Time for a Change

We are the last country in the world still using the English system of measurements. England gave up on it long since. (Even their currency is decimal now.) As a practical matter we buy our soda in liters, and our car mechanics use mostly metric tools. In the Carter administration, our road signs started using kilometers and miles, but Reagan cut that out in a hurry, along with the 55-mph speed limit.

But, if we are the last country in the world to use metric measurements of space, weight, and volume, we still have a shot at being first in one measurement advance. Let’s institute metric time. The French and Russian Revolutions brought us ten-day weeks for a while, but that didn’t last. Everybody has been tinkering with the yearly calendar for literally thousands of years, so that’s nothing new. But the second, the minute, and the hour are still linked inexorably to 60. Why? It corresponds to nothing in the natural world (like the week, but unlike the day and the year.) The Babylonians started it, and nobody has had the nerve to quit.

Well, it is, literally, about time. Why not a metric second, and minute, and hour? One hundred seconds to the minute, one hundred minutes to the hour, and—how many seconds to the day? That depends. Do we want to keep the length of our current second? It was arbitrarily chosen in the first place, but ditching it now could be messy, since it corresponds to a unit on the Atomic Clock, which has become the basis of the GPS system and a bunch of other important scientific and technological institutions. If we keep it, that’s 864,000 seconds to the day. Which breaks down into 8.64 hours per day.

The advantage to this system of measurement comes when we start calculating working hours versus leisure. Assuming we work (in current measurements) 10 hours a day, 7 days a week, that would, in the new system, come out to slightly less than a 25-hour work week! We are unlikely to arrive at that kind of arrangement using our current measures, so let’s grab it while we can!! That was what they promised us back in the Kennedy 60s, and finally we have a shot at it.

Red Emma

Why Are There Poor People?

Beck’s comment on my last post inspires this query. “[T]he existence of our poor,” says Beck, “emerges from a massively systemic problem with the way our political and economic systems are structured.” It also triggers my recall of an old album of comedian Bill Cosby about the joys of a college education, titled “Why Is There Air?” Cosby chats about the various kinds of people he met in college, from the philosophy majors who went around asking “why is there air?” to the athletes who knew perfectly well why there is air—it’s for blowing up basketballs.

Cosby, however, not having been a philosophy major himself, didn’t stop off and look at Aristotle’s multiple analysis of causality. There’s:

• The material cause: “that out of which”, e.g., the bronze of a statue.
• The formal cause: “the form”, “the account of what-it-is-to-be”, e.g., the shape of a statue.
• The efficient cause: “the primary source of the change or rest”, e.g., the artisan, the art of bronze-casting the statue, the man who gives advice, the father of the child.
• The final cause: “the end, that for the sake of which a thing is done”, e.g., health is the end of walking, losing weight, purging, drugs, and surgical tools.

So okay, the material cause of poverty is lack of resources. That’s easy. F. Scott Fitzgerald and Ernest Hemingway between them made it plain. The poor are different from us because they have less money, or none at all.

The efficient cause requires an economodicy (it’s a monstrous word, but I can’t think of a better one for justifying the ways of The Invisible Hand to man.) Maybe the Invisible Hand is the efficient cause.

The final cause: the perceived self-interest of everybody, I suppose.

The formal cause is the really difficult one, here. We tend to regard poor people as useless. In fact, they are anything but useless.

Let’s stipulate to two classes of poor people: the working poor and the begging poor. The begging poor are necessary as a spectre to frighten the working poor into continuing to work. If there were no homeless people or panhandlers, Wall Street would have to hire out-of-work actors to impersonate them. (In my conspiracy theorist moments, I suspect they did, at least in the early ‘80s.) Poverty gives people an incentive to work harder to make money for other people as well as for themselves. Without poverty, we would all be lounging in some Polynesian Eden, picking breadfruit off the trees and getting semi-dressed for the next luau.

And the working poor are necessary to do the things for which machines are still too expensive. In Saudi Arabia, where oil reserves have pretty much abolished poverty among native Saudis, they actually have to import an entire population of poor people to do their manual labor, mostly from Asia.

This explanation of the formal cause of poverty, of course, requires some entity to do the formulating. In economics, that’s a whole field of study in itself. The Invisible Hand? The Ruling Classes? I tend to the latter explanation, if only because I can’t get my mind around the notion of what an Invisible Hand can be planning. Yes, there are people in positions of power in our economy who consciously and deliberately see the existence of poverty as one among many implements creating The Workable Economy. That was, essentially, the thinking behind the developments that brought one generation after another of new workers into newly-created poor people’s jobs. First it was married women, to do the clerical work. Then it was teenagers, to flip burgers. Then it was former welfare recipients, now “reformed” into the private sector, to become temporary or part-time workers with no job security, even from week to week, and no benefits. Somewhere along the line, undocumented immigrants got into the act, to do anything American poor people wouldn’t or couldn’t do for the wages available.

