Health Care Reform Part Deux: Delivery

Progress! That's what I'm making on my promise to write about the big picture with health care reform. As I outlined several posts ago, there's a lot more to fixing our broken-down jalopy of a health care system than just making sure everyone has insurance (and we can't even get that done). Insurance, when implemented properly, can make care affordable to everyone, but we need to take a look at the care we're getting. How far does our dollar take us? Health insurance reform is going to do very little to stem the rising costs of care. Making reforms in the health care delivery system is where we can hope to really make care more affordable and sustainable. Its going to be a long journey though...

As much as the pharmaceutical industry is making a killing in this country, its not where the majority of money in the health care system is directed. But its a big part and I'll get to that shortly. Where is most of it going? To doctors! Who'd have thought...

The root problem to a lot of our overspending lies with a payment system called 'fee-for-service'. Essentially this means that for each scan, test, and diagnostic a doctor orders for a patient, they get paid. And in an age where everyone wants every scan performed to rule out the possibility of each infection and cancer known to man, the costs from this type of system really add up. If I was going to give your car a tune-up and went ahead and replaced the windshield, slapped on new tires, and repainted it, in addition to what you would have expected, such as changing your oil, you'd probably be upset when it came time to pay the bill. Well our health care payment system works in much the same way. We don't pay based on health outcomes, we pay based on each step a doctor takes to get us there, whether is forwards, backwards, or sideways.

Now I don't want to seem like I'm accusing all doctors of blatantly profiteering at the expense of their ignorant patients. I certainly feel that in a payment system such as this, there is a certain subtle, unconscious factor regarding profit incentives to consider, but I'd be a really bad psychiatrist, so I'm going skirt that issue. As mentioned before, many patients actually demand such courses of action. We increasingly live in an era where people are more educated about their health through mechanisms such as WebMD, which leads to a lot of self-diagnosis. Patients show up to their doctors offices armed with articles and ideas about what's ailing them before a doctor can even examine them. In this type of climate doctors are obliged to order a plethora of tests due not only to patient demands, but also out of fear that they will be sued if they miss something that an extra test may have discovered. This is what is referred to as 'defensive medicine', and operating under duress and out of fear is no way to practice medicine.

Tort reform (making it harder to sue doctors) is one of the Republicans' few pet issues when it comes to health care, and I have to say that I agree with them on this one for the most part. I think their claims regarding the cost-effect it will have are overblown, but in the long run tort reform will reduce doctor's fears of being sued and assist in the reduction of over-testing patients. This, however, is just one small piece of the puzzle.

First of all, we have too many people showing up to their doctors' offices very sick, as is highlighted in a recent CDC report on patients not receiving or delaying seeking care due to the cost. Lack of insurance coverage is one thing that keeps people from getting regular treatment, so insurance reform will hopefully help to alleviate some of this problem. But even when people are insured we see this problem. A major cause of this is the simple fact that there are far more 'specialists' (surgeons, dermatologists, cardiologists, etc.) than 'general practitioners' (family doctors). Specialists, on the whole, earn a lot more money than physicians, making these jobs more attractive to medical students with large debt loads. But its detrimental effects are twofold: (1) there are fewer physicians to give patients primary, preventative care (i.e. regular check-ups and good health advice) that would keep them from developing conditions requiring specialists, and (2) it creates a very large pool of individuals who stand to profit from people having serious conditions.

Now I'm not saying that specialists want to see patients get sick so they can make money (though for hospital administrators its great business), but it is easy to see that our system is not aligned with our goals. Preventative care is far less expensive than specialized care, such as chemotherapy and surgery. We need to create more incentives for medical students to enter the general practice field and create more incentives for students unwilling to tackle the commitment of medical school to pursue careers as nurse practitioners, who in many states can provide much of the same type of care that a general practice doctor can.

In addition to increasing our focus and incentives for preventative primary care, we need to do a better job of coordinating that care. What will this look like? Doctors will increasingly work in group, rather than private practices. Institutions such as Kaiser Permanente are great examples of this model. Kaiser does everything in-house. They provide the insurance, they own the hospitals, and they contract with a doctors' group that works exclusively with them. They coordinate care and negotiate prices within their own structure to help keep costs reasonable and efficiently track a patient's health.

