MEDICAL TUESDAY . NET

NEWSLETTER

Community For Better Health Care

Vol VII, No 11, Sept 9, 2008

 

In This Issue:


1.                  Featured Article: The Brain's Memory-Forming Neurons

2.                  In the News: How to Improve Health in Old Age

3.                  International Medicine: Why the National Health Service is Doomed

4.                  Medicare: Spending

5.                  Medical Gluttony: Excessive utilization is ubiquitous; but it's not entirely the patient's fault.

6.                  Medical Myths: Europeans Wonder Why We Persist in the Myth About Medical Killings

7.                  Overheard in the Medical Staff Lounge: The Elections Have Suddenly Become Interesting

8.                  Voices of Medicine: At Home in Guatemala

9.                  The Physician Patient Bookshelf: Perspectives on Euthanasia and Mortality

10.              Hippocrates & His Kin: How to Keep Our Memory Function Working

11.              Related Organizations: Restoring Accountability in HealthCare, Government and Society

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The Annual World Health Care Congress, co-sponsored by The Wall Street Journal, is the most prestigious meeting of chief and senior executives from all sectors of health care. Renowned authorities and practitioners assemble to present recent results and to develop innovative strategies that foster the creation of a cost-effective and accountable U.S. health-care system. The extraordinary conference agenda includes compelling keynote panel discussions, authoritative industry speakers, international best practices, and recently released case-study data. The 3rd annual conference was held April 17-19, 2006, in Washington, D.C. One of the regular attendees told me that the first Congress was approximately 90 percent pro-government medicine. The third year it was 50 percent, indicating open forums such as these are critically important. The 4th Annual World Health Congress was held April 22-24, 2007 in Washington, D.C. That year many of the world leaders in healthcare concluded that top down reforming of health care, whether by government or insurance carrier, is not and will not work. We have to get the physicians out of the trenches because reform will require physician involvement. The 5th Annual World Health Care Congress was held April 21-23, 2008 in Washington, D.C. Physicians were present on almost all the platforms and panels. This year it was the industry leaders that gave the most innovated mechanisms to bring health care spending under control. The solution to our health care problems is emerging at this ambitious congress. Plan to participate: The 6th Annual World Health Care Congress will be held April 14-16, 2009 in Washington, D.C. The World Health Care Congress - Asia was held in Singapore on May 21-23, 2008. The 5th Annual World Health Care Congress – Europe 2009 will meet in Brussels, May 23-15, 2009. For more information, visit www.worldcongress.com. The future is occurring NOW. 

To read our reports of the last Congress, please go to the archives at www.medicaltuesday.net/archives.asp and click on June 10, 2008 and July 15, 2008 Newsletters.

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1.      Featured Article:  The Brain's Memory-Forming Neurons, Scientific American

The Brain May Use Only 20 Percent of Its Memory-Forming Neurons By Nikhil Swaminathan

Study shows that that pace at which a brain cell activates a key protein may influence its role in memory formation—a finding that could lead to new Alzheimer therapies

Remember the old myth that people only use 10 percent of their brains? Although a new study confirmed that bromide to be apocryphal, it did find that we may only use 20 percent of the nerve cells in our midbrain to form memories.

Researchers at the University of California, Los Angeles, and The Hospital for Sick Children in Toronto monitored neurons in the lateral amygdalae (two almond-shaped regions on either side of the midbrain associated with learning and memory) of mice to see whether the presence of the CREB (cAMP response element binding) protein plays a key role in signaling brain cells to make memories. CREB, a transcription factor that typically increases the production of other proteins in cells, is believed to be involved in memory formation in organisms from sea slugs to humans. Scientists hope that their findings, reported in the current issue of Science, may help pave the way to new treatments for Alzheimer's Disease.

Researchers injected a vector designed to return CREB production to normal in mice that had been genetically modified to underproduce the protein. After being injected, these mice, who also were memory-impaired, performed as well as normal mice in memory tests. During the trials, researchers played a sound and then shocked the animals; when the sound was played again, normal mice and those with rescued CREB function froze—for a certain[short?] period of time—a reaction typical of fear.

When the researchers later dissected the mice's brains, they found that the fluorescent probes they had attached to the CREB vectors showed they had affected only about 20 percent of the neurons in the lateral amygdala. "That surprised us. We thought that we would have to affect a lot more neurons in order to see a big change in memory," says study co-author Sheena Josselyn, a neurophysiologist at The Hospital for Sick Children. "Not all [neurons] participate in every memory. Maybe we're biasing these neurons to participate in this memory and [CREB is] all you need'' to compel it."

To determine if the CREB-producing cells were involved, the scientists then tried to follow the memory-making process by inserting a probe, which would give off a fluorescent tag if RNA from a gene known as Arc had recently been transcribed in brain cells. Arc levels are normally low in a cell but increase considerably when neuronal activity has taken place. The RNA is transcribed in the nucleus of a cell and then transported through the cell's body to its dendrite, the projection of the neuron that receives information from other cells. "Arc RNA provides a really good molecular marker of when this neuron was active," says Josselyn. She adds that if the team found RNA in the nucleus of neurons immediately after a training event, they knew cells had been active within the last five minutes; if the probe was in the dendrite, they estimated activity had taken place 20 minutes earlier. . .

The results: the memory trace, signified by Arc, showed that activity had taken place in 20 percent of neurons. "We think that it's really a competition, that neurons are really battling it out" amongst each other to be involved in the memory-making process, says Josselyn. "It's like grading on a curve … the same number [20 percent] of students are going to get As"—or in this case help make the memory.

