Health Care

Probably nothing inspires more personal dread than the idea that ones health insurance is not secure. We are unique among the industrialized world, because we seem to be unable to insure our entire population. I have to agree with most of what John Kerry has proposed for our health care system. It might appear to cost more in the near term, but I think that it is difficult to predict lost time, earnings, ingenuity, and productivity from a chronically ill society. Another aspect of our collective consciousness is our reliance on tertiary or quaternary health care. We seem to dislike the idea of public health.

However, we have seen a highly successful public health campaign recently to reduce smoking both public and private. As a result, lung cancer deaths are being reduced. Obesity is another public health care problem not only in the industrialized world but in the developing world as well. We would do well to promote a healthier lifestyle for our population. It will require a great deal of collective will to work on a problem whose effects are not yet visible, but obesity leads to increases in high blood pressure, diabetes, and heart disease. All are currently major health problems that consume a large proportion of health care dollars. It will only get worse in the future if we do not address the issue now.

The ever increasing prices for prescription drugs add significantly to health care costs. There is no doubt that a delicate balance exists for the major drug companies in terms of the large outlays of cash that must be issued upfront before the success of a product is known. But, as consumers, we should have the ability to use safety tested generics and to import brand name drugs form other industrialized countries. This would slow the trend toward higher prices in this country, and it might end the tacit subsidizing of drug companies by US consumers because most governments place caps on drug prices that the US government does not.

Paperwork is a clear and definable mess for most health care professionals. Legions of administrators have been added to the system ostensibly to deal with the issue. But what is needed is a more extensive electronic filing system, a common insurance application form like the one used for residency programs, and a common insurance claim form. These changes would streamline the system and reduce costs in the future.

Environment

The current state of the environment has not been discussed with any consistency during this election, probably because there seem to be other more pressing matters to occupy our time. However, it comes to the heart of many policy decisions that appear more in the forefront. By the environment, I am not strictly talking about our national parks or recycling. While these are certainly important, I believe that the issue of energy - consumption, conservation, and acquisition are what we should be focusing on at this point. And we should be focusing on this issue in a global way. If we are at the forefront of innovations in energy policy, it will certainly help not only the environment but our economy as well.

Fossil fuels, the root of many of our policy evils. The way I see it, we have had a wonderful ride living our lives over the past 60 years or so at the expense of oil, coal, and natural gas reserves around the world, but the time is rapidly approaching when we will have to start reducing that dependence in a real way. As a society, we are going to have to start to think in the collective. How do our actions affect others? We consume a disproportionate amount of energy per capita. There are those who believe that we are currently approaching a milestone in oil production: the world has consumed half of all known oil reserves. Demand will outstrip supply. The question is, can we think in the long-term when it is hard to envision the consequences?

While the Kyoto accords are imperfect, they are the best worldwide effort to date. As such, we should support them while working on an improved version that expects countries such as China to accept their fair share of sacrifice.

It is inconceivable to me that the auto industry is allowed to produce vehicles that are built to get only 5-10 miles per gallon with 30 gallon fuel tanks. And worst of all, they are marketed in such a way as to make the middle-aged feel more rugged; as if one would be doing some heavy off road driving on the streets of Manhattan. Hybrid technology is currently the best that we have to offer, and it should be used more extensively. We should be giving the consumer incentives to purchase such vehicles, and we should be mandating that all vehicles produced by a specified date use the technology. Incentives should be given to the auto industry to ramp up research into hydrogen fuel cells, and the international community should also expect that vehicles sold worldwide use the latest fuel saving devices. Markets in Mexico and China are rapidly expanding their vehicle base, and cities such as Mexico City are already covered in smog.

Energy use at home is also a big issue. There was a recent article in the New Yorker that had a very interesting perspective on big city energy consumption. The author purported that cities such as New York actually used less energy per capita than the equivalent energy consumption if the population were spread out over a larger area. This is because New Yorkers are living in such a small area that they use more public transportation, the buildings are more energy efficient, and the population is more likely to conserve because they live in more cramped quarters. This makes sense intuitively. Cities such as Baltimore are very spread out. There is a poor public transportation system, and people have to drive everywhere. We should be investing in big city infrastructure and regional planning so that public transportation is an acceptable alternative for the city commuter. Only when it is a reality can we expect people to use their automobiles less frequently.

Home energy consumption needs to be transformed as well. We should be offering incentives for local energy companies to be expanding their interests into renewable sources of heating and electricity such as solar panels and wind technology. Hooking these home sources of electricity into the larger energy grid would allow local purchase and selling of energy credits if a home produces more energy than it consumes.

In the end, greater sacrifices will have to be made by all, and we will have to start thinking of ourselves as part of the global community more than we have in the past.

Quotes - October

"Those who wander are not always lost"


"Each friend represents a world in us, a world possibly not born until they arrive, and it is only by this meeting that a new world is born"

Secrecy

A revealing article in a recent issue of the Times. The New York Times > International > International Special > After Terror, a Secret Rewriting of Military Law

The Tibetan Snow Lion 

Iraq

Iraq, cradle of civilization.

I am feeling just a little deceived on this issue. And talk about waffling. There appear to be new reasons each week as to exactly why we invaded. Saddam was a 'bad' man, we are going after the terrorists before they come after us, there were WMD, he was trying to re-establish his nuclear weapons program, we are spreading democracy throughout the Middle East. Let's pick one and stick with it! I think that few reasonable individuals would argue with the invasion of Afghanistan after September 11. Clearly, a State sponsoring terrorist activity within its borders. But Bush has turned foreign policy on its head.