In terms of changing our payment methods, there are a few ideas floating out there that warrant some examination. 'Fee-for-performance' and 'episode-of-care' are perhaps the most promising. Fee-for-performance is pretty much what it sounds like... namely doctors are not paid per test performed, but based on overall health outcomes. Episode-of-care means that rather than paying for treatment at a hospital, the going home and having a relapse of some sort, and having to go back to the hospital and pay again, you would only pay once for whatever it is that ails you, and if the hospital fails to take care of that properly, they eat the additional cost. These methods obviously incentivize quality care rather than overtesting.

And lastly, I told you we'd get back to the pharmaceutical industry, which accounts for roughly 14% of medical expenditures in the U.S.. Big Pharma is far-and-away the most profitable industry within the Fortune 500 companies. There is a lot of truth to the argument that we in the United States subsidize pharmaceuticals for the rest of the world; there is no government regulation of drug prices and we pay from 50-100% more for the same drugs as they do in other developed nations such as Canada, France, and Britain. Drug companies will regularly point this out and say that unless we can force other countries into higher prices, the rates in the U.S. are necessary to sustain very expensive research & development (R&D) of new drugs. This is true, but what they don't mention is that they spend about twice that much on marketing and promotion of their products, as detailed here.

As with much of the rest of our health care system, the incentives in the drug industry are misaligned. The industry focuses primarily on therapeutic drugs that people will have to take for the rest of their lives to control certain disease states. Even worse, the proportion of designer drugs (like Viagra) continues to rise. People take these sorts of drugs every day, for long periods of time, ensuring that sales will continue and profits grow. Contrast this to the idea of producing and marketing vaccines, usually a one-time-only products, and you can see why investment in vaccines doesn't make much financial sense. And when much of the vaccine-preventable disease burden is concentrated in the developing world (i.e. no money), the incentives for vaccine research decline even further.

To take a step in the right direction we need to promote the use of generic drugs (inexpensive reproductions of brand-name drugs once their patent expires) and reign in the practice of pharmacies drastically inflating their cost, as shown here. Additionally, we need to ensure that insurance companies provide incentives to purchase these cheaper generics, such as covering their full cost and only a fraction (or none) of the cost of the more expensive brand name drugs. It has been shown that when given the choice (equal copays for generics and brand-names) consumers will almost always choose the more expensive brand-names, contributing to our inflated health care costs. As for vaccine development and the developing world, that's a problem for another post entirely.

As you can tell by the extreme length of this post, there are a myriad of ways that we can begin to reduce our health care costs in this country, and universal coverage is only the first tiny step forward. These reforms will take years, and even decades, but research into these reforms and new programs to test them are already beginning to occur. It is up to the American public to be as informed about the potential of these ideas as it is about the potency of Viagra.

Catharsis

I'm not in a great mood tonight, so when I decided to check Politico's website one more time tonight (I do it several times per day), I was naturally infuriated by the arch-enemy of logic, the one and only Sarah Palin, who has cast her lot in with the 'birther' movement. You can read more here.

"I think the public is still rightfully making it an issue" she says. No, Sarah, you are making it an issue. You are not the public. All the proof you could want is documented here, and as you can tell by the exasperated comments of Hawaii public health officials, this attempt to discredit the President of the United States is pathetic.

Sarah, I say this from the bottom of my heart and with the utmost sincerity... fuck off. I have no problem with those with opposing viewpoints, there are millions and millions of them, and I respect a great many of their viewpoints that are validated by personal experiences, religious convictions, and political theory. You, however, are a distraction to constructive political discourse in our nation, where there is precious little to begin with. You are an ill-informed, self-important bimbo who ought to meet the same fate as those wolves you shoot from helicopters. I pity your family who you have put through hell for your own personal gain and I can only hope that God is as merciful as my fellow Episcopalians like to think he is.

Glacial Pace

Sen. John Ensign

Yes, in regards to the next two parts of my series on health care reform I'm moving about as fast as Congress, its pitiful really. But they're almost done, so I'll continue pretending that people read this and actually care.

It has been an important day however, so I had to make a few quick notes:

• The Congressional Budget Office released a report saying the Dems' health insurance reform plan would reduce premiums for the majority of people buying insurance on their own (non-employer based) and that little would change in regards to pricing for those getting it through insurers. Not perfect, but certainly a plus for the good guys (i.e. those fighting for health insurance reform... not the Dems as a whole). You can see the CBO's report here or read about it in the devious liberal media.
• John Marcotte's petition to add a proposition called the '2010 California Marriage Protection Act' to California's next voting cycle might sound like more conservative prejudice, but rather its a satirical attempt to ban divorce in California. You can see his website here.
• The Republican party continues to implode and John Ensign refuses to resign over his extra-marital affair for the most noble of reasons. Didn't he demand Clinton resign over the Lewinsky scandal? Oh, yes... yes he did.
  
