best medical care. Having practiced in this system, once he graduated, Mad Dog quickly saw the dangers and problems with this system. Community hospitals often cleared out after 5 PM, with no doctors on the wards, patients left entirely in the care of nurses, who often spoke little English and were inadequate to their tasks.  Doctors, busy in their offices, could not come in to see their patients who had arrived earlier in the day, and so they called in "holding orders," for patients based on what the Emergency Room doctor who had seen the patients told the doctors who had not seen the patient.  Too many telephone calls from nurses ensued, too many doctors called in orders over the phone, blind.

When Mad Dog arrived in the hospital, he discovered Mad Dog's twenty-third law applied: Whatever you had been told over the phone, it was wrong.

The English hospitals were far safer, far better run in 1972 than the American hospitals were in 2000, until the American hospitals finally discovered and accepted the idea of "hospitalists," doctors who stayed anchored on the wards, able to go to the bedside, examine the patient, generate orders for tests and treatments based on what they could see first hand. True, they did not "know" the patients as well as the patients' family doctors, but they knew the acute illnesses very well and they knew what was happening in the immediate present. 

Hospitalists provided better care. 

There are a whole host of ways in which the National Health System of the United Kingdom, circa 1972  surpassed the care in the United States even 40 years later, from the use of midwives, the organization of superior home care following hospitalization, the rational restriction of extreme care for patients who would not benefit, to the use of blood products in the treatment of gastrointestinal bleeding. 

And all through those years, when the United States health care system was wasting money, providing inferior care and spending far more money than Britain doing all this, the Republican Party and the conservative voices all loudly proclaimed, "We have the best health care system in the world. People come here from everywhere around the world for the best care. Why would we want socialized, inferior medicine when we've already go the best?"

Of course, we might have had the best care for the top 10% of America's richest people (although Mad Dog doubts even that) but we clearly had inferior care for the rest of the 90% of American citizens.

And 2012, the Republican Party still blocked the path toward improving American healthcare, and the result was Obamacare, about which the Republicans still loudly complain and they plan to seize control of Congress in 2014, riding on the horse they have been whipping while facing its tail rather than its head. 

Saturday, February 8, 2014

Reasons to love the New Hampshire Seacoast

E. B. White wrote an ode to New York City and what made it great. Among the forces he noted was the "newcomers," that steady stream of people who gave the city its vitality, with all their enthusiasm for the place. 

The same is likely true of the New Hampshire seacoast. For Mad Dog, who grew up in the Washington, D.C. area, and then spent 8 years after college in New York City, the Seacoast has been a new love affair, and the bloom hasn't worn off after 6 years. 
In some ways, Mad Dog has got accustomed to the rhythm of life here and what seemed so charming at first--the fact that most Hampton stores closed down by 3 PM, Saturday and are not open Sundays, hearkened back to  the 1950's, when blue laws closed stores on Saturdays and forbade the sale of alcohol on weekends in suburban Washington. Moving to Hampton seemed like walking through a portal in a time warp; Mad Dog was back to a town like the one he had grown up in, frozen in time, 50 years ago.  Now, Mad Dog has got used to the laundry closing at 3 PM on Saturday and plans his morning to get things done early Saturday. 

It's really just fine, and it makes him feel good to know the shop keepers have Saturday afternoon off to go hike up Mount Major or to go surfing.

Some pleasures remain fresh: Reading the Police Log in the Portsmouth Herald.  Some of Mad Dog's favorites:  1. Responded to complaint from woman who said her neighbor called her "obese."  2. Took report from woman who said a young man with "nasty blue eyes" was harassing her while she was cross country skiing. 3. Took report from woman who said a man was following her in a car,  while he may have been delivering newspapers.
These reports, Mad Dog has it on good authority,  are not fictional. They are simply entered and logged in and the newspaper serves them up dry and without comment. 

