Ed Felien : Komen and Cancer: Cause and Effect?

These women are protesting the Komen Foundation's defunding of Planned Parenthod -- later retracted -- at headquarters in Dallas,  February 7, 2012. But there may be other reasons to say "Shame on Komen!" Photo by Rex C. Curry / AP. Image from PBS.

Komen Foundation:
Is the 'Race for the Cure'
actually a 'Race to Obscure'?

Even more troubling than the revelation of their right-wing anti-choice agenda was the realization among many critics that principal sponsors of the Race for the Cure produce or use products that actually cause cancer.

By Ed Felien / The Rag Blog / April 18, 2013

MINNEAPOLIS -- Last year the Komen Foundation, the chief sponsor of Race for the Cure, pulled $700,000 in funding from Planned Parenthood for breast cancer screening and service grants as part of the right-wing attempts to defund and destroy Planned Parenthood. A storm of protest forced them to retract their move and apologize to Planned Parenthood, but damage to their brand may have already been done.

But, even more troubling than the revelation of their right-wing anti-choice agenda was the realization among many critics that principal sponsors of the Race for the Cure produce or use products that actually cause cancer. A race for the cure might be a way to run away from an honest disclosure of the causes of cancer. A Race for the Cure might just be a Race to Obscure.

The national Komen Foundation Partners include American Airlines, BMW, and Ford Motor Company. In an article, “Relationship Between Genetic Damage from PAH in Breast Tissue and Breast Cancer,” F. Perera and others in Carcinogenesis, July 2000, say Polcyclic aromatic hydrocarbons (PAH) are widespread environmental contaminants that are generated by gasoline and oil combustion and also are found in cigarette smoke and broiled meat. In lab experiments, PAH cause mammary cancer in animals.

Another Komen Foundation Partner is OxyChem. They manufacture bonding resins, chlorine, polyuerethane chain extenders, and solvents. The American Journal of Industrial Medicine in 1991 noted that breast cancer mortality was 1.64 times higher among pharmaceutical workers and 1.51 times higher among electrical equipment manufacturing workers who are often exposed to high levels of solvents.

Last year one of the local platinum sponsors was C. H. Robinson, a freight forwarder that used mostly diesel powered 16-wheelers to transport 11.5 million shipments. But diesel fumes cause lung cancer, the World Health Organization declared in June of 2012, and experts said they are more carcinogenic than secondhand cigarette smoke. “There is a clear association, a causal role, of diesel engine exhaust, particularly with lung cancer in humans,” according to Dr Kurt Straif.

Over 10 years ago, the Minneapolis Women’s Cancer Resource Center sponsored "The Toxic Industry Tour -- Stop Cancer Where it Starts." Their first stop was the downtown garbage burner because of its dioxin emissions. From their report:

The Hennepin County Incinerator located in downtown Minneapolis emits dioxin, which causes cancer. Dioxin is a by-product of burning chlorine-based products such as #3 polyvinyl chloride (PVC) plastic in children’s toys, bottles, and paper and wood products. Plastic wraps such as Saran Wrap are particularly toxic.

Dioxin is a known carcinogen as classified by the U. S. EPA. Dioxin is the most harmful substance known to humankind. The U. S. EPA Dioxin Reassessment Report issued after years of study found dioxin to be 10 times more harmful to human health than originally reported.

Municipal incinerators like HERC are the major air polluters emitting dioxin, followed by hospital incinerators. The pulp and paper making industry is another major polluter of the air and rivers and ultimately fish and humans.

The most common form of dioxin is a byproduct of the bleach used to make paper white. When that paper is burned, dioxin is released. Winona LaDuke wrote in The Circle, in August 2001, “With the help of new sophisticated tracking mechanisms, it is found that the residue of our own garbage is what is in the breast milk of Alaskan women.” Of the top 10 sources of dioxin in the breast milk of Inuit women in a remote Canadian village, two came from Minnesota.

In their pamphlet “Dioxin Phase-out -- Why we can’t wait,” the Women’s Cancer Resource Center says,

Most Americans get 280 times the EPA’s "safe" amount of dioxin daily. We’re exposed to 95% of the dioxin through meat and dairy products. That’s because airborne dioxin coming from incinerators or factories can travel 1,000 miles, settling onto plants, soil and water. Grazing animals eat the plants and store the dioxin in their fats and internal organs. As we eat full-fat milk, cheese, or fatty meats or fish, we take in dioxin.

Hennepin County Environmental Services says it does the following with:

• Poison, such as pesticides, insecticides, etc.  ("incinerate them at very high temperatures")
• Corrosive products (acids and bases), such as lime remover, oven cleaner, etc.("these wastes are incinerated")
• Flammable solids, such as adhesives, driveway sealer, roofing tars, etc. ("high temperature incineration")
• Oxidizers, such as bleach, hardeners, etc. ("high temperature incineration")

Incineration doesn’t get rid of the problem, it just puts it into the air.

The Toxic Industry Tour made two other stops.

They stopped at the corporate offices of TruGreen-Chemlawn because the company uses dicamba, a known carcinogen, the organochlorine 2,4-D (the same compound as Agent Orange sold as Trimec). The National Cancer Institute found children are 6.5 times more likely to develop leukemia if their parents used pesticides.

They stopped at Koch Refinery because they emit benzene. Benzene is the same carcinogen in cigarettes. The company has since seen fit to comply with Minnesota Pollution Control Agency regulations and stop their emissions.

Carol Johnson, the environmental program coordinator at the Women’s Cancer Resource Center, said in 2006, “In 1940 1 in 20 women had breast cancer; in 1972 it was 1 in 14; today it is 1 in 8. Are we willing to accept 1 in 4? Because that’s where we’re headed.”

Barbara Ehrenreich, speaking about the Komen Foundation and Race for the Cure in a speech at the 2002 Breast Cancer Action Town Meeting, said: “While they want a cure -- we ALL do -- they say almost nothing about the need to find the CAUSE of breast cancer, which is very likely environmental. This omission makes sense: Breast cancer would hardly be the darling of corporate charities if its complexion changed from pink to green.”

[Ed Felien is publisher and editor of Southside Pride, a South Minneapolis monthly where this article was also published. Read more articles by Ed Felien on The Rag Blog.]

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Thorne Webb Dreyer and Sarito Carol Neiman : Bon Voyage, Doctor Keister

Dr. Stephen R. Keister, 1921-2012.
Dr. Stephen R. Keister, 1921-2012:
Bon Voyage, Doctor Keister

By Thorne Webb Dreyer and Sarito Carol Neiman / The Rag Blog / April 12, 2012

It seems the cancer always wins! Tomorrow I go to the Manchester Presbyterian Lodge for final care by Great Lakes Hospice. I am beginning to hear the splash of Old Charon's oars in the waters of the Styx. It ain't all that bad with the memories of all of you fine folks to take along.” – Steve Keister, in a message to his friends and his colleagues at The Rag Blog, February 2, 2012

Dr. Stephen R. Keister left us late Friday night, April 6, 2012, after a long-running bout with prostate cancer. He died in hospice care in his longtime home, Erie, Pennsylvania, at the age of 90.

The cancer may have won but we seriously doubt that Old Charon, the ferryman of Greek mythology (who carried souls of the newly deceased into the world of the dead) succeeded in transporting Steve all the way to Hades.

Steve, ever the philosopher and the reformer, probably recruited the wizened old seaman to his own cause of universal health care and they’re out there now, organizing for a single-payer system in the Afterlife.

Steve Keister, who turned 90 last October, was a retired physician who practiced internal medicine in Erie, PA, from 1950 until 1991, specializing in rheumatology; he was the region’s first practicing rheumatologist.

He attended Duke University where he became interested in the writings and philosophy of Moses ben Miamon, Voltaire, and Sir William Osler. He obtained his M.D. from the University of Maryland and did his postgraduate training at the Mercy Hospital in Pittsburgh and Hamot Medical Center in Erie.

His medical honors were many and after retirement he remained active in scholarship and volunteer work. And Steve found a second passion late in life, dedicating himself to progressive social change, and especially to the cause of universal health care, working with Physicians for a National Health Plan and other activist groups, and writing about health care reform for The Rag Blog.

According to his daughter, Cindy Hepfer, "Steve has always been a voracious reader, continued to play tennis until his 60s when he took up golf instead, and enjoyed having friends in in the evening for drinks and conversation."

And, “after retirement,” Cindy said, “Steve continued his family’s tradition of trying to preserve the tenets of the nation’s Founding Fathers by active membership in People for the American Way, Americans United for the Separation of Church and State, and Amnesty International.”