• They're all guilty: I've never liked Nancy Pelosi. Add another reason to the list... she spends too much government money on flowers. Follow the link to see more examples of line items released in the quarterly listing of House office expenses.
• And lastly, God obviously blessed this year's Haji (I'm thinking he does that every year, but anyways) as the dreaded massive outbreak of H1N1 that was feared never materialized, with only 5 deaths attributed to the disease. Unfortunately, a new strain of MRSA has emerged with a mortality rate of nearly 50%.
  

UC Berkeley Student Fee Protests!

This is a test... I've just learned how to post text, photo, and video to WSD via my cell phone. Hooray 21st century!

Part I: Health Insurance Reform (Finally!)

Like so many amateur bloggers out there I continually disappoint my imaginary readers by failing to follow up on posts in a timely manner. I'm referring to my intended 3-part series on health care reform that has been delayed due in large part to my starting a new research position and the massive protests here at UC Berkeley (more on all that soon).

So, I promise, its coming... really soon. All of it. Seriously.

In fact, here's Part I: Health Insurance Reform

Please be forewarned, this is not intended to be a up-to-date analysis of the latest House or Senate bill. Those damn things change every other hour as our elected representatives are busy making sure there isn't anything drastic enough in there to upset anyone, ever, about anything. Its like ripping all the teeth out of T-Rex: not nearly as effective, what's he going to do, get you with those gimpy little arms? Ha! Yeah right...

What this is intended to do is review several of the key components to effective health insurance reform that are currently being debated (and a few ignored). The next two posts will focus on what needs to happen once we complete the slow, painful crawl towards passing an insurance reform bill.

So, the big thing about the current proposal is that the Dems, and even some Republicans think we ought to have universal coverage, meaning every legal citizen of the United States should be covered by some sort of health insurance plan. The current proposal going forward is to have individual or employer mandates, basically requiring that people have health insurance by law, much in the same way that most states require that drivers have auto-insurance. An individual mandate would mean that each person is personally responsible for acquiring their own insurance, either through their employer, a private plan, or via government programs like Medicare and Medicaid for those that qualify. An employer mandate would mean that employers must provide health insurance for their employees through one of the aforementioned means, the way many businesses currently do. There would be certain exceptions for small businesses and the like due to the cost-burden that comes with this. Some argue this would stifle growth in an already hurting economy, others say (and its been proven) that over the long-term, at least, the costs are simply passed on to the employees in the form of lower wages.

Depending on the final version of the bill, both employers and individuals who do not have insurance will face fines. The government intends to provide subsidies to businesses in the form of tax breaks so that they can afford to provide insurance to their employees, as well as direct subsidies to individuals in the lower-income brackets who cannot afford insurance on their own. The insurance industry is currently all about this plan, because it adds millions of customers to its base. Much in the same way that hot-dog vendors would be really psyched if the government suddenly passed a law saying everyone had to eat hot dogs, or face a fine.

What the insurance companies do not want to see is the emergence of a public option. This is where much of the contention over the final bill lies. A public option would be an OPTIONAL government-run health insurance plan (like Medicare and Medicaid) that anyone could purchase. It would essentially provide competition to private health insurers and force them to keep their costs low, since the government wouldn't be worried about making profits. Much in the same way that the Post Office competes with companies like FedEx and UPS. This public option would, ideally, be financed by the premiums it charges for its customers. An analysis by the Congressional Budget Office determined the bill passed by the House (H.R. 3962) would actually reduce the federal deficit over 10 years. Of course the Dems have been very strategic about what they put in the bill so the price tag comes out at a politically palatable number, meaning some spending related to health care will likely be passed in separate bills. I'd be more comfortable, at this point anyways, that the entire plan will come out roughly even, give or take a few billion dollars.

I'm not going to make exhaustive arguments about why I think there should be a strong public option, since you can easily find those with a Google search. I will, however, say that major health insurers, on average, spend 16-20% of their budget on overhead (pretty inefficient by most standards) and since 1970 the number of health care administrators in the U.S. (not confined solely to insurance companies, but hospitals and other providers as well) has risen 3000% (yes, three-thousand) while the number of physicians in the U.S. has risen just 200%. Something to think about... I'll delve into that more in the next post.

But anyways, the public option would become part of a 'national insurance exchange' and compete with private insurers. But what in God's name is an insurance exchange? Professor Jacob Hacker of Yale's political science department describes it as such...

