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History > 2009 > USA > Health (III)




Andrea Ventura

Autism Doesn’t Have an Age Limit



















Autism Doesn’t Have an Age Limit


May 31, 2009
The New York Times


To the Editor:

I was greatly moved by “Growing Old With Autism,” by Karl Taro Greenfeld (Op-Ed, May 24), and I, too, wonder how people with autistic spectrum disorders and their families will evolve as their numbers grow.

I have the great privilege of working with these families, providing psychopharmacologic consultations for their children’s behavioral and emotional difficulties.

I have followed many autistic children and teenagers who have had daily structure at private schools and work experiences, a friend or two, and periodic extracurricular social activities, including “dances.”

Mr. Greenfeld is right: once the structure and socialization of school ends, it is completely up to the family to figure out what to do next. The families that make it (those that do not implode from stress and lack of support) have so little to guide and support them.

These families deserve medals for their efforts. But what they could really use is financing directed at programmatic needs for their adult children.

Steven Marc Sokoll
Haverford, Pa., May 25, 2009

The writer is a child and adolescent psychiatrist and teaches at the University of Pennsylvania School of Medicine.

To the Editor:

I am the mother of a 35-year-old adult woman with autism and painfully aware of the sobriquet “refrigerator mothers,” who, Karl Taro Greenfeld explains, were “mistakenly blamed for their children’s withdrawn, antisocial condition.”

There have been important advances in clinical behavioral intervention studies that have evolved over the last 30 years into an impressive body of highly refined treatment modalities (or best practices) for autism. What has not kept pace is the creation of educational curriculums and dynamic methods to train young service providers.

There is not only a dearth of college-level teachers to use these best practices, but also no discernible career path along which these young professionals may advance. How can we expect undertrained health care workers, even if they are the most dedicated and caring of individuals, to work with autistic adults when all we offer them are the bluntest of tools and only the prospect of an early burnout?

It is essential that families, legislators and professionals unite to organize and finance academically rigorous venues where this important body of information can be collected and disseminated, and where a validating program for professional growth can be established.

Tondra Lynford
New York, May 24, 2009

The writer is a clinical psychotherapist and a co-founder of Resources for Children With Special Needs.

To the Editor:

I have a 21-year-old son with autism. I just spoke at the Autism One Conference in Chicago, about “Biomedical Interventions for Older Children.” My son’s doctor, Michael Elice, presented as well and reminded parents that it is “never too late” to try to ameliorate the symptoms of autism.

By following the “Defeat Autism Now” protocols — and this doctor’s advice — we have been able to help our son control his concentration, behavior and stomach problems. He is not cured. But we will keep trying.

As the children of the current autism epidemic grow older, it is crucial to understand that age should not be a deterrent to interventions.

Barbara Fischkin
Chicago, May 25, 2009

To the Editor:

As I read the article by Karl Taro Greenfeld, I became alarmed that he had set up an opposition between adorable tykes (the subject of current research) and frightening adults (whom no one knows what to do with). But he identifies a real problem.

My son lives in a state-financed unit dedicated to providing treatment for young men with autism. In the last year, the parents of these men have asked the state for a small amount of money so that the institution can open a smaller unit in the community to which our sons could “graduate.”

Why would we do this when the state’s economy is in free fall? Because each bed vacated by one of our sons will become available for another young man — perhaps now in a psychiatric hospital, inappropriately, or perhaps in a prison, frighteningly — who cannot get the services he needs.

Randi Davenport
Chapel Hill, N.C., May 24, 2009

The writer is the author of the forthcoming “The Boy Who Loved Tornadoes.”

To the Editor:

Karl Taro Greenfeld’s article applies to all disabilities. My child has cerebral palsy, and there are not enough programs out there.

People always look at the children but never the adults. We could save so many more people with all sorts of problems, but when families can no longer care for them, where do they go? What kind of life do they have?

I do not want to think of the day when I can no longer care for my child. We must learn to see the whole picture for all these people.

Kristina Fallon
Lexington, S.C., May 24, 2009

To the Editor:

I am the parent of a 23-year-old nonverbal young man with autism and live in Illinois, a state that ranks at the bottom in the provision of services for developmentally disabled adults.

In Illinois, educational entitlements end at age 22. After that, there is nothing except a handful of nonmandated programs with long waiting lists that live hand to mouth, dependent on the ups and downs of the state budget each year. What is needed is a breakdown of the artificial distinction between services for children and services for adults. Autism is the same in children and in adults.

Fund-raising for research into childhood autism may make for a more effective appeal, when accompanied by images of affected children, but the subtext of that appeal is that adults with autism don’t matter and are beyond help.

Our son still lives with us. Like all parents of adults with autism, we dread the day when we will have to find an alternative living arrangement.

Ronald Kallen
Highland Park, Ill., May 24, 2009

The writer is a pediatric nephrologist.

    Autism Doesn’t Have an Age Limit, NYT, 31.5.2009, http://www.nytimes.com/2009/05/31/opinion/l31autism.html?hpw






On Sotomayor,

Some Abortion Rights Backers

Show Unease


May 28, 2009
The New York Times


WASHINGTON — In nearly 11 years as a federal appeals court judge, President Obama’s choice for the Supreme Court, Sonia Sotomayor, has never directly ruled on whether the Constitution protects a woman’s right to an abortion. But when she has written opinions that touched tangentially on abortion disputes, she has reached outcomes in some cases that were favorable to abortion opponents.

Now, some abortion rights advocates are quietly expressing unease that Judge Sotomayor may not be a reliable vote to uphold Roe v. Wade, the landmark 1973 abortion rights decision. In a letter, Nancy Keenan, president of Naral Pro-Choice America, urged supporters to press senators to demand that Judge Sotomayor reveal her views on privacy rights before any confirmation vote.

“Discussion about Roe v. Wade will — and must — be part of this nomination process,” Ms. Keenan wrote. “As you know, choice hangs in the balance on the Supreme Court as the last two major choice-related cases were decided by a 5-to-4 margin.”

Because Judge Sotomayor is the choice of a president who supports abortion rights at a time when Democrats hold a substantial majority in the Senate, both sides in the debate have tended to assume she could be counted on to preserve the Roe decision.

Immediately after Mr. Obama announced his selection on Tuesday, leaders of several other abortion rights groups spoke out in support of Judge Sotomayor, and several conservative groups opposed to abortion rights attacked her, saying they were convinced that the president would not nominate someone who opposed abortion rights.

But in his briefing to reporters on Tuesday, the White House spokesman, Robert Gibbs, was asked whether Mr. Obama had asked Judge Sotomayor about abortion or privacy rights. Mr. Gibbs replied that Mr. Obama “did not ask that specifically.”

Presidents have miscalculated in their assumptions about the abortion views of Supreme Court nominees before. When the first President Bush nominated David H. Souter in 1990 to fill the seat that Judge Sotomayor would assume if confirmed, Mr. Souter was known as a “stealth nominee” with no paper trail on abortion.