Of course, most employers who pay poverty wages don’t actually like employing poor people. Poor people are fat, and ugly. They have lousy teeth and sometimes questionable personal hygiene. And they keep missing work, or being late, usually because they’re sick or their cars have broken down or somebody in the family has some dumb problem and can’t take care of it without help. Whenever possible, employers prefer hiring people who are middle-class by virtue of the earnings and assets of other family members, and who therefore won’t start living and looking like poor people simply by virtue of not having enough money. That is, the employer is looking for a subsidy from the worker’s family, in return for the inestimable gift of a job. If I show up at a Mercedes dealership with a bus token and assume that the dealer will stake me to the rest of the cost of the car, I’m pretty nervy. But an employer who pays poverty wages and expects the families of his workers to stake him to workers with the look and behavior and work habits of middle-class people is just being rationally self-interested.

Anyway, that’s why there are poor people. Beck calls this a problem with our economic structure. That depends, obviously, on what the economic structure is for. A case can be made that poverty is a solution, from some points of view.

Red Emma

Mean(s) Testing and Compassionate Conservatism

Most self-proclaimed conservatives who believe government has any legitimate role in alleviating poverty, believe that role must begin with means testing, that is, checking to make sure that any would-be recipient of government aid to the poor really is poor. They underline their case with horrifying references to “welfare queens” using food stamps to buy steak and lobster, and travelling to and from the welfare office in Cadillacs. The goal these compassionate conservatives claim to be aiming at is a reasonable one–let’s give scarce public resources only to the people who really need them. Even when public resources are more plentiful, they are still most effective when targeted to those most in need.

But the c.c.’s–who normally presume that all the consequences of any governmental program not aimed at killing the enemies of the people at home (police) or abroad (army) are unintended–seem to have lost their grip on this fundamental law as it applies to means testing. Means testing really does have unintended consequences. At least, one hopes they are unintended. (Oliver Stone probably thinks they are intended.)

First, the eligibility line for any means-tested program is always set at least a couple of notches below the income which would enable a person to purchase all of the goods and services supplied by such programs in the private sector. There is always a group of people in the middle, too poor for private health insurance but too rich for Medicaid, too poor to be able to afford a balanced diet on their own funds but too rich for food stamps, too poor to be able to afford the rent on a decent private-sector apartment large enough for the whole family but too rich for public housing, too poor to be able to afford a lawyer but too rich for Legal Aid. Naturally that group in the middle will direct their envy and anger, not upward at the legislative and regulatory bodies that set the eligibility standards, nor at the agencies that administer them, but at the people below them who do qualify. This too, we must presume, is unintended.

Second, the procedure for qualifying for such programs requires the applicant to supply humiliating and exhausting detail about his or her personal life, beginning of course with the public (or at least on-the-record) acknowledgment of being poor. Most of us would rather confess to having sex with an underage dead chicken than to poverty, these days. But the mere admission of poverty is never enough. Verification must be supplied: paycheck stubs, rent receipts, utility bills and so on. The official purpose of the ritual is to weed out ineligible applicants. But the effect is to weed out any of the eligible applicants who still retain any pride or still value their personal privacy. This mostly gets rid of applicants without dependents, since most of us will endure a lot more humiliation and intrusion to provide for our children and disabled or elderly relatives than for ourselves. Anyway, we know for a fact, and repeated studies have verified it, that nearly half of those eligible for governmental assistance to the poor either never apply for it, or drop out of the process in the very early stages. We have known it for well over 50 years. I’m with Oliver Stone on this one–we want it this way.

Third, once we have designated a program as being for “the poor” and no one else, no one else but the poor will have any interest in maintaining it, or administering it properly and effectively. Once a program has been labeled “for poor people only”, its days are numbered. Why should “we” pay for a program that benefits only “them”?

Most of us have lived with this situation so long that we respond almost reflexively, “But of course the people who need the programs can’t afford to pay for them–otherwise, why would they need them? And of course the people who pay for the programs don’t need them. The best we can do is appeal to their sense of generosity and charity. ” (We do that, of course, only after a concerted campaign to discredit those virtues.) But we literally cannot imagine any other way to distribute public benefits, except by putting the people who pay on one side of the Great Divide and the people who receive on the other, and making sure than never the twain shall meet.

Well, no, it’s not quite accurate to say we cannot imagine any other way. We have in our midst a program open to most citizens and residents of this great country regardless of their current resources, and paid for by almost all of us. It is the most popular government program in the history of this country. And it is currently under constant assault in a relentless effort to discredit, privatize, and ultimately destroy it precisely because, to most of us, until very recently, it was proof positive that government could do something useful in alleviating poverty without humiliating the beneficiaries of the program.