"It’s a place where individuals can go and shop for a health plan. Today, large employers can select from a choice of plans that spread risk and reduce administrative costs because of the large work force. But the options available to small employers are much more expensive. And individuals find it very difficult to get coverage. The exchange would make a range of more affordable options, including a public plan, available to individuals and employees of small businesses." The full Q&A with Dr. Hacker regarding the insurance exchange can be found here.

There are also those out there who are communist enough to want to go even further than a public option; they want a single-payer system, such as the British National Health Service (NHS). Essentially this would mean that the government is more or less the sole provider of insurance. This is not a political reality on the national stage, but there are certainly reasonable arguments in favor of this type of system. California is one state where there is considerable momentum behind the idea of a single-payer system. While politicians on the national stage don't want to touch anything this toxic for fear of being labeled a Marxist-Nazi, we may see experiments in this type of system on a state level in the coming decade.

Lastly, making these structural reforms is important, but efforts also need to be made to reduce operating costs of insurance companies (remember the overhead cost thing?). If the government is going to force millions more into the arms of insurance companies, they ought to make sure that all that money is being spent efficiently. The same applies to the government, both to its potential public option, and its current Medicaid and Medicare programs. There are several provisions within the current bill aimed at reforming Medicare and making it more efficient, and while many out there would have your grandmother thinking that Obama is going to destroy Medicare, this is hardly the case.

There you have it folks, health insurance reform. We've taken the first steps, but we're a long way off from acheiving anything. The Senate has to force a bill to the floor to be voted on, and even if something gets passed with the unlikely help of a few key 'centrist' democrats and the ever-agitating Joe Lieberman (just another reason to hate Connecticut), the House-Senate conference committee to hammer out final legislation promises to be a circus in its own right.

Parts 2 & 3 of my health care reform series will be posted by weeks' end... but don't hold me to that.

Should I Get A Flu Shot?

We're taking a brief timeout from my health care reform series to continue harping upon a subject that I may have beaten to death... but people keep asking me the question, so once again, here is my answer to, 'should I get a flu shot?'

The short answer: YES

The long answer: If possible, you should get both the seasonal influenza vaccine and the 2009 H1N1 vaccine. The seasonal, trivalent (3 strains) vaccination which protects against seasonal variants of H3N2, H1N1, and Influenza B, does not protect against the 2009 H1N1 (swine flu). A separate monovalent (1 strain) vaccine has been developed for this virus and is currently being distributed nationwide as quickly as production allows. Both vaccines come in an injectable, inactivated form or in an intranasal, attenuated (weakened) form. The nasal spray form is recommended for all healthy people aged 2-50 years old. If you fall outside those age ranges, are pregnant, or have certain chronic or immunosupressive conditions (lung disease, heart disease, asthma, etc) you should get a shot of the killed vaccine instead.

While older populations and the very young are the most susceptible for seasonal influenza, those individuals from 6 months to 24 years of age, as well as those 24 to 64 years old who have medical conditions that put them at greater risk for infection are the most at risk for 2009 H1N1. There is some evidence that people over the age of 55 may have some protective antibodies due to previous exposure to a similar H1N1 strain that circulated in the early 1950's, but this has yet to be backed by significant evidence.

Finally, many people should also consider getting a pneumoccoal vaccine to protect against secondary bacterial pneumonia infections that take advantage of the body's weakened immune defenses while infected with the flu. Secondary bacterial pneumonia can be a deadly complication of the flu virus. It is recommended that all adults over age 65 receive the pneumococcal vaccine, as well as those 2 to 64 years of age who fall into the following categories: chronic cardiovascular, pulmonary, or liver disease, alcoholics, residents of nursing home or long-term care facilities, anyone with immunocompromised or immunosupressive conditions, as well as any adults who smoke cigarettes or have asthma.

Contrary to paranoid conservatives, new-agey liberals, and a sensationalist media, flu vaccine (both kinds) is perfectly safe. I've addressed the safety of vaccines in general in previous posts. Read up if you like, or leave comments with questions and I'll gladly answer them. And before you ask, yes, flu vaccine does have the potential side effects of dizziness, sexual nightmares, and sleep crime.

Check the CDC's website for full flu vaccine and pneumococcal vaccine facts as well as the latest press update regarding the status of H1N1 influenza in the United States.

Health Care Reform? We Haven't Even Started...

