Monthly Archives: July 2010

Mutilated Afghan woman on the cover of Time

Bibi Aisha on cover of TimeThe woman on the cover of Time is Bibi Aisha, an 18-year-old Afghan woman. Time’s online photo gallery — Women of Afghanistan: Living Under the Taliban Threat, which displays an additional image of Aisha — tells her story:

[She] was dragged from her home by the Taliban after running away from her husband. Despite her pleas that her in-laws had been abusive, that they treated her like a slave, that she had no choice but to escape, a Taliban commander said that she must be punished, lest other girls in the village try to do the same thing. Aisha’s family members carried out the punishment: her brother-in-law held her down while her husband sliced off her ears and nose, then left her to die. She is now hidden in a secret women’s shelter, where she was taken after receiving care from U.S. forces.

The lead paragraph in Time’s story on Afghan women and the Taliban repeats Aisha’s story in slightly more dramatic prose:

The Taliban pounded on the door just before midnight, demanding that Aisha, 18, be punished for running away from her husband’s house. Her in-laws treated her like a slave, Aisha pleaded. They beat her. If she hadn’t run away, she would have died. Her judge, a local Taliban commander, was unmoved. Aisha’s brother-in-law held her down while her husband pulled out a knife. First he sliced off her ears. Then he started on her nose.

A worthy cause or “Afghansploitation”?

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Bullying, education, and compassion

Phoebe PrinceNew York Times opinion piece on bullying, stressing the importance of education to change behavior.

It’s important, first, to recognize that while cellphones and the Internet have made bullying more anonymous and unsupervised, there is little evidence that children are meaner than they used to be. Indeed, there is ample research — not to mention plenty of novels and memoirs — about how children have always victimized one another in large and small ways, how often they are oblivious to the rights and feelings of others and how rarely they defend a victim.

In a 1995 study in Canada, researchers placed video cameras in a school playground and discovered that overt acts of bullying occurred at an astonishing rate of 4.5 incidents per hour. Just as interesting, children typically stood idly by and watched the mistreatment of their classmates — apparently, the inclination and ability to protect one another and to enforce a culture of tolerance does not come naturally. These are values that must be taught.

Yet, in American curriculums, a growing emphasis on standardized test scores as the primary measure of “successful” schools has crowded out what should be an essential criterion for well-educated students: a sense of responsibility for the well-being of others. …

As an essential part of the school curriculum, we have to teach children how to be good to one another, how to cooperate, how to defend someone who is being picked on and how to stand up for what is right.

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Climate change and mass migration

Fence between India and BangladeshThe New Republic article, “Will Climate Change Lead to Mass Immigration from Mexico?,” is timely, given the prominence in the news of Arizona’s immigration law. The migration that will follow climate change is certainly an issue that should be kept in the public’s awareness.

The author, Bradford Plumer, points out that most climate-change induced migration will happen within developing countries – country folks from villages will move to urban centers. Historically this is nothing new.

Migration from one country to another is harder to predict. A powerful symbol of what to expect is the fence along the 2,500 mile border between India and Bangladesh. The majority of land in Bangladesh is less than 20 feet above sea level. By the end of the century, more than a quarter of the country will be under water. The fence will prevent migration to India.

Right-wing seeks common cause with environmentalists

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Atul Gawande: Modern death and dying

The good deathAn article in The New Yorker by Atul Gawande on how modern clinical medicine has turned death and dying into an experience we would not wish on our enemies. This is so much in need of being said. And heard, discussed, and acted upon.

Our medical system is excellent at trying to stave off death with eight-thousand-dollar-a-month chemotherapy, three-thousand-dollar-a-day intensive care, five-thousand-dollar-an-hour surgery. But, ultimately, death comes, and no one is good at knowing when to stop. …

Spending one’s final days in an I.C.U. because of terminal illness is for most people a kind of failure. You lie on a ventilator, your every organ shutting down, your mind teetering on delirium and permanently beyond realizing that you will never leave this borrowed, fluorescent place. The end comes with no chance for you to have said goodbye or “It’s O.K.” or “I’m sorry” or “I love you.”

People have concerns besides simply prolonging their lives. Surveys of patients with terminal illness find that their top priorities include, in addition to avoiding suffering, being with family, having the touch of others, being mentally aware, and not becoming a burden to others. Our system of technological medical care has utterly failed to meet these needs, and the cost of this failure is measured in far more than dollars. The hard question we face, then, is not how we can afford this system’s expense. It is how we can build a health-care system that will actually help dying patients achieve what’s most important to them at the end of their lives.