But conservative and liberal advocates alike believed that Justice Souter would vote to overturn Roe v. Wade, so much so that abortion rights advocates protested outside his confirmation hearing with signs reading “Stop Souter, or Women Will Die.” Then, two years later, Justice Souter shocked the political world by voting to uphold abortion rights.

As president, Mr. Obama has sought to avoid being drawn into the culture wars of the last several decades and has encouraged each side in the abortion debate to be respectful of the other’s opinions. But there are clear political advantages to his choice for the court not being perceived as having a strong position on abortion rights.

Judge Sotomayor’s views on abortion rights could still become clear if a past writing comes to light. During Justice Samuel A. Alito Jr.’s confirmation process in late 2005, for example, the National Archives released an old Justice Department job application in which he said the Constitution does not protect a right to an abortion.

But at this point, Judge Sotomayor’s views are as unknown as Justice Souter’s were in 1990, said Steven Waldman, the editor in chief of BeliefNet.com, a religious Web site, where he has blogged about her lack of an abortion rights record.

“Everyone is just assuming that because Obama appointed her, she must be a die-hard pro-choice activist,” Mr. Waldman said, “but it’s really quite amazing how little we know about her views on abortion.”

None of the cases in Judge Sotomayor’s record dealt directly with the legal theory underlying Roe v. Wade — that the Constitution contains an unwritten right to privacy in reproductive decisions as a matter of so-called substantive due process. Several of her opinions invoke substantive due process in other areas, however, like the rights of parents and prisoners.

She has also had several cases involving abortion-related disputes that turned on other legal issues. While those cases cannot be taken as a proxy for her views on the constitutionality of abortion, she often reached results favorable to abortion opponents.

In a 2002 case, she wrote an opinion upholding the Bush administration policy of withholding aid from international groups that provide or promote abortion services overseas.

“The Supreme Court has made clear that the government is free to favor the anti-abortion position over the pro-choice position,” she wrote, “and can do so with public funds.”

In a 2004 case, she largely sided with some anti-abortion protesters who wanted to sue some police officers for allegedly violating their constitutional rights by using excessive force to break up demonstrations at an abortion clinic. Judge Sotomayor said the protesters deserved a day in court.

Judge Sotomayor has also ruled on several immigration cases involving people fighting deportation orders to China on the grounds that its population-control policy of forcible abortions and birth control constituted persecution.

In a 2007 case, she strongly criticized colleagues on the court who said that only women, and not their husbands, could seek asylum based on China’s abortion policy. “The termination of a wanted pregnancy under a coercive population control program can only be devastating to any couple, akin, no doubt, to the killing of a child,” she wrote, also taking note of “the unique biological nature of pregnancy and special reverence every civilization has accorded to child-rearing and parenthood in marriage.”

And in a 2008 case, she wrote an opinion vacating a deportation order for a woman who had worked in an abortion clinic in China. Although Judge Sotomayor’s decision turned on a technicality, her opinion described in detail the woman’s account of how she would be persecuted in China because she had once permitted the escape of a woman who was seven months pregnant and scheduled for a forced abortion. In China, to allow such an escape was a crime, the woman said.

Phillip Jauregui, president of the conservative Judicial Action Group, said he was not convinced by any anti-abortion overtones to such rulings because, he said, even “the most radical feminist” would object to forcing women to abort wanted pregnancies.

Mr. Waldman of BeliefNet.com also noted that Judge Sotomayor was raised Roman Catholic, although there are many judges who do not follow the church’s dogma — like opposing abortion and the death penalty — in their jurisprudence.

Moreover, he said, it is significant that as a group, Hispanics include a higher percentage of abortion opponents than many other parts of the Democratic Party’s coalition. Judge Sotomayor’s parents moved from Puerto Rico.

“At the very least, she grew up in a culture that didn’t hold the pro-life position in contempt,” Mr. Waldman said.

Mr. Jauregui said he agreed with Ms. Keenan that Judge Sotomayor ought to say what she believed about Roe v. Wade before any confirmation vote.

“I don’t think, when we’re talking about a job as important as a justice who could serve for decades, that it’s acceptable for someone to be stealth,” he said.

    On Sotomayor, Some Abortion Rights Backers Show Unease, NYT, 28.5.2009, http://www.nytimes.com/2009/05/28/us/politics/28abortion.html?hp






2nd Death in New York City

Linked to Swine Flu


May 25, 2009
The New York Times


A second New York City resident, a woman from Queens in her 50s, has died from swine flu, the city’s health department said on Sunday.

The woman had an underlying health condition that made her more at risk from the disease, said Jessica Scaperotti, a health department spokeswoman.

Mitchell Wiener, an assistant principal at a Queens middle school, who died on May 17, became the first person in New York State to die of the flu strain that has swept across much of the world since it was first identified in April.

Ms. Scaperotti declined to reveal any further details of the latest death, including the hospital where the woman had been treated. But she said that the woman died sometime over the past two days and that testing had confirmed that the woman had the H1N1 virus. She would be the 11th confirmed death caused by swine flu in the United States.

Mayor Michael R. Bloomberg, in a statement released Sunday night, said: “My father also died in his 50s because of an underlying health condition. I remember how hard that was on my mother, my sister and me, and my thoughts and prayers are with this woman’s family.”

The number of people hospitalized with swine flu since the beginning of the outbreak in New York City at the end of April had risen to 94 on Sunday from 68 Saturday and 57 on Friday, health department officials said, suggesting that the rate of infection and hospitalization might be increasing.

Ms. Scaperotti could not say how many of those patients were now hospitalized or how many were in critical condition. On Friday, St. Luke’s-Roosevelt Hospital Center said it had a patient in critical condition with swine flu at its location in Morningside Heights. Doctors there were optimistic that the patient’s condition was improving.

“As we see more cases in the community we are going to see more severe illness and possibly death,” Ms. Scaperotti said. “If you’re sick right now with flu, you probably have H1N1.”

By Friday, 12,022 cases of swine flu, including 86 deaths, had been reported to the World Health Organization from 43 countries. More than half of the cases were from the United States; of the deaths, 75 were reported by Mexico.

On Sunday, health officials in New York continued to stress that anyone with underlying health conditions — like diabetes, asthma, emphysema or a compromised immune system — who is exposed to flu should seek medical attention.

“It’s obviously a very stressful time for people in Queens,” said Eric N. Gioia, a Queens councilman. “I don’t know anyone who doesn’t know someone who has gotten the flu.”

“We all want a lot more information,” he added. “We feel there’s a huge disconnect with what’s going on out there with what we’re hearing from City Hall.”

The flu’s New York City history began in Queens at St. Francis Preparatory School, where hundreds of students became ill and 69 cases were confirmed, and it has caused dozens of city schools to close. Twenty of the schools — all but four in Queens — are to reopen on Tuesday, including Intermediate School 238 in Queens, where Mr. Wiener, 55, was the assistant principal.

Seventeen public schools and programs will still be closed, although they are all slated to reopen by Thursday.

In addition, at least four yeshivas in the greater Flatbush area of Brooklyn have voluntarily closed due to swine flu, according to Assemblyman Dov Hikind, who represents the district.