In a eulogy, Steve's friend Don Swift said that Keister was not only a "gentleman scholar," but that he was also "a mensch, a person of integrity and honor," and that he was "all about trying to heal a broken world."

Fellow Pennsylvania activist and writer Carl Davidson said, “We knew him well here in Western Pennsylvania, especially as an unwavering voice for Medicare for All, and then some. He supported PDA's [Progressive Democrats of America’s] efforts here, but his own views were with the socialist left. Raise a fist and a red rose for him this May Day. He will be missed.”

About her father’s involvement with The Rag Blog, Cindy Hepfer said, “You have certainly given him a mission in these latter years of his life! I thank you for giving Dad a creative outlet and a way to share his goodness and intelligence with others.”

Keister's heavily-researched opinion pieces published by The Rag Blog were rich with personal reference and backed up with facts, figures, and links. They were erudite, yet peppered with wonderful colloquialisms reminiscent of an earlier era, and always filled with quotes and observations from great thinkers, scientists, and philosophers ranging from Rabelais, Pliny the Younger, and Confucius, to Aldous Huxley, Sir William Osler, John Ruskin, and Will Rogers.

And, if you read a column by Dr. Stephen R. Keister, you never had any doubt about where the author stood on the subject.

Though always full of hope personally, Steve became increasingly disillusioned with the medical system in this country and the growing dominance of the pharmaceutical and health insurance companies.

In his writing, he often reflected on the lessons of a lifetime in medicine.

“I entered the practice of medicine in 1950, an idealist, believing in the lesson of the Good Samaritan,” he wrote. “I believed that all persons should be provided with medical care…”

But, “Somewhere in the 1980s medical care, with great planning and premeditation, was usurped by the health insurance cartel in collusion with the pharmaceutical industry. Medicine was changed from a proud profession to a business, and the physician degraded to a ‘health care provider.'"

In his final column for The Rag Blog, entitled “I Cry for My Country,” Dr. Keister wrote:

Having passed the age of 90 I wish that my final days could be days of happiness and good wishes for those about me; however, it appears that fate has ordained otherwise. It would be a great course of satisfaction to see an enlightened, progressive United States as a homeland for my grandchildren. Instead we find a nation that is descending into quasi-feudalism and subservience of the many to the few.

At the time Steve submitted his final column, we at The Rag Blog were aware of his worsening physical condition. We included the following introduction to his piece:

Our dear friend, Dr. Stephen R. Keister, turned 90 on Sunday, October 9. For the last three years Steve has written -- with a unique and singular voice -- dozens of columns about the sad state of our health care system. And in that time he has become the heart and soul of The Rag Blog. He claims this is his last column, but we promise not to hold him to that commitment! We hope he will continue to share his wisdom with us for many months to come.

But we knew it wasn’t likely.


Steve Keister approached death much as he handled life, with vigor, intellectual curiosity, and an open mind. According to his daughter, “He was analyzing the dying process for as long as he could and communicating his thoughts to those around him.”

“He had observed repeatedly to several of us that he was not afraid… and that he always liked to sleep.” Cindy said. "I told him how brave I thought he was and that he shouldn't be afraid to reach out for the sleep that he wasn't afraid of.”

We communicated with Steve during his final weeks and he shared his feelings and observations about the process of dying.


Saying goodbye

"Death is someone you see very clearly with eyes in the center of your heart: eyes that see not by reacting to light, but by reacting to a kind of a chill from within the marrow of your own life." -- Thomas Merton

"The greatest challenge of the day is: how to bring about a revolution of the heart, a revolution which has to start with each one of us?" -- Dorothea Day

How do you say goodbye to a friend? We mean really goodbye -- not “so long, see you later.” Saying goodbye, really, is an opportunity one doesn’t have often or early in life.

When we are young and a friend dies it is usually sudden, unexpected. One day the person is here, the next day that person is gone. And even when we know that death is coming, our culture as a whole does not tend to support the ceremony of saying our goodbyes while that person is still alive. Instead we are supported to remain in denial -- “you can beat this thing, I know you can!”

We are encouraged in so many ways, subtle and not so subtle, to save our goodbyes for when it’s too late for the person who’s leaving to hear them. And by the time we are old enough to see (if we dare to look) the glimmer of our own departure on the horizon, we have no practice in saying goodbye, either as one who is leaving or as one who will remain.

Stephen Keister was a friend. His contributions to The Rag Blog over the past three years have been rooted in a rich lifetime of experience as a physician and proud “secular humanist” and, as such, his insights have been invaluable as we have collectively wrestled with all the implications of the crisis in health care that has plagued the United States now for decades.

His passion for his subject was not abstract or ideological; it was his very life. In his first Rag Blog column, published on Nov. 17, 2008, Dr. Keister was clear where he stood on the question of healthcare reform:

To take the burden off future generations this country must get in step with Western Europe in quality and extent of health care for all. According to the Commonwealth Fund our health care rates 26th in the world and as of Nov. 13 [2008] … U.S. patients, compared to seven other countries, suffer the highest number of medical errors. 44% of chronically ill patients did not get recommended care, fill a prescription, or see a doctor when sick because of costs. 41% of U.S. patients spent more than $1000 in the past year on out of pocket costs, compared to 4% in Britain or 8% in the Netherlands.

We must make sure our elected representatives are not taking baksheesh from the pharmaceutical and insurance industries and support single payer, universal health care devoid of insurance company participation. The nation and your family depend on you not sitting idly on your butt. Call, E-mail, demonstrate!

We lost that battle, obviously. But the war is not yet over, as the sad compromise that became “Obamacare” now finds itself in the Supreme Court. Steve Keister did not live to see the outcome of the current scuffle. But it’s clear, no matter what the outcome, there is still no cause for sitting idly by.


When we heard that it was time to say goodbye to our friend Stephen Keister, we wanted to find a way to honor the occasion. Not to respond with denial, nor to save all our tributes till after he was gone.

So we did what anybody might do if they just found out that a wise and beautiful friend was about to leave for good. We sent him a list of questions, hoping it would offer the opportunity to share what is happening with him now. True to form, he responded both as a scientist and as a humanitarian, the rare combination that has made it such an honor and privilege to publish him over the years.

Here is his response, in his own words. In a sense, this is Steve Keister’s final column. We would like to thank writer and educator -- and Steve's close friend -- Don Swift, for facilitating our final communication with Steve Keister.

Recently I’ve received a request from Thorne Dreyer and his many friends at The Rag Blog, to give him some insight into the situation in which I am involved -- that is, terminal cancer of the prostate, under the care of the good people at the local hospice organization.

Initially, I think we’d better discuss what hospice exactly covers. In my last article in The Rag Blog, entitled “I Cry for My Country,” I refer to several instances of hospices run purely for the financial benefit of the folks in charge. In other words, once again we are faced with the terrible American attitude of money above all else. Therefore, I would suggest that anybody who is interested in legitimate hospice care get a copy of the pamphlet entitled, “When Death Is Near: A Caregiver’s Guide.”

Hospice in the United States is a reasonably new organization, and the hospice in Erie was one of those founded on the basis of charitable giving. Some 25 years ago, Dr. David Dunn, a very capable general surgeon who had spent time in Great Britain during the war, became interested in the hospice movement and spent several months studying the technique as utilized in the U.K. Subsequently he came back to the United States and established a purely volunteer movement, which was soon overburdened, and ultimately taken over by his son, Dr. Geoffrey Dunn at the Great Lakes Hospice, where it remains today.

I became involved in this personally, having been diagnosed with carcinoma of the prostate some 12 years ago. This was treated initially by irradiation and subsequently hormone therapy. Approximately mid-2011, bone scans showed spread of the cancer to the various bones of my body. I tended to ignore this, which was possibly a mistake on my part, because of several factors. At the age of 90 I was enjoying the company of both the Edinboro University retired faculty group, and an 89-year-old lady, who was the best of companions, on the 8th floor of my building.

The question arises, why did I resort to hospice care?

I was not fully aware of the signs of the deteriorating effects of metastatic cancer. I was aware of the fact that we develop painful areas in the bones, but I completely ignored the systemic symptoms of the disease, which are: 1) increased fatigue; one will sleep up to 18 hours a night; 2) complete loss of appetite; one desires nothing, even a glass of milk, for a meal; 3) desire for solitude and lack of interest in things of everyday origin.

These taken together mean something to an alert physician and, happily, Dr. Jeffrey Dunn of hospice stopped by one evening to discuss books, and I discussed my symptoms with him. He said, “Gee, Steve, you’re a candidate for hospice care -- your cancer is spreading.” So the next day I was a hospice patient, and have never regretted it to this day.