For months we've been inundated by what the media refers to as the 'Health Care Debate'; politicians, lobbyists, tea-party protesters, and media pundits trying to influence how we're going to achieve health care reform. Well, we haven't even scratched the surface. To be honest we haven't even begun talking about true health care reform, merely health insurance reform. And while there have been some modest proposals and a bit of discussion outside the realm of health insurance, the real debate that needs to occur has largely been relegated to the sideline.

With both houses of congress actually making moves to get bills out of committee and onto the floor, it is crucial to remember that when a health insurance reform bill passes, and one will, the job is not yet done. While we may actually see some fairly meaningful insurance reform occurring by 2013, the real change that needs to take place will take decades and will depend not on the commitment of the Obama administration, Harry Reid, Nancy Pelosi, or any other individual or group of politicians, it will depend on the public's ability to continue to demand the change that the majority of population knows is necessary.

So what really needs to occur in order for this painstaking health insurance reform push to mean anything? I'm going to break it down from my perspective across a series of posts in the next few days. In my opinion, true health care reform needs to occur in three ways: (1) health insurance reform, (2) health care delivery reform, (3) food reform.

Health Insurance Reform Includes...

• Universal Coverage and no exemptions based on pre-existing conditions
• A robust public option and state-based experiments in single-payer systems
• An inclusive, national insurance exchange
  
• Personal and employer mandates
• Death panels
  
• Subsidies for low-income populations and tax-exemptions for small businesses
• Reduction in insurance overhead costs and cost-saving measures to Medicare

Health Delivery Reform Includes...

• Reduction in prescription drug costs and greater incentives towards use of generics
• Payment method alterations and the elimination of 'fee-for-service'
• Movement towards group practice and local/regional coordination of care
• Increase in and incentives for primary care doctors and nurse practitioners; reduction in specialists
• Socialist-Fascist bureaucrats to the staff the death panels
• Effective use of deductibles to control unnecessary spending
• Tort reform and medical courts to reduce 'defensive' medicine
  

Food Reform Includes...

• Increase in food labeling measures for nutrition facts and ingredients
  
• Tighter quality controls, greater transparency, and decentralization of the meat-processing industry
• Experimental taxes on sugary drinks and other unhealthy foods
• Greater nutrition education and other measures to counteract the obesity epidemic
• Higher taxes on the overweight and obese (that's 2/3 of the population you know)
  

Can you spot the outliers in each set of reforms? In my next three posts I'll attempt to break down and expand upon each step in the process. We'll also ponder how it is that Fox News can manage be such stalwart defenders of the public's interest... a truly amazing news organization they are.

The Higgs-Boson Particle & the Future Dictating the Present

Wow... I've always enjoyed theoretical physics, partly due to the sheer impossibility of wrapping one's head around some of the concepts, and partly due to my former roommate's willingness to translate the more basic theories into remedial English for me to more easily ponder. Also, Carl Sagan, that guy is great.

The most audacious experiment in all of modern physics is known as the 'Large Hadron Collider' (LHC), an 18-mile diameter ring buried underneath the border between France and Switzerland. The purpose of this $9 billion behemoth, operated by the European Organization for Nuclear Research, known by the acronym CERN, is to essentially smash protons into one another at just shy of the speed of light. At certain points within the machine, the proton beams will be allowed to cross and smash into each other. Scientists hope to study the potential new particles that arise from these collisions. The most prized of these theoretical particles is called the Higgs-Boson particle, also known as the 'God Particle', which is theorized to imbue all things with mass.

Well it turns out that God doesn't want us playing with his particle. The project has been beset by various delays over the past 9 years of its construction, the most recent coming in the form of the connection between to magnets being destroyed shortly after the machine was switched on. Oh, and a French particle physicist employed by CERN was recently arrested for potential ties to the North African wing of Al-Qaeda. Nevermind that the lunatic fringe has repeatedly warned that such a colossal machine working on the edge of our scientific knowledge could inadvertently create a black hole and destroy the world.

Now, two highly-regarded physicists, Dr. Holger Bech Nielsen and Dr. Masao Ninomya have postulated that these various hurdles and delays may not simply be coincidence. Rather, they propose that the existence of a Higgs particle is so 'abhorrent' to nature, that the future may in fact be attempting correct the past and prevent a Higgs from forming.

I'll give you a moment to read that over again...

"It must be our prediction that all Higgs producing machines shall have bad luck,” Dr. Nielsen said in an e-mail message quoted in this recent NYT essay. Further evidence can be found in the fact that in 1993 the United State Superconducting Supercollider project, also designed to find the Higgs, was cancelled, even after billion of dollars had been spent, he argues. So yes, they are basically saying that the future is correcting the past.