It is the same percentage, but not the same neurons, however, that create each memory. Also, researchers are not certain what causes naturally boost CREB function and, therefore, the likelihood of any particular neuron participating in making a memory. But Josselyn speculates that the brain likely "differentiates different memories by having different neurons encode them."

In the future, Josselyn says, this mechanism could be harnessed to produce a new treatment for Alzheimer's disease. "In time, we're going to have some sort of neuron-replacement therapy for Alzheimer's," she says, conceding, "It's a little sci-fi right now." But, if new neurons are inserted into a damaged brain, modulating CREB function could help bias the healing brain to use the functioning neurons and not its injured population.

www.sciam.com/article.cfm?id=the-brain-may-use-only-20&print=true

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2.      In the News: How to improve health in old age and increase life span, Scientific American

Socializing with Youth Improves the Elderly's Health, Life Span, by Erica Westly,

A gene associated with Alzheimer's disease may play a role

 "Youth is a wonderful thing," George Bernard Shaw once said. "What a crime to waste it on children." Humor aside, recent research suggests that youthful energy may not be "wasted" after all. Through social interactions alone, the young can pass some of their vigor on to the elderly, improving the older generation's cognitive abilities and vascular health and even increasing their life span.

Although researchers have documented these benefits in mammals, such as rats, guinea pigs and nonhuman primates, the reason for the effect has remained unclear. Now biologist Chun-Fang Wu of the University of Iowa offers a genetic explanation in the May 27 issue of the Proceedings of the National Academy of Sciences. Wu and graduate student Hongyu Ruan found that the presence of youthful, active fruit flies doubled the life span of a group of flies with a mutation in Sod1, a gene that has been linked in humans to Alzheimer's disease and amyotrophic lateral sclerosis (ALS), a motor-neuron disorder also known as Lou Gehrig's disease.

Fruit flies are quite social, Wu explains; social cues govern both their reproduction and aging process. And their genes are easier to manipulate than those of their mammalian counterparts—by altering Sod1, Wu created flies that died after only about two weeks, a quarter of their normal life span. When housed with younger flies, however, the Sod1 mutants lived for about 30 days. The mutant flies also became more physically fit, according to heat-stress tests and other measures, when housed with the younger "helpers." Clipping the younger flies' wings significantly reduced the positive effects on the mutants' life span, suggesting that physical activity plays a key role in the life-extending mechanism.

Physical activity is well known to benefit elderly humans, but working out in a social setting with younger people seems to be especially valuable. Sharon Arkin, a psychiatrist at the University of Arizona, runs a clinical program in which Alzheimer's patients engage in communal exercise sessions with college students. She showed that her program stabilizes cognitive decline and improves patients' moods.

So could the Sod1 gene be playing a part in humans? Wu thinks it is possible. Besides the gene's association with Alzheimer's, Wu found that flies with the Sod1 mutation were more receptive to social cues than flies with other age-accelerating mutations were. Further studies are needed to determine the therapeutic potential of intergenerational socialization—but visiting the grandparents probably couldn't hurt.

Editor's Note: This story was originally printed with the title "Talk to Teens, Live Longer"

www.sciam.com/article.cfm?id=talk-to-teens-live-longer

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3.      International Medicine: Why the National Health Service is Doomed.  From The Sunday TimesAugust 31, 2008. Click on the response from the ones trying to survive.

Swallow this and you'll get a better NHS by Karol Sikora

A 40-year-old mother of two young children with kidney cancer wants a new drug – it's her only hope. The emergency room wants another triage nurse to reduce waiting times from four to two hours. And the ophthalmologists want to give two patients a new drug to prevent age-related blindness. Each intervention will cost £30,000. You only have £30,000 left – it's your call.

Rationing healthcare is never easy. Ageing populations, technological innovation and an informed, demanding public are causing financial meltdown in all healthcare systems across the world. Insurance schemes, such as the NHS, that rely on tax as the main source of funding are doomed. The elderly and retired pay little tax yet consume the majority of healthcare. So the young have to pay for innovative medicines for the old out of their pay packets. This is just not sustainable.

The sentimentality we attach to Britain's NHS will disappear as a new generation realises the financial implications. The Ipod (insecure, pressurised, overtaxed and debt-ridden) generation, now in their thirties, will simply rebel by voting out politicians who want to maintain the current system. A major change in how we pay for healthcare is inevitable.

Innovation is everywhere. The human genome project, robotics, nanotechnology, new imaging methods and gene therapy are all leading to new drugs and procedures to improve our quality and length of life. We are converting previous killers such as coronary artery disease, stroke and cancer into chronic, controllable illnesses. Stem cells from different organs will be used to create tissue banks to replace defective body parts. Brain implants will repair the defects that lead to dementia and disorders such as Parkinson's. All come with a hefty price tag.

Medicine will become personalised. By understanding the individual's genetic make-up and by using a set of sophisticated molecular diagnostics, we will prescribe courses of treatment optimised for them. Personalised care will not just be about drugs. It will involve choices about lifestyles and retirement plans. The current one-size-fits-all model will disappear.

Living long and healthily will end in a speedy downward trajectory to death – for most people in their eighties. Superb palliative and end-of-life care will be normal. This will provide a more financially balanced system making a good-quality, healthy life affordable for all. In the good old days doctors did the rationing covertly. Now we have the National Institute for Health and Clinical Excellence (Nice) providing central guidance based on complex economic formulae and 149 primary care trusts (PCTs) who buy healthcare for their constituents. You can't choose which PCT you use – it chooses you by your postcode. Naturally they all come to different conclusions about the best way of spending their money. That creates the postcode lottery.