Hospice nationally will provide 90 days of care under Medicare. They do not provide inpatient care in a convalescent or nursing home, but otherwise, medicine, equipment, medical care, etc., is provided by the program. I currently am in the Presbyterian Lodge in Erie, and everything is going according to program. I realize I have not long to live, but realize too that I have much to be thankful for throughout my 90 years.

I am also asked how I have rationalized the facing of death, and the question mentions that Socrates, the Zen masters, Jesus, Buddha have all offered alternatives. However, I have somehow avoided these alternatives and looked at this as a purely biological process. We are born in pain, we live largely in pain, and hopefully we can avoid dying in pain.

I’ve been assured by several of the hospice workers that the easiest people to care for are those that are the “secular humanists” who approach each stage of life as a natural event and do not interfere or complicate matters with various philosophical pictures.

While is it true that good hospice care professionals, if possible, provide a role of helping family and friends come to terms with the impending loss of a loved one, some of us are beyond that stage. At the age of 90 we have few living relatives and depend entirely on friends. Happily, I have been blessed with many, many friends in my recent lifetime -- perhaps more so than earlier in my life.

The final question in the submitted list is very interesting and very apropos to the present time. It is: If you could make a new Hippocratic Oath for the 21st century to be given to every student graduating from medical school, what would it be?

This I have given much thought, and do not feel intellectually qualified to answer this at the present time. But I do feel that certain factors should enter into the situation. I do think the philosophy of Dorothea Day and Thomas Merton should play a big part, and within their thinking, we who allegedly feel we are Christians should remember the Sermon on the Mount and the Beatitudes.

In addition to that, from the ethical standpoint we should remember the teachings of two physicians of the last century: Sir William Osler and Dr. W.W.G Maclaclhan of Pittsburgh, both of whom treated people of prominence, the well-known, but at the same time never turned their backs on the poor, the underprivileged or the disabled.

I once again wish to thank my friends in Austin, Texas, my friends in my retired professors' group in Edinboro University, my children, including my daughter Cindy and son-in-law Will (both librarians), and my grandson Jonathan and his wife Alice (both modern musicians with a technique I do not understand but in which apparently they are doing great work). And finally, my dear friend on the eighth floor at 1324 South Shore Drive.

Peace. Peace to all. Thank you.

More of Stephen Keister’s last words can be found in his last columns for the Rag Blog. His final column ended with a challenge for us all to carry on the work of birthing a better world:

I cry for my country, and while asleep I hear in my dreams the mass gatherings of my youth singing, "Arise ye prisoners of starvation, arise thee wretched of the earth, for justice thunders condemnation, a better world's in birth."

Bon voyage, Doctor Keister. You will be missed.

[Thorne Dreyer edits The Rag Blog, hosts Rag Radio, and is a director of the New Journalism Project. He lives in Austin. Sarito Carol Neiman is a freelance editor, author, and actress who lives in Junction, Texas. Together they edited Austin's Sixties underground newspaper, The Rag.]

Find articles by Dr. Stephen R. Keister on The Rag Blog.

Images courtesy of Cindy Hepfer.
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Sarito Carol Neiman : The Anti-Angels of Health Care

Cartoon from The New Yorker.
Shredding the envelope:
Healthcare on the ground - Part III:

The anti-angel forces

By Sarito Carol Neiman / The Rag Blog / September 22, 2011

[Shredding the Envelope ("Ruminations on news, taboos, and space beyond time") is Sarito Carol Neiman's (occasionally) regular column for The Rag Blog. This is the third in a series. Read Part I here.]

The computer workstation in my dad’s room, according to the sales pitches of companies who sell them, was designed with the best of intentions to improve both the efficiency and quality of care in hospitals.

It would allow Dad’s caretakers to enter the latest information about his care (vital signs taken, medications given, observations observed) and to retrieve any information about him and his condition they might need -- on the spot, without having to go and fetch it from (or take it to) its central location at the nursing station down the hall.

It would allow them (in theory) to spend a little extra time in the rooms with the patients, as they entered or retrieved their information -- assuming they could safely mix “quality time” with the patient and the entry/retrieval of complex data at the same time. (An assumption of multitasking ability whose superhuman dimensions the sales pitches overlook.)

In theory, this computer workstation could be part of a vast network of computers, consolidating input gathered from every healthcare professional who had ever seen my dad for any reason. It could offer a more comprehensive picture of Dad’s medical history and current condition than any single human could possibly manage.

Imagine the possibilities... if such a network had been in place from the beginning of this years-long saga, and if all the professionals involved in Dad’s care had been doing more than just their jobs, he very likely would never have ended up in the hospital in the first place.

Those are some pretty hefty “ifs.” And as good a starting point as any to take a look at the “anti-angel forces” at work in the U.S. healthcare system.

Let’s take care of the big stuff first. Let’s assume that our “inalienable rights” to life, liberty, and the pursuit of happiness include the right to healthcare -- not as a consequence of having the money to pay the going market rates for it, but as a consequence of being human. Let’s assume, in other words, that there is no need for private insurance companies, hence no fear that a person’s medical history will be used to deny coverage, or to charge an arm and a leg for it.

Let’s further assume that we can agree that being a healthcare provider is a very special calling indeed, and that those who take up the calling should be honored and rewarded for making that choice, rather than being thrust into indentured servitude by a mountain of postgraduate debt, forced to pay for that debt by performing procedures rather than spending time with and understanding their patients, and being stalked by “ambulance-chasing” lawyers whose primary motive is to make a buck on their mistakes and on the suffering of the victims of those mistakes.

(More about the whole “tort reform”/malpractice thing at another time.)

So now we’ve taken care of the big stuff, we get to the sticky, non-systemic, human bits.

Of course, a universal “inalienable right” to healthcare would need us all -- hospital administrators, doctors, nurses, aides, and patients, all of us -- to behave sensibly, like grown-ups.

We would understand that sometimes things get broken and can’t be fixed, and not every mistake is the result of malice or incompetence. We would know the futility, even harmfulness, of squandering scarce resources on experimental fixes that are likely to fail, or only extend suffering rather than heal. We would understand that death is a natural and inevitable part of the continuum of life.

We would do our very best to keep ourselves healthy and, when those efforts fail, do our best to comprehend the reasons and take responsibility for whatever part we might play in getting better. We would know when to push on against all odds, and when to call it quits. We would celebrate every small victory, and we would know when to allow ourselves to grieve.

We would, in other words, be able to see every health crisis for the opportunity it brings -- to take stock of our priorities, to allow ourselves to love and be loved, to heal the old and untended wounds that so often seem to surface at these times.

To help us get from here to there, though (it’s unlikely we’re just going to wake up and find ourselves there), we’d have to start with a clear-eyed look at what we’ve got now.

The computer workstation in my dad’s room, attached conveniently out of the way on the wall, was a neutral presence, at first glance. And, as advertised, it was undoubtedly a time-saving, mistake-reducing tool. It wasn’t until it broke down for a few days that I began to understand how it was also being used by “anti-angel” forces.

As long as this tool was functioning, nurses came and went with their tasks-to-perform and medications-to-give on what was apparently a rigid, inflexible schedule. It didn’t matter whether Dad was eating his breakfast, having a phone conversation with a loved one, or peacefully asleep -- the pills had to be given, the BP cuff strapped on, the thermometer inserted. Toward the end of his stay, when he was better able to move around, he discovered that the only way to assert his right to uninterrupted peace and quiet was to go and sit on the toilet.

When the computer workstation tool stopped functioning (and I confess to an irrational fear that I might be blowing the cover of a complex angel-conspiracy) somehow it became fine to let Dad finish his breakfast, or his phone call. To come back a few minutes later to do whatever was on the nursing agenda to be done. Not a problem, said the gracious smiles and body language of the nurses carrying the pills and thermometers. I’ll come back in a little while when you’re done.

And they didn’t forget, either -- it wasn’t as though these important tasks magically disappeared from the “do-list” just for lack of computer assistance.

That’s when it occurred to me that behind the hunched shoulders and grim determination of nursing “business as usual” was a Big Brother element that the nurses were fully aware of, but the workstation sales pitches don’t mention. A function more interesting to hospital administrators and lawyers, say, than to doctors or other actual hands-on providers of Dad’s care.

It works like this: the nurse turns on the computer and scans in her badge (nurse presence accounted for) at a certain time (schedule adhered to and trackable by the minute) followed by scans of medication labels, or keystroke entries of vital signs (asses covered). Checked off the list, tidy and impersonal, easily scanned by those whose interest is that no unpredictable breezes of individual human needs or circumstance should interfere with the hum of the well-oiled (and litigation-protected) hospital machine.

