Prevention and the Cost of Health Care

by Shiban Ganju

USA_National_Health_Plan One formula to cut the cost of health care: stay healthy until you die. Unfortunately for the payers of health care, disease intervenes between health and death. That costs money. And the more chronic the disease, the more money it gobbles up.

Prevention and management of chronic disease are two important planks of cost-saving in the Obama health plan. But will it reduce the expenditure? Only if staying healthy generates more profits for all compared to profits generated by caring for the sick. And that needs a strong political will for financial reengineering of the system.

A health care system aims to fulfill a need of a society but often falls short of its aspiration. The devil lurks in its delivery. In a simplistic form, a health system aims to achieve the following:

  1. Prevent the preventable.
  2. Cure the curable.
  3. Research the unknown.
  4. Palliate the incurable.
  5. Rehabilitate the disabled.
  6. Minimize suffering when death is inevitable.

We derive maximum value for the money spent on the top three ventures on the list. But we spend disproportional amounts of available money in ‘sick’ care and in trying to cure the incurable. And we spend less in ‘health’ care to keep the population healthy. In the USA, only 2 to 3 percent of health expenditure goes for prevention. The medical industrial complex, which profits by treating the ‘disease’, has little incentive to invest in ‘prevention’, which does not yield high return on investment.

So the often asked question: does prevention decrease the cost of health care? The question has thee dimensions. First: is the question relevant? Second: How does one measure cost? Third: what can we prevent?

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Roland Garros 2009 Dialogue

A conversation about the upcoming French Open between three tennis fans: Sydneysider Lucy Perkins, New Yorker Asad Raza, and Ecuadorian-North Carolinian Juan José Vallejo.

Asad Raza: Hey guys, thanks for coming aboard the 3quarksdaily raft. So here we are at Roland Garros time, again, where for the last several years Rafa Nadal has been the bear that eats Roger Federer. J.J., you have the best account of the state of their rivalry I've heard. Care to run through it?

Juan José: I'm currently toasted, but I promise I'll send my run-through tomorrow. Hope you're all doing well!

Lucy: JJ! If I had thought one of us was gonna delay writing on account of being under the influence, you would have been my THIRD choice. I'll check back in after Fed's straight-set drubbing of Rafa in his HOME MASTERS FINAL. Oh yes. (Ed. Note: this message written eight hours before Roger Federer's May 17th straight-sets defeat of Rafael Nadal in the Madrid final.)

Juan José: Eh…oops. Wrong choice of words there!

What happened was that yesterday ended up being way more exhausting than I expected. It all started at 7:40 in the morning, when I woke up to fish for an internet stream so I could watch my Manchester United clinch the English Premier League title. Which they did, and I was very happy. Shortly after the celebrations ended, Nadal and Djokovic were on.

Now, I had already written off the match as a straight sets defeat for Djokovic, since he was playing on his third straight week, and Nadal even had a walkover in his “home” tournament. But then the match started, Nadal looked terrible and Djokovic looked good. When Djokovic served out the first set, I thought he had a great chance to win this, if Nadal didn't improve dramatically. Djokovic was playing his game, not even going for anything spectacular, and it seemed that staying the course would be enough to win the match. Then, at 1-2 in the second, Nadal calls for the trainer, and he gets his knee taped. I thought, hey, now there's an enormous chance. Djokovic adjusted on the fly, making Nadal hit loads of backhands, since the taped knee was his right one, which he pushes off when he hits off his backhand side. That was a nice adjustment to see. So I thought, man, this is really going to happen! Even if it was similar to last year's Nadal-Ferrero match in Rome, who cares, it was a clay win over Nadal. And Nadal didn't look good. He wasn't moving well. He looked like he was about to retire.

But of course, that didn't happen. What happened instead was that he stopped missing. Welcome to Nadal hell. However, Djokovic was still playing well, so even when he lost that second set tiebreaker, I thought he had a big chance in the third. So it was no surprise to see him go up a break. But then cramps hit, he gets broken, and the real match started.

I'll echo Djokovic in saying that there is very little to say about what followed. All the evidence you need to see was there in those last games of the third set. It was unbelievable, it was ridiculous, it was crushing, and it was heartbreaking, in a strange way. The worst way to endure a defeat is if your sporting entity choked, and that was not the case. But it also hurts when your sporting entity plays as well as he can possibly play, and still lose. As an Agassi fan, I've been through that before. It's a special kind of heartbreak.