Politicians intervene directly in the workings of Nice. Two years ago Patricia Hewitt suddenly announced that Herceptin would be available for women with breast cancer even though it had not gone through the Nice process. And we've not heard the last of the current furore over drugs for kidney cancer rejected by Nice three weeks ago. In June, Alan Johnson, the health secretary, said: "All the cases I've seen involve kidney cancer and drugs that have been too slow getting through the system. They've been licensed but Nice have spent a long time before they've approved them. We need to bring the time right down so those drugs are available on the NHS very quickly." He clearly didn't anticipate a negative Nice decision. I suspect by Christmas the drugs will be approved. Otherwise this episode could lose too many votes.

It's time to open the debate about whether the NHS should be able to provide not just an efficient, well-defined core package of services but allow patients to contribute or insure for improved services, such as top-up medicines. This could reduce the inequity resulting from the current confusion where some patients have to receive all their care privately. This is simply unaffordable to many who have paid their tax-based insurance premium to the NHS for the core package. Being open about the possibilities could lead to a set of innovative insurance products to pay for specific options and herald an era of real patient choice.

How much we are willing to pay for an extra year of good-quality life is a key question for the baby-boomer generation. And how we will allow individuals to contribute to their care in an equitable way. Consumerism and social solidarity are not comfortable companions. We are impinging on the very core of NHS doctrine – care given freely on the basis of medical need and not ability to pay. Its high priests are now very worried.

Radical structural change to the NHS is vital. Competition and choice drive up quality and access, so leading to greater value, just as we've seen in other consumer areas such as mobile phones, budget airlines and the high street. Sensible incentives linked to performance and outcomes are essential. Drastic reform, not more money, is now needed. Treating the NHS as a religion is irrational, bad for our health and not a good solution.

Professor Karol Sikora is medical director at CancerPartners UK, a private cancer company.

HAVE YOUR SAY. The question is surely how much extra cash an individual is willing to pay for an addition to the life span of SOMEONE ELSE who is not a family member of his and unknown to the individual. UK medical services are the worst of any developed major European country. The NHS must be scrapped and replaced. G McKay, Epping, England

Read all 16 comments

www.timesonline.co.uk/tol/comment/columnists/guest_contributors/article4641109.ece

The NHS does not give timely access to health care; it only gives access to a waiting list.

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4.      Medicare: Spending

Medicare Spending Across the Map by Amy Hopson, Research Associate, and Andrew J. Rettenmaier, Executive Associate Director, Private Enterprise Research Center, Texas A&M University

Executive Summary Though talk of fundamentally reforming Medicare has been limited lately, the baby boomers' imminent retirement and the continued rise in health care costs will force Medicare back to the forefront of upcoming policy discussions.

The Medicare Trustees and the Congressional Budget Office both predict that Medicare spending as a percentage of gross domestic product (GDP) will double by 2030. Therefore, all possible means of making Medicare more efficient should be considered in light of its increasing importance to taxpayers. One possible avenue for reform is seen in the wide regional variations in Medicare spending that exist and have persisted through time. If Medicare reimbursements could be constrained to the levels existing in the lower cost areas, the program's costs could be reduced significantly.

But why do Medicare costs vary so dramatically from area to area? Why, for example, is average Medicare spending in Los Angeles almost 70 percent higher than in Green Bay, Wisconsin? The purpose of this study is to examine the county-by-county variation in Medicare spending, look for causes of this variation and suggest reforms that can narrow the variation that can't be explained by the causes we can observe. These reforms not only address the regional variation, but more importantly reduce the program's costs. Most previous studies have analyzed Medicare spending differences at the state or hospital referral region (HRR) level. Since there are just over 300 HRRs and over 3,100 counties, this study allows for closer examination and more precise analysis of the regional variation.

Among the regional variations in Medicare spending that were found:

·          County-level Medicare spending is high states like New Jersey, with 95 percent of its counties in the top fifth of spending.

·         Maryland, Louisiana, Massachusetts and Texas are also high cost areas, with all having more than half of their counties in the top fifth of spending.

·         In contrast, average county-level Medicare spending is low in Vermont, Idaho, New Mexico, South Dakota, Oregon and Iowa, all with more than half of their counties in the bottom fifth of spending.

But perhaps the high-cost counties are high cost simply because they have higher risk Medicare populations, or possibly the retiree population's income or demographic characteristics are associated with higher spending. Additionally, the health care market's characteristics may be driving the higher costs. All of these causes are considered in explaining the average total Medicare spending in each county. The results indicate that:

·         Higher Social Security benefits as well as more Supplemental Security Income imply higher spending.

·         Higher percentages of Hispanics and Blacks are related to higher average Medicare spending in the counties.

·         Higher percentages of female retirees in a county are positively related to spending, while higher percentages over age 85 are negatively related.

·         Higher health care sector wages are associated with lower Medicare spending, but managed care penetration has a positive effect on spending.

·         The most important factors are the health risks among a county's Medicare beneficiaries which are (as expected) associated with higher spending.

·          The observable county characteristics along with a measure of the health care risks explains about 40 percent of the variation in average Medicare spending across the counties in the continental United States.

Does the regional variation observed in the raw county by county averages persist after removing the effects associated with the observable differences in county characteristics? The geographic concentration of high and low cost counties is lessened to some degree, but it is still true that many of the high cost counties remain in the high cost categories. Specifically:

·         Of the six states that had more than half of their counties in the highest fifth of spending, four continued to have more than half of their counties in the top fifth of spending after adjusting for county characteristics.

·         New Jersey was a notable exception in that only 24 percent of its counties remain in the top fifth of spending after accounting for the county characteristics. This indicates that the New Jersey counties' retired population's health risks, income, demographics and health care market explain much of the reason why they are high cost counties.