The Times articles gives a more thorough account of the two physicists and their theories, more fully described in this publication, and followed up by this paper. As far as most others involved with the project are concerned, it will be moving forward soon, when they begin to inject particle beams into the machine in November.

Regardless of the outcome (and sure hope its not a world-ending black hole) isn't it exciting to live in a time where we can recreate the Big Bang in a hole in the ground, realistically postulate about time-travel, and have so many options on the 99-cent value menu?

Timeout: I Win!

I'm sure most people would say this has nothing to do with public health, but the success of my fantasy football team has a lot to do with my personal health, so I thought I'd point out that I totally beat Yahoo! Sports blogger Andy Behrens to the punch when I proclaimed that Steve Smith of the New York Giants was now the #1 Steve Smith in the league, supplanting Steve Smith of the Panthers.

I made my claim in this post, on Sunday October 4th. It took Behrens until Wednesday to make the same obvious realization... This guy gets paid to write about sports, and I blog about public health in my spare time. I think Yahoo! should hire me instead.

Adam - 1, Yahoo! Sports - 0

Also, Yahoo's weekly point projections for fantasy players is awful.

In The Kitchen with Shark Eyes

The following is a contribution to my blog from my friend Rob White. While he may have trouble using a telephone, he's a great guitar player and fantastic cook. I love cooking, and eating, so I asked him to contribute a recipe. It probably won't be the last. Soon I'll delve into the abyss that is the nexus of food and public health... But for now, here's Robbie, aka 'Shark Eyes'...

I was recently asked to make a contribution to the Woolsey Street Digest, I assume in the interest of rounding out the publication’s flourishing readership. Specifically, I have been contracted to talk about the world of food and why not? I can’t imagine any better combination than one man’s musings on the politics of public health and infectious disease followed by a self indulgent foray into the world of amateur gastronomy. I know nothing makes my tummy grumble like a rousing story about humanity’s inevitable destruction at the hand of some pandemic de jour.

Despite my cynicism, I have recently had few people ask me to share some of my recipes with them and this might be a good venue to slake their, presumably, unquenchable hunger for my secrets.

The first recipe I would like to share is one which I had a tremendous amount of trouble with and only finally got working recently. People's opinions regarding the process of making French bread, as I have found, can be extremely divisive. There are innumerable recipes available, all of which insist that they constitute the perfect loaf of French bread. I’m not sure that my recipe is perfect but I can say that it has worked for me consistently where others have failed. I don’t have pictures for this recipe, but in the future I’ll try to provide some visual aids.

Shark Eyes' Perfect French Bread

-4 cups white flour (You can substitute as much as half with wheat flour if you would like)

-1 tbs. salt

-1.5 cups water (warm but not uncomfortably hot to touch)

-1.75 tbs. active dry yeast

-a pinch of sugar

Add sugar and yeast to water and mix in a large bowl. Let sit for about 10 minutes until the yeast activates and bubbles on top of the water. Mix salt into 3 cups of four and slowly add to the yeast mixture, constantly stirring, to incorporate the flour. Once the first 3 cups of flour are added, cover and let sit for about a half hour.

Uncover and add the last cup of flour (1/4 cup at a time) and mix with your hands until it forms a soft dough. It may only take ¾ of a cup but that is okay. Pull your dough ball out of the bowl and knead for 5 minutes on a clean floured surface then let it rest for about 7 minutes (use that time to wash and dry the mixing bowl and coat it with olive oil) and then knead for 5 more minutes. Form the dough into a ball and put it into the oiled bowl. Roll the ball around and make sure to coat it on all sides with the oil. Cover the bowl with a damp towel and let rise in a warm place for at least an hour and a half and until the dough at least doubles in size (often times I’ll let the dough rise for up to three hours and it fills a rather large mixing bowl).

Once the dough has risen, punch it down in the bowl then bring it back out onto your flowered work surface. Knead for a few more minutes. Cut the dough in half and make them into balls again. This recipe will make to large baguettes so I usually save one half in a plastic bag, in the refrigerator (it will last at least 4 or 5 days and it makes really good pizza dough). Let the dough that you are using sit for a few minutes longer then, with a rolling pin make the dough into something that resembles a rectangle that is about 8” by 12”. It might look more like an oval and that is okay. The key is that it is fairly even. Next, tightly roll the dough in on itself so that it is starting to look like a loaf of bread. Pinch the dough along the seam to seal then, with the seal facing up, pull the dough from the bottom on both ends up and incorporate it into the seam. This process is difficult to describe and I am making it sound more complicated than it is. The objective is to seal up the loaf so that there are no holes. Use your common sense and it will be fine.