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Suicide among veterans is an “absolute crisis”

Soldier crying, PTSDAccording to the Times, 347 soldiers were killed last year, and 381 committed suicide.

Legislation to provide funds for the mental health of military personnel and veterans was removed from a Congressional bill last year for budgetary reasons. The Times comments:

Considering the two wars were declared and waged with scant attention to their full costs, lawmakers add insult to injury by invoking budget concerns for the traumatic needs of actual warriors.

The medical director of the American Foundation for Suicide Prevention testified before a House subcommittee this month that suicide among veterans is an “absolute crisis.”

A provision on mental health care for the military appears again in the National Defense Authorization Act for Fiscal Year 2011. It’s been approved by the House and needs final approval by the Senate. You can email your senator from the Senate contact information page. Senators are listed in order of state.

As a blogger wrote at the site where I found this photo, “The real question is, why don’t we care anymore?”

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A financial expert argues: Global warming is real

Obama on climate change: I'm sorry
Jeremy Grantham is an expert on investing – stocks, bond, commodity markets. The asset management fund GMO, where he’s Chairman of the Board (the ‘G’ stands for Grantham), was responsible for $107 billion at the end 2009. He has a reputation for predicting market bubbles, valuing history, and giving advice that’s worth listening to.

So when Grantham tells investors the equivalent of “you better believe climate change is for real,” this gives me hope. If greed got us into this mess, maybe greed can get us out of it. Ultimately it’s the American way, right?

Unfortunately for investors, Grantham thinks it’s too soon to profit from attempts to stave off global warming.

Global warming will be the most important investment issue for the foreseeable future. But how to make money around this issue in the next few years is not yet clear to me. In a fast-moving field rife with treacherous politics, there will be many failures. Marketing a “climate” fund would be much easier than outperforming with it.

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Obama appoints Berwick to head CMS

Health care reform opposition protestersDonald Berwick’s nomination to head the Centers for Medicare and Medicaid Services (CMS) had been in limbo since April. Republicans opposed Berwick, in large part, because he admires the British National Health Service. For conservatives, this translates into rationing and the dreaded “death panels.” The Senate was in recess, so Obama went ahead and made a recess appointment.

Both Democrats and Republicans objected to Obama’s use of this tactic. Congress has become so polarized, however, that presidents must increasingly resort to this option. The statistics for recent presidents: Reagan 243, Clinton 139, George W. Bush 171, and Obama (so far) 15.

Even former heads of CMS who supported Berwick object to the recess appointment. Here’s Gail Wilensky, as quoted in The New England Journal of Medicine:

[H]is appointment is tainted, certainly in the eyes of Republicans — even those who had not spoken out on sensitive issues that Don had raised in previous statements and writings. . . . Don will carry an extra burden because he was not confirmed by the full Senate through the normal confirmation process.

This sounds somewhat reasonable, but with so much opposition to health care reform among Republicans, a recess appointment is hardly a tipping point.

Without FFS payments, doctors aren’t “motivated”

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The earth’s scars

I came across this poem today. I remember receiving it from Cathy Edgett in the days following 9/11. As we collectively watch oil rise from a gash in the ocean’s floor, it seems appropriate again. The tragedy is not so much the literal mutilation of the earth as it is the ratcheting up of our collective disillusion with politicians and corporate executives, whose financial interests take precedence over the common good.

Try to Praise the Multilated World

Remember June’s long days,
and wild strawberries, drops of wine, the dew.
The nettles that methodically overgrow
the abandoned homesteads of exiles.

You must praise the mutilated world.
You watched the stylish yachts and ships;
one of them had a long trip ahead of it,
while salty oblivion awaited others.
You’ve seen the refugees heading nowhere,
you’ve heard the executioners sing joyfully.

You should praise the mutilated world.
Remember the moments when we were together
in a white room and the curtain fluttered.
Return in thought to the concert where music flared.
You gathered acorns in the park in autumn
and leaves eddied over the earth’s scars.

Praise the mutilated world
and the gray feather a thrush lost,
and the gentle light that strays and vanishes
and returns.

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Links of interest: Can honey combat MRSA?