The schools were Magen David Yeshiva, Yeshiva Tiferes Yisroel, Masores Bais Yaakov and Yeshiva Shaarei Torah.

Each school had an unusually high absentee rate, and upon investigation this weekend, school officials discovered probable or confirmed swine flu cases.


David W. Chen and Jennifer 8. Lee contributed reporting.

    2nd Death in New York City Linked to Swine Flu, NYT, 25.5.2009, http://www.nytimes.com/2009/05/25/nyregion/25swine.html?hp






Op-Ed Contributor

Growing Old With Autism


May 24, 2009
The New York Times


IN mid-2007, I set off to meet with geneticists, epidemiologists and doctors who specialize in researching and treating autism. I was seeking a novel therapy for my 42-year-old autistic younger brother Noah. I was also looking to discover how heightened awareness of autism — it is now among the most financially successful and mediagenic diseases ever, with hundreds of millions of dollars a year going to research, and regular press coverage — might have resulted in new and innovative programs for adult autistics like Noah.

Autism was already widely being described as an epidemic, affecting as many as 1 in 150 8-year-olds, according to the Centers for Disease Control and Prevention. We had come a long way since Noah got his diagnosis in the late ’60s, the so-called dark ages of autism, when many pediatricians believed they had never seen a case, and so-called refrigerator mothers were mistakenly blamed for their children’s withdrawn, antisocial condition.

But now, with autism described to me as “the disease of the decade” by Peter Bell, the executive vice president of programs and services for the advocacy group Autism Speaks, I thought perhaps there was hope, even for low-functioning adult autistics like Noah.

Noah has been my family’s focus for decades. As a baby, he had been very slow to turn over, crawl or walk, and each subsequent developmental milestone was even more delayed as he grew into adulthood. My parents did everything they could for him, moving us from New York to Los Angeles in the early 1970s to be closer to a pioneering autism program at the University of California at Los Angeles, opening their own day care center for the developmentally disabled, even creating a one-on-one assisted-living situation for Noah — years before this became common — so that they could delay institutionalizing him.

I toured those state hospital systems with my parents when we started looking for a place for a growing-up Noah. Those were terrifying visits: adult patients wearing helmets and restraints, howling and hitting themselves. This was during the ’70s when the scandals at state psychiatric hospitals like Letchworth Village in New York and Camarillo in California were making terrifying headlines. Clients at Camarillo were dying from neglect and improperly administered medications. We had to keep Noah out of that system for as long as we could.

Eventually, when he was 22, Noah had to leave home. He graduated from his special needs school on a bright, sunny Orange County day; he was beaming, handsome in his bright blue cap and gown.

But for the profoundly autistic, graduation is perhaps the saddest day in their lives. For those who cannot enter the work force, continue on to more education or find some sheltered workshop environment with adequate staffing, there are few options. Far too few programs and resources are allocated for adults with autism.

Noah has been in and out of sheltered workshops, but these are always under threat because of state budget deficits. Noah has been asked to leave some programs because he was too low-functioning. For several years, we have been trying to find a day program where he might interact with others and perhaps perform some simple, menial job. We have long since given up any hope that he might continue in adulthood the behavioral therapies that are now considered standard for autistics; unless the family is willing to pay the bulk of the cost, there is very little out there for men and women like Noah.

For purposes of fund-raising and awareness-raising, autism has been portrayed as a childhood disease. The federal Department of Health and Human Services has characterized it as a “disorder of childhood.” There are practical reasons for this: early intervention has been shown to be the most effective therapy. The trend in autism treatment has been to steadily lower the age at which intensive intervention commences — as early as five months, according to some experts. Yet autism is not a degenerative condition; the vast majority of those 1 in 150 children who are afflicted will survive to adulthood.

As I spoke with the experts, I began to see that the focus on children had influenced not only the marketing of autism, but also research and treatment. It seemed the majority were interested in children only, the younger the better.

“The best time to look is at the early ages, when autism is developing,” Sophia Calimaro, vice president of research at Autism Speaks, told me a few months ago, explaining that was also where there had been the most treatment success. “I’m not making excuses, but that’s really why more research into adults with autism hasn’t been done.”

Low-functioning adult autistics are viewed with sympathy but not much scientific inquiry. No one has broken down how many dollars are actually flowing to adult autistics, but at the International Meeting for Autism Research in Seattle in May 2007, I counted more than 450 papers and presentations and three dozen talks on autism given by academics and specialists; of those, only two dealt with low-functioning adults, and neither included a cohort large enough to be statistically relevant.

The careful measurements of brain function, or dysfunction, were almost all done on children. A few cognitive and emotional development studies dealt with adults, but these were overwhelmingly focused on high-functioning autistics and people with Asperger’s syndrome.

Autism Speaks, the major sponsor of autism research projects, has not broken down the proportion of funds that go to adult-oriented research, but Mr. Bell, whose teenage son is autistic, laments that “it’s low, too low. ... We have to change the paradigm for those of us who have kids who are going to grow up and need more and better services.”

That change can’t come soon enough. Even with state-of-the-art early intervention — eight hours a day, seven days a week — many autistics will need support throughout their lives. The reality is that very few, perhaps only 10 percent, of those as severely autistic as Noah benefit from the current interventions to the point where they become functioning members of society.

If the current C.D.C. estimation of prevalence is correct, then there will be an awful lot of adult autistics who need lifetime support and care. Noah’s life has been a grim study in how scarce those resources are. Without them, his behavior has regressed.

A recent “psychological and psychopharmacological” report by the California Department of Developmental Services said Noah exhibited a “failure to develop peer relationships, a lack of social or emotional reciprocity,” and it described some of his “maladaptive behaviors” like “banging his head against solid surfaces, pinching himself and grabbing others.”

“Noah may also,” it noted, “intentionally spit at others, pinch or scratch others, dig his fingernails into others, and/or pull others’ hair. He may bite, head-butt and hit others; throw objects at others, and hit/slap his head when he is highly agitated.” He is a handful.

Now, imagine a few hundred thousand Noahs.


Karl Taro Greenfeld is the author, most recently, of “Boy Alone: A Brother’s Memoir.”

    Growing Old With Autism, NYT, 24.5.2009, http://www.nytimes.com/2009/05/24/opinion/24greenfeld.html






First Death

for Washington Assisted-Suicide Law


May 23, 2009
The New York Times


SEATTLE — A woman with pancreatic cancer has become the first person to die under a law passed last year allowing doctor-assisted suicide in Washington, according to an advocacy group that pushed for the law.

The woman, Linda Fleming, 66, of Sequim, Wash., died Thursday evening after taking lethal medication prescribed by a doctor under the law, according to a news release by the group, Compassion and Choices of Washington. The release said Ms. Fleming received a diagnosis of Stage 4 pancreatic cancer a month ago, and “she was told she was actively dying.”

Ms. Fleming was quoted in the release as saying: “I am a very spiritual person, and it was very important to me to be conscious, clear-minded and alert at the time of my death. The powerful pain medications were making it difficult to maintain the state of mind I wanted to have at my death.”