Now prepare a baking sheet. The best way to do this is to use a high sided baking sheet upside-down. Oil the bottom of the pan and, if you have it, sprinkle some corn meal on. Then lay your loaf out on the pan seam side down. Let it sit and rise a bit more while you ready the oven.

Set the racks in your oven so that one rack is near the bottom and the other is in the middle/top. On the bottom rack put an oven-proof dish with water in it. This will create steam which will help make your bread nice and crispy. Turn the oven on to bake at 450 degrees. Once your bread is about the size you want it to be, make perpendicular slits along the top of the bread every couple inches along its entire length. Brush the top of the bread liberally with water and put it into the oven on the upper rack and bake for 15 or 20 minutes. It is ready when the loaf looks golden brown and delicious.

So that is the recipe. It looks more daunting than it actually is. Try it once and you will realize that it is well worth the effort. It is a fun thing to do on a lazy Sunday, especially if you are hung over. Focusing on the recipe will help keep your mind off of that sick feeling and the finished product, along with some hot soup, will help to sop up the alcohol lingering in your stomach.

The Socialist Plot Thickens!

The Greek Socialist party has won the Greek national elections, unseating the conservative New Democracy party. Socialist leader George Papandreou lead his party to victory by advocating a $4.5 billion stimulus package and cracking down on tax-evaders, a crime which costs Greece roughly $30 billion annually.

Sound like anyone you know?

Obviously Papandreou is taking his socialist marching orders directly from the the Obama White House, as evidenced by this press release from the Greek Embassy earlier this year... Soon the entire Medditeranean region will be littered with universal health care, free education, and Nazis. Yes, Nazis. Thank god American conservatives have enlightened us all in revealing that Obama is both a socialist AND the next Hitler. Because Hitler was a socialist... and that makes total sense.

On a totally unrelated note, I remembered reading about this study that conluded that conservatives are more biologically inclined towards fear. Food for thought.

Thus concludes my Sunday Sarcasm post. Thank you Steve Smith #2 for scoring me 24 points in my fantasy league today. I'm officially making a motion that Steve Smith of the Panthers be relegated to #2, and you promoted to #1.

Grad School is Busy

Some quick notes since its been a heavy schoolwork week here at Berkeley...

• I had to finally present my 40-minute research project on potential infectious causes of autism. My verdict: autism is caused by a genetic predisposition triggered by a prenatal environmental insult, most likely a range of infections including congenital rubella, herpes virus, mycobacteria, and lyme disease.
• Principles of Infectious Disease midterm in T-Minus 2 hours, 25 minutes... Did you know that our centralized, industrialized food industry is contributing greatly to diseases such as E. coli, salmonella, and so on? Not to mention all the hormones and antibiotics they use to fatten up our animals contributing to antibiotic resistance. Here's a sweet article from the NYT that shows the intrinsic link between the health insurance industry and food industry and how its all going to get flipped on its head soon. Thank you Ryan Marriott.
  
• Early epidemiological studies in Canada (British Columbia to be precise) indicate a marked increase of H1N1 infections in those who have received the seasonal influenza vaccine. Canada may well be halting all seasonal vaccinations for those under 65 years of age. Read more about it on ProMed.
  
• Speaking of the flu, did you know that Single Malt Scotch is one of the best mediums for protection against the flu? I should have known. Check it out yourself. Thanks Kate Corvese.
• The healthcare debate rages on... yesterday the Senate Finance Committee rejected two amendments to Max Baucus' bill that would have included a public option. The first, introduced by John Rockefeller IV of West Virginia was shot down by the entire cohort of Republicans on the committee, plus 5 Democrats. The second, more palatable (to conservatives at least) option was introduced by Charles Schumer of New York, and was also defeated by the Republicans with the help of 3 Democrats. Let's take a moment out of our busy day to thank the following Democrats for killing the public option that they have all previously publicly endorsed: Max Baucus of Montana, Kent Conrad of North Dakota, and Blanche Lincoln of Arkansas voted against both bills. Thomas Carper of Delaware and Bill Nelson of Florida voted down Rockefeller's but supported Schumer's.
  
