Michael Hebert's Open Salon Blog

Help! My Kids Watched the Obama Back to School Speech!

Wed, 9 Sep 2009 00:09:30 -0400

When I heard President Obama was delivering a speech to all American school children, I did what I usually do under such circumstances — I turned on Fox News and waited for further instructions. Authorities recommended keeping my children home for their own safety, so that’s what I did. Little did I realize that, despite my precautions, the Eye of Big Brother would reach into my own home.

I thought I was doing the right thing by providing them with an ample supply of American-made corn chips and carbonated drinks, and situating them in front of the TV. I turned on a child-friendly channel. Then I left the room for one minute — just one minute! — to get my morning nip of Milwaulkee’s Best. When I came back, the TV had inexplicably changed to another channel, and my kids were staring into the screen at Obama, hypnotized. They were Obamazombies.

As fast as I could I found the remote and cut the TV off, but it was too late. The damage was done. My son stood on the coffee table, swinging his Slinky in the air, and shouting, “Workers of the world unite, you have nothing to lose but high insurance premiums!” My daughter looked up at me and said, “Dad, why do we always have to do what the oil companies tell us?”

Trembling, I sent them to their room, and desperately hoped the effects would wear off. For awhile, things looked good. Then, frightening things started to happen. A note appeared above the water faucet in the kitchen that said, “Clean, fresh, low cost water courtesy of your local government.” My kids insisted that we go to the public library instead of Barnes and Noble. They said there was no point in paying for a service the government could provide for free. I couldn’t believe my ears.

A few days after the speech, my daughter collected all the Band-Aids in the bathroom and distributed them to the kids in the neighborhood. She called it “low cost health care.” That same afternoon, the kids collected all of their toys into in one box, marked it “Sharing,” and announced that all toys would from now on be “Community Property.”

But rock bottom was a conversation I overheard while I was washing the dishes one night.

DICK: I think I’m gay.
JANE: That’s okay, Dick. There’s nothing wrong with that. Learn to own those feelings.

In a panic, I did what any good parent would and phoned my local Republican Congressman. A polite aide answered, and told me there has been a rash of similar incidents in the community lately. She said she would mail me an instruction book immediately.

Within a few days, I received my copy of The Republican Child Reconditioning Manual. The RCRM was full of helpful hints on turning my brainwashed kids around. The key to the manual was right there on page 3, a listing of the core Republican values.

Possession is the most important human right.
Freedom is the greatest American value, and we are going to give it to the world if we have to kill every foriegn-born human to do it.
Immigrants don't bathe.
The Second Amendment trumps the First. That's because God loves firearms and hates pornography.
The only appropriate emotion for a homosexual is self-hatred.
Corporations are people too.

By forcing my kids to memorize these principles, I was able to get them back in their right minds. Things are now back to normal.

Just the other day, as we were driving home from school my son noticed a bum lying on the street and said, “Why doesn’t he have a job, Dad?” Oh, what a relief.

Don’t let this happen to you. If your kids show signs of Obamatization call your local Republican leader fast. It could be a matter of life or death. Don’t be a statistic.

Katrina, 4 Years Later

Fri, 28 Aug 2009 23:08:29 -0400

It has been four years since Hurricane Katrina, and I find myself grasping for words. Many good things have happened since the hurricane struck the Gulf Coast — and many not so good. If you were to go back to New Orleans now, you could travel quite a bit around town and never see a trace of the storm. Businesses and restaurants are open everywhere, schools are up and running, hospital emergency rooms bursting as usual. You have to go to the eastern part of town, to the area I used to live and practice in, to see the scars.

Where I used to live, St. Bernard Parish, about a quarter of the population is back. My old house was razed two years ago, and a year after that, we sold the bare slab to a neighbor.

The sad legacy of Katrina is that the poor of New Orleans, the inhabitants of the eastern side of the city, are the ones who have not been able to return. For New Orleans this a particularly grievous injury; I do not know of a city in America that has so consistently drawn from the creativity of its poorest citizens. Jazz, the jazz funeral, Mardi Gras Indians, much of the city’s unique cuisine, its folk art, even its manner of speaking come from the poor folk. It is an irony that New Orleans always sought to expand its middle and upper class, but it was the people who had nothing who gave the city the most.