I am referring, of course, to Social Security. Until a decade ago, the closest thing to a means test for Social Security (or its younger brother, Medicare) was an earnings limit. Now, even that is long gone. And the compassionate conservatives–including even some “centrist” liberals–cannot stop fulminating at the thought that Bill Gates will someday be able to collect his $1,100.00 per month from the public treasury. Under current law, most of that $1,100.00 would actually be taxed away (although the value of Gates’ Medicare would not.) Most American senior citizens can live with that arrangement, because it spares them the necessity of confessing poverty and pleading for charity. But conservatives and “centrists” simply cannot swallow the idea of giving a public benefit to anyone without collecting the recipient’s dignity in return. Indeed, now that we have finally given up on the idea of privatizing Social Security, our main suggestion for “saving” it is to means-test it.

Most honest conservatives will come out and say that, regardless of where it comes from or what we call it, any aid to the poor from the non-poor is charity, and the poor should acknowledge that fact. Means-testing is one of the more effective ways of rubbing it in. Which might be acceptable, if we were willing to allow dignity to the recipients of our charity. If “poor” were not a four-letter word. If we did not, at heart, believe that all of us get what we deserve and deserve what we get. Or don’t get.

I prefer the Jewish tradition in its view of charity. To the extent that we have any resources, they come ultimately from the Holy One, Who makes all of us conduits for those resources. I like the approach of Maimonides, Writing in the 1200s in highly-urbanized Spain and Northern Africa, he is realistic, and perfectly willing to admit that there are phony beggars out there, people who claim needs they do not in fact have. The Holy One has allowed these fakers to exist, he tells us, to create a benefit of the doubt for people who refuse to give to beggars (Maimonides was realistic about those people, too.) If all the beggars out there were really destitute, he says, anyone who failed to give to one of them when s/he could afford to would be committing a grave sin. Since some of them are fakes, those who refuse to give are guilty only in proportion to the ratio of real beggars to phonies. Ultimately, he says, means-testing is the job of the Holy One.

Cynthesis

The Lotos Marketers

Is it weird or what, that a huge proportion of our law enforcement resources are dedicated to keeping one group of people from taking one set of drugs, and an equally huge proportion of our mental health resources are dedicated to making another set of people take another batch of drugs?  Sounds to me like a failure in marketing.  And that’s not even taking into account what the pharmaceutical establishment spends on direct advertising, to get yet another group of people to take yet another batch of drugs.

Psychoactive drugs have a lot of problems. For one thing, some of them are dangerous if not carefully monitored.  Most of them can be dangerous in combination with other psychoactive drugs, or other kinds of medication, or even some common kinds of food or drink.  There is no drug that works for everybody with a particular diagnosis, and there are some people for whom no psychoactive drug works.  But what makes it worse is that, even when a drug “works,” that does not necessarily entail making the patient feel any better.  Normally, we 21^st-century Americans expect a drug to be something you take when you’re feeling bad, and then it makes you feel better. But for people with mental illness, especially the manic phase of bipolar, a drug may well be something you take when you’re feeling absolutely terrific, and then it makes you feel awful, or at best, blah.  This makes medication compliance problematic.

Cocaine dealers have no such problem.  They have no marketing budget. They advertise only by word of mouth.  They don’t have to wine and dine physicians to get them to prescribe their product (though, if we are to believe Sudhir Venkatesh in Drug Lord for a Day, they do have to cultivate a structure of lower-level dealers.) They dispense their product to people who are feeling blah, or even worse, and the purchaser ends up feeling terrific for a while, and then really awful until the next dose.  Which pretty much guarantees that there will be a next dose.  Psychiatrists should be so lucky.

Cocaine dealers, of course, might have trouble getting their product past FDA (unless it has been around so long as to be Generally Regarded As Safe, which maybe it has.) Quality control in manufacturing is spotty at best, and the distribution chain may degrade the product even further.  But nobody has to stand over the cokehead to make sure the dose is properly ingested, or remind him/her to be sure to come back for the next one.

At any rate, what the manufacturers of psychoactive drugs obviously need is a pinch of cocaine or a spoonful of sugar or something to make those who take their products feel good, or better still, terrific, at least for the first few hours after taking it. (Yes, I do remember the intoxicant invented by sci-fi writer Robert Heinlein, which made you feel absolutely awful after drinking it in the evening, and the next morning you would wake up feeling utterly blissful. It was called, if I remember correctly, “Scrotch.”  Much though I respect a lot of Heinlein’s imagined futuristic products, most notably the water bed, I think Scrotch is a behavioral loser. Most people, especially those in search of a good high, just aren’t that good at deferring gratification.)

Maybe we just need to condition patients to associate taking their meds with something else really pleasant, like good food, or sex, or music.  Something, at any rate, more fun than having a social worker stand over you to make sure you’re really swallowing.  Or maybe we need to play tricks on  patients to make them see the medication as a reward (the way we condition small children to want candy by giving it to them when they follow the rules.)  “Eat all your spinach or you can’t have your meds tonight,” “Last one in the water doesn’t get meds,” or whatever.