In November, voters approved the Death with Dignity Act, 58 percent to 42 percent, making Washington the second state — after Oregon — to allow assisted suicide. The laws in both states have been deeply controversial, particularly among religious groups. Washington passed its law after the United States Supreme Court in 2006 rejected an effort by the Justice Department to block Oregon’s law, which took effect in 1998.

In Montana, a state judge ruled in December that doctor-assisted suicide was legal under the state’s Constitution, but the state is appealing that decision.

Steve Hopcraft, a spokesman for Compassion and Choices, said the group was “not leading a campaign in any other state right now.”

The Washington and Oregon laws allow terminally ill patients who are at least 18 and have been found mentally competent to self-administer lethal drugs under the prescription of a doctor.

In Oregon, 401 people used the law through 2008. Since the law took effect in Washington in March, six prescriptions for lethal medication have been dispensed, but a spokesman for the State Department of Health, Donn Moyer, said it had not received any forms saying a patient had used the medication. Under the law, doctors who write such a prescription have 30 days to report that it had been used.

Mr. Moyer, saying privacy laws prevented the state from providing information about a specific death, said he could not confirm Ms. Fleming’s death.

In Oregon, not everyone who received a prescription has taken the drugs.

Some critics fear that physician-assisted suicide will pressure people with terminal illnesses who have low incomes or are disabled to end their lives to avoid becoming a financial burden to loved ones. Supporters cite studies that they say have refuted that idea.

Ms. Fleming, who was divorced, filed for bankruptcy in 2007 with $5,800 in credit card debt, according to court records and a lawyer who had represented her, Hugh Haffner.

Mr. Haffner said that when she filed for bankruptcy, Ms. Fleming, a former social worker, had been unable to work because of a disability and lived in subsidized housing on $643 in monthly disability checks.

Virginia Peterhansen, who said she had befriended Ms. Fleming about six months ago through a book group, said Ms. Fleming bought a 1982 Oldsmobile station wagon days before she was told she had cancer and that she had hoped to learn to contra dance.

Robb Miller, the executive director of Compassion and Choices of Washington, said that he had spoken to Ms. Fleming and that, although he was unaware of her bankruptcy filing, her situation presented “none of the red flags” that might have given his group pause in supporting her. He said Ms. Fleming’s two children and her former husband “were involved and supported her choice.”

The family could not be reached for comment.


Alain Delaquérière contributed research.

    First Death for Washington Assisted-Suicide Law, NYT, 23.5.2009, http://www.nytimes.com/2009/05/23/us/23suicide.html?hp






At the Hospital,

the Faces of Fear and Swine Flu


May 22, 2009
The New York Times


The staff wore green masks, the patients wore blue. As the sun set over Queens on Wednesday, the witching hour began in the pediatric emergency room at Schneider Children’s Hospital.

Fathers came home from work, mothers thought twice about putting their children to bed with a fever, and as if under mass hypnosis, they headed for the hospital.

They were a New York polyglot of unease, Orthodox Jews in sheitels and skullcaps, Muslim women in headscarves, Asian people, black people and white people. They all wanted one thing: to have their children checked for swine flu.

“What brings you here?” said the swine flu “greeter,” a young medical resident, her voice muffled by her duck-billed N95 mask.

If the answer was flu, whole families got masks and were sent to the left. For anything else, they went right.

As officials announce the latest school closings each day — eight new ones on Thursday — and public officials tread a delicate line, trying to seem on top of the disease while not spreading panic, parents have turned to emergency rooms as the arbiters of the maddening ambiguity of the disease. To worried families, the H1N1 virus is like a bogeyman in the night, and the trip to the hospital the equivalent of checking under the bed.

Is it a deadly scourge, a Stephen King novel come to life, or only a mild inconvenience? The emergency room is the place where public relations and public fears confront science, where families go to find peace of mind.

The doctors try to suppress their cynicism and understand the fear, knowing that in most cases, they will not even bother to test for flu. The ritual of putting on masks, checking patients, then sending them home with kind words and an admonition to stay in bed and drink plenty of fluids is almost like a game of charades.

“The doctor said to me, ‘I could look in your eyes and tell who’s really sick,’ ” said Esperanza Straughter, as she led her strapping 13-year-old son, Tyrell, out of the emergency room after his visit.

Ms. Straughter, who carried a thermometer in her handbag, said she had retorted, “I’m glad you can, because I can’t.”

The last reading on the thermometer had said 102, and her son had awakened coughing and nauseated. Still, she said, she had to accept the doctor’s verdict. Tyrell, a precocious ninth grader in gray sweatpants, looked bored by the whole experience, and eager to go home.

Across New York, emergency room visits began to surge on Saturday, as schools closed like falling dominoes and word spread of an assistant principal who was in critical condition with swine flu; he died on Sunday night.

At Maimonides Medical Center in Brooklyn, the pediatric emergency room usually averages 80 to 85 patients a day at this time of year. On Saturday, it treated 135 patients and on Sunday 145, a two-day record. On Tuesday, the number spiked to 169, according to Dr. Estevan Garcia, director of pediatric emergency medicine.

At Schneider, in the Glen Oaks section of eastern Queens, there were 227 visits on Sunday, 262 on Monday and 273 on Tuesday, almost quadruple the norm. On Wednesday, 212 people walked in.

From 6 p.m. on Wednesday until the wee hours on Thursday, Dr. Jill Leibowitz, a 27-year-old second-year pediatric resident, was designated the pediatric emergency room greeter. In deference to her long hours breathing in potentially contaminated air, Dr. Leibowitz wore the N95 mask, with its superior filtering power, rather than the standard surgical mask worn by patients and many other members of the staff.

As “American Idol” played on the television overhead, Dr. Leibowitz repeated her introductory riddle — “What brings you here?” — over and over again. She managed to convey both authority and empathy, no small feat, given her tousled hair and glasses askew over the mask.

As patients entered, they were “cohorted,” in medical lingo, meaning that they were separated from the general population and quarantined in a 40-foot hallway (normally a psychiatric emergency area), lined with molded plastic chairs, sealed by glass doors at either end, a giant fish tank of people in face masks.

A sign was taped to one door with a message emphasized in yellow highlighter: “Not all patients seen will be tested or given prescriptions for medication.”

In accordance with city guidelines, “We’re no longer routinely testing children who don’t have underlying conditions,” said Dr. Joy Nagelberg, chief of pediatric emergency medicine at Schneider.

“The overwhelming majority, you would look at them and say that they’re fine,” she said. “You would be surprised that they’re here at all.”

A resident, Dr. Adam Persky, rapped on a glass door to the quarantine area and asked for swabs. He had a woman who was six weeks pregnant with a fever in the adult emergency room and he was going to test her for flu.

Nurses strode by carrying paper plates of ziti, pizza, broccoli and chicken cutlets ordered in for them by the administration.

Raquel Cillacis, 18, arrived with her 6-year-old sister, Jasmine, around 8 p.m., having fled the crowd of people in masks at Queens Hospital Center. Raquel was disappointed when doctors told her they were not testing for flu; they said she had an “upper respiratory virus” and her sister was pronounced fine.