(An example: in New Orleans, blue collar natives are sometimes called "Y'ats," a diminutive of a greeting originally used in the Lower Ninth ward and in St. Bernard. When two middle or lower class New Orleanians meet, one will say "Where y'at?" -- that is, "where are you at?" -- which means "how are you doing?" Though many people still greet each other this way, the orginal Y'ats now live in other cities.)

A year after the storm, I read New Orleans, Mon Amour, a book of essays by Andre Codrescu, a New Orleans immigrant who wrote movingly about the city in a series of audio essays on NPR in Katrina’s aftermath. In the book, Coudreseu said of these essays:

I wrote several radio reports and poetic essays after the Katrina apocalypse….They are not meant to signal the end of the city itself … but they are eulogies nonetheless, for something that was and will not be ever again, no matter how many commissions meet and how far the price of real estate soars. You can rebuild a house, but you can’t restore a soul.

When I first read those words I was unable to get my mind around them. It didn’t seem possible that the old city was truly gone. But it turned out to be true. Much of the city is back the way it was, but hidden parts of it, both physically and spiritually, are ruined and hidden from sight. As the city recovers it is reinventing itself, but it is not the place that it was. I am not sure I can explain the difference. I can only suggest that you read Frenchmen, Desire, Good Children by John Chase, a book written long before the storm, and then Condrescu’s elegaic Mon Amour and try to taste the subtle change in spirit.

New Orleans has always been a city buried in its past, so much so it was often hard to tell if time was moving forward. This was exasperating and endearing in equal portions. Now, the city has to look forward. Recovery demands that. As the people who live there turn their eyes towards the sun for the first time, they are creating a new city but at the same time are letting part of the old disappear.

The Islanos community of St. Bernard, the murky neighborhoods of the Lower Ninth, large swaths of stately dilapidated Mid City, the remnants of the Creoles of Color culture are all gone. And that’s that.

It will be all right. It has been all right, sort of. What saddens me, though, it that New Orleans always was, beneath the surface, an atypical American city. What is likely to happen is that the lost parts of the city will return as replicas of America elsewhere. Our country seems to be gradually homogenizing, and it is a tragedy that a little sliver of difference has become slightly more like the rest, all because the U.S. Army Corps of Engineers can’t build a decent levee.

Is the Whole Foods Boycott Fair?

Fri, 21 Aug 2009 09:08:23 -0400

Rule number one in business: Don’t insult your customers. (Spoiler alert: More vulgar version of this rule below.)

When Whole Foods Market CEO John Mackey argued in a Wall Street Journal op-ed that American citizens do not have “any intrinsic right to health care, food or shelter . . . . [t]his "right" has never existed in America,” he succeeded in violating that prime rule. Thousands of Whole Foods customers have reacted with a boycott effort, including an online petition with 20,000 signatures so far.

This raises a question: Does Whole Foods deserve this kind of attack? After all, Mackey is a U.S. citizen and entitled to his political opinions. Nor is he the only CEO in the U.S. who is against health care reform. Perhaps it is unfair that Whole Foods is somehow being singled out. Moreover, a consumer boycott is more likely to hurt hourly employees than the CEO himself. Layoffs from tumbling sales could result in more people without insurance rather than less.

From a practical standpoint, Whole Foods’ problem is that it caters to a liberal progressive clientele. It advertises on its website that it “sells the highest quality natural and organic foods available” and is “caring about our communities and our environment.” It further claims that “our success helps us bring about change in the marketplace, which we hope will lead to good things for you and us and the planet.” A company like that is angling for upper class liberals, coincidentally one of the core groups pushing for health care reform. Mackey should have taken the hint when the Journal agreed to run his piece in the first place. Any article conservative enough to get past the editorial staff at the WSJ is bound to anger an upper class liberal.