So the only influence I was under all day was from a pint of Guiness I had stored in our refrigerator here for extreme emergencies. It had been sitting there for about 9 months. So that and videos of Manchester United celebrating made me happy again.

Anyway, we're missing the Madrid final here because of Amy's birthday brunch. I'll talk about the Federer-Nadal thing when I get back.

Asad: Actually, I think it's quite appropriate that we ended up talking about Djokovic, who has been pushing Rafa on clay more than anyone else–Federer may have won the Madrid final, he might owe Novak part of that check–it was the match with Novak that took the starch out of Rafa. Or did Federer make a true breakthrough just when none of us expected him to beat Nadal on clay again, Luce?

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My Life as a Crime Fighter: The Case of the Predator Psychiatrist – Part 2

Part 1 of “My Life as a Crime Fighter: The Case of the Predator Psychiatrist” can be found HERE.

[Note: Some names and details have been changed to protect the privacy of individuals, especially the victims.]

Wearing a Wire

I offered to go see the psychiatrist, Dr. Joseph R. Dorsey, and try to get him to make incriminating statements about having sex with his patient, Gertrude (Gerti) Kossik. Gerti's husband, Nathan, and her (now former) lover, Janice Wines, were surprised that I would offer to play cloak and dagger. It never occurred to them, but they felt it could help their complaint with the New York State Department of Education concerning Dorsey's medical license, as well as their civil case. Their attorneys, Willard Marino and Robert Cohen, thought it was a great idea. I agreed to wear a wire, a concealed tape recorder, to gather the evidence. It wouldn't be a problem getting access to Dorsey because we knew each other from varied professional events in the mid-Hudson Valley. Also, I consulted with him about IBM employees who were having adjustment problems at work. I was at his office once or twice, so there shouldn't be a problem making an appointment to see him under the pretense of discussing matters about a couple of employees.

The trial attorney, Bob Cohen, gave me a legal briefing on the secret recording of telephone and personal conversations. By this time, I was sure Bob had been a yeshiva student, if not a trained rabbi, in an earlier life. Not only did he look and sound like a biblical scholar, but he would raise his right hand, index Wearing_a_wire_wcctvvest finger extended and pointing toward heaven, to emphasize the authority of his points of analysis and conclusions, “Now if you consider the intent, and the fact that it will be a matter for both a civil and administrative trial, …”. Later I told him he presented himself like a biblical scholar. He smiled at me and said, “Thanks. That's a great compliment.” I asked why he was called a 'trial attorney'. “Don't all attorneys participate in trials?”, I asked. He smiled again and said, “Asking me that question is good news for you.” “How's that?”, I replied. He straightened up a bit and said, “It means you've been fortunate, to this point in your life, not to have been involved in matters that required interactions with lawyers.” He went on to explain the distinction between solicitor and barrister in the U.K. While we don't have the same formal classification in the U.S., there is an informal and practical alignment that results from personal preferences and experiences among attorneys. My status as a legal ingénue would come to an end in a couple of years.

For New York State, the law concerning the secret recording of a conversation is as clear as it is simple. Anyone can can record any telephone conversation, or personal conversation, to which one is a party. There is no requirement to inform the other person in advance of, during, or following the conversation. Permission from the other party, or parties, is not required. The laws in other states will vary. For example, Linda Tripp was violating the laws of the State of Virginia when she secretly recorded her conversations with Monica Lewinsky.

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On Criticizing Israel

Justin E. H. Smith

I would like to lead my life, with Spinoza, sub specie aeternitatis. I truly would. But every now and then my fellow men show themselves to be so brutish that I have no choice but to come back down to earthly reality and cry shame. Such a moment was the Israeli siege on Gaza that began at the end of last year, which prompted me to try to do what I could, with the low-grade weaponry of rhetoric, to convince the unconvinced that this was a thing to be harshly denounced. What did I do? Well, I wrote up my case, and I made it known through various low-voltage electronic media. Why did I not do more, like Jeff Halper? As I've said, I am hardly a philosophe engagé. I confess to doing as little as possible.

In any case, my minor foray into activism was also a learning experience. What did I learn? Among other things, I learned that, as one might fear, criticism of Israel really does draw the creeps out of the woodwork: there are indeed many out there who are far too eager to see in Israel's aggression the confirmation of their own fantastical, alternative accounts of the secret forces guiding world history. I also learned that there are many out there who take the opinions of these alienated, ill-informed bigots far too seriously, and who mistakenly suppose that any and all criticism of Israel must come from, or lead to, that same dark place.