Or maybe we should just sack all the psychiatrists and psychiatric nurses and social workers and replace them with drug dealers who know their job, and who, furthermore, don’t get paid unless the patients actually take the meds. This solves two problems at once, providing lawful and socially useful employment for drug dealers, and keeping psychiatric patients properly medicated. We could put all the disemployed shrinks and their flunkies to work in the newly expanded ObamaCare system caring for all the people who have finally gotten access to health care, thereby solving yet a third problem.  Tune in next week for the latest proposal to combine high-grade cocaine with a contraceptive. You heard it here first.

Red Emma

 

 

Starve and Shoot

How do you get rid of a mule when everybody else on the farm really likes it? First you cut out one of its daily feedings, then you cut back to food every other day, then every third day. By that time, the mule is so weak it can’t do any work at all, so nobody will blame you if you shoot it.

How do you get rid of a program (whether government, corporate, or TV) that people really like but you (one of the people in charge) really hate?  It’s easy.  You underfund it, understaff it, reorganize the caseload and the chain of command every four months or so, move it around so nobody can find it, and, in general, deprive it of all the things that made people like it in the first place. Then, when you kill it, if people notice its absence at all, they’ll just say good riddance, it had already jumped the shark anyway.

I have personally been involved in one such shameful episode (you may have your own) in our nation’s history, when the federal agency I worked for became the target of its own administration’s dislike.  That was how I found out that the administration, if it has any smarts at all, will not respond by firing everybody and shutting the agency down, because that’s expensive.  You have to pay severance and accumulated leave and set up COBRA payments and so on.  So instead, you just reorganize them every four months or so, which is just about the optimal length of time for people to have finally regained their competence and figured out where the copier paper has been moved to after the last reorganization.  A couple of rounds of this and everybody except the most hidebound and unimaginative careerists will quit on their own, one at a time, which is financially a lot easier to cope with than mass firings.

And of course, everybody has had the experience of not being able to find a favorite TV program as it gets moved around the clock and then replaced every other week or so by some kind of “special,” so that when it finally shows up again, you’ve forgotten most of the plot line.  If that doesn’t work, the producers just keep switching writers until the characters start sprouting multiple, and non-credible, personalities and the audience loses interest, which is mostly what happened to ER in its last couple of seasons.  Somebody who was a lesbian feminist in season 4 suddenly falls in love with her boss, gets pregnant, and becomes a stay-at-home wife-and-mother, and so on in season 6, then dies of cancer just in time for the finale of season 7, which, if the other characters are having similar gyrations, is probably the series finale too.

And then there’s the standard way bosses deal with high-performing employees they for some reason don’t like.  You change their job descriptions, or change their actual duties without changing their job descriptions; you move their cubicles to Outer Darkness, if possible you change their working hours—you get the picture.  And the hapless target of these behaviors, if s/he has never experienced them before, is likely to think, “If I can put up with this without letting my job performance deteriorate, they won’t fire me.”  Which is precisely the opposite of what’s really happening—they aren’t cr*pping on you instead of firing you, they’re cr*pping on you preparatory to firing you.  First they starve the mule, preferably until its performance deteriorates into total uselessness, and then they shoot it.

Red Emma

Health Care: the Reform Before the Reform

We’re hearing a bunch of different messages about what “health care reform” involves. Obama is now saying it means “health insurance reform,” which many of us have trouble with.  I have a very good auto insurance policy. It neither drives nor maintains my car.  But we all seem pretty clear that we want to cover everybody (or nearly everybody), and that we want to reduce the cost of both health care and health insurance. Whether these various goals are mutually compatible is a whole other question.

But there are things that we can perfectly well do before getting into the details of who is to be covered for what, and perhaps one of the most important is to solve the medical data problem.  Right now, your medical records are paper full of illegible doctor longhand, plus some transcribed and typed notes, plus X-ray films plus images from scans, EEGs, and EKGs.  Depending on your age and state of health, those records may fill a single folder, or, like Mr.Wired’s, be the thickness of the entire New York City phone directory. Furthermore, those records may be taking up space in the office of several different offices and facilities, because Doctor #3 wants to know what Doctors #1 and 2 found when they checked you out for hallux valgus, how they treated it, and whether the treatment worked, before she takes up where they left off. So she has had you send for all of the records from Doctors #1 and 2, and, when necessary, pay for the copying and shipping.  Copying, meaning the originals stay where they started out.  Most health care facilities have at least one room devoted entirely to record storage, sometimes a lot more.

Sometimes, not unreasonably, patients decide they want to keep a set of their own medical records.  This requires another set of copying fees, and another quantum of storage space.  In addition, it requires the patient to find someplace to store X-ray films (which are, essentially, photographic negatives with all their attendant storage problems, and furthermore are roughly four times the size of most paper documents and places to store them.)

BTW, in many other countries (Chile is the one I know best), the medical records are considered the property of the patient, who keeps his/her own set of copies and takes them from doctor to doctor as needed.  I don’t know whether the doctors in question make and store their own set of copies. Considering that doctors do retire, move away, and die, this approach has a lot to recommend it.  Indeed, these days, doctors move around a lot more than they used to, and tracking down one’s records after a few years can be really difficult.