Some patients asked for face masks even though they had come to the emergency room for other reasons, like Tami Pitre, who brought her 14-year-old son, Michael, after he was hit in the head by a lacrosse stick during a scrimmage.

For others, the visit was an adventure. Rakin Ahmed, a boisterous 6-year-old in a blue face mask, happily rubbed Purell on his hands from one of the many dispensers around the hospital while his exasperated father tried to make him stop.

His father, Mumazzad Ahmed, an electrical supervisor, said he had been unnerved by all the news reports about swine flu and wanted to have Rakin checked out. His wife was against it. But since they lived just a mile from the hospital, he brought the child in. Rakin was fine.

“I wish I hadn’t come,” Mr. Ahmed said. “I think this whole thing is a hoax. I hope it all goes away.”

A 16-year-old girl named Rachel came into the hospital already on Tamiflu. Her pediatrician had tested her for flu and prescribed the drug to everyone in her household, said her father, who asked that the family not be identified further for fear of alarming their neighbors.

The family drove to Schneider from Brooklyn, saying they preferred it to their neighborhood hospitals. They were given a police escort after her father was stopped for running red lights and he told the officers that his daughter was sick.

“The doctor listened to her breathing and told us to leave her alone, let her get back in bed,” Rachel’s mother said, as they left the hospital at about 11 p.m.

The trip was worth it, just for peace of mind, Rachel and her parents agreed through their masks.

Before midnight, admissions slowed to a trickle, and the swine flu greeter, Dr. Leibowitz, had slumped on a plastic chair.

Her last flu case, a 12-year-old boy, arrived at 3:30 a.m. Half an hour later, she took off her greeter’s mask and signed out. But the patients kept coming.

    At the Hospital, the Faces of Fear and Swine Flu, NYT, 22.5.2009, http://www.nytimes.com/2009/05/22/nyregion/22er.html?hp






On Abortion,

Obama Is Drawn Into Debate

He Hoped to Avoid


May 15, 2009
The New York Times


WASHINGTON — In nearly four months in office, President Obama has pursued a careful two-pronged strategy on abortion, enacting policies that secure a woman’s right to the procedure while vowing to move beyond the culture wars that have divided the nation on the issue for more than three decades.

Now, Mr. Obama is suddenly in the thick of the battle he had hoped to transcend, and his delicate balancing act is being put to the test.

The confluence of two events — his commencement speech on Sunday at the University of Notre Dame, in Indiana, and his forthcoming choice of a candidate to replace Justice David H. Souter, who is retiring from the Supreme Court — threaten to upend Mr. Obama’s effort to “tamp down some of the anger” over abortion, as he said in a news conference last month, and to distract from his other domestic priorities, like health care.

The invitation from Notre Dame, a Roman Catholic institution, has riled opponents of abortion, who object to giving such a platform to a supporter of abortion rights. The local bishop has vowed to boycott the ceremony. Some graduating seniors are planning to protest it. Conservatives, frustrated by what they regard as Mr. Obama’s skillful efforts to paint himself as a moderate, are all over the airwaves denouncing him as “the most radical, pro-abortion of any American president,” as Newt Gingrich, a former House speaker, said on Fox News.

The White House must now decide whether to engage in the debate and, if so, how deeply. Mr. Obama’s communications adviser, Anita Dunn, said in an interview that the president was likely to “make reference to the controversy” in his speech on Sunday. “You can’t ignore it,” Ms. Dunn said, “but at the same time, you can’t allow it to become the focus of a day that’s actually supposed to be about the graduates.”

While the address has galvanized abortion opponents, the Supreme Court opening has galvanized backers of abortion rights. Both sides expect Mr. Obama to pick a candidate who would uphold Roe v. Wade, the 1973 decision that established a constitutional right to abortion. But interest groups are taking no chances. “Take Action: Protect a Woman’s Right to Choose!” declared the Center for Reproductive Rights in an e-mail message to supporters on Wednesday.

Mr. Obama frames his position on abortion as a nuanced one — he calls it a “a moral and ethical issue” best left to women and doctors — and he envisions himself forging consensus around causes like reducing unintended pregnancies and promoting adoption. As he said in a 2007 speech to Planned Parenthood, “Culture wars are so ’90s.”

As president, Mr. Obama, who during the campaign answered a question about when human life begins by saying it was “above my pay grade,” has tried to straddle the abortion divide. He has done so partly by reaching out to religious conservatives, partly by avoiding the most contentious legislative battles and partly by reversing the policies of his predecessor, George W. Bush, a faithful ally of abortion opponents, in piecemeal fashion — all while the nation has been consumed by the economic crisis.

He has named abortion rights advocates to top jobs; Dawn Johnsen, a former legal director of Naral Pro-Choice America, is his pick to run the Justice Department’s Office of Legal Counsel. He has repealed the so-called Mexico City rule, which prohibited tax dollars from going to organizations that provide abortions overseas; lifted Mr. Bush’s limits on embryonic stem cell research; stripped financing for abstinence-only sex education; and is seeking to undo a last-minute Bush regulation giving broad protections to health providers who refuse to take part in abortions.

Cecile Richards, president of Planned Parenthood Federation of America, said she told allies that their movement was emerging from “eight years in the wilderness.”

But even as Mr. Obama has delighted abortion rights advocates, he has dialed back some earlier ambitions. In 2007, he promised Planned Parenthood that “the first thing I’d do as president” would be to sign the Freedom of Choice Act, which effectively codifies Roe v. Wade. Now he says the bill is “not my highest legislative priority,” as he put it at a recent news conference.

Mr. Obama is also reaching out. At his direction, his top domestic policy adviser, Melody C. Barnes, is convening a series of discussions with people on both sides of the debate, with a goal to draft a set of policy recommendations by late summer.

“What we’ve said to people is, ‘This isn’t an opportunity to relitigate Roe v. Wade,’ ” Ms. Barnes said. “The president wants us to talk about reducing unintended pregnancies, but he doesn’t want this to be the conversation that never ends. His goal is to get something done.”

David P. Gushee, a professor of Christian ethics at Mercer University in Atlanta who backed Mr. Obama despite their differences on abortion, has participated in the talks. He said the president was sending a message to moderate Catholics and evangelicals that “he clearly knows what the bright red lines are and is trying to avoid stepping over them.”

But religious conservatives and more ardent abortion opponents who have not been included say Mr. Obama is trying to have it both ways. Charmaine Yoest, president of Americans United for Life, an advocacy group, said that if the president really wanted to forge consensus, he would advocate rules allowing parents to be notified if their teenage daughters sought an abortion and banning the procedure known as partial-birth abortion. As an Illinois state senator, Mr. Obama voted “present” on such initiatives, enabling their defeat.

“Moderate rhetoric, hard-left policies,” said Senator Sam Brownback, Republican of Kansas, a vocal abortion opponent, assessing Mr. Obama’s approach.