The doctors didn’t have to use this workstation, however. They could, if they wanted to look something up... but they didn’t have to, nor did they have to tell it whatever it was they did while they were there.

My sense was that the whole workstation set-up not only reflects but also reinforces the subordinate and purely functional role of nurses in the system as it is. In most hospitals -- with a few notable exceptions, I have heard -- nurses are told what to do (“doctor’s orders”), expected to pass along requests or problems from the patients, and rarely if ever encouraged (or even allowed) to express an opinion, make a recommendation, or question a decision by the doctor that their best intelligence tells them might not be a good idea. A bit silly, to put a better face on it than it deserves -- given that the nurses spend far more time with patients on an hour-by-hour basis than any doctor can possibly afford to spend.

It also, of course, reflects the fact that as the system is set up now, the actions of doctors and the reasons behind those actions are largely protected from public view, and are not required to be shared with other members of the team unless the doctor chooses to share them.

Doctors.

When I first met Dad’s surgeon, I didn’t like him much. Not because I thought he was incompetent -- on the contrary, I was satisfied that he was the best available anywhere near Dad’s home. My dislike was more in the realm of “bedside manner.”

I can’t really blame him for the fact that at our first meeting he was uninterested in knowing who I was or why I was there, to the point of being dismissive. He had, after all, already met and spoken with several members of the family along the way, and at that point I must have seemed like yet another potential burden of irrelevant and time-consuming human interaction that he would just as soon avoid.

Plus, he’s a surgeon after all, not a GP -- the skill sets required to do an excellent job in those two realms are different. Even if the skills to do more than the job might overlap or even be the same.

Over subsequent meetings our relationship was rocky, with additions of ego-prickliness alongside any deficits in bedside-manner skills. He didn’t like being questioned, especially in front of his entourage. This dislike, it seemed to me, carried the weight of a reflexive assumption that my questions were posed as a challenge, rather than as a sincere effort to understand.

I did my best to accommodate the lesser angels of his nature, to reassure him that I absolutely trusted his medical expertise, while still honoring my own concerns for the rocky spots in Dad’s recovery and whatever support I might be able to lend as a “person on the ground.” In the end, I didn’t want him to change, really -- I thought he could use a good “right-hand” person, more a GP type, whom he trusted and who trusted him, to take care of the squishy bits of listening patiently and explaining things to people like me, and maybe translating my concerns into a language he could better understand and relate to.

We worked it out, somehow -- the mutual respect and understanding between him and Dad was undisturbed, and when he finally came in with the happy news that Dad could leave the hospital and go on to the next stage of getting strong enough to go home, I was as fully included in the sharing of that news as was appropriate, given who was most directly affected.

I was also delighted to hear that during Dad’s recent follow-up visit, the doctor showed him “before and after” X-rays of his lung, and the transformation that had taken place. The news nicely balanced what happened that day when Dad was having such a hard time, convinced he wasn’t getting any better and grumbling about having to go downstairs for a new X-ray every morning.

When the doctor came by, I suggested maybe Dad could see a before-and-after picture, so he could look for himself how things were going. The response was a little explosion of exasperated breath, an energetic (if not physical) throwing up of the hands, and a “that’s not so easy, it’s all on computer” before turning around and (energetically) stomping out the door.

I liked it when I heard the news that the doctor had managed that “show and tell” … because I know it helped Dad, as it would have helped him on that day I suggested it in the hospital, to get a handle on whether the whole ordeal had really been worth it. Maybe, I thought, just maybe he had heard me after all. Maybe he’ll remember it the next time one of his patients is having a hard time convincing himself it’s all worth it.

We all have a lot of work to do if we are going to meet the challenges of providing thoughtful, competent, whole-person healthcare in this world.

We’ll have to figure out the best ways to weed out those who are thoughtless and incompetent and in jobs they aren’t suited for. And we’ll have to work on minimizing the harm done by our natural human tendencies to want magic pills, and to substitute a messy and mysterious wholeness with discrete and manageable, but lifeless, parts.

We’ll need to figure out how to shift our focus from avoiding the worst to striving for the best.

We’ll have to take a deep look at the role of lawyers in the healthcare system, and the hopeless, despairing greediness they so often foster in our lives. We’ll need to acknowledge that no amount of money can alleviate pain and suffering, and that often, all any of us really wants is a heartfelt apology, shared grief, and support for moving through a loss. And yes, too, sometimes, the satisfaction of knowing that an incompetent, greedy, or careless practitioner will never be able to harm anyone again.

It’s a lot of work, and it needs us all to do more than just our jobs. And at the moment, for me, it’s right up there among the top jobs on the list of those most important and meaningful.

[Sarito Carol Neiman (then just “Carol”) was a founding editor of The Rag in 1966 Austin, and later edited New Left Notes, the national newspaper of Students for a Democratic Society (SDS). With then-husband Greg Calvert, Neiman co-authored one of the seminal books of the New Left era, A Disrupted History: The New Left and the New Capitalism and later compiled and edited the contemporary Buddhist mystic Osho’s posthumous Authobiography of a Spiritually Incorrect Mystic. Neiman, also an actress and stage director, currently lives in Junction, Texas. Read more articles by Sarito Carol Neiman on The Rag Blog]

• Read "Healthcare on the Ground, Part I" by Sarito Carol Neiman / The Rag Blog / Sept. 1, 2011
• Listen to Thorne Dreyer's July 29, 2011, Rag Radio interview with Sarito Carol Neiman.

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Sarito Carol Neiman : Healthcare on the Ground II: The Angels

Nurse as guardian angel? Art by Amy Jordan / folkartblondes's photostream / Flickr.
Shredding the envelope:
Healthcare on the ground – Part II

The angels are the ones who are doing more than just their jobs.

By Sarito Carol Neiman / The Rag Blog / September 7, 2011

[Shredding the Envelope ("Ruminations on news, taboos, and space beyond time") is Sarito Carol Neiman's (occasionally) regular column for The Rag Blog. This is the second in a series. Read Part I here.]

My brother called them “angels” in his email dispatches from the surgery waiting room. By this, I know now that he meant the ones who look you in the eye, who respond to your questions directly and without evasion. Without hollow boilerplate responses, meant to reassure those anxiously awaiting some news or a verdict that nobody yet has.

The angels are the ones who are doing more than just their jobs.

Being a guy, and more specifically a guy who loves understanding the workings of things, my brother was also impressed by the airport-like, huge computer display on the wall of the waiting room that showed which operating room was occupied by which surgeon, how much longer it was expected to be in use… it functioned as a reassurance in itself, like the clock displays on the crosstown Manhattan L line that tell you how many minutes away a train is from where you’re standing.

He and my sister… and whoever else might have been there from the family (who will no doubt forgive me for not remembering just now)... could watch, as the slot representing Dad kept getting extended. From the initial four to a total of seven hours, by the time it was all said and done.

Scott & White has a reputation for being one of the best in Texas. High-tech, computerized in all its dimensions, there is a mini-version of air traffic control opposite each nursing station, where selected vital signs of each patient in each room are on live display, broadcast from a little monitor each of them wears (or not, as needed, I assume) in a pocket sewn into their gowns, with its wires and sensors silently attached to their bodies and capturing heartbeat, respirations, temperature. When a nurse comes into the room, tasks completed and supplementary notes are entered via keyboard and screen attached to the wall next to the door, not on the iconic hospital “clipboard.”

All very reassuring, even laudable. But for the patients themselves, and their families, it’s the angels who count.

I have met many, so far, in the course of this journey. I’d say the majority of them have been “new”… interns, nurses in training, residents. (Maybe “the system” tends to beat angelhood out of people who are in it too long. I sense I should camouflage their names to protect their innocence.)

R, whose extraordinary sensitivity and respect toward Dad, on what had started as a really difficult day, seemed to help him tap into a new reservoir of strength within himself to turn things around by the end of the day.

B, whose eagerness to learn and clear enthusiasm for finding out what was broken and fixing it was so infectious, it earned him immediate forgivenesss for stepping on Dad’s toe the first time he approached his chair. When he came in the next day, clearly with an “assignment” to ask the patient a couple of questions, I saw B’s future as a great among angels reflected in my Dad’s honest, simple responses.

Dad is generally the sort of guy who will say “I’m fine” while bleeding to death from a gunshot wound. He’s also very perceptive. If he figures you don’t REALLY want to know, he will say, “I’m fine.”

B stood exactly in front of Dad, looked him in the eye, and said:

B: “Do you have any questions at all about your treatment that haven’t been answered?”

Dad: “I don’t know what’s wrong with me.”