On one hand, I sympathize with Whole Foods. It’s just an opinion, after all. Whole Foods isn’t in charge of U.S. health care, and certainly its CEO has as much right to express his opinion as anyone else. The problem, however, is that there is a good time and a bad time to express obstructionist views. Health care reform is becoming a more and more urgent matter, and obstructing its passage looks less and less like loyal opposition and more and more like a high stakes game of organic chicken. This year, health care costs are north of 17% of GDP, and by 2015 will exceed 20% of GDP. To do nothing is to court economic catastrophe. And to argue for a conservative free market approach at this late date is nothing short of hypocritical.

Republicans ruled Washington from 1994 to 2008, and did nothing over that span to reform health care. After the Republicans shot down the Clinton plan in 1994 and won the House and the Senate, they had every opportunity to put their own ideas into action. Bill Clinton was always a centrist president, and probably would have gone along with any reasonable proposal. None was offered.

America is at the point now where the condition of our health system has passed the point of urgency, and is headed towards emergency. Expenses are rising at 7.5% a year. Did you get a 7.5% raise last year? If so, can you expect to get a 7.5% raise next year, and every year until you retire and can apply for Medicare? If your answer is no, you will eventually lose your private insurance plan. Premiums will outstrip your income until you can no longer afford it. That is a certainty.

That's why it is way too late in the game for us to go back to the free market drawing board. Conservatives had their chance, a long, lingering chance, and they chose to sit on stacks of corporate profits instead. Mackey, a self-described libertarian, wants to let free markets work. Even if free markets do work, how long will it take? The only thing the current free market system has done is drive prices relentlessly upward. Mackey blathers about future deficits, but we have a deficit right now, and I fail to see how private insurance is going to pay it off. Since the rapid growth of Medicare costs doom us to deficits for the next few years anyway, why not quickly institute a public option, get control of costs from the bottom up, and reform the entire system all at once? That seems like the sensible path to a balanced budget. But expecting Blue Cross, United Healthcare, and Cigna to save us is a fool’s hope. These companies are motivated by profit. They couldn’t care less how large the federal deficit is.

We are in the eleventh hour, which is why, reluctantly, I favor the Whole Foods boycott. Heath care has dominated the news for about a month. It has taken a herculean effort just to get the fight to this point, which in my estimation still only offers a 50-50 chance of workable reform. We have reached take-no-prisoners time. We are at the point in the hockey game when the team that is behind pulls its goalie out so it can charge the opponent’s goal with every available player. If we lose here, it could be years before the chance comes around again, and by then, the carnage will only have mounted.

If Whole Foods has to be made an example of, so be it. For decades, corporations have been steering health care debate in a direction favorable to them. Billionaires always seem to have bigger megaphones than thousandaires. The only way corporate America will go along with reform is if it learns the lesson Whole Foods is about to learn today: Don’t piss your customers off.

Death Care Reform

Thu, 13 Aug 2009 00:08:45 -0400

Section 1233 of the House-drafted legislation encourages health care providers to provide their Medicare patients with counseling on . . . end of life treatments, and may place seniors in situations where they feel pressured to sign end of life directives they would not otherwise sign . . . .

[T]his provision could create a slippery slope for a more permissive environment for euthanasia, mercy-killing and physician-assisted suicide because it does not clearly exclude counseling about the supposed benefits of killing oneself.
— House Republican Leader John Boehner (R-OH) and Republican Policy Committee Chairman Thaddeus McCotter (R-MI), July 23, 2009

The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care.
— Sarah Palin, August 7, 2009

America has been in desperate need of a serious health care debate for years. Which is why it is so disappointing to see an honest and productive public debate polluted by blatant lies, as told to us by politicians who are supposed to be informed.

As many have observed elsewhere, the myth of euthanasia and death squads stems from a single provision attached to one of the reform bills allowing doctors to bill for the time they spend counseling patients about end-of-life care. There are no provisions for death squads. In fact, as a doctor who has discussed end-of-life issues with his patients many times, I resent the implication that by talking with patients about death I am taking my place next to Dr. Kevorkian.