·         At the other end of the distribution, two of the five states that had more than half of their counties in the lowest fifth of spending still have more than half in the bottom fifth after adjusting for county characteristics.

·         This persistence indicates that factors other than those controlled for cause some areas to be high or low cost. There are several possible reasons why some areas have higher than expected costs. Higher concentrations of uninsured individuals in a county may lead to cross subsidization from Medicare. The legal environment in some states may lead to more aggressive use of protective medicine. Also, the practice of medicine may vary from area to area in a persistent way. Regardless of the cause, there are remedies that address the high cost areas leading to more efficient use of taxpayers' dollars. . .  To read the proposed remedies and the entire study, go to www.ncpa.org/pub/st/st313/st313.pdf.

Amy Hopson Research Associate, Private Enterprise Research Center, Texas A&M University, and Andrew J. Rettenmaier, Executive Associate Director, Private Enterprise Research Center, Texas A&M University, Senior Fellow, National Center for Policy Analysis, NCPA Policy Report No. 313, July 2008. ISBN #1-56808-188-x,
National Center for Policy Analysis, 12770 Coit Rd., Suite 800, Dallas, Texas 75251, (972) 386-6272

Government is not the solution to our problems, government is the problem.

- Ronald Reagan

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5.      Medical Gluttony: Excessive utilization is ubiquitous; but it's not entirely the patient's fault.

MedicalTuesday has had this section on excessive medical utilization since its inception seven years ago. We don't even highlight excessive use such as five or ten percent, items on which the government devotes years of discussion in Congress, debates, hearings, and then passes legislation which generally makes the situation worse. Most of our examples are 100 percent, 1,000 percent or even 10,000 percent excessive utilization without the patient perceiving it as over use. Patients actually brag that the best way to get a complete medical evaluation and physical examination is to go to the hospital emergency room and enjoy. A patient told me last week, that he'd never been to the emergency room before, but that he got royal treatment in the finest hotel with plush surroundings. He said, "I think I got everything that the Mayo Clinic could possible offer in six hours and didn't even have to fly to Rochester, Minnesota."

Would you or I act any differently? If you're in your late 60s and your spouse has been after you to go to a cardiologist and get "checked out" and a hospital ER doctor says you need "this 'n' that" and you know that Medicare is footing the bill, could you face your spouse who has been very worried and say you declined the "Full Monty" evaluation for your heart? Could you forgive yourself if you really had a coronary as you lie in the casket thinking, "I should have been a Glutton and maybe avoided this trip."

There's no real dialogue between the doctor and the patient with chest pain when the doctor looks out the window and sees the $100 million hospital expansion that depends on his/her holding up his/her end of the Faustian bargain when paying the expansion price, which does not affect him or her or the patient. Medicare is going under anyway and poor ole little me can't make a difference in saving it. So, nurse, where did you put that order sheet?

Saving Medicare involves a simple solution - not easy, but simple. By going back to the original law and have patients pay a healthy deductible when going into the hospital (or better yet a 5 percent co-payment) as well as a 20 percent co-payment on all items in Medicare B and D, and outlawing MediGap insurance, cost control would be achieved immediately. Very, very simple, but not easy to do and stay elected.

Congress is not interested in saving Medicare and not getting re-elected. Once, the government is involved in an entitlement, there is no hope for rational thinking. The Medicare age should have been indexed for life expectancy and since people live 15 to 20 years longer, the Medicare Age should be at least 75 and continue to be indexed. One can't add an extra 10 years of retirement income and retirement health benefits and not expect bankruptcy. My patients at age 75 look far younger than my patients at age 60 looked twenty years ago.

Designing the Patient-Centered Health Plan for America  www.healthplanusa.net/index.htm.

A National Health Care Plan  www.healthplanusa.net/DelMeyer.htm.

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6.      Medical Myths: Europeans wonder why we persist in the myth about medical killing.

The Economist is in the habit of ridiculing America's moral torpidity. This came up because of the moral stand of Sarah Palin. They don't understand prenatal killing or even partial birth killing as bad. They don't understand why Sarah Palin didn't kill her Downs or mongoloid child while still in utero.

But then European physicians have never had a problem killing humans, even if they were not their patients. Some even think that the disabled should be put out of their misery with a lethal injection like we give first-degree murderers. However, Europeans take issue with the killing of killers who are truly evil persons. They will kill the aged and infirmed and sometimes those that aren't so aged or infirmed. Sometimes it's just because they need the bed.

At an international medical meeting, I was sitting at a table of mostly European doctors. I asked about how common Euthanasia was in their countries. Several of the doctors had participated in it. The doctor sitting next to me was from The Netherlands. He stated that he felt badly about one instance where he wanted to put a patient in the hospital and the patient declined stating that she feared she would be put to death and she wasn't ready to die. He assured her that he would be watching over her to make sure that didn't happen. Sunday was his day off. On Monday, when he went to look for his patient, he could not find her and after inquiry located the doctor who was caring for her. He was told that she was given "the injection" because they needed the bed.

Once you have a culture of death, it's hard to stop. Where would you stop? How many days after conception? How many months into a pregnancy? Or if you missed, could you still suck out the brains as the baby is crowning into the world? Or if you missed a Mongoloid or Downs Syndrome, snuff out the life right after birth? Or if the patient becomes disabled and crippled, do it any time which is recommended by some Princeton professors already. Or if the patient is aged and feeble, move things along with a "lethal injection" but make sure the patient isn't a criminal—that would be capital punishment. Or if the patient is doing well, but occupies a hospital bed and someone younger needs it worse, just give her the "lethal injection" to free up a bed.