Should one then refrain from criticizing Israel altogether? This is a privilege no one would dream of granting to any other state in the world, and one I certainly don't grant to my native country or to my adoptive one. Or should one instead insist that such delicacy around the question, such special treatment, is itself a manifestation of the same sort of unhistorical, unscientific Sonderweg-thinking that, under other circumstances, has been used not to hold Israel above all criticism, but rather to blame Jews for whatever goes wrong with the world? I know which of these two approaches I choose, and I insist that to say this is also a choice to stoke antisemitism is not only a fallacy, but also a smear.

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Atheistic Materialism in Ancient India

By Namit Arora

KushanCourtesan Various societies at different times have dazzled with their bursts of creative and intellectual energy. Historians have a penchant for dubbing them Golden Ages. Examples include the Athens of Herodotus, the Baghdad of Haroun al-Rashid, and the India of the Buddha. But though India has long been famous for its “ancient wisdom”, the few historical sources that survive shed woefully inadequate light on the Buddha's society. By contrast, far better portraits of classical Greece and Abbasid Baghdad are available to us.

Still, evidence at hand suggests that around 600-500 BCE, in parts of the Indo-Gangetic plain of north India, people were asking some very bold and original questions: What is the nature of thought and perception? What is the source of consciousness? Are virtue and vice absolute or mere social conventions? Old traditions were under attack, new trades and lifestyles were emerging, and urban life was in a churn, reducing the power of uptight Brahmins.

SarnathTurbanaedMale Philosophical schools flourished in a marketplace of ideas, and included chronic fatalists, radical materialists, self-mortifying ascetics, die-hard skeptics, cautious pragmatists, saintly mystics, and the ubiquitous miracle mongers. “Rivalries and debates were rife. Audiences gathered around the new philosophers in the kutuhala-shalas—literally, the place for creating curiosity—the parks and groves on the outskirts of the towns…. The presence of multiple, competing ideologies was a feature of urban living.”[1] It was also an age of nascent democratic republics, which, like Athens later, did not ultimately survive the march of monarchy and empire.[2]

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Monday Poem

Figurehead
Jim Culleny

Sometimes a poet will sail
the line of a poem
like Leonardo DiCaprio:

a figurehead on
Titanic,
arms spread, embracing the wind,
the air, the fabulous future,
poised before the next word,
only to find it isn’t there:
the right word,
the one that says it all,
the one that pulls the rabbit out of the hat of the poem,
that drops scales from blind eyes,
that gives ears their plum and brain its due
and (without the need to be said)
ends its longing for what the heart
already knew

My Experiments with Cooling

by Aditya Dev Sood

Delhi2 This is Delhi in its glory. Hotter, even, than when I knew it as a child, the temperatures these days scratching past the 45 degrees Celsius that were their absolute threshold then. Every day the earth baking, every night the atmosphere billowing in response, plumes of invisible heat unsettling the skies, a sudden imbalance and extreme of the natural order, corrected by crazy dust storms in the late afternoon, whose special, threatening light, one knows, will never break to rain. The dust is everywhere. On window sills and on the floors of my home, on doorknobs and banisters, and even hidden atop curtain rods and high shelves. The body is always tormented by the heat, always seeking respite, coolness, moisture, a wet towel, ginger-lemonade, the direct draft of an air-conditioner.

Last summer, when I was remodeling this house, I had six air-conditioners installed, one for each room, most of them split units, their umbilical tubing buried within the masonry. When we moved in, at the end of September, they seemed excessive, perhaps even a bit of a waste. This month, they seem barely adequate, and my family's warnings prescient — don't skimp on the aircon or you'll regret it in the summer, when you most need it. The units loom over each room, promising Singaporean efficacy, but delivering Patna levels of cooling.

In the center of the two-storied house is a kind of small atrium, or large shaft, which stretches from plinth to roof. My neighbor has one just like it — it is mandated by local zoning. The idea was, in those pre-aircon-days of the Raj and early Indian post-coloniality, that air would circulate through the house, gathering heat from the groins and armpits of its wilting inhabitants, before entering the atrium and rising up as hot air must, but also following Bernoulli's principle, that fluids will accelerate as they pass through a narrower channel. The logic of air-conditioning, sadly, runs so directly counter to this ecological understanding of architecture, as a coordination of air flows from outside the building, in through its interiors, all the way out its top.