We cannot enact health care reform without dealing with end-of-life issues. Death is the inevitable outcome of a lifetime of medical care, an outcome that will occur no matter how good the doctors and nurses are. The best doctors eventually lose 100% of their patients, just as the worst ones do. The difference is how the end comes about.

Counseling is the cornerstone of end-of-life care. Since death is inevitable, at some point most patients and their families will have to address matters such as life support, ventilator care, and extraordinary medical treatments. The proposed provision would allow doctors to allocate time apart from a regular visit to sit and talk about fears patients and families have about the dying process, rather than having to cram the discussion in between medical complaints at an annual office visit, or worse, having to bring it up at for the first time at the bedside of a dying patient. I can hardly think of a more humane and important use of a doctor’s time.

In my work, I welcome the opportunity to give advice. Unfortunately, many patients don’t want advice — they want drugs, diagnostic tests, or a referral. They want something from me, something that often only requires my signature. And either they don’t care what I think, or they have so many concerns that I end up as an expedient ordering a drug or a test for each symptom and sending them on their way.

This is not what I spent 8 years of medical training for. All that knowledge is there to be shared, and I should be paid to share it. But I am not paid to share information; I am paid to sign things. This is the end-result of a system that rewards providers for seeing patients in large volumes and devalues old fashioned talking and listening.

What’s wrong with a Medicare provision that lets me sit down with a patient for half an hour and explain to her what CPR is, and when it is beneficial; what a ventilator is and why she might want to be on one or not; what is meant by “life support” and when life support makes sense and when it doesn't?

The most important decision a doctor makes is when to treat and when not to treat. There are times when doing something is much worse than doing nothing at all. Patients need to understand that sometimes doing nothing is the best treatment. That is what end-of-life counseling is all about.

Such explanations take time, and a great deal of experience and skill. It is one of the most challenging tasks in my work, and one every doctor ought to be paid for. When a patient knows his insurance will cover end-of-life counseling, he is more likely to feel comfortable asking his doctor to explain the dying process. Patients deserve that service, and it should be a standard part of every health plan.

Some time ago, I treated a middle aged man I’ll call George who destroyed his liver with chronic drinking. He had bleeding ulcers and esophageal varices, a condition in which a diseased liver produces massive bulging veins in the lower esophagus that are prone to catastrophic bleeding. George bled so rapidly that it took more than two dozen units of blood over the course of a week just to keep him semi-conscious. When he was awake, which wasn’t often, he asked nurses and doctors to please take all the tubes out. I wanted to, but he was too confused for me to trust his mental state.

His out-of-town family said travel was “too expensive” for them to come visit him in the hospital. After he spent a couple of weeks in intensive care on just about every medication we could pour into him, his relatives finally showed up. We carefully discussed withdrawing care. Nothing we were doing was going to save him, I observed, and we seemed to be merely prolonging his suffering. I pointed out that he expressed the desire to be taken off the ventilator, that his condition was hopeless and his liver was completely shot, and that he was not a candidate for the only procedure that had any chance of helping him — a liver transplant. I told them he might be more comfortable and die more peacefully at home, surrounded by loved ones.

After listening to my explanation, his sister said to me, “I’ll have to talk it over with my family.” Which she did, I guess. The next day she sent word that the answer was no. They wanted everything done.

Eventually we got him off the vent and moved him to a regular room. He lay there in a state of delirium for a few days, all alone, and died. I felt horribly sad for this man, and harbored mixed feelings of frustration with and pity for his relatives, who were so overwhelmed by the urgency of the situation that they were afraid to make the decision to let him die peacefully at home. Instead, they left him to die a lonely, antiseptic end.

We have to do better than this. If George had left a living will or consulted with a doctor prior to his fatal event, all this misery might have been avoided. Such conversations are not about euthanasia. They are about preparing for the inevitable. Talking to patients about end-of-life issues will no more lead to euthanasia than planning fire drills will lead to arson.

This kind of counseling is necessary. Not only should it be encouraged, it should be considered a normal a part of medical care, like mammograms and serum cholesterol checks. The people who argue otherwise don’t care about alleviating human suffering. They want to scare people into turning against health care reform.