Polls show that the American public is deeply conflicted over abortion and that support has declined steadily over the years. In 1995, roughly 60 percent of Americans believed abortion should be legal in all or most cases. Last month, in a survey by the Pew Research Center, that number stood at 46 percent. A Gallup survey that examined seven decisions early in Mr. Obama’s presidency found that the least popular was the one to overturn the ban on sending tax dollars to organizations that provide abortions overseas.

Douglas W. Kmiec, a constitutional scholar and former Notre Dame professor who was an outspoken critic of abortion when he worked for Presidents Ronald Reagan and the elder George Bush, said he had been advising the White House to use the speech at the university on Sunday to tackle the controversy head on, with the president making the case that “we already have agreement, we both respect life, we both view abortion as a moral tragedy.”

But as to whether Mr. Obama can indeed transcend the culture wars, Mr. Kmiec sounded uncertain.

“If there’s anybody who can, it’s the president,” he said. “Whether the culture wars will let him is the question, and the answer is unknown.”

    On Abortion, Obama Is Drawn Into Debate He Hoped to Avoid, NYT, 15.5.2009, http://www.nytimes.com/2009/05/15/us/politics/15abortion.html


















Jeff Koterba

Omaha World Herald, NE        Cagle

14 May 2009















Cancer Patients

Challenge the Patenting of a Gene


May 13, 2009
The New York Times


When Genae Girard received a diagnosis of breast cancer in 2006, she knew she would be facing medical challenges and high expenses. But she did not expect to run into patent problems.

Ms. Girard took a genetic test to see if her genes also put her at increased risk for ovarian cancer, which might require the removal of her ovaries. The test came back positive, so she wanted a second opinion from another test. But there can be no second opinion. A decision by the government more than 10 years ago allowed a single company, Myriad Genetics, to own the patent on two genes that are closely associated with increased risk for breast cancer and ovarian cancer, and on the testing that measures that risk.

On Tuesday, Ms. Girard, 39, who lives in the Austin, Tex., area, filed a lawsuit against Myriad and the Patent Office, challenging the decision to grant a patent on a gene to Myriad and companies like it. She was joined by four other cancer patients, by professional organizations of pathologists with more than 100,000 members and by several individual pathologists and genetic researchers.

The lawsuit, believed to be the first of its kind, was organized by the American Civil Liberties Union and filed in federal court in New York. It blends patent law, medical science, breast cancer activism and an unusual civil liberties argument in ways that could make it a landmark case.

Companies like Myriad, based in Salt Lake City, have argued that the patent system promotes innovation by giving companies the temporary monopoly that rewards their substantial investment in research and development.

Richard Marsh, Myriad’s general counsel, said company officials would not be able to comment on the lawsuit until they had fully reviewed the complaint.

The coalition of plaintiffs argues that gene patents actually restrict the practice of medicine and new research.

“With a sole provider, there’s mediocrity,” said Wendy K. Chung, the director of clinical genetics at Columbia University and a plaintiff in the case.

Dr. Chung and others involved with the suit do not accuse Myriad of being a poor steward of the information concerning the two genes at issue in the suit, known as BRCA1 and BRCA2, but they argue that BRCA testing would improve if market forces were allowed to work.

Harry Ostrer, director of the human genetics program at the New York University School of Medicine and a plaintiff in the case, said that many laboratories could perform the BRCA tests faster than Myriad, and for less money than the more than $3,000 the company charged.

Laboratories like his, he said, could focus on the mysteries still unsolved in gene variants. But if he tried to offer such services today, he said, he would be risking a patent infringement lawsuit from Myriad.

Christopher A. Hansen, senior national staff counsel for the civil liberties union, said the problem was with the patent office, not the company. He recalled that when he first heard that the office had granted a patent for a gene, “I said that can’t be true.”

As the A.C.L.U. explored the restrictions on competition that companies like Myriad had put in place — blocking alternatives to the patented tests, and even the practice of interpreting or comparing gene sequences that involved those genes — the restrictions started to look like not just a question of patent law, Mr. Hansen said, but of the First Amendment’s guarantee of free speech as well.

“What they have really patented,” he said, “is knowledge.”

A patent was also granted to a single company for genetic testing on long QT syndrome, which can lead to heart arrhythmias and sudden death, and to the HFE gene, linked to hereditary hemochromatosis, a condition in which iron accumulates in the blood and can cause organ damage. Doctors and scientists have complained about both patents.

On the other hand, the company that owns the patent to the gene CFTR, which has been linked to cystic fibrosis, has licensed the testing to dozens of laboratories, drawing praise from the medical world.

The decision to allow gene patents was controversial from the start; patents are normally not granted for products of nature or laws of nature. The companies successfully argued that they had done something that made the genes more than nature’s work: they had isolated and purified the DNA, and thus had patented something they had created — even though it corresponded to the sequence of an actual gene.

The argument may have convinced patent examiners, but it has long been a sore point for many scientists. “You can’t patent my DNA, any more than you can patent my right arm, or patent my blood,” said Jan A. Nowak, president of the Association for Molecular Pathology, a plaintiff in the case.

So far, however, two panels of government experts who have looked at the issue have not found significant impediments to research or medical care caused by gene patents. A 2006 report from the National Research Council found that patented biomedical research “rarely imposes a significant burden for biomedical researchers.”

That report and others, however, warn that the patent landscape “could become considerably more complex and burdensome over time.”

In the future, genetic tests are likely to involve the analysis of many genes at once, or even of a person’s full set of genes. Some 20 percent of the human genome is already included in patent claims, amounting to thousands of individual genes, says a draft report from the National Institutes of Health. The report warns that “it may be difficult for any one developer to obtain all the needed licenses” to develop the next generations of tests.

For Lisbeth Ceriani, a single mother from Newton, Mass., and a plaintiff in the case against Myriad, the biggest obstacle that gene patents present is one of cost. She has had breast cancer and a double mastectomy, but wants to have BRCA testing to determine her risk of ovarian cancer and help her decide whether to have her ovaries removed. But Myriad has refused to work with her insurance plan, Mass Health, and paying for the test herself is beyond her means.

She is reluctant to have surgery that might prove unnecessary, she said, but she also worries about her 8-year-old daughter and the inherited risk she might face. Which is why, Ms. Ceriani said, she wants to “find out if I have the mutation, so I can take the necessary steps to stay on the planet.”

“I want to be here,” she said, “to make sure she does her screening by the time she’s 30.”

    Cancer Patients Challenge the Patenting of a Gene, NYT, 13.5.2009, http://www.nytimes.com/2009/05/13/health/13patent.html?hpw







Can Health Insurers Be Cost-Cutters?


May 13, 2009
The New York Times


To the Editor:

Paul Krugman (“Harry, Louise and Barack,” column, May 11) is absolutely right: the Obama administration should always remember the self-serving profit motives of the health care industry.

But this is not 1993, and most Americans are now clamoring for health reform. The administration is not without leverage at the bargaining table; in fact, it comes with a strong hand. If industry is endorsing quality, efficiency and best of all, prevention, let’s make it walk the talk.

The administration can (and should) demand that a reformed approach to health include substantial investments in prevention. This may be America’s chance to create a health system that truly protects and promotes our health; old villains cannot stand in the way.