First, he abandons the anti-ballistic missile treaty, then the Kyoto accords, then the International Court of Justice, not to mention the United Nations. No one can argue that these are perfect agreements or institutions, but they are steps on a path toward multilateral engagement and problem solving in a collective. Instead we have a stated policy of pre-emption which allows us to use overt aggression as we see fit, because we know what's best. Or should I say, because George W. Bush knows what's best. I thought that blind trust in our elected officials went out the door with Vietnam and Watergate.

Unfortunately, now, what do we do? Some propose that we leave as quickly as possible. I think that this is probably a mistake. The best that could be hoped for in that situation is an uneasy three way alliance between Kurds, Sunnis, and Shias. The worst scenario would be civil war. It is going to take a long time to establish the institutions necessary for reasonable representative government, and thus, I fear that we will be involved heavily for the long-term. That does not mean that we should not get ourselves out as soon as possible, but it will require a massive international effort that understandably, is just not there right now.

Fighting terrorism. The thrust of much of our efforts overseas, but the most interesting point in this policy of ours, and one that is ignored by the administration, is that we are probably encouraging terrorist recruitment and activity. Terrorism flourishes under political instability and social unrest. Just the situation we are seeing in Iraq today. Maybe, we should not be promoting governments that are oppressive and maybe we should be looking for alternatives to our dependence on that one critical fossil fuel. Engagement and social change - these are powerful forces.

Here is an interesting article in The New Yorker - The New Yorker: Fact

Civics

Ah, Civics, a long lost subject, but with the election just 8 days away, it seems an appropriate topic. We have quite a unique electoral system, as is well known after the 2000 election, since it is possible to win the election without winning the popular vote. That is because, when we vote, we are voting for electors that meet in December and actually vote for the President. Originally, the individual with the second most votes for President became the Vice President, but this changed with the passing of the 12th amendment when separate ballots were instituted.

And I quote from the Constitution, "each state shall appoint, in such a manner as the legislature thereof may direct, a number of electors, equal to the whole number of senators and representatives to which the state may be entitled in the Congress." What is interesting about this process is the lack of explanation as to its implementation. So, interpretation comes into play. Should someone get all of the electoral votes if they win the popular vote, or should the votes be apportioned by the percentage of the popular vote received or district won. There is no wrong answer to this question. All methods appear valid, and all have been used by the majority of States at one time or another. Currently, most States use the winner take all strategy. There are only two that apportion the votes on popular vote percentage - Maine and Nebraska. This leads us to major point number one- the Constitution was created with interpretation in mind. You know my stand on strict constructionism.

This year, there is an initiative on the Colorado ballot to switch how they parcel out their electoral votes from winner take all to apportionment. What is not very constructive about this ballot initiative is that it will be enforceable with this election, which seems like changing the rules in midstream to me. It's fine to change methods for the next election, but why create an issue that will probably require review by the State Supreme Court at the very least. I think that it is inviting disaster. It is akin to Florida in 2000. Clearly a mess, and while the Supreme Court's ruling didn't make me very happy, they were within their rights to look at the issue. They are charged with reviewing federal matters, and I think that the election of the President qualifies. As you can guess, I voted for Gore by the way. Another issue that is really going to be watched is vote tampering. Not in the strict sense, but if allegations are true that there is organized and wholesale disqualification of registering voters because of their party affiliation, there is going to be a problem. Major rule number two- Do not screw around with the process while it's happening, it just makes everyone cranky.

Like P. Diddy says, Vote or Die

Let's here your thoughts.

In Memoriam-Steve Z. Miller, MD

Unfortunately, my original post was somehow deleted and is unrecoverable, so I will try to re-create it with some additions and/or deletions depending upon my memory.

As is now well known in the New York area, a colleague and early mentor of mine was killed in a commuter plane crash outside of St. Louis, Missouri on Oct. 19. He was on his way, with like minded individuals, to give a series of lectures for the Arnold P. Gold Foundation concerning humanism in medicine. It was one of his particular interests. He was a passionate advocate for that voice inside all of us that speaks to the intangible aspects of medical care. He believed that with work people could become more enlightened and that they could affect the lives of others in a positive way. I found out that he was only 5 years my senior. We are, in a sense, contemporaries, but he was well beyond me in stature. He was synonymous with our institution. Everyone knew Steve from the medical students on up to faculty in all parts of the hospital. His presence was everywhere. It is hard to imagine that he will not be walking the halls in the future, but he will be here for many years to come. Needless to say, the community of individuals who worked with Steve remains in a state of shock. We are a rather large, semi-dysfunctional family. He spent most of his adult life studying, teaching, and treating pediatric patients and their families in the same locale. I have chosen much the same path. It would be difficult to express my sadness to his wife and children, but hopefully, it is enough to let them know that I am thinking about them.

I have been thinking for a long time now about putting my thoughts down for discussion in the area of current affairs, both foreign and domestic. I am no expert, but there seems to me to be a dearth of voices in the medical community concerning the issues that affect our lives. Yes, we may make comments in the hallway or on our way to rounds, but careful discussion and analysis, in short, activism are rare. However, this is exactly why I went into medicine. I was inspired by doctors who had spent much of their careers caring for those in other countries with limited resources. They had to deal with politics and local custom as a matter of course, and they did this with relish. These early role models remind me very much of Steve. He was engaged, resilient, and he, too, had to deal with politics and local custom. So, it is with sadness but new found inspiration that I begin this journey no matter how shaky the start may be.

Thank you Steve.


I am attaching a link to the Gold Foundation so that you can see the work that they hope to accomplish - Arnold P. Gold Foundation

Also, don't hold back. Future writings will be my opinion. Let's here everyone's voice here.

Steve