B: [Clear, simple response to describe Dad’s condition, and the surgery he had just undergone, and why. A nod from Dad. Understood, at last, beyond whatever descriptions he had been given, and had only abstractly/theoretically comprehended, before he went under the knife.] "Is there anything else you want to know?"

Dad: "Why am I not getting better?"

To which B responded that it takes time, it had been a huge ordeal, and actually Dad was doing remarkably well under the circumstances, better even than might be expected. Other people had said the same words, but B really knew those words were true. For the first time, Dad had been told the reality as certainly as it could be known, by a person so transparently honest and sincere that he could take a deep breath and move on to crossing the next river.

There are angels among the oldtimers, as well. Notably “Ida sweet as apple cidah” as Dad introduced her to me (referencing an old song he knows), an ageless woman with a huge presence that just lights up the room when she walks in. I don’t feel the need to protect her innocence, because her face tells you she’s seen it all – and I’m pretty sure the gods of the nursing angels have her under their fiercest protection, or she wouldn’t still be around. Just as she has all “her” patients under her protection, to the extent she’s able.

Or T, who hasn’t yet seen it all but has seen a lot for someone as young as she is, and who doesn’t have such a big sunny presence as Ida but is more the silent and subtle breeze who comes and goes without creating a disturbance, and whose eye never misses the smallest detail of expression on a face indicating that something might be amiss. She catches things even before they happen, an invaluable gift.

Most angels seem to live toward the middle of the healthcare food chain – they are the nurses, or the interns and residents who haven’t yet been professionalized into wearing the straightjacket of “lawsuit aversion” so many doctors seem to have around them, like an invisible shield against genuine human contact.

On the bottom of the food chain are those who are just passing through a minimum-wage job until they can find something better. There are notable, and wonderful exceptions to the “check it off the list” insensitivity of many aides in the modern, large-hospital system. Those exceptions, in my experience of them, are very special angels indeed. Just really, really good folks who love taking care of people and their environments, and making both the person and the environment as comfortable as possible. We should pay them what they deserve, so they can keep doing that priceless work without having to take a second job to support their families.

I feel a third part to this series coming on. And that is to take a look at what are the “anti-angel” forces at work in the system. What they are made of, both on a “systemic” and a human level. It’s going to need a bit of research on the system level (nothing fancy) and maybe a bit more distance on the human level than I can manage right now.

Right now, I need to get back to my Dad’s room in the hospital, and make sure he has something to eat that he enjoys for “dinner” (in real life outside the hospital, dinner for my Dad is usually a light snack. Hospital “nutrition departments” don’t operate in that mode.) And that he’s settled in comfortably for the night.

I’ll be back.

[Sarito Carol Neiman (then just “Carol”) was a founding editor of The Rag in 1966 Austin, and later edited New Left Notes, the national newspaper of Students for a Democratic Society (SDS). With then-husband Greg Calvert, Neiman co-authored one of the seminal books of the New Left era, A Disrupted History: The New Left and the New Capitalism and later compiled and edited the contemporary Buddhist mystic Osho’s posthumous Authobiography of a Spiritually Incorrect Mystic. Neiman, also an actress and stage director, currently lives in Junction, Texas. Read more articles by Sarito Carol Neiman on The Rag Blog]

• Read "Healthcare on the Ground, Part I" by Sarito Carol Neiman / The Rag Blog / Sept. 1, 2011
• Listen to Thorne Dreyer's July 29, 2011 Rag Radio interview with Sarito Carol Neiman.

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Sarito Carol Neiman : Healthcare on the Ground

Image from Sky Dancing.
Shredding the envelope:
Healthcare on the ground, Part I

By Sarito Carol Neiman / The Rag Blog / September 1, 2011

[Shredding the Envelope ("Ruminations on news, taboos, and space beyond time") is Sarito Carol Neiman's (occasionally) regular column for The Rag Blog. This is the first in a series.]

I have spent the past three days doing my best to be a helpful and healing presence in Room 422 of Scott & White Hospital in Temple, Texas. My going-on-85-year-old dad is in that room, doing his best to recover from a 7-hour surgery called, in medical terms, a “decortication” of his right lung.

It was needed because at some time in the past year or few, given the best guess of his surgeon, he suffered internal bleeding as a side effect of taking Coumadin, the trade name of warfarin, which is a blood thinner for humans that started out as a hemorrhaging agent used as rat poison.

The Coumadin website features a couple of happy, healthy-looking, stock-photo human beings -- one of each gender -- on its front page. In my dad’s case, this rat poison turned wonder drug apparently contributed to the creation of a leathery and constricting pouch around his right lung that threatened to suffocate him to death.

Coumadin earned Bristol-Myers Squibb roughly $222 million in the year that I know my Dad was taking it. He might have been taking it for more years, I don’t know, but I remember that particular year because I was in Texas at the time, and saw the alarming and extensive bruising he got from a minor fall, soon followed by an alarming rectal bleeding that prompted a colonoscopy recommended (ridiculously and incompetently, in retrospect) by his GP, for which I served as driver to and fro because Dad was too freaked out altogether to properly handle it on his own. The fact that he actually asked for my help was alarming in itself, given what I knew about him and how he never, ever asks for help.

I told him at the time I thought his blood thinner was to blame. Because he’s my dad and I’m still the kid in his mind, and because he knows perfectly well I’m not a doctor, and because he, like most Americans, suffers from a combo of intimidation and awe-struckness by what passes for a medical profession in this country -- and, probably most of all, because he liked the heart doctor who prescribed that Coumadin in the first place -- he dismissed the very idea out of hand.

Long story short, after a bout of alleged pneumonia in December of last year, Dad found himself making emergency-room visits because he couldn’t breathe, which grew in frequency to around every three weeks or so, to drain a liter or two of fluid from his pleural cavity. His GP finally recommended the local small-town lung specialist, and she decided Dad might be suffering from TB.

That “might be,” under Texas law, required her to report him to the state health department, and in turn, required the state health department to initiate the “might be TB” protocol, regardless of whether any lab results were still in process or inconclusive. Dad was confined to his house, and the capital-S “state” came by in person each day in the form of a nurse to dispense and personally witness the swallowing of massive doses of antibiotics that made Dad itch and feel horrible.

A couple of weeks passed, and a new, alternative diagnosis of some exotic bird flu (suffered mostly by AIDS patients, I discovered in my research) was substituted for the TB. But for some inexplicable reason the visits by the state nurses with their sick-inducing and now-irrelevant pills continued.

At this point my brother and I intervened, working in tandem from New York and Texas, and dragged Dad off to a different, carefully researched and selected as the best in the drive-able neighborhood, “second opinion” lung specialist.

Excellent idea, difficult execution. At their first meeting, which my brother attended to keep himself in the loop of what we had initiated, the new specialist talked more to my brother than he did to his hard-of-hearing, neither well educated nor articulate but by no means incompetent or dumb patient.

As a consequence, Dad felt infantilized and disrespected. He rebelled, and told us to butt out, he would henceforth handle his health concerns on his own. We complied, what to do, he’s the dad.

Image from Why Evolution is True.
Another couple of months (along with another couple of emergency fluid-draining procedures) passed before Dad finally accepted the second-opinion specialist’s recommendation, based on scans showing a massive “black area” on the right lung, to have a deeper evaluation of the underlying problem at Scott & White Hospital in Temple, Texas.

This part of the story in itself was a massively revealing look into the practical, on-the-ground, failings of the American “free market-based” healthcare system. I will have to leave it to others with a more intimate knowledge of the workings of that system, and the details of its economic interests and corruptions, to provide any fact-based insight into the underpinnings of it, or how the recently passed “Obamacare” might actually address any of those failings -- or not.

What I do know from experience is that the way things are set up now, my father -- before my brother and I intervened -- had seen three different doctors over the past several years. A cardiologist, a general practitioner, and the local lung specialist recommended by the general practitioner when he started drowning in his own fluids.

There was never any actual collaboration among the three. Perhaps they had a vague awareness of each other’s existence, a kickback arrangement, or simply a star next to a name in the rolodex. There was apparently no requirement, or even commonsense expectation that they might consult with one another and, based on their common experience of the same human being and his health issues, work together toward a diagnosis of a current health crisis experienced by that human being and decide on a course of treatment.

Apparently, in the case of the local lung specialist (at least in Texas) there was not even a requirement that when a patient asks that his/her records be provided to another doctor, as part of obtaining a second opinion, those records must be provided. Because when the woman who diagnosed Dad first with TB, and then with an exotic bird flu, was asked for those records, she refused to hand them over.

Dad had to undergo a repetitive, unnecessary, and not altogether un-harmful extra round of tests and scans and nuclear exposures in order to replicate what she had already done.