Larry Cohen
Executive Director
Prevention Institute
Oakland, Calif., May 11, 2009

To the Editor:

Paul Krugman outlines proposed cost-cutting by the “medical-industrial complex.” Why, thank you, medical- industrial complex! How nice to suggest lowering costs.

At the risk of seeming ungrateful, I wish to point out that the problem with voluntary cost reduction is that it’s voluntary. As long as the logic of our system is set by a huge for-profit multipayer bureaucracy, we will continue to get low value on the health care dollar.

Our nation’s ability to afford decent health care for all our citizens must not depend on voluntary self-regulation of for-profit entities. We need single-payer national health insurance. Let’s circle the wagons around health care, not around private insurance companies and Big Pharma.

Laura S. Boylan
New York, May 11, 2009

The writer, a clinical associate professor of neurology at New York University School of Medicine, is on the board of directors of Physicians for a National Health Program, Metro New York.

To the Editor:

The rumor mill has it that the health insurance lobby has deemed universal health care a done deal as long as the public option is taken off the table. But Paul Krugman is right. The Obama administration should say no and gird for a fight.

Conservatives consider government too incompetent to run anything, and would outsource all public administration to the private sector given the chance. But these same conservatives declare government-sponsored health insurance to pose unfair competition with private insurers. If such a government enterprise would be, by its nature, inefficient and incompetently administered, how could it be unfair competition and a threat to private enterprise? Which is it?

Is government an inefficient monolith, or a more effective conduit of health care for the American people? Conservatives cannot have it both ways.

Tom Predhome
Brooklyn, May 11, 2009

To the Editor:

Re “Health Care Industry Is Said to Promise to Hold Down Costs Voluntarily” (news article, May 11):

The offer by the stakeholders in the health care industry to cut the rate of increase in health care spending is deceptive and merely an attempt to delay the enactment of reform measures that include realistic cost constraints. How much could actually be saved by lifestyle changes in the population, better management of chronic illnesses, the use of electronic health records and so forth is uncertain, though these efforts would certainly improve health care.

The two largest components of health care costs today are administrative expenses (estimated at between 20 and 25 percent of spending, or $450 billion or more) and unnecessary or excessive care (estimated at between 20 and 30 percent). Unless reducing costs in these two areas is pursued aggressively, health care spending will continue to balloon, increasing the unfinanced government liabilities and damaging the economy.

Robert A. Levine
Norwalk, Conn., May 11, 2009

The writer, an attending neurologist at Norwalk Hospital, is the author of the forthcoming “Shock Therapy for America’s Health Care System.”

To the Editor:

How soon we forget. The Bush administration’s notion of “voluntary compliance” as a regulatory tool was found to be utter nonsense. Now the Obama administration is pushing the same idea for getting industry to control health care costs. It’s still utter nonsense.

The only effective cost-control mechanisms are competition and consumer choice. Both are in short supply.

Ron Sheppe
Rochester, N.H., May 12, 2009

    Can Health Insurers Be Cost-Cutters?, NYT, 13.5.2009, http://www.nytimes.com/2009/05/13/opinion/l13care.html?hpw







Reminders on Health Reform


May 13, 2009
The New York Times


Lawmakers who were paying attention got two powerful reminders this week of the critical need for them to pass the strongest possible reforms to bring down health costs and cover the unconscionable number of Americans — more than 45 million — who remain uninsured.

The more dramatic was the latest annual report from the Medicare trustees, released on Tuesday, which found that the recession had made Medicare’s already tenuous financial condition even worse, hastening the day the program’s hospital fund will face insolvency unless reforms are enacted. As Peter Orszag, the director of the Office of Management and Budget, repeatedly stresses, the only way to solve the fiscal problems of the big entitlement programs is to slow the relentless rise in the underlying health care costs.

The other reminder of the need for change was a pledge by leaders of the major health care industries to cut $2 trillion from projected health care spending over the next decade. It was a promising development, but probably not the “watershed event” that President Obama had proclaimed it. So far, all we have is a vague and unenforceable promise that may never materialize.

On Monday, groups representing insurance companies, drug and device makers, doctors, hospitals and a labor union pledged at the White House to shave 1.5 percent off the annual rate of growth in health care spending. That would reduce the growth rate from a projected 6.2 percent a year over the next decade to 4.7 percent a year, a seemingly modest amount that would, over time, produce substantial savings for the health care system, the federal government and individual families.

We hoped it was a sign that the industry believes major reforms are inevitable and is better off cooperating with the reform effort instead of opposing it.

For disparate elements of the health care industry to profess a willingness to reduce the unsustainable growth rate in health care costs is a huge difference from the early 1990s when the insurance industry and other special interests combined to defeat the Clinton administration’s health care proposals.

In the course of promising savings, health care leaders seemed willing to accept such long-sought reforms as comparative effectiveness studies to determine which medical procedures or products work best. Whether they will be willing to accept dictates that they use the best procedures or products seems doubtful.

Skeptics are right to be worried that health industry leaders are primarily trying to head off strong federal policies and regulations by making toothless pledges of voluntary action. None of the health care groups have agreed to accept any particular cuts. None have agreed to drop previous opposition to specific reforms under discussion in Congress. None are able to guarantee that their members will accept guidance from their national associations.

The industries need to come up with concrete proposals that the Congressional Budget Office can evaluate in terms of likely impact on health care spending. And Congress needs to find some mechanism to force savings from the industry if its voluntary efforts fail to reduce costs as promised.

    Reminders on Health Reform, NYT, 23.5.2009, http://www.nytimes.com/2009/05/13/opinion/13wed1.html?hpw






Op-Ed Columnist

Harry, Louise and Barack


May 11, 2009
The New York Times


Is this the end for Harry and Louise?

Harry and Louise were the fictional couple who appeared in advertisements run by the insurance industry in 1993, fretting about what would happen if “government bureaucrats” started making health care decisions. The ads helped kill the Clinton health care plan, and have stood, ever since, as a symbol of the ability of powerful special interests to block health care reform.

But on Saturday, excited administration officials called me to say that this time the medical-industrial complex (their term, not mine) is offering to be helpful.

Six major industry players — including America’s Health Insurance Plans (AHIP), a descendant of the lobbying group that spawned Harry and Louise — have sent a letter to President Obama sketching out a plan to control health care costs. What’s more, the letter implicitly endorses much of what administration officials have been saying about health economics.

Are there reasons to be suspicious about this gift? You bet — and I’ll get to that in a bit. But first things first: on the face of it, this is tremendously good news.

The signatories of the letter say that they’re developing proposals to help the administration achieve its goal of shaving 1.5 percentage points off the growth rate of health care spending. That may not sound like much, but it’s actually huge: achieving that goal would save $2 trillion over the next decade.

How are costs to be contained? There are few details, but the industry has clearly been reading Peter Orszag, the budget director.

In his previous job, as the director of the Congressional Budget Office, Mr. Orszag argued that America spends far too much on some types of health care with little or no medical benefit, even as it spends too little on other types of care, like prevention and treatment of chronic conditions. Putting these together, he concluded that “substantial opportunities exist to reduce costs without harming health over all.”