Where does it all end?

Oregon offers state-assisted suicide if Medicaid treatments are too expensive. And that's in our own country - pretty close to home.

It never ends once it starts. Are we all headed for the slippery slope? Are we all Hitlers who decide when life is not worth living?

Or maybe Sarah Palin came along at just the right moment in history. She may effectively turn a few things around as Vice President. But she will be even more effective when she makes history as the first woman president in 2016. And she will make further history when she starts her second term on the 100th anniversary of the Women's Suffrage Amendment in 2020. As a member of Feminist for Life, she may do more for Women's Liberation in the next eight years than the entire feminist movement for the past 60 years. Hats off to her.

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7.      Overheard in the Medical Staff Lounge: The Elections have suddenly become interesting.

Dr. Ruth: Wasn't Sarah Palin a breath of fresh air last week?

Dr. Dave: I would certainly agree to that.

Dr. Michelle: And not a day too soon.

Dr. Dave: The other party is really scrambling all at once.

Dr. Edwards: We haven't heard much from the other Vice Presidential candidate.

Dr. Dave: He probably doesn't know what to say. He and his presidential running mate are the first and third most liberal socialistic candidates in their party.

Dr. Rosen: The most socialistic ticket in America in decades.

Dr. Edwards: There certainly is no balance on that ticket.

Dr. Rosen: Do you think this sudden turn of events will return the doctors to their traditional conservative roots?

Dr. Yancy: I certainly hope so. I wasn't going to vote this year, but suddenly changed my mind. All at once, there's hope for America.

Dr. Dave: There's hope. But will it change the playing field?

Dr. Rosen: You don't think this is just a fluke, do you?

Dr. Ruth: I certainly hope it's not.

Dr. Dave: If we can get her elected as the first Woman Vice President, then in 2016, we may have the first Woman President.

Dr. Michelle: Wouldn't that be great if by 2020 on the 100th anniversary of the women's suffrage amendment, we would have a Lady President?

Dr. Dave: And people are already referring to her husband as the First Dude. I think that rather fits.

Dr. Rosen: Coming out of the oil fields and into the White House? I haven't noticed, does he wear cowboy boots?

Dr. Dave: He certainly must if he goes moose hunting.

Dr. Rosen: Good point. I'll keep my eyes peeled.

Dr. Ruth: He's a breath of fresh air also.

Dr. Rosen: It's turning out to be the most fascinating campaign of my life!

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8.      Voices of Medicine: A Review of Local and Regional Medical Journals

SONOMA MEDICINE, the Magazine of the Sonoma County Medical Association, Summer 2008

At Home in Guatemala By Julie Kiser, MD

I work in a three-room clinic in Las Cruces, a small town in northern Guatemala. We have dirt roads and draw our water from a well, and we usually have electricity.

A few weeks ago, a 17-year-old mother came to our front porch with her two small children. The 10-month-old had rotavirus and was dehydrated, so I brought water, sugar and salt from our kitchen, and together the mother and I made one liter of oral rehydration drink.

The mother said the 3-year-old, a girl, had an earache. I examined both kids: temperature, pulse, respiration, ears, lungs, belly. The girl had a fever and a tender liver. From the clinic I got microscope slides, cloroquine and primaquine. Back on the porch, I stuck the girl's finger and made a thick and thin smear to read in the afternoon. As the mother held her daughter, we pushed in the first dose of three days of bitter cloroquine. Then I wrote the record of the visit on two green cards, one for each child, and gave them to the mother. She paid me a few coins, which I returned to our pharmacy fund.

During the mother's visit, I was nurse, pharmacist, lab tech, records clerk, doctor, accountant and mom's helper. We were outside in the fresh air. The only copy of the medical chart went home with the patient, who will bring it when she returns.

Dr. Kate Feibusch and I have lived in Guatemala with our daughter, Mira Moore, since December 2000. We live in the northern state of Petén. Kate and I graduated from the Santa Rosa Family Practice Residency in 1999 and 1997, respectively. The residency sent us off with an excellent education and an ethic of service. When Sonoma Medicine asked us to write about our lives here, I saw a way of sending gratitude to our teachers and our circle of Santa Rosa friends.

Although we love seeing patients, direct patient care is not our only job here; we also administer a project that supports rural health workers. Last week, for example, I rode with Mira in the back of a pickup truck over dusty roads for three hours, carrying a box of medicines and a mosquito net. My destination was the Unión Maya Itzá, a community established in 1996 by refugees who returned at the end of Guatemala's civil war. They and their children now farm near the Usumacinta River, Guatemala's western border with Mexico.

We stayed in the community for two days with a rural health worker named Angelina, a 34-year-old mother of three. She has seen about 70 patients a week for the last five years. She receives emergencies at all hours, including births and wounds requiring suturing. When necessary, she keeps patients overnight in her home.

During my stay, Angelina and I consulted on her difficult cases, including a neighbor with psychosis who takes chlorpromazine. The day I arrived, I visited a man with high fever and vomiting, possibly caused by leptospirosis. I repaired Angelina's sphygmometer and restocked her chest of medicines. I had brought a dermatology book with me; we reviewed the appearance of tinea corporis, tinea pedis and kerion. We set a date for my coworkers to apply fluoride to school kids' teeth. I also talked with Angelina and her husband about building an annex, in order to move the medical consult out of their living room. Angelina taught Mira and me more words in Q'eqchi', one of 20 Mayan languages spoken in Guatemala. Angelina, like many indigenous Guatemalans, is bilingual. She speaks Spanish and Q'eqchi' (pronounced *EK-chee, where * is a click in the back of the throat).