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A journey through the heart of Iran

Hooman Majd in Newsweek:

ScreenHunter_07 May. 24 17.43 The layers of contradiction that make up the modern Islamic Republic of Iran are both pervasive and confounding, and not any less so in Yazd. Set amid the blistering deserts of central Iran, the city is home to the kind of fierce religiosity bred in Islam's starker landscapes, and many of its sons were sacrificed to the bloody war with Iraq. Yet it is also a capital of pre-Islamic Persia, and is well known for its Zoroastrian temples and grave sites. (At one fire temple, priests continue to tend a flame that they claim has burned for more than 500 years.) It is the only city in the world that can boast two native sons, Khatami and Moshe Katsav, who simultaneously served as presidents of Iran and Israel. Even the mosque where Sadoughi leads prayers is named after a Jewish convert.

The sermon that Sadoughi had delivered that morning had been equally impossible to categorize. He defended the inflammatory speech that President Mahmoud Ahmadinejad had delivered earlier that week at a United Nations conference on racism, chiding Western nations who “allegedly are … defenders of free speech” for walking out. But he also criticized the government, in this case for failing to ensure that Iranian pilgrims traveling to Iraq were adequately protected, a large number of them having been killed the day before in a suicide bombing near Baghdad. And he conceded that the United States had elected a new president who had promised to change its relationship with Iran. He declared that Iranians were waiting to witness real deeds from Washington, not mere rhetoric. But at the end of his 30–minute sermon, unlike past Friday prayers and prayers that same day in Tehran, there were no chants of “Death to America” or “Death to Israel,” not even halfhearted ones. Later that night in his office he repeated, wistfully, the same sentiment—that words alone were not enough from the United States, not for Iranians, who are master rhetoricians, and who well understand the many uses to which they can be put.

More here.

‘Israel won’t yield to U.S. demands, won’t halt settlement construction’

From Haaretz:

ScreenHunter_06 May. 24 16.58 Strategic Affairs Minister Moshe Ya'alon spoke to Channel 2 on Saturday about the meeting between Prime Minister Benjamin Netanyahu and U.S. President Barack Obama, held earlier this week, saying that Israel's government will not allow the U.S. to dictate its policy, and that “settlement construction will not be halted.”

“Settlements are not the reason that the peace process is failing, they were never an obstacle, not at any stage,” Ya'alon told Channel 2 News. “Even when Israel pulled out of [Palestinian] territory, the terror continued. Even when we uprooted [Jewish] communities, we got 'Hamastan.' That is why I propose that we think about it – not in slogans and not with decrees.”

According to Ayalon, “we will not halt the construction in the settlements within the framework of natural growth. There are people here who are living their lives, raising children. Housing is required ? it wasn't housing that has prevented peace.”

More here.

The Perfect Pantomime

From Ms. Magazine:

PerfectPantomime_sm Between the ages of 14 and 21, I spent countless hours cross-examining the emaciated reflection in my mirror. “What’s wrong with you?” I’d demand. “Who are you, anyway? And why don’t you know who you are?” Yet instead of recognizing my obsession with weight loss as a sign of an identity crisis, I told myself my problems would be solved if I just lost a few more pounds. Like most girls with eating disorders in the ’60s and early ’70s, I never received treatment. Then, at 22, I fell in love. My lover knew how to see and hear and touch me. He fed me pasta, wine and laughter, and, in so doing, taught me how to nourish myself. Suddenly, starving my body made no sense. But shadows of self-doubt remained and, within them, the half-life of my eating disorder. I no longer deprived myself of calories, but for decades, I “could not” eat meat. Evenings and weekends, I “had to” work, while everyone else had fun. And although I thought I was content with my husband, the slightest marital disagreement would render me mute. Instead of confronting our problems, I would run away, literally, often running through injuries for hours. By the age of 36, this relentless physical punishment had permanently crippled my right ankle.

Then, my marriage of 20 years fissured and, at age 46, I once again became a stranger to myself. The woman who lived in my skin would stand blinking blindly in front of the bathroom mirror.

More here.