Of course, Mad Dog would be world's happier if they closeddown the Seabrook nuclear plant. If ever Mad Dog packs up and moves to Maine, it will be because he is seeking a refuge from being at ground zero. When he moved up to Hampton from Washington, D.C., it was surprising the  number of his friends, who,  bidding him farewell, said, "Well, I don't know about New Hampshire, but at least you won't be living at ground zero any more."  And that cheered Mad Dog at some level. But then he discovered his house is about 2 miles, as the crow flies, from the Hampton Falls/Seabrook plant.

When Mad Dog was in middle school, a Congressman parent of one of his classmates gave a talk at a school assembly about the impossibility of hiding from the world and the problems which afflict it. This was 1960, before anyone every heard of "globalization."  He told the story of one of his friends who, tired of living at ground zero, moved to Idaho or Montana, one of those Western states with no people. And he built his home and felt, for the first time in years, safe. But then he drove by an isolated area fenced off with barb wire a few miles from his new home, only to discover it was home to a nuclear missile silo. So there he was, back at ground zero. 

 It made Mad Dog think of that poor man whose farm in Mananas, Virginia became a killing ground at the first battle of the Civil War. So he moved his farm south, to Appomattox, and 5 years later, the war found him there--but of course, that is where the war ended, so he was there at the beginning and the end of the greatest upheaval in American history.

Mad Dog has no ambition to be at the center of American history, at his age. All the movers and shakers he knew in Washington and New York brought to mind Dylan's words:
Princess on the steeple, all the pretty people
They're drinkin', thinking they've got it made.

Nope. They didn't.
People here, in New Hampshire may feel constrained some days. May feel the world is out there, throbbing, growing, doing and here we are in small towns, going to jazzercise on Saturday mornings, and dropping our dogs off at the Barking Dog when we go into Boston for the night. But the fact is, we can go into Boston--C&J connects us to Boston and Manchester airport connects us to the world, as does the internet and so now we can live in the boondocks and live our doggy lives and not be isolated.

Wednesday, February 5, 2014

Chris Muns to the Media: Do Not Bear False Witness

Howard Altschiller
Rep. Chris Muns

Alfred Dreyfus 

Chris Muns, a Hampton Democrat recently introduced a bill in the New Hampshire House of Representatives which would require news media to remove from their websites stories about individuals arrested for crimes if these people were subsequently acquitted.  
Mad Dog has not spoken with Mr. Muns about his thinking on this legislation, but on first consideration, the motivation must be to right a wrong committed against the accused, who was later exonerated. At first blush, this sounds like an acknowledgement that being accused of a crime of which you are innocent is a terrible thing. And the harm continues as long as your picture and the accusation and the report of the trial remains on the internet. At least in past centuries, the records would fade with memories, newspapers would be used for kindling and a person could put the whole experience behind him. Now, not so much. The internet is eternal. In fact, the problem on the internet is frequently distinguishing a report which is a decade old from one which happened today.

Howard Altschiller, publisher of the Portsmouth Herald, predictably, objected. His paper can report on an arrest, a trial, splash it all over the front pages and then simply not report the acquittal, or bury that story in the back pages. And he likes it that way. It's his right, guaranteed by the First Amendment, to say whatever he likes about anyone and to keep it out there.

Full disclosure here: Mad Dog is a lifetime member of the American Civil Liberties Union. Mad Dog applauded when the ACLU supported the right of the Ku Klux Klan to march through a Jewish suburb in Michigan with anti Semitic placards. (Best thing for a bad product is good advertising.) But Mad Dog has always been aware the ACLU, which supports Mr. Altschiller and opposes this bill, is absolutist about the First Amendment.  It is easy to be consistent and pure, when you are an absolutist, but the wisest course often lies in the middle. For the pure ACLU zealot, the man who cries "Fire!" in a crowded theater when there is no fire, has the right to do that. Not for Mad Dog; certain circumstances demand some restriction of the right to free speech if that right tramples on other important rights.