Our main job is to visit volunteer medical workers called "health promoters" and teach them in formal classes. From January to March this year, for example, I presented three five-day courses. The first course, in Spanish, covered musculoskeletal medicine, including back pain and common knee and shoulder problems. The second course was a Q'eqchi' version of the first course, presented to five women and 15 men. The same group received my third course a month later, on diagnosis and treatment of skin problems. . .

Now Kate and I are teachers. We remember warmly our teachers at the residency, including Drs. Rick Flinders and Lou Menachof. Like them, we provide health care to the poor. As we are the last stop for many difficult and challenging cases, we must go to the limits of our abilities. The philosophy of the Santa Rosa residency was to prepare for a broad practice, including procedures. We do a lot of minor procedures, including using ketamine anesthesia for kids and trauma. We also repair extensor tendons of the hand. We refer to a local hospital when a patient needs an appendectomy or a cesarean section. Since we have no X-ray or ultrasound, I especially appreciate the physical diagnosis skills from our early training. Much of the musculoskeletal medicine I teach, I learned from Dr. Veronica Vuksich. We do our own blood smears, Gram stains and TB slides, and we use the intensivist skills learned from Dr. James Gude because we receive emergencies from a 100-mile radius. Kate completed a fellowship at the HIV clinic in Santa Rosa, and she is the main coordinator of HIV care in the region. . .

People live very simply here. A typical house is made of sticks and boards with a roof of palm leaves or tin sheeting. Families sow the land with corn and store sacks of harvested corn in their houses. To make a meal, women rub kernels off the cobs, cook the kernels with lime and then grind them to make corn dough. They pat the dough into tortillas, which they cook over a wood fire and serve with black beans.

We work for the service arm of the Catholic Church, but our financial support comes from a U.S.-based organization called Concern America. Since its establishment in 1972, Concern has worked quietly with refugees and materially poor communities in 15 countries. It is a non-religious nonprofit that makes long-term commitments. Our project has been in Las Cruces for 12 years and employs six Guatemalan health workers whom we consider peers. Julia Martinez, for example, has worked full-time for our project since 1999. She is my age, 46, and she has seven children aged 27 to 12. . . .

·         Guatemala is only 700 miles south of the United States, but its health indices are among the worst in the world. Guatemalan women face 20 times the maternal mortality of American women. The Guatemalan government spends $15 per capita on its public health system, compared to the American expenditure of $2,000 per capita. Trade agreements with the United States favor pharmaceutical companies and restrict the use of generic medicines in public clinics. For these reasons, our project involves itself in local and national politics. . . .

Specialist physicians who are willing to give us their cell phone number can be especially helpful. On occasion we get really stuck with a case requiring a specialist, and we need somebody to call. We run into orthopedics, ophthalmology, oncology and surgery cases out here in the sticks, and a friendly, informed American colleague could help us think things through.

To find out more about supporting our work or visiting our clinic in Las Cruces, go to
www.concernamerica.org or contact Kate and me directly at kate_julie@yahoo.com.


Dr. Kiser, a family physician, lives and works in Guatemala with Dr. Kate Feibusch and their daughters Mira and Toby.

To read the entire article, go to www.scma.org/magazine/scp/sm08/kiser.html.

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9.      Book Review: Spiritual and Medical Perspectives on Euthanasia and Mortality

DENIAL OF THE SOUL - Spiritual and Medical Perspectives on Euthanasia and Mortality, M. Scott Peck, MD, Harmony Books, New York, 1997, xi & 242 pp, $23, ISBN: 0- 517-70865-5.

Physician, psychiatrist, theologian, and author of the best-seller, The Road Less Traveled, F Scott Peck, MD, gives us an in-depth look at the current euthanasia movement and its origins in the inability of physicians to "pull the plug." Peck states that although Dr Kevorkian gives him the shivers, he must credit him more than any other individual for the genesis of this book. Almost single-handedly over the past five years, Kevorkian has turned the debate over euthanasia into a national issue within the United States.

But Kevorkian didn't inspire Dr Peck to write this book–it was the public response to his behavior. Peck was surprised by the number of people who admire Kevorkian..He was even further surprised by the larger number who, though they feel no affections for Kevorkian, nevertheless deeply approve of what he has been doing in assisting the suicides of those who are ill. Most of all, Peck has been surprised by the huge number of Americans who do not find Dr Kevorkian's work particularly objectionable.

The whole debate is strangely passionless and seemingly simplistic. But the subject of euthanasia is far from simplistic–it involves questions about who, if anyone, has a right to terminate a life; whether it's the same as or different from suicide or homicide; whether it differs from merely "pulling the plug;" and what role does pain, both physical and mental, play in euthanasia decisions. Among the stories he tells, is one about Tony, a patient of his when he was a psychiatric resident. He felt Tony's craziness was organic and referred him to neurology where he was found to have a large frontal brain tumor. The tumor was inoperable and failed to respond to radiation treatment.

Weeks later when Peck rotated on the neurology service, Tony, now unresponsive and on a ventilator, reentered his life. He wondered why anyone would decide to place Tony on life support. Was this "heroic" medicine, or just a measure to prolong a life that had lost its essence? Peck asked his chief of neurology at Letterman General Hospital whether this effort to prevent inevitable death was the right thing to do? The Colonel commended him, obtained a portable EEG, and found an occasional distorted brain wave and pronounced that the patient was not yet certifiably brain-dead.