So anyway, creating, maintaining, storing, and transmitting paper medical records is expensive.  Regardless of what happens with the more global aspects of health care reform this year, we could cut medical costs a lot by digitizing the records.  Many practitioners do that now.  My orthopedist puts my X-rays on his computer monitor, where he can zoom in on areas of particular interest and show me utterly cool and fascinating things about them.  He can also email them to anybody who wants them. But his software may or may not be compatible with that of my physical therapist.  That’s where the Reform Before the Reform comes in.
We not only need to digitize medical records, we need a standard system for doing so, so that this information can be readily transmitted to anybody with a bona fide need to see it.  We could, of course, just wait till Microsoft crams their version (which they are undoubtedly working on in some cellar in Seattle) down everybody’s throat.  And in the meantime, health care providers who have committed their resources to some other system will of course be out of luck.  VCR vs Beta, anybody?

Health care is more important than home movies.  It’s important enough for the government to play a role in deciding on a digitization standard.  Presumably the National Institutes of Health would be the place to start.  But obviously the real world of private medicine has to be involved as well.  AMA?  There may be some professional organization of medical IT specialists with contributions to make as well.  Ideally, the private side should be getting together to formulate its standard, which the NIH boffins can then examine for obvious and not-so-obvious glitches.  Mr. Wired suggests that unless the glitches are deal-breakers from the point of view of NIH, their critique should be kept out of the process, or a very minimal amount of tweaking done to produce a workable product.  That product, with recommendations from the private sector and NIH, should then be forwarded to the Surgeon General for his rubber stamp.  Probably the resulting system should be open code and licenseable to everybody who wants it. After a reasonable period of time (5 years or so), all government agencies that deal with individual medical records can legitimately require that they be digitized in the Standard Format, whatever it may be, and then, probably, everybody else will follow suit.

Within ten years, the system will have eliminated at least half the paper storage space (I’m assuming that the original originals will continue to be kept on paper, as a backup), and most of the costs of transmission and copying.  As an additional benefit, that digitized information can be made available almost instantly on demand for emergency responders.

Obviously, such highly personal records will need to be kept under varying levels of security.  One level for emergency responders, another for primary care providers, maybe another level for insurers, and so on.  Which is a lot easier to do (and where necessary, undo) digitally than on paper.  A person’s entire medical record could be kept on a single memory stick, and the emergency provider portion of it, probably, on a chip the size of the one embedded in my cat’s back to identify her if she goes astray.

No matter what else happens to the health care system over the next decade, this single advance can cut costs and improve care by significant amounts.  I don’t offhand know whether any other country has done this yet.  I know that various providers are doing it locally. The Veterans Administration is working on it.  But universality is more important here than anywhere else.  I welcome comments from the docs here, and anybody else with specialized knowledge to contribute.

CynThesis

The Velvet Floor

or Benefit of Clout

Michael Vick’s rehabilitation pops up in the moral/religious blogs a lot these days.  It raises a lot of issues.  Like, who deserves a second chance? A second chance at what?  Is a professional athlete a role model, and if so, what are his obligations?  What about “morals clauses” in actors’ contracts?  What is forgiveness, and who is entitled to it?

I’m trying to dodge most of those questions right now, and deal with the one that gripes me most—the velvet floor.  That is, when ordinary people like you and me mess up, generally speaking, that’s the end of us.  If we get busted for felonies, we will do our time, and we will next be seen greeting customers at Wal-Mart or waiting tables at Denny’s, if not panhandling on the street or living in seedy Section 8 apartments on our Social Security benefits.

But when somebody rich or important gets busted, for just about anything short of first-degree murder, in the first place s/he is likely to do only minimal time in a reasonably decent institution. And upon getting out—well, junk bond fraudster Michael Milkin served his 22 months, and was then released to a halfway house where he was required to pay $1,300.00 per week for his room and board.  This was in 1993, when nobody I knew personally even earned $1,300.00 per week, much less lived anyplace where that was the cost of room and board.  And then there was Martha Stewart, who did 5 months in, and redecorated, a relatively decent women’s federal joint in West Virginia, and then returned to her $16M estate on Long Island to complete her sentence with house arrest.  Now she has paid her debt to society and is back running her enterprises and living the gracious life.  And now, Michael Vick is back on the street, reinstated in the NFL, and signed to a multi-million dollar contract.

OTOH, O.J. Simpson is in prison. Reportedly the institution is one of the newest and smallest in the state of Nevada, but he is in there for between 9 and 33 years, and, unlike Milkin, he is not in a position where he can talk his sentence down by giving information to the government, which already knows everything it wants to know about the original crime.