People like Boehner, McCotter, and Palin are responsible for the fear that leads to deaths like George’s. They too will die one day, and if they succeed in their aims, their reward will be the horrors of the health care system they wrought.

I wish I could call it justice, but I can’t bring myself to wish that kind of suffering on anyone.

When the "Scientific Truth" Is No Such Thing

Thu, 6 Aug 2009 16:08:39 -0400

This week, the New York Times reports that between 1998 and 2005 the drug company Wyeth paid private companies to ghostwrite 26 scientific papers extolling the benefits of its hormone drugs Premarin and Prempro. The papers were then signed by doctors and medical researchers and published in medical journals without any disclosure of the financial role the drug company played in producing them.

Wyeth defends the papers, saying that everything in them was “scientifically accurate.”

Drug companies have manipulated the medical community to publish favorable data for years, and this is not the first time one of them has been caught. In 2001, Merck camouflaged (and may have deliberately excluded) data from the VIGOR clinical trial suggesting the blockbuster drug Vioxx could cause heart attacks. More recently, Merck and Schering-Plough delayed publication of very important data about the efficacy of the drug Vytorin, with the excuse that they were still trying to interpret the information. The delay was so long and so egregious that Congress finally had to order them to release the results. Turns out Vytorin doesn’t work.

In the 1990s, hormone replacement therapy (HRT) with medications like Premarin and Prempro was all the rage in primary care. Everyone seemed to think that giving postmenopausal women hormones would curb the progression of osteoporosis, and prevent both heart attacks and strokes. Some doctors advocated giving almost every post-menopausal woman hormones, no matter what her situation. For a time, this position was backed by a flurry of research papers, many of which we now know were little more than paid advertisements by Wyeth. However, in 2002 a major government-funded trial showed that hormone replacement therapy has no impact on heart disease, and may in fact increase it modestly. Worse, it was linked to a marked increase in breast cancer. At that point the HRT business started to fall apart. Now what’s left is to figure out is why HRT prescription writing got so out of hand in the first place, considering the scarcity of that good data proving its value.

What about Wyeth’s protest that all the articles it paid for were “scientifically accurate”? I don’t doubt they were. Most advertising is factually accurate also. The problem is, you can lead someone to believe a falsehood by telling him nothing but truths. For example, the following statements about arsenic are all absolutely true: (1) Arsenic is a naturally occurring chemical; (2) it exists in plants and animals; (3) humans consume arsenic when they eat mushrooms and fish. Knowing all this, one might be convinced to down a vial full of arsenic.

A bunch of little truths do not necessarily add up to one big truth, any more than a pile of sticks can ever be a log cabin.

Here’s an example from my personal experience. There is a class of drugs designed to suppress stomach acid called proton pump inhibitors (PPIs). The PPI market is very profitable and very competitive, and chances are you are familiar with the brand names: Prilosec, Nexium (the “purple pill”), Prevacid, Protonix. Blockbusters all. For the last 5 years, drug reps have bombarded me in my office with scientific papers that telling me the “facts” about PPIs. Our drug, one rep told me, has the highest healing rate for stomach ulcers. Another told me his drug was scientifically proven to have the fastest onset of action, implying quicker symptom relief. A third trumpeted higher serum levels after 16 hours, meaning its effects lasted longer. All of these claims had one thing in common — they were scientifically accurate. The problem was that these little truths didn’t tell me what I really wanted to know. Do the advantages any of these drugs justify their price, which is many times their generic equivalents? Or would a generic work 90% as well for 90% of the people, at 20% of the price? (Compare generic omeprazole, at $24, with branded Nexium, at $160.)

Wyeth, and the sorry doctors who signed their names to these ghostwritten papers, will defend themselves by arguing that they were truthful. But truth, in that strict sense, has nothing to do with it. The question is, was the “truth” they propounded intended to lead doctors and patients to make the right decisions, or was it intended to mislead?

To me, that big truth is pretty obvious.