Recalling the anguish of the family in waiting, Peck looked at Tony for the next 15 minutes, cut the levophed drip in half, went to the doctor's lounge, smoked a cigarette, returned 10 minutes later, found Tony dead, and informed the family. As they wept, speaking to each other in Italian, he could not tell whether they were weeping in grief or relief. He concluded, probably both. He, of course, had the presence of mind not to tell anyone about what he had done.

Peck wishes that he could have shared his solo decision 30 years ago. If he had, he would have opened himself to court-martial for unacceptable medical behavior. His actions would have been considered euthanasia or physician suicide. Today the decision to "pull the plug" is made in conjunction with the family and other physicians and occasionally the ethics committee.

Peck then takes us on a journey of inadequately treated pain, which is now a precursor to physician assisted suicide. Nothing fuels the euthanasia debate so much as the fear of intractable pain. Peck states that if there were such a thing as intractable untreatable agonizing pain, one could make a case for physician-assisted suicide. In his entire professional life, Peck has never found one case in which pain could not be controlled with the appropriate type of morphine cocktail. Peck gives the fear of pain a lengthy treatment because he feels that many people look to euthanasia as a cure for physical pain they believe they will have to endure during the natural process of dying. But according to Peck, it is emotional–not physical pain that is the center of the euthanasia debate.

Once Peck establishes that it is emotional, not physical pain that is the center of the euthanasia debate, he then turns to mental illnesses, to suicide, natural death, and murder. Although he believes physician-assisted suicide should be illegal, he points out that not all people can obtain Hospice care to relieve pain and suffering and there are many unsympathetic physicians out there. He wishes there were a vigorous discussion in religious congregations, but feels they will do almost anything to avoid open debate. The author contends feels that all of these issues must be adequately explored before the underlying simplicity of the spiritual perspective will be accepted. We must become articulate in the Euthanasia–Physician Assisted Suicide debate before it's too late.

This book review is found at www.healthcarecom.net/Denial_of_the_Soul.htm.

To read more book reviews, go to www.delmeyer.net/PhysicianPatientBookshelf.htm.

To read book reviews topically, go to www.healthcarecom.net/bookrevs.htm.

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10.  Hippocrates & His Kin: How to keep our memory function working.

As we snooze, our brain is busily processing the information we have learned during the day. Sleep makes memories stronger, and it even appears to weed out irrelevant details and background information so that only the important pieces remain. Our brain also works during slumber to find hidden relations among memories and to solve problems we were working on while awake.

The latest research suggests that while we are peacefully asleep, our brain is busily processing the day's information. It combs through recently formed memories, stabilizing, copying and filing them, so that they will be more useful the next day. A night of sleep can make memories resistant to interference from other information and allow us to recall them for use more effectively the next morning. And sleep not only strengthens memories, it also lets the brain sift through newly formed memories, possibly even identifying what is worth keeping and selectively maintaining or enhancing these aspects of a memory. When a picture contains both emotional and unemotional elements, sleep can save the important emotional parts and let the less relevant background drift away. It can analyze collections of memories to discover relations among them or identify the gist of a memory while the unnecessary details fade—perhaps even helping us find the meaning in what we have learned.

 www.sciam.com/article.cfm?id=how-snoozing-makes-you-smarter

Work and sleep continues to be our tradeoff challenge - to get enough of both for a productive life.


Global Consultations

Consultants who are unable to travel to remote areas of the world can now serve these people due to the fact that world wide cell phones are nearly a local call. For those specialists who are willing to give their cell phone number to workers in Guatemala or other remote countries, they can discuss a patient's problem with the family doctor providing consultative care and never leave their office or home. The marvels of the technology age are unlimited.

Global medicine is indeed coming into its own.

To read more HHK, go to www.healthcarecom.net/hhk2001.htm.

To read more HMC, go to www.delmeyer.net/hmc2005.htm.

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11.  Organizations Restoring Accountability in HealthCare, Government and Society:


 

                      The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at www.ncpa.org and register to receive one or more of these reports. This month, become an informed voter by comparing the health plans of the candidates. Read John Goodman's analysis for Barack Obama and for John McCain.

                      Pacific Research Institute, (www.pacificresearch.org) Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog. This month, do some serious studying of the Tax Implications of Single-Payer Health Plan.

                      The Mercatus Center at George Mason University (www.mercatus.org) is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government. Read about federal overspending.

                      The National Association of Health Underwriters, www.NAHU.org. The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. www.nahu.org/publications/hiu/index.htm. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business. Be sure to review the current articles listed on their table of contents at www.hiu-digital.com/hiu/200808/. To see my recent column, go to http://hiu.nahu.org/article.asp?article=1660&paper=0&cat=137.

                      The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at www.galen.org. This month, read the WSJ article by Ms Turner: Much to our surprise, the Census Bureau reported yesterday that the number of people in the U.S. with health insurance actually increased by 3.6 million last year. That's the good news. The bad news is that nearly three million of them got their coverage through government programs. . .

                      Greg Scandlen, an expert in Health Savings Accounts (HSAs) has embarked on a new mission: Consumers for Health Care Choices (CHCC). Scroll down to read the initial series of his newsletter, Consumers Power Reports. There are two levels of membership to receive this newsletter by email and other benefits. Be sure to read Prescription for change:  Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn.

                      The Heartland Institute, www.heartland.org, publishes the Health Care News. Read the late Conrad F Meier on What is Free-Market Health Care?. You may sign up for their health care email newsletter.

                      The Foundation for Economic Education, www.fee.org, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Richard M Ebeling, PhD, President, and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed sixty years ago. This month, read The State Is Morally Hazardous to Your Health.

                      The Council for Affordable Health Insurance, www.cahi.org/index.asp, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse." Read their version of the affordable health plan.