How honey kills bacteria (The FASEB Journal)

Honey bee on flowerTo characterize all bactericidal factors in a medical-grade honey, we used a novel approach of successive neutralization of individual honey bactericidal factors. All bacteria tested, including Bacillus subtilis, methicillin-resistant Staphylococcus aureus, extended-spectrum β-lactamase producing Escherichia coli, ciprofloxacin-resistant Pseudomonas aeruginosa, and vancomycin-resistant Enterococcus faecium, were killed by 10–20% (v/v) honey, whereas ≥40% (v/v) of a honey-equivalent sugar solution was required for similar activity.

Secret Ingredient That Kills Bacteria Identified In Honey (Medical News Today)

“We’ve known for millennia that honey can be good for what ails us, but we haven’t known how it works,” said Gerald Weissmann, M.D., Editor-in-Chief of the FASEB Journal, “Now that we’ve extracted a potent antibacterial ingredient [defensin-1] from honey, we can make it still more effective and take the sting out of bacterial infections.”

A sweet solution to antibiotic-resistance? (Time)

The researchers are hopeful that they can build on these initial findings to develop new uses for this potent ingredient in honey, and in light of an alarming trend of antibiotic-resistance, ultimately even put defensin-1 to use as an alternative to current antibiotics.

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The physician as humanist

Still life with porcelain bowl and plums Ladislaus Rath BergerI have eaten
the plums
that were in
the icebox

and which
you were probably
saving
for breakfast

Forgive me
they were delicious
so sweet
and so cold

— William Carlos Williams

William Carlos Williams is part of an honorable tradition in the history of medicine — the physician/poet. He followed the example set by previous physician/poets, such as John Keats, Friedrich Schiller, and Oliver Wendell Holmes (of “Chambered Nautilus” fame). Physicians have also been writers, painters, musicians, philosophers, and – since the 19th century – photographers.

Yet in 1980 the historian G.S. Rousseau expressed concern that modern physicians no longer embodied the humanist tradition of their predecessors. Now that medicine had overwhelmingly become a science and not an art, he claimed, the interests and accomplishments of physicians had narrowed. (emphasis added)

In our century nothing has influenced the physician’s profile more profoundly than the loss of his or her identity as the last of the humanists. Until recently, physicians in Western European countries received broad, liberal educations, read languages and literature, studied the arts, were good musicians and amateur painters; by virtue of their financial privilege and class prominence they interacted with statesmen and high-ranking professionals, and continued in these activities through their careers. It was not uncommon, for Victorian and Edwardian doctors, for example, to write prolifically throughout their careers: medical memoirs and auto-biographies, biographies of other doctors, social analyses of their own times, imaginative literature of all types.

In twentieth-century America, the pattern has changed; only the most imaginative physicians can hope for this artistic lifestyle as a consequence of the economic constraints and housekeeping demands placed upon the doctor …. [T]he diminution of ‘humanist’ content in the training of physicians has lent an impression – perhaps falsely so but nevertheless pervasively – that medics are technicians, anything but humanists. As a by-product, it has nurtured a myth (already old by the eighteenth-century Enlightenment) that medicine is predominantly a science rather than an art. Both notions require adjustment if physicians hope to return to their earlier enriched, and probably healthier, role.

Rousseau’s comment on constraints (for “housekeeping demands” substitute “dealing with insurance”) is even more true today, especially for primary care physicians. A liberal education that values the humanist tradition is also in danger. See, for example, Martha Nussbaum’s Not For Profit, where she writes that contemporary education favors profitable, market-driven, career-oriented skills and devalues imagination, creativity, and critical thinking – qualities essential to the art and science of medicine.

But Rousseau’s assessment that physicians lack artistic interests is simply not true. Physicians continue to be prolific in their contributions to the ‘humanist’ tradition, most visibly as writers.

A plethora of physician/writers

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The physician as reader of poetry

Dog looking in windowHere’s another wonderful poem from a recent issue of The Journal of the American Medical Association. It’s also about an animal, but with a different mood and tone.

It’s called “Why My Wife Should Let Me Have a Dog” and the poet is Gary Stein. Only the first 150 words are available to non-subscribers, but one can appreciate the poem even in its truncated version.

Why My Wife Should Let Me Have a Dog

If I had a dog his soft fur would not foliate
the sofa or trigger asthma attacks
in my dear wife, ending with a hospital trip,
an adrenaline shot and those inhaler tubes
littering the house.