My hunch is that there is plenty that could be done (at the very least, putting aside the overall problems of non-socialized medicine for now) to reform Medicare and free it from its current entrapments in inappropriate, costly, exploitive, and profit-motivated ways of doing business that reward doctors for procedures and tests performed, versus rewarding them for helping people get healthy and stay that way.

But, in keeping with the “Shredding the Envelope” premise, I also have a hunch that we have to tackle the softer and more human dimension first and foremost, before we can deal effectively with the hardware.

That’s the subject of Part II of this post.

I’ll be back.

[Sarito Carol Neiman (then just “Carol”) was a founding editor of The Rag in 1966 Austin, and later edited New Left Notes, the national newspaper of Students for a Democratic Society (SDS). With then-husband Greg Calvert, Neiman co-authored one of the seminal books of the New Left era, A Disrupted History: The New Left and the New Capitalism and later compiled and edited the contemporary Buddhist mystic Osho’s posthumous Authobiography of a Spiritually Incorrect Mystic. Neiman, also an actress and stage director, currently lives in Junction, Texas. Read more articles by Sarito Carol Neiman on The Rag Blog]

• See "Healthcare on the Ground II: The Angels" by Sarito Carol Neiman / The Rag Blog / Sept. 7, 2011
• Listen to Thorne Dreyer's July 29, 2011 Rag Radio interview with Sarito Carol Neiman.

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Dr. Stephen R. Keister : Fighting Money-Driven Medicine

Cartoon by tunin-s / toonpool.com.
The mouse that roared:
Fighting money-driven medicine

By Dr. Stephen R. Keister / The Rag Blog / May 18, 2011

As I look at the health care situation in this country, I am reminded of the Peter Sellers movie, The Mouse That Roared.

We have Physicians for a National Health Program and Healthcare-NOW! aligned against the wealthy corporations, associations, and professional societies -- who control the media, that in turn feeds distorted information to the American public-- while at the same time holding hostage our elected representatives.

Granted there are a few bits of encouraging news such as the Sanders/McDermott single payer bills being introduced in Congress, the ongoing progress of single payer legislation in Vermont, and a single payer health care bill passing the health committee in the California Senate.

In Maggie Mahar’s powerful book, Money Driven Medicine: The Real Reason Health Care Costs So Much -- which I would strongly advise all single payer advocates to purchase and read – there is a thought-provoking paragraph in her last chapter:

But what the consumer movement seems to ignore is that before patients can reclaim their rightful place in the center -- and indeed as the raison d'etre -- of our health care system, we must once again empower doctors. Physicians must be free to practice patient-centered medicine -- based not on corporate imperatives, doctors' druthers, or even patients' demands, but on what scientific evidence suggests would be in the best interests of the patient. In other words, society needs to recognize doctors as professionals.

We are very, very far from that ideal. The doctor-patient relationship has been destroyed in the financial interest of the health insurance industry, the pharmaceutical industry, the hospital associations, the nursing home cartels, the medical equipment industry, and all those collateral institutions that bleed away the health care resources from the American people.

A major aspect of the problem, and one that appears only rarely on the public radar, is the terrible cost that comes from medical errors. This discussed in detail in the Public Citizen Health Letter of March 2011:

Preventable medical errors hurt millions of Americans every year. Many suffer unspeakable pain, become disabled, lose their livelihoods, sometimes even lose their lives, because of these medical errors. Two hundred and fifty thousand Americans die each year due to these errors, and close to 900,000 deaths in total per year come as a result of unnecessary surgery, hospital-acquired infections, adverse drug reactions, medical errors, even bedsores. From adverse drug reactions alone, the number of deaths was 420,000 in 1997 as reported by Dr. Lucien Leape of Harvard.

If this isn't a crisis, I don't know what is. The pain and suffering is enormous, and so is the financial cost. It would be reasonable to assume that at least $200 billion or more per year is added onto our national health care costs as a result of these errors, and we can anticipate these numbers will continue to rise yearly unless there is intervention and some serious changes begin to take place. Safety must become a major priority, instead of profits. A priority shift is imperative.

We begin to see why our money-driven health care system still ranks something like 26th in the industrialized world -- in both cost and quality. Yet we have idiots like Sen. Rand Paul (who during his election campaign falsified his board certification), making the statement: "The right to health care is slavery" as quoted in Raw Story of May 11, 2011.

Paul is merely one of many elected representatives who oppose true health care reform. There is a pattern here. These are the same folks who oppose tax increases for those Americans making over $250,000. Why? In the May 2011 issue of Vanity Fair, Nobel Prize winning economist Joseph Stiglitz provides a simple and compelling explanation:

Virtually all U.S. senators, and most of the representatives in the House. are members of the top 1 percent when they arrive, and are kept in office by money from the top 1 percent, and know that if they serve the top 1 percent well that they will be rewarded by the top 1 percent when they leave office,

These are the same "representatives of the people" who voted in the House of Representatives, 235-191 to defund a program in the new health care law that finances the construction of preventative-care clinics at schools. These wellness clinics are intended to provide primary care, dental services, and mental health care for youths who otherwise would not receive early medical attention, resulting in lower health-care costs in the long run. These same Neanderthals voted to defund any tax deductions as medical expenses for abortions, regardless of medical need, save in cases of rape or incest.

In previous articles I have dealt at length with the greed and manipulation of health care by the health insurance industry and PhARMA. One of great corporate interests that dominate health care today is the medical equipment industry. ProPublica published an outstanding article by Charles Ornstein and Tracy Weber on this subject. Of course this is only the tip of the iceberg, since it only covers one sub-speciality medical society. The payoffs to others, with orthopedic implants, home health care equipment, etc., is truly mind-boggling. Again, this is one of many topics presented in Maggie Mahar's very well documented book.

I recently have encountered two questionable decisions by the FDA. We, of course, we're well aware that the appointees to the FDA by President George W. Bush, were creatures of the pharmaceutical industry. I had assumed that the situation had been corrected within the Obama administration. Time will tell.

Colchicine is a medication derived from the Autumn Crocus that for many centuries has been used for the treatment of acute gouty arthritis. I first encountered it in my pharmacology classes in medical school in 1942. Its use was first described as a treatment for gout in De Materia Medica in the first century CE. It is mentioned in the Eber's Papyrus, ca. 1500 B.C. It was brought to America by Benjamin Franklin who suffered from gout.

In my latter years I have encountered mild attacks of gout and hence have maintained a small supply of generic colchicine tablets in my medicine cabinet, a bottle of 30 tablets costing $15. Last week I stopped by my neighborhood pharmacy for a refill. The price had jumped to $152.

It seems that over all of these years no formal “randomized clinical trials” had ever been carried out; hence, the FDA granted exclusive rights for three years to URL Pharma to carry out those trials, and at the same time gave them exclusive rights to sell the medication under the trade name of Colcrys -- at whatever price that they might deem appropriate. Go here to learn more.

On April 20 Raw Story ran an article by David Edwards, titled, "Big Pharma set to take over medical marijuana market.” In 2007 GW Pharmaceuticals announced that it had partnered with Otsuka to bring "sativex" -- or liquified marijuana -- to the U.S. The companies recently completed Phase II efficacy and safety trial testing. Phase III is generally thought to be the final step before the drug can be marketed in the U.S.

The Phase III trials will be directed at the treatment of pain in patients with advanced cancer who experience inadequate analgesia during optimized chronic opioid therapy. Saltivex is the brand name for a drug derived from cannabis salvia. It is an extract from the whole plant cannabis, not a synthetic compound. Naturally no facts have been revealed regarding pricing!

At the same time the FDA is poised to approve the drug for big Pharma, state-licensed medical marijuana dispensaries that provide relief for thousands of Americans are under attack by other federal agencies. Raw Story reported on May 4, 2011 that the DOJ plans to arrest state licensers, which could doom the medical marijuana industry. These two events would almost seem to be too coincidental!

As we carry on this fight I recall a quote from T.B. Macauley, in a letter to H.S. Randall, in 1857:

Either some Caesar or Napoleon will seize the reigns of government with a strong hand, or your republic will be fearfully plundered and laid waste by barbarians in the Twentieth Century as the Roman Empire was in the fifth; with this difference, that the Huns and Vandals who ravaged the Roman Empire came from without, and your Huns and Vandals will have engendered within your own country by your own institutions.

I think our situation is less like that of France in 1789, but closer to Germany in 1934. Hence, the idea of a Caesar is not far-fetched and even more frightening.