Sure enough, the health industry letter talks of “reducing over-use and under-use of health care by aligning quality and efficiency incentives.” It also picks up a related favorite Orszag theme, calling for “adherence to evidence-based best practices and therapies.” All in all, it’s just what the doctor, er, budget director ordered.

Before we start celebrating, however, we have to ask the obvious question. Is this gift a Trojan horse? After all, several of the organizations that sent that letter have in the past been major villains when it comes to health care policy.

I’ve already mentioned AHIP. There’s also the Pharmaceutical Research and Manufacturers of America (PhRMA), the lobbying group that helped push through the Medicare Modernization Act of 2003 — a bill that both prevented Medicare from bargaining over drug prices and locked in huge overpayments to private insurers. Indeed, one of the new letter’s signatories is former Representative Billy Tauzin, who shepherded that bill through Congress then immediately left public office to become PhRMA’s lavishly paid president.

The point is that there’s every reason to be cynical about these players’ motives. Remember that what the rest of us call health care costs, they call income.

What’s presumably going on here is that key interest groups have realized that health care reform is going to happen no matter what they do, and that aligning themselves with the Party of No will just deny them a seat at the table. (Republicans, after all, still denounce research into which medical procedures are effective and which are not as a dastardly plot to deprive Americans of their freedom to choose.)

I would strongly urge the Obama administration to hang tough in the bargaining ahead. In particular, AHIP will surely try to use the good will created by its stance on cost control to kill an important part of health reform: giving Americans the choice of buying into a public insurance plan as an alternative to private insurers. The administration should not give in on this point.

But let me not be too negative. The fact that the medical-industrial complex is trying to shape health care reform rather than block it is a tremendously good omen. It looks as if America may finally get what every other advanced country already has: a system that guarantees essential health care to all its citizens.

And serious cost control would change everything, not just for health care, but for America’s fiscal future. As Mr. Orszag has emphasized, rising health care costs are the main reason long-run budget projections look so grim. Slow the rate at which those costs rise, and the future will look far brighter.

I still won’t count my health care chickens until they’re hatched. But this is some of the best policy news I’ve heard in a long time.

    Harry, Louise and Barack, NYT, 11.5.2009, http://www.nytimes.com/2009/05/11/opinion/11krugman.html?ref=opinion







Where Did All the Doctors Go?


May 4, 2009
The New York Times

To the Editor:

Re “Shortage of Doctors Proves Obstacle to Obama Goals” (front page, April 27), about a lack of primary care providers :

As those of us responsible for delivering health care know, the battle between specialists and primary care doctors has been going on for years, and one side has been winning.

The marketplace has rewarded specialists financially, and like any other special interests, they are amply financed for this conflict. Still, I don’t fault them. They have studied and worked hard, and are responding to market incentives, like good red-blooded Americans.

What we really need is a European-style single-payer system, with primary care doctors who emerge from their training with European-style debt loads: zero.

Georganne Chapin
Tarrytown, N.Y., April 27, 2009

The writer is president and chief executive of the Hudson Health Plan, a not-for-profit managed care organization.

To the Editor:

Your article says, “The experience of Massachusetts is instructive,” and that is an important point.

As we strive to improve our health care system, we must remember that no one knows what will work. This is not Britain, Spain or France, and the Bronx is not Pocatello. A failed national experiment could be an expensive disaster. We must try different experiments in the laboratories of the states.

Stewart Wetchler
Williamsburg, Va., April 27, 2009

The writer is a doctor.

To the Editor:

Obama administration officials are right to be concerned about shortages of primary care doctors. We have known about this problem for 30 years — and could learn a lesson from Britain on how to fix it.

In the United States, primary care doctors are paid, on average, about 40 percent less than specialists. Doctors know this; medical students know this. In a national survey last fall of medical students, only 2 percent said they were considering a general internal medicine practice.

Britain faced a similar shortage of primary care providers, along with a need to boost productivity and preventive care. Starting in 2004, general practitioners who hit their marks on improved services enjoyed substantial increases in pay. In the first year alone, these doctors saw their earning rise 10 percent, on average, and British patients saw a welcome increase in primary care services.

Sounds like a plan to me.

Richard M. Scheffler
Berkeley, Calif., April 27, 2009

The writer is a professor of health economics at the University of California, Berkeley.

To the Editor:

Attracting and retaining doctors and other providers in primary care is not a problem that can be solved by simply spending more money on fees and adding more students in medical schools.

As a primary care doctor for 32 years, I can unequivocally state that doctors and nurses are driven out of the field because of the dual and often conflicting role we now play.

In addition to trying to provide the highest possible standard of care while being second-guessed by insurers, we are asked to assume the sole responsibility for controlling the cost of health care in a system in which we have little power and no reward for the effort.

Medical subspecialists and surgical specialists have little interest in accepting responsibility for this work, and who can blame them?

In truth, primary care has become two jobs, which is why the salary doesn’t adequately compensate for the work required.

Martin P. Solomon
Brookline, Mass., April 29, 2009

The writer is medical director of Brigham and Women’s Primary Care of Brookline and an assistant clinical professor of medicine at Harvard Medical School.

To the Editor:

Another possible solution to the shortage of primary care doctors is to relieve medical students of the large debts they accumulate during their education. These costs dissuade students from entering primary care because of the expected lower income.

There are a number of ways to accomplish this. For example, we could forgive the loans of graduates who enter primary care and agree to work in a rural or underserved area. I believe that freedom from debt would allow many more students to choose primary care.

Walter Gamble
Brookline, Mass., April 28, 2009

To the Editor:

Thirty-six years ago, as one of the first members of the National Health Service Corps, I was sent to western New Mexico, where there was a shortage of doctors.

Although delivering primary care to this medically needy population was probably the most meaningful period in my medical career, there were difficulties, including the lack of accessible specialty care. Seriously ill patients were transported 160 miles to the nearest tertiary medical center. I realized that most of my primary care services could have been delivered by a nurse practitioner.

Many of the medically underserved areas are geographically remote and lack educational and cultural opportunities that would encourage doctors’ families to set roots. Instead of sending doctors from afar, the government should train local nurses to become midlevel practitioners. By using a sophisticated electronic medical record, these practitioners could develop enhanced relationships with specialists in larger medical centers.

Mark A. Goldstein
Boston, April 27, 2009

The writer is chief of the Division of Adolescent and Young Adult Medicine at Massachusetts General Hospital for Children.

To the Editor:

Medical students in good standing should have the option of becoming “government doctors.” We should give them a very generous salary, befitting their learned and difficult profession, further adjusted for those willing to work in underserved areas or in specialties for which the need is greatest.

They would receive medical and malpractice insurance and retirement benefits, as well as an office allowance for rent, staff and supplies, and would serve anyone who walked in. Perhaps this could be financed by a national lottery.

Gregory R. Barison
Boston, April 29, 2009

Where Did All the Doctors Go?, NYT, 4.5.2009, http://www.nytimes.com/2009/05/04/opinion/l04doctors.html