But that’s where Benefit of Clout comes in.  It’s analogous to Benefit of Clergy in the Middle Ages.  Remember?  That’s what Henry II and Becket fought over.  Becket won, though at serious cost to himself.  As a result, if you were a cleric (a status which, at that time, could range from archbishop to a merely literate male) and got busted for a first-time offense, your penalty was to lose your clerical status.  Kind of like Simpson lost his Public Image after being busted for the murder of his wife.  After the SECOND offense, you would be treated like any other criminal.  Like Simpson, in fact, after his hare-brained extortion, robbery, and kidnapping scheme.

Closer to home, my former alderman, who got busted a while back for taking a bribe, is now out of prison and making good money in real estate (or as good as anybody in real estate makes these days.)  I liked him; I felt bad when he went to prison.  But if I had done the same thing, I would probably still be behind bars. And when I got out, I would have nothing but my Social Security.

I’m not saying that Michael Vick SHOULDN’T have been reinstated in the NFL and signed by the Eagles.  Presumably he’s still a good football player, capable of doing the job he has been hired for.  His conviction was not for anything that impacts on his athletic performance.  Apparently he kept in shape while behind bars.  I’m just pointing out that the benefits of wealth and influence survive all kinds of public bad behavior, at least the first time around.  And maybe we need to think about whether they should.

Red Emma

It All Started With the Witch Doctor

Since our Fearless Leader wants more stuff on health care, I’m contributing an abbreviated version of my first lecture in a course I occasionally teach, called “Professional Standards for Mental Health Workers.”  It has a heavily historical/anthropological slant, since my students, though highly competent and hard-working, generally have a lousy background in history, which I feel puts them at a serious disadvantage.

Let’s start with the premise that all professions are priesthoods, and all originate with healing the sick.  Terms like “witch doctor” and “medicine man” point clearly in this direction.”  “Medicine”, in Native American religious tradition is a synonym for “religious ritual/power.”  Like most pre-industrial medical traditions, it is based on the assumption that “sickness” can arise from or affect the body, the intellect, the emotions, and the spirit, in varying combinations.  Among the Navaho, for instance, many illnesses are believed to result from “sleeping with kinfolk,” contamination from proximity to corpses, or witchcraft–that is, the improper behavior of the patient or somebody else.

So the “medicine man” has to know things about the patient that the patient would  never want to become public knowledge. The patient will submit to treatment (and pay the doctor) only if the confidentiality of that information can be guaranteed.

Arthur C. Clarke, the science fiction writer, says that any technology we don’t understand is for all practical purposes magic. Healing the sick has always been one of the major attributes of divinities and their priests/shamans—a much more useful form of miracle than making water flow uphill or rods flower or whatever.  The ability to heal implies POWER, which is scary to those who lack it.  It implies, specifically, four kinds of power:
 power to heal
 power to withhold healing (“I don’t like you, or your brother killed my brother, so I won’t set your broken leg, nyah nyah nyah”)
 power to kill (anybody familiar with herbs knows poisons and abortifacients as   well as healing herbs)
 power derived from knowledge (about the natural world and about the patient–unavoidable access to confidential info) (imagine a delirious patient raving about a passionate interlude with a person to whom s/he is not married, for starters.)

So most cultures generate some kind of code for their priests and healers, to restrain this power and keep it channeled in paths likely to be useful for the culture as a whole. In this lecture, I assign the students to ask any professional or skilled craft person they meet during the week about the professional ethics of that craft, and get written documentation if possible.  I have gotten some fascinating samples: taxi drivers, sexual surrogates, veterinarians, child care workers, chefs—a long way from the Hippocratic Oath, which I generally see as the Ur-Document of its kind.  But they all have pretty much the same restrictions in common:
 Restrictions on use of knowledge and information
 first, do no harm:  for instance
 no poisons;
 in some cultures, no abortifacients
 no exposure of patients’ secrets (no blackmail)
 No favoritism in use of skills and knowledge, which must be made available to all, regardless of personality, affiliation, or resources
 No “overreaching”–using rare and necessary skills to extort undue recompense (pecuniary, or, for instance, sexual favors) (The course, naturally, has a whole lecture devoted exclusively to the issue of sex with patients/clients, which seems to be a problem for every profession with the possible exception of accountants, engineers, and veterinarians.  We’ve been blogging about Fountainhead lately, so you know it’s an issue for architects.)

The lecture then goes into a wildly condensed and popularized history of medicine, which I figure the various docs here are perfectly capable of providing us far beyond my poor amateurish power to add or detract.  The point of it, however, is not what technology and information has become available at various points in our history, but how we use it. Thus, it’s important to keep in mind that there is a big difference between:
(1) what we can conceive  of doing
(2) what we can actually do
(3) what we are  actually doing
(4) what most people actually have done.