[Dr. Stephen R. Keister lives in Erie, Pennsylvania. He is a retired physician who is active in health care reform and is a regular contributor to The Rag Blog. Read more articles by Dr. Stephen R. Keister on The Rag Blog]

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Dr. Stephen R. Keister : Back from Break, Republicans Resume Assault on Poor and Infirm

The Republicans are back. Image from xrodgers / Flickr.
Renew attack on poor, elderly, infirm:
Republicans back from Easter break

By Dr. Stephen R. Keister / The Rag Blog / May 5, 2011

"Wherever there is great property, there is great inequality. For one very rich man, there must be at least five hundred poor, and the affluence of the few supposes the indigence of the many." -- Adam Smith

I pen this over the Easter Weekend, the most holy day on the Christian calendar, when devout believers retreat to consider the basic tenants of the faith, the Sermon on the Mount, and the Beatitudes.

It seems that many of the Republican legislators have lost the spirit of the occasion and more likely have attended a black mass in preparation for their return to Washington to resume their attack on the poor, the elderly, and those with little hope. And perhaps -- as part of their regressive anti-science ideology -- they will nullify the pardons of Galileo and Copernicus and perhaps initiate an assault on Pasteur's “germ theory.”

As Mark Twain, no great fan of Congress, noted, "Congressman is the trivialist distinction for a full grown man."

On April 13, the House of Representatives voted to repeal the Prevention and Public Health Fund by a vote of 236 for and 183 against. This negated legislation that over eight years would provide funds to states and communities for preventive health care programs.

The same day, voting 189 for and 234 against, the House voted to defeat a Democratic amendment to keep the health fund in operation for the benefit of senior citizens. And, on the same day the House voted 235-193 against approving a budget that would privatize Medicare and raise the Medicare eligibility age from 65 to 67 and convert Medicaid to a block grant program run by the states and permanently extend Bush era tax cuts.

That same day the House voted 241-185 to remove funding from Planned Parenthood from the fiscal 2011 budget.

This is the Republicans’ first step in Rep. Paul Ryan's plan to finally eliminate Medicare, Medicaid, and Social Security, projects started during the presidency of the “sainted” Ronald Reagan.

The demise of Social Security has temporarily been put on hold while they dismember and destroy the health entitlement programs. There are various estimates available about the potential cost to our senior citizens. The proposal to privatize Medicare would, once in effect, provide the Medicare patient with a proposed $15,000 in vouchers annually but would not address what the individual should do once the voucher runs out.

Remember that coronary bypass surgery can result in a bill of somewhere around $100,000 -- and there are available estimates (TPMDC) that it could cost $20,000 yearly to purchase private insurance! In addition, many of us forget that Medicaid not only pays for a degree of health care for those who cannot afford private insurance, but it pays for nursing home care for the elderly when their personal savings are depleted.

The alleged objective of all of this is to “balance the budget” -- while nothing is done about restoring a reasonable tax rate to the very wealthy nor significantly reducing the cost of fighting questionable foreign wars and maintaining several hundred foreign military bases, many with 18-hole golf courses.

As a matter of fact, the Republican budget would further decrease taxes for the most wealthy 1% of the population while withdrawing a great amount of help to the poor, the disabled, and the elderly.

The vote on Planned Parenthood continues an out-and-out lie that that organization is primarily an abortion provider. Nothing can be farther from the truth. This is merely a symptom of the Republicans’ bigoted attitude regarding women that dates back to the Middle Ages.

Anyone who has read Silvia Federici's Caliban and The Witch knows that in all this there is a deep-rooted feeling that the female is subservient to the male -- and the attack on Planned Parenthood attests to this inner loathing for women.

Planned Parenthood was founded to provide birth control information to women, thus helping to prevent unwanted pregnancies that at the time of the organization’s founding could have led to "back-alley" abortions. Its purpose was to prevent the birth of children that families could not afford to take care of, children who would end up living in poverty, being abused by the unwanting parents, or ending up as wards of the state.

Planned Parenthood’s services include cervical cancer screenings, HIV testing, general health care, and, on rare instances, referral for termination of pregnancy if medical indications dictate.

The nation stands on the edge of a return to medieval times, a time of the two-class society of the baron in his castle and the serfs in their hovels -- and the Republicans aspire to bring this about under the guise of national financial security. Perhaps the Republicans wish to be the Lord's tax collector, each year presenting themselves at the peon's farm, with swords drawn, to collect the baron's taxes.

This said, even we progressives are aware of the excessive cost of health care in the United States compared to that in other developed nations. We are, first off, the only nation where health care is dominated by unregulated health insurance companies, a fact that adds 30-40% to the nation’s overall health care costs.

Another problem we face is the new concept of "concierge medicine," where a physician limits his practice to several hundred patients a year, with a yearly membership fee of $1500. The concept is ideal, and takes us back to our own practices in the 1950s-60s, but we did not receive, let us say, $300,000 up-front! In those days there was no insurance and patients frequently left saying, “Doc, I will send you $10 a week."

We also have the hospital-endowed medical practices, which I alluded to in a prior article, that charge for the physician's visit and add an additional cost “for the hospital.” This, of course, does nothing to reduce health care costs.

I urge everyone to read this article on medical malpractice liability in Canada. It offers an excellent review of the often misunderstood Canadian health care system, and also shows how malpractice costs can be reduced for physicians.

Another reason that our costs are so high is the lack of primary care physicians. Let us look as how it was once was... I was a rheumatologist before I retired after 40 years of practice in 1999. When presented with a new patient with arthritis, of any of 20-30 varieties -- after an hour’s interview and examination -- I could have a correct diagnosis 90% of the time and was able to forgo a lot of expensive testing.

Our job then was to explain the condition to the patient, review treatment and its side effects, and obtain a minimum of lab work to appraise any side effects that might accompany the specific treatment to be used. From there on it was the patient and me -- united in facing the rheumatoid arthritis, lupus, psoriatic arthritis, or scleroderma – whichever might apply.

Today, the physician’s schedule is overloaded (and many now close their offices at noon Fridays, and over the weekend the answering service refers patients to the ER for intercurrent care). A frequent visit for a new patient begins with the receptionist demanding insurance cards and ID, and the completion of a three-page history form. This is followed by a 10-minute visit with a physician's assistant, a further 5-10 minutes with the doctor, and then referral for a plethora of lab studies, and very possibly one of a variety of scans that cost from $500-$1,000.

Instead of time, which if used correctly is reasonably inexpensive, we start with hundreds of dollars of testing that might well have been avoided. Then we are placed on absurdly expensive medications that cost two to three times more here in the USA than in Europe or Canada.

Of course, we must pay for the joy of seeing all of those pharmaceutical ads on TV. The United States and New Zealand are the only nations that provide their citizens with the joy of seeing all of this illuminating garbage. Further, we as patients, must indirectly pay for all of the often vulgar physicians’ ads in the yellow sections, on roadside sign boards, or in the local newspaper.

And we must carry the heavy costs of emergency room visits for ourselves, and for the multitude of those poor folks with no regular medical care who must resort to the very expensive ER care in time of need. The medical care system must pay the costs of palaces built by the for-profit nursing home industry to charge some $6,000 or more per month for our elders’ care when no other option exists.

Further, if one is sincere in adhering to the Hippocratic Oath, a physician is here to serve -- but not to belong to the extremely wealthy sector of the community. This I referred to in my last contribution to The Rag Blog. Should we ever adopt a system of universal, single payer health care we could arrive at a fair and equitable system of physician payment. Please check out the suggestions of National Nurses United.

I have been asked how, with the fear of malpractice hanging over their heads, physicians can omit doing "necessary" studies. I recall advice from an older family practitioner when I started practice in 1950 (when malpractice insurance cost $75 a year!). He advised me: "Keister, always take time with the patients, and before they leave your office, be sure all their questions and anxieties are put to rest. If you are aware that you have made an error in treatment or management, fess up and discuss the matter with your patient."

I listened, and practiced for 40 years without incident, and was amazed on occasion how forgiving folks could be. Malpractice costs, as many physicians argue, are partly caused by greedy lawyers. However, much of the cost is related to scams pulled off by the malpractice insurance companies, and by physicians who do not devote enough thought or time to patient care.

Instead of "cutting" reasonable costs, our leaders in Washington should start a government program of subsidizing the education of primary care physicians as is done in all other advanced nations. Perhaps, with an adequate supply of physicians, a reasonable reimbursement system, and a health care system akin to that in many European countries, and other nations like Japan and Korea, we can resolve this cost problem once and for all.

One final thought: Since the advent of medicine dictated by the insurance cartel in the 1990s, I have found it offensive that in their literature the physician is characterized as a "provider.” At the same time the patient is deemed a "consumer.” Dr. Paul Krugman addresses this issue in an article in The New York Times titled, “Patients Are Not Consumers."