                      The Independence Institute, www.i2i.org, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter. This month, read this article about those who would support a self-serving political agenda at the expense of your health, wealth, and job mobility.

                      Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at www.quebecoislibre.org/apmasse.htm to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis. This month, read about the Disney Film, Wall-E.

                      The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at www.fraserinstitute.ca for an overview of the extensive research articles that are available. You may want to go directly to their health research section. Read about A free and prosperous world through choice, markets and responsibility.

                      The Heritage Foundation, www.heritage.org/, founded in 1973, is a research and educational institute whose mission is to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. The Center for Health Policy Studies supports and does extensive research on health care policy that is readily available at their site. This month, read about the Warnings for our Health Care Economy.

                      The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at www.mises.org to obtain the foundation's daily reports. This month, read the Awful Truth about Ten Republican Senators who refused to go to their own convention. You may also log on to Lew's premier free-market to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or find out why anyone would want to be an MD today.

                      CATO. The Cato Institute (www.cato.org) was founded in 1977 by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. This month, read about what happens when you're too big to FAIL and too big to SURVIVE.

                      The Ethan Allen Institute, www.ethanallen.org/index2.html, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.

                      The Free State Project, with a goal of Liberty in Our Lifetime, http://freestateproject.org/, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]

                      The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, war time allows the federal government grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in war time we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to www.stcroixreview.com.

                      Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at www.hillsdale.edu to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month, read Mark Steyn. The last ten years of Imprimis are archived.

* * * * *

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 Words of Wisdom

Half the harm that is done in this world is due to people who want to feel important. They don't mean to do harm - but the harm does not interest them. Or they do not see it, or they justify it because they are absorbed in the endless struggle to think well of themselves. -T. S. Eliot

Civilization is not inherited; it has to be learned and earned by each generation anew; if the transmission should be interrupted for one century, civilization would die, and we should be savages again. -Will and Ariel Durant, www.tsowell.com/quotes.html

Some Recent Postings

AMERICA ALONE, The End of the World as we Know It, by Mark Steyn  www.delmeyer.net/bkrev_AmericaAlone.htm

HEALTH CARE CO-OPS IN UGANDA - Effectively Launching Micro Health Groups in African Villages, by George C. Halvorson www.delmeyer.net/bkrev_HealthCareCo-OPInUganda.htm

A CALL TO ACTION - Taking Back Healthcare for Future Generations by Hank McKinnell  www.delmeyer.net/bkrev_ACallToAction.htm

PUTTING OUR HOUSE IN ORDER - A Guide to Social Security & Health Care Reform by George P. Shultz and John B Shoven  www.delmeyer.net/bkrev_PuttingOurHouseInOrder.htm

In Memoriam

Jack A. Weil, patriarch of western clothing, died on August 13th, aged 107
From The Economist print edition Aug 28th 2008

IN THE annals of fashion the snap-fastener, or press-stud, holds a humble place. Few care that it was invented in Germany, as the Federknopf-Verschluss, in the 1880s. Not many appreciate that some varieties have discs and grooves, while others boast sockets with studs. And almost no one considers that they give a man style. But Jack Weil did.

Mr Weil reckoned that a cowboy on a horse, if wearing a shirt with buttons, was liable to get snagged on sagebrush or cactus or, worse than that, get a steerhorn straight through his fancy buttonhole. He was pretty certain, too, that a cowboy losing a button would feel disinclined to sew it on again. The answer to all those difficulties was to make shirts with snap-fasteners. And for 62 years, in a red-brick warehouse in the LoDo district of Denver, Mr Weil did exactly that.

He also added a few more customisings. Pockets with sawtooth flaps, to keep tobacco in; a yoke fit, to broaden out the shoulders; body-hugging seams, to show the fine muscles of a cattleman; and deep cuffs. The hats, belts, buckles and bolo ties, which he also commercialised, were optional. But the snap-fasteners were de rigueur: topped with pearl and backed with tin, square or circular or diamond-shaped, strong enough to pass without cracking through the wringer of a 1940s washing-machine, and flash enough to turn heads on the streets of Denver on a Saturday night. "A cinch", as Mr Weil proudly said.

Until he created his shirts, there was no distinctively western look in American couture. There were cowboys; but they wore dusty working clothes, accessorised with sweaty bandannas and clanking spurs, that no one much cared to copy. Indeed, Mr Weil early on in his career made work-gear for cowboys, and learnt an important fact: they had no money. If he wanted to make any money himself, he would have to appeal not to the catwalk instincts of cattlemen, which were hard to spot, but to wannabe easterner cowboys who lived in, say, New York. Fortunately, there were plenty of them. . .

To read the entire obit, go to www.economist.com/obituary/PrinterFriendly.cfm?story_id=12000749.

On This Date in History – September 9

On this date in 1776, the Continental Congress changed the name of the reveling United Colonies to the United States. So today is the birthday of the name United States.

This date in 1850, is the anniversary of the admission of California to the United States as the 31st state. This was the date that our nation spread coast to coast - from the rockbound coast of Maine to the sunny shores of California, where they had recently struck gold.

After Leonard and Thelma Spinrad

 

MOVIE EXPLAINING SOCIALIZED MEDICINE TO COUNTER MICHAEL MOORE's SiCKO

Logan Clements, a pro-liberty filmmaker in Los Angeles, seeks funding for a movie exposing the truth about socialized medicine. Clements is the former publisher of "American Venture" magazine who made news in 2005 for a property rights project against eminent domain called the "Lost Liberty Hotel."
For more information visit www.sickandsickermovie.com or email logan@freestarmovie.com.