These days we pretty much presume that we can develop any technology we decide we want to develop. The areas of cosmetic medicine, infertility treatment  and organ transplantation seem to be where we have actually decided we want to develop technology.  Economics is probably the driving force behind these choices.  Doing things people want is almost always more profitable than doing things people need.  It took medicine a while to come up with serious work in the former area, but now medical science has clearly taken that ball and run with it.  More about this later.
At the same time, mental health issues, which seem to be more and more salient as a source of real social problems, are being offered less and less attention from everybody except the drug companies.  This is probably economically driven too.  Drug companies can make lots of money in large gobs, while the more labor-intensive methods of treating mental illness dribble out the money in tiny drips to lots of people. .  The things psychotherapy can do–usually over long periods with close attention–are miles away from what most psychiatric patients actually get.
All of the chapters of the history of medicine exist in the US today, side by side, like the rings on a tree.  There is a ring in which sickness is still believed to result from the patient’s improper behavior (these days, we have given up on policing health in the bedroom, and taken up jackbooted thuggery in the dining room instead, but the results are the same.)  There is another ring in which the most drastic intervention is the most highly regarded (especially in the treatment  of cancer, where chemotherapy does a lot of the same thing that purges and bleeding used to do–the Ben Tre “destroy the village to save it” theory of medicine.)   There is a ring in which the doctor’s job is to keep the patient comfortable until nature takes its course (that’s what hospice care is all about.)  There is a ring in which medicine actually works, like a well-run car repair shop.  And finally, the local “wise woman” is still around (herbal shops and healers in Chinatown, Hispanic neighborhoods, and New Age enclaves, etc.)

The economics of medicine work differently in each of these rings.  Undoubtedly, whatever finally comes out of Congress (if anything) will not be fine-tuned to these distinctions.  Probably we should be looking for a minimalist and mostly-preventive approach: make sure everybody, regardless of ability to pay, gets vaccinations, wellness counseling, treatment for infectious diseases, mental health care, and palliative end-of-life care, and let the Almighty Free Market do everything else. Mental health care, BTW, should be required to include some treatment for whatever DSM-V calls the compulsion to scream and shout disruptively at public meetings.  Without it, our democracy cannot survive.

CynThesis

Do Americans Watch Too Many Hospital Shows?

Watching Marcus Welby may have led Americans of a Certain Age to expect house calls and long conversations with their doctors.  Watching ER may have led younger Americans to expect a lot of noisy rapid action.  Watching Grey’s Anatomy or General Hospital may have led many of us to sneak a peek into supposedly empty hospital rooms in hope of catching younger medical personnel in flagrante delicto.  Popular culture undoubtedly shapes our expectations of the health care system, for better and for worse.

Age, class, and gender play their part, too.  Younger males, especially blue-collar men, want as little contact with the health care system as possible.  Real men don’t go to doctors and don’t take meds.  Real blue-collar men watch ESPN, which rarely deals with medical issues other than the ingestion of illegal substances by professional athletes. Naturally, this tends to make doctors, when seen at all, the bad guys.

Women generally get stuck functioning as the designated interface with the health care system on behalf of everybody else in the family until they are old enough to need somebody else to handle those duties on their own behalf.

Middle-class, educated, white-collar Americans have higher expectations, because in addition to watching Private Practice and Hawthorne, they read Scientific American and the Health section of the daily paper.  Which leads them into the same trap we collectively fall into:  losing track of the distinction between what we can imagine being able to do, what science has worked out the how-tos for but not implemented yet, what elite medical care can provide if paid enough for it, what is actually being done in the majority of American facilities, and what poor people can get if they’re really lucky.  The popular culture culprit here may not be a hospital show at all, but CSI and other purveyors of gee-whiz technology.  In an earlier generation, we didn’t have so much trouble realizing that Dr. McCoy’s scanner was a couple of centuries away. Today, we rarely think about the fact that the various non-invasive technologies for imaging and surgery  that we really do have available now are EXPENSIVE.  ER was pretty good about discussing the financial facts of medical life where they were relevant to the plotline, but of course, in an emergency room, the law requires every bona fide emergency patient to be treated regardless of ability to pay, so the issue didn’t necessarily come up until much later, usually long after the show was over.

Quite possibly what popular culture and the health care system should be working on together is a medical version of Car Talk.  You know, that Public Radio show on which, every Saturday morning, two Italian-American mechanics (both MIT-educated, and one of whom has a PhD, so much for blue-collar credentials) take questions from listeners nationwide about the foibles and failings of cars and mechanics.  They have a pretty healthy and realistic attitude toward both.  Cars are mortal.  All cars eventually disintegrate and die.  Mechanics are fallible and sometimes greedy.  Car dealers and their repair and maintenance facilities are not necessarily much better.  But most of us can keep our cars running for well over 100,000 miles by paying attention to telltale noises (Car Talk makes me wonder if good hearing and possibly even perfect pitch are Bona Fide Occupational Qualifications for a car mechanic), tending to routine maintenance regularly, and not doing Really Dumb Things.  Some car problems are Really Dangerous, and some are just trivial or unpleasant.  Check with your mechanic to see which is which, and don’t hesitate to get a second opinion when the first one doesn’t sound right. Since most of their calls involve cars over five years old (that’s forty-five in people years), they have no gee-whiz technology to call upon, just basic grease-monkey stuff.  [Cars with GPS and rear view cameras are still brand new and under dealer warranty, so the Car Talk Boys never hear about them.]