It is perfectly clear that the insurance industry considers the Hippocratic Oath passe and believes that the profits of the free-market should reign supreme.

[Dr. Stephen R. Keister lives in Erie, Pennsylvania. He is a retired physician who is active in health care reform and is a regular contributor to The Rag Blog. Read more articles by Dr. Stephen R. Keister on The Rag Blog]

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Dr. Stephen R. Keister : Political Idiots and Economic Dementia

Aldous Huxley: the "dogmatism and proselytizing zeal... of religious or political idiots."
Huxley's 'political idiots' and
public health in America

By Dr. Stephen R. Keister / The Rag Blog / April 13, 2011

"At least two thirds of our miseries spring from human stupidity, human malice and those great motivators and justifiers of malice and stupidity, idealism, dogmatism and proselytizing zeal on behalf of religious or political idiots." -- Aldous Huxley

I begin writing this on a Friday morning, feeling depressed and disillusioned, as the Congress considers a "government shutdown," noting the absurd and idiotic reasons that the Republicans would use to justify such a bizarre act, proposing it in the name of demented economic theory and with the underlying motive of destroying programs currently in place designed to enhance the lives of our elderly and the disadvantaged of this country.

In his Hightower Lowdown column, Jim Hightower recently wrote about a novel called Alpaca,

a remarkably portentous piece of political writing by one of America's first billionaires, Dallas oilman H. L. Hunt. Self-published in 1960, the 191-page book laid out his vision of a libertarian, plutocratic utopia.

Hunt's ideal society was one in which the wealthiest would have a disproportionate say in government. He saw them as the achievers and, as proven by their riches, the most meritorious of citizens. They should get not one vote, he believed, but three, for they could be trusted to protect the volatile masses from the rise of populists.

Hightower sees Hunt’s vision given new life in the current Republican efforts to create a two-class society, a vision financed to the tune of millions of dollars by the U.S. Chamber of Commerce, the American Action Network, Crossroads GPS, and the various enterprises of the Koch Brothers.

This brings me to a point of playing the swami and looking ahead at the future of health care in the United States and the complicity of various physicians in accelerating this crisis.

First let me note a recent CNN poll showing that 75% of Americans want funding levels for Medicare to stay the same or go up. For Social Security, 87% of Americans want funding levels to stay the same or go up. Yet, these same folks have their fate resting in the hands of a Republican Party that exhibits the ideological zeal of the Spanish Inquisition and a Democratic Party and President who look at "compromise" in the same frame as Neville Chamberlain did at Munich.

Currently we who are on Medicare have 75% of our expenses paid for through the Medicare Trust Fund... monies we invested in the fund through our payroll taxes during our working days. These were not payments into the U.S. Treasury, but into a government sponsored "pension fund,” supposedly to be used for no other purposes than paying Social Security and Medicare benefits. Of course this trust was undermined by the Bush administration when the actual funds were used to subsidize warfare throughout the world, and were replaced with government bonds.

Some of us are fortunate enough, having the initial 75% of our medical costs paid by Medicare, to purchase Medicare Supplemental Insurance to cover the 25% not paid by Medicare. Supplements are not to be confused with "Medicare Advantage Plans" which were intended by the Bush administration to be the first step in privatizing Medicare and at the same time hurry the depletion of the Trust Fund. The Republicans have always opposed Medicare as well as Social Security.

The current Republican proposal calls for Medicare -- by the year 2030 -- to pay 32% of medical costs while the individual will pay 68% out of pocket. The GOP plan will gradually increase the eligibility age and give the states more control over the plan. The 32% distributed by the government will be given as "vouchers" in set amounts to purchase private insurance plans.

Of course these plans will cost much more because of the need to pay excessive executive salaries, stockholders, and higher administrative costs. Furthermore, the "doughnut hole" in the Medicare prescription drug benefit will continue at 100% under the Republican suggestions. An excellent review of the thinking behind the Republican plan is addressed by Wendell Potter in CommonDreams.

The Conservative Party, which currently controls the Parliament in the United Kingdom, in the interest of reducing the budget, is attempting to reduce payments to the national health system. This has created a major crisis in British politics -- mass demonstrations in the city streets, strong denunciation of the planned cuts by the British Medical Association ("we do not want quasi-privitization, with a mountain of paperwork, we want time to spend with our patients as we have now"), defections by coalition members in the Parliament, public cries and newspaper editorials regarding decreased help to the disadvantaged, the elderly, undernourished children.

Of course, the British, like most Europeans, are of a different culture than we have in the United States; theirs is a culture of community while ours is based on Ayn Rand's premise of "what is there in it for me?” But let us leave the UK and move on to our state of Vermont where the possibility of a single payer health care system is playing out. This I alluded to in my last Rag Blog submission.

As evolution of single payer care develops in Vermont there is a degree of division among the physicians: the primary care physicians approve of the plan while "certain other" physicians say they will leave the state.

We are at a point that we must take a look at the economics of the practice of medicine. First, I would note that, since I entered medical school in 1942, I have seen an attitude that says we should not increase our medical school graduation rate to a point where we have an excess of doctors in the country.

This is illustrated in recent years by the increased number of foreign graduates practicing in this country, the development of nurse practitioners and physician assistants, and the recent development of non-university affiliated osteopathic physician trade schools.

How are our domestic graduate physicians trained? Just who are these folks? All doctors start out by taking a four-year pre-med course in an undergraduate field of study. Then for the more fortunate we have four years in a university-affiliated medical school. This is followed by three years of residency training for those who wish to be family physicians, while for others, a year of general internship is required, followed by three years of specialty residency in an accredited hospital. Thereafter, one is required to take another year of fellowship in a sub-speciality.

So we see that those in the primary care specialties, internal medicine and its sub-specialities (allergy, endocrinology, rheumatology, neurology for example) have had six years training after medical school. Then we have those in the surgical sub-specialities (cardiac surgery, orthopedics, urology, for example), who have also has six years post-medical school training.

Why then the great income disparity among physicians? Those who work with their hands make some 7-10 times more than the physician who works with his mind. Why does the cardiac surgeon deserve a fee per hour 10 times that of the pediatric endocrinologist who cares for a child in a diabetic coma? Both may be life-saving procedures; the pediatrician is surely saving a life. What is it in the culture of the United States that has created this discrepancy?

Guess which physicians are considering leaving Vermont if single-payer health care passes and becomes law? One would envision in Vermont a physician payment system akin to that of the Mayo Clinic or Cleveland Clinic where the participating physicians are paid a negotiated salary rather than a procedure-based payment. This would explain, as well, why Vermont would be a magnet for the physician who wishes to be an independent contractor again, a professional, free of the dictates of the insurance industry, but by and large a primary care doctor.

There is an excellent new book called "The Hippocratic Myth" by M. Gregg Bloche, M.D. -- who is an attorney as well as a physician. Bloche was involved in the investigation of torture by physicians and psychologists at Guantanamo, and he reviews all violations of the Hippocratic Oath, in medical practice, the insurance industry, government, and the courts.

About reward systems, Bloche says:

More important are the reward systems that today favor technological wizardry over biological breakthroughs -- or time spent with speaking to patients or thinking through their problems. I recall doing some simple math, while a medical student on surgical rotation, and figuring out that my attending made more money per minute for time spent in the operating room than the actress Debra Winger made during her steamy scenes in that year’s hit film, An Officer and A Gentleman.

He took in $7,000 a case from Medicare for coronary bypass surgery, and on some mornings he'd have two cases going at once, in adjacent rooms. He could pull this off because his eager residents and fellows, counting on the same payoffs someday, did almost all of each case, from "cracking" the chest (to open it) to closing up ribs and muscle when work was done.

He put in about 20 minutes on each case, sewing in some of the little leg veins used to bypass blocked arteries. Had he spent this time talking with patients, he'd have taken home perhaps a few hundred dollars.

I fear that we face a broken medical system, as well as a broken political system. I call your attention to two recent publications. One is an extensive book review published in the Scientific American, titled Health Care Myth Busters: Is there a High Degree of Scientific Certainty in Modern Medicine?” The other is from The New York Review of Books: "Drug Companies and Doctors: A Story of Corruption,” by Dr. Marcia Angell.

In the meanwhile the negotiations, the compromises, continue in Washington bring to my mind a statement by Margaret Mead: "It may be necessary temporarily to accept a lesser evil, but one must never label a necessary evil as good."

[Dr. Stephen R. Keister lives in Erie, Pennsylvania. He is a retired physician who is active in health care reform and is a regular contributor to The Rag Blog.]

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