So Mr. Altschiller says it is important to put on the public record the accusation (the arrest and trial) and to keep it there, even if the outcome of the trial  is exoneration. What he is really saying is that in some cases the only punishment meted out to guilty parties is the arrest, the "perp walk" the photos of the accused in handcuffs, humiliated, shuffling with chains binding his ankles, and the trial. And if the jury votes not guilty, well, that's just the jury getting it wrong, but we can make that accused pay every day thereafter, by keeping his image on our website and keeping the accusation fresh every day, because we know he's guilty; judicial process be damned.

"O.J. Simpson was acquitted of second degree murder charges; George Zimmerman was acquitted of second degree murder and manslaughter in the killing of Trayvon Martin," he notes. Which is to say: They got away with murder, but as a newsman, I can keep after them.

But what of the unjustly accused and legally exonerated?  

Alfred Dreyfus is the  name which has become symbolic of unjust accusation and the harm  that can do.  Unjustly accused of treason, he was railroaded toward conviction, before it was overturned and it eventually became clear who the real culprits were and how Dreyfus was chosen as the fall guy because he was Jewish in a France where anti-Semitism was a fact of life.  

What of the man accused of a rape or murder he did not commit? Should he continued to be dogged by this suspicion because a newsman or a cop has decided he was guilty, no matter what the jury thought?

In a less dramatic way, Mad Dog has felt the sting of an accusation which has become indelible in the record. In 1975, Mad Dog responded to a Code Blue, ran up 8 flights of stairs to the operating room, where a man had gone into "complete heart block" when the anesthesiologist put him under general anesthesia.  Mad Dog placed a temporary pacemaker, trundled the patient off to the ICU, wrote a note and left the patient in the care of the ICU staff. Two years later, a sheriff showed up at Mad Dog's with lawsuit papers. The patient had died and the lawyers were suing anyone who had written a note in the chart.  For having saved the patient (temporarily) Mad Dog endured several years of depositions, trips to New York City, and small outrages connected with frivolous charges of ineptitude. From that day onward, every time Mad Dog applied for a license to practice medicine in a new state, every time he applied for hospital privileges, he had to write another essay about that lawsuit. 

So charges, false charges which cannot be put to rest, which continue to haunt you are a violation; they are an offense against the falsely accused. 

Mr. Altschiler cites the First Amendment, but there is also a Fifth Amendment, which says the accused shall not be "deprived of life, liberty, or property without the due process of law."  Can it not be argued the man unjustly accused has been deprived of liberty? We ordinarily think only the government can deprive a man of his liberty--by jailing him, but there are other ways to deprive a man of liberty without the government depriving him: The man who cannot apply for a job, who cannot walk into a bar or join a club because he is listed on the internet as an accused felon, or a sexual pervert, is he not deprived of liberty by unbridled freedom of accusation, unrestrained freedom of speech?

And then there is the Ninth Amendment: "The enumeration in the Constitution of certain rights shall not be construed to deny or disparage others retained by the people."  Which is to say, just because we haven't said so specifically, that doesn't mean the right to enjoy a reputation unsullied by judicially refuted accusations is not contravened simply because we haven't mentioned that specifically. 

You may say, there is another remedy, short of muzzling a free press: The man who was found not guilty can sue the Portsmouth Herald for slander.  But the bar for "slander" is rightly set high: You must prove the defendant 1. Published accusations he knew were false  and published these with 2. Intent to harm (malice of forethought)   and 3. Harm was actually done, specifically and how and how much.  Not likely that remedy is going to help many unjustly accused and found innocent. 

Mr. Muns is running for New Hampshire State Senate. He has taken on the media. He has not done this because he is a conservative who hates the media. He is not a conservative, nor even a card carrying liberal. He is simply thoughtful, and this bill is where his thoughts have led him.  It is not a politically smart move. 

As someone said in "The Wire":  "It's not a good idea to piss off people who buy printer's ink by the barrel."