Sunday Poem

Telephoning In Mexican Sunlight
Galway Kinnell

Talking with my beloved in New York
I stood at the outdoor public telephone
in Mexican sunlight, in my purple shirt.
Someone had called it a man/woman
shirt. The phrase irked me. But then
I remembered that Rainer Maria
Rilke, who until he was seven wore
dresses and had long yellow hair,
wrote that the girl he almost was
“made her bed in his ear” and “slept him the world.”
I thought, OK this shirt will clothe the other in me.
As we fell into long-distance love talk
a squeaky chittering started up all around,
and every few seconds came a sudden loud
buzzing. I half expected to find
the insulation on the telephone line
laid open under the pressure of our talk
leaking low-frequency noises.
But a few yards away a dozen hummingbirds,
gorgets going drab or blazing
according as the sun struck them,
stood on their tail rudders in a circle
around my head, transfixed
by the flower-likeness of the shirt.
And perhaps also by a flush rising into my face,
for a word — one with a thick sound,
as if a porous vowel had sat soaking up
saliva while waiting to get spoken,
possibly the name of some flower
that hummingbirds love, perhaps
“honeysuckle” or “hollyhock”
or “phlox” — just then shocked me
with its suddenness, and this time
apparently did burst the insulation,
letting the word sound in the open
where all could hear, for these tiny, irascible,
nectar-addicted puritans jumped back
all at once, as if the air gasped.

Rethinking the Global Money Supply

From Scientific American:

Rethink-the-global-money-supply_1 The People’s Bank of China jolted the financial world in March with a proposal for a new global monetary arrangement. The proposal initially attracted attention mostly for its signal of China’s rising global economic power, but its content also has much to commend it. A century ago almost all the world’s currencies were linked to gold and most of the rest to silver. Currencies were readily interchangeable, gold anchored exchange rates and the physical supply of gold stabilized the money supply over the long term. The gold standard collapsed in the wake of World War I. Wartime financing with unbacked paper currency led to widespread inflation. European nations tried to resume the gold standard in the 1920s, but the gold supply was insufficient and inelastic. A ferocious monetary squeeze and competition across countries for limited gold reserves followed and contributed to the Great Depression. After World War II, nations adopted the dollar-exchange standard. The U.S. dollar was backed by gold at $35 per ounce, while the rest of the world’s currencies were backed by dollars. The global money stock could expand through dollar reserves.

President Richard Nixon delinked the dollar from gold in 1971 (to offset the U.S.’s expansionary monetary policies in the Vietnam era), and major currencies began to float against one another in value. But most global trade and financial transactions remained dollar-denominated, as did most foreign exchange reserves held by the world’s central banks. The exchange rates of many currencies also remained tightly tied to the dollar.

More here.

Declarations of Independence

Ami_150 Amitava Kumar in the Minnesota Review:

One of the things that can be said about much of postcolonial criticism is that it is boring, although it'd be more accurate to say that it is often unintelligible and boring. However, when I arrived in this country, in the late eighties, and read postcolonial critics for the first time, I was intrigued. They seemed such a welcome change from my teachers in Delhi. As an undergraduate at Hindu College, I would take a bus to the university. I'd look out of the window, and when we were crossing the gates of Nigambodh Ghat, I'd sometimes see men carrying in their arms little bundles wrapped in white. Each bundle was a child whose corpse was being taken to the river by the father. A small mute procession would follow some men, but often a man would be alone with his enormous burden. I would watch for a few moments from the bus—and then I'd arrive in class. My professors would be delivering lectures on Locke or Rousseau from notes held together with tape—the yellowing paper would flake off in little pieces when shaken in the air.

The pedagogical climate appeared dramatically different when I came to the US. In this country, I suddenly felt that criticism was something that was both fresh and live. My teachers were the critics whose writings one read in academic journals. What I was being taught was original work. In some classes, such work also felt urgent. I had never read Edward Said before, or others whose names brought them somehow closer to me in my imagination, critics like Homi Bhabha and Gayatri Chakravorty Spivak. But I didn't share the belief, seemingly dear to the editors of special issues devoted to postcolonial theory, that the 3.2 million poor in Chiapas or the half-million beggars in Calcutta hungered to read debates between the elite of New York and New Delhi in the pages of scholarly journals. My indifferent education in Delhi meant that I hadn't received any real training in writing, academic or non. But it became clear to me, as the years passed, that I wanted the words I wrote on the page to be worldly, sensual, even personal. I was trying to make postcolonial theory look more like what the larger world associated with postcolonials like Salman Rushdie. Couldn't our analyses become more exuberant, imaginative, and even playful? I wanted very badly to be a writer, and any writer needs readers, but it seemed impossible that postcolonial theorists would ever acquire a real audience.