This is precisely the level of technology most of us need to hear about when our bodies act up, except that we don’t usually give off telltale noises (other than the stuff stethoscopes listen for, which was probably a much larger part of the practice of medicine seventy years ago.)  Unfortunately, doctors are mostly too nervous about getting sued to offer medical advice to strangers on the public airwaves (note that the Car Talk Boys never issue any disclaimers about their advice. Is this because so far, most of us don’t sue our mechanics?)  There should be ways to work around this.  Because, at least until we start heading into the Geezer Years, most of us think of our bodies pretty much the way we think of our cars: we just want to keep them running reasonably well at reasonable cost for as long as possible.  We want our doctors to function like good car mechanics.  Mostly, we want them to specialize in doing things we mostly think we could do for ourselves if we wanted to take the time and trouble, but it’s easier to let somebody else do it.  We want hints on how to do some of the easy stuff for ourselves, and then we just want to leave the complicated stuff to them.  If we could drop our bodies off at the hospital and come back for them later, most of us probably would, especially if we could get a suitable loaner in the meantime (Here’s a slightly used Mel Gibson, shouldn’t give you any trouble, but it’s only got a quarter tank of gas, be sure and have dinner on the way home tonight…)

And in the Geezer Years, we probably don’t expect what the medical establishment seems to think we do.  We don’t want to live forever. We just want to keep functioning more or less normally for as long as possible. We don’t want to fight as long as possible.  Whose idea was it to depict medical intervention in terms of combat in the first place anyway?  These days, a lot of patients regardless of gender seem to buy into the model, but I suspect that’s mostly because they are made to think they ought to.  I know the denizens of That Other Blog will say I’m pushing euthanasia or assisted suicide or something, but I think if the medical establishment were willing to tell patients it’s okay to give up or give in beyond a certain point, a lot of people would, thereby sparing themselves a lot of unnecessary pain and perhaps also cutting down on the enormous proportion of lifetime health care expenditures that is now spent in the last six months of life.    Nurses are often better at talking about these realities than doctors, and maybe they should be encouraged to do it more often.  It is their primary job, after all, to care about how the patient feels. Maybe hospital chaplains should be recruited for these discussions too; they are mostly connected with faith traditions that tell us the soul is more important than the body, after all.  Doctors, on the other hand, tend to see themselves as the patient’s designated champion in the combat against death.

Well, enough of awkwardly chosen metaphors (a man’s reach should exceed his grasp, or what’s a metaphor?)  Now that Obama has started talking about what used to be health care reform as health insurance reform, we will need to start looking elsewhere to change the health care system.  Stay tuned for The Body Talk Boys, Mark and David Welby, and don’t eat like my brother.

CynThesis

Revisionist News

or, The Sanford Hypotheses

In deference to a friend of mine who used to work for the Appalachian Mountain Club (http://www.outdoors.org/), I am hoping to revise the commonly accepted view of what Mark Sanford was doing over Independence Day weekend, to forestall the snickers one currently hears whenever the phrase “hiking in the Appalachians” comes up.  The Appalachians are a beautiful place and do not deserve to have their reputation thus sullied.

In fact, it is entirely possible that the Guv really was hiking in the Appalachians at the beginning of that weekend.  And then, he was abducted by

UFO aliens       )

Communists      )    pick one

Terrorists          )

who flew him to Argentina and dumped him in an inappropriate bed for purposes of public embarrassment.  Obviously, Sanford and his staff were dealing with the only thing that would have been more embarrassing than a tryst in Buenos Aires—a kidnapping by critters most of us don’t believe in.  Give it a thought.

Red Emma

The Bennigan’s Index, July ’09 edition

The latest victim of The Economy here in Chicago is the Symphony Store, where Chicago Symphony memorabilia are sold on the first floor of the Symphony Center.  It now has a “closing” sign out front, alas.  On the other hand, it is located right across the street from our local Bennigan’s, which has reopened!!

On yet another hand, the Spertus Institute of Jewish Studies recently moved into a super-fancy bespoke building (is that the proper term?), and has now closed down most of it, allegedly until the economy improves.  Times are hard even in the nonprofit sector.

Jane Grey

More Haste, Less Speed

Mr. Wired and I have long accepted that “rush hour” is in fact the slowest time to get anywhere on most roads.  Now we are also adjusting to the fact that, if you have a medical emergency that needs immediate attention, the “emergency room” is the last place you want to go for that attention.  The last time we did, in April, we were there for 10 hours before even being triaged. If you are visibly bleeding from an artery or a bullet wound, the staff may take more immediate notice, but anything else, no matter how acute and alarming the symptoms, will run you into double-digit waiting times, at least on the South Side of Chicago.  Not sure whether this is a deliberate policy to discourage use of the ER for anything that does not require transportation by ambulance.  Any ideas from the docs among us?

CynThesis