His rich brown eyes will convey profound
intelligence and sensitivity to the subtlest
shifts in my mood. Those eyes will never
get infected and fill with viscous yellow pus
we must wipe with Q-Tips and cure with
sticky ointment, awkward for us both.

My dog will lie by my feet while I read
the Sunday Times he fetched from the lawn
and delivered dry from his slobber-free
mouth, and he’ll wait for his walk
until I complete the crossword.

And when we walk he’ll heel until I hurl
a tennis ball. Watch him streak across
the grassy field, catch it on first bounce
and, with gleeful tail, surrender the prize to me
for another . . .

The rest of the poem continues to suggest the narrow line between comforting pleasures and the all-too-easily-imagined darker side of life. The last two stanzas begin “And when I have my heart attack …” and “While waiting for the ambulance ….” The poem concludes:

… this beast …
a gift as perfect as our children who,
when we play tennis, won’t serve as hard
as they can and will blow some shots
to let me think that by some necessary miracle
I’ve survived and will win in the end.

For the complete poem, consult the June 23/30 issue of JAMA, available in almost every public library.

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The physician as poet

SquirrelEach issue of The Journal of the American Medical Association includes a poem, usually written by a physician. I found this one, by Laurie Rosenblatt, MD, especially moving.

There is harm

because there is this innocent animal,
the body;

because a baby’s unguarded gaze,
and the open regard
of animals both hold patience
with the world,
with mineral fact. Impenetrable

consciousness
arising from, locked into flesh. So

the body’s harm

astonishes,
for instance when met in the eyes
of the squirrel, run over, still
alive
beside the road,

eyes near bursting
meeting your own
and holding
something—

   a plea?
Because there is
absence

of words, no telling
what is wanted, what
will help:
the question, “What is right to do?”

if anything,

and a need
to be
out from under this

responsibility,
my god, such need.

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The indignity of the waiting room

Patients in waiting roomThe following vignette happens to come from London, but it could have happened anywhere in the world. The author, Richard Horton, is a physician and the editor-in-chief of The Lancet.

The new University College London Hospital is a gleamingly modern institution. Filled with space and light, the physical interior signals a warm welcome to visitors. It’s a pity, therefore, that a fraction of the human encounters with staff suggest the contrary trait of indifference.

Recently, I had an opportunity to spend time in the second floor specialist x-ray reception. I arrived at 8•40 am. The person sitting behind reception had a debilitating condition that rendered him unable to say good morning, smile, or to offer a polite hint of understanding for the anxiety a visitor might be feeling. “Take a seat and they’ll call you”, was the best he could do. The same words were repeated blankly to every new patient. Any further question was met with either a shrug or “don’t know.”

I gathered from conversations among those of us waiting that one man had been sitting in reception since 7 am. Well into his 70s, he was clearly nervous, biting his lower lip and muttering silently to himself. Occasionally, he pulled his appointment letter from his bag to double-check the instructions. He walked to the reception desk to ask what had happened. The same careless shrug, with another, “Just take a seat and they’ll call you”. Unable to see a way through this wall of unhelpfulness, he did as he was told. Eventually, he asked a passing nurse for help. She listened and looked him in the eye. But she said that sorry, she could not assist him. He must wait.

Increasingly forlorn, he rebelled. He walked out to find someone who would help him. A nurse returned and began asking reception staff what was happening. More shrugs and obfuscations. The nurse eventually managed to extract from reception the name of the doctor the patient was supposed to see. She reassured the man that the doctor would be called. Seeing that the patient was decidedly sceptical, the nurse promised to return. It was now 9•30 am, two-and-a half hours since the man’s arrival.

By 10 am, as I left, the doctor had been found and was talking with the patient. A happy resolution to a small drama. But no thanks to some staff, who showed no interest and little compassion in solving his predicament or offering him their help. A beautiful hospital does not make up for bad attitudes.

Related posts:
The doctor/patient relationship: What have we lost?
Contempt and compassion: The noncompliant patient
The Economist reviews Kaiser Permanente health care
Health inequities, politics, and the public option

Resources:

Photo source: Tipping Points

Richard Horton, Offline: Just take a seat and they’ll call you, The Lancet, July 3, 2010, Vol. 376 Issue 9734 p. 12 (free registration required)

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