• Harry Reid and Chuck Schumer today scrambled to say they would push a public option, though likely watered down, to the full senate. Such a watered down version could resemble a proposal by Olympia Snow (R) of Maine, where a public option would kick in only in states where private insurance is deemed unaffordable. Said Schumer, "there is not one way to Rome, there are lots of ways to Rome." Someone please tell Chuck we're not trying to get to Rome, we're trying to get to the doctor's office.
• Speaking of health care reform: UC Berkeley students, tonight at 6pm, in Boalt Hall there will be a panel discussion among three professors regarding the issue. William Dow (former health economics advisor to W), Helen Halpin (current health care advisor to Obama), and Steve Shortell (Dean of the School of Public Health, health care policy specialist) will debate the merits of all the current proposals. Should be balanced and informative ('What does that mean?' you ask... yes I've almost forgotten as well).
  

Protests!

The Huffington Post had a special featuring the funniest protest signs from this year. This one obviously takes the cake... the rest can be seen here and are well worth your time.

Speaking of protests, I made my way over Sproul Plaza on the UC Berkeley campus today for a rally protesting budget cuts, layoffs, furloughs, and tuition increases to the UC system... While I expected a few hundred protesters, it turns out the police estimated that there were about 5,000 union workers, staff, faculty, and students there. Many professors cancelled class and hundreds of students staged walkouts in solidarity with the striking unions.

The rally began noon and by 2pm the crowd had begun marching through the UC Berkeley campus, eventually making its way to Addison & Shattuck, where it stalled traffic for roughly 30 minutes before moving back up to Bancroft & Telegraph where it held a sit-in for a good portion of the afternoon. As of 8:30pm organizers had occupied Wheeler Hall and chained the doors shut as they contemplate their next moves.

Newsworthy coverage of the event can be found here and here. The website for the protest organizers can be found here. The website for UC President and budget-cut extraodinaire Mark Yudof can be found here.

Below are pictures from the rally at Upper Sproul Plaza and the march through campus taken from my mediocre camera-phone...

Thursday Morning Charlie Foxtrot: Kerry is French, Obama Claims Presidency of the World

Is it just me or has all that 2004 campaign hooplah about John Kerry being a Francophile finally come true? That look on Kerry's face is priceless: bored, smirky, and pompous. Slap a beret on his head and a cigarette holder in his mouth and he could run for mayor of Paris.

Obama addressed the U.N. General Assembly this week, stating "... We have also re-engaged the United Nations, we have paid our bills, we have joined the human rights council... and we address our priorities through this institution." He went on this week to secure a commitment from Russia for possible sanctions on Iran if they fail to make progress in October 1st negotiations regarding thier nuclear program, chaired a UN Security Council session during which a measure strengthening nuclear nonproliferation was unanimously passed, continued to goad the Israelis and Palestinians towards restarting the stalled peace process, and now he'll be running off to the G-20 summitt being hosted in Pittsburgh.

You'd think getting poor people some health care in the richest country in the world be easy after that... But I guess when the opposition is claiming that gay marriage is a path towards socialism and that Playboy makes men gay then I guess you've got your work cut out for you.

At least all the articles lauding Glenn Beck as the most influential lunatic in the country have started to subside....

Get Your Flu Shot!

In the course of researching potential infectious etiologies of autism, in conjunction with being enrolled in the Infectious Disease & Vaccinology division of Berkeley's School of Public Health, I've learned quite a bit about vaccines in a relatively short time. While I won't be developing any vaccine patents yet (or ever), I can dispel some myths and put forth a quick primer on vaccines for anyone that actually cares...

The two myths I hate: (1) vaccines (particularly MMR vaccine) can cause autism, and (2) getting your seasonal flu shot can actually give you the flu.

(1) Autism is a complex phenomenon for which the etiology (cause) has yet to be identified. It is likely a combination of genetic predisposition triggered by certain environmental factors, possibly certain viral infections while the child is in utero. In 1998 a British study was put forth hypothesizing a link between Measles, Mumps, and Rubella vaccine (MMR). In an article published this year by Jeffery Gerber and Paul Offit of the Infectious Disease Division at Philadelphia Children's Hospital, titled Vaccines & Autism: A Tale of Shifting Hypotheses, Gerber and Offit thoroughly point out the many flaws in the original British study. Their article goes further in citing numerous studies which have found no link between autism and vaccines, as shown in the table below...

Put very simply, the erroneous link between austim and MMR vaccine is due to timing. Most children are vaccinated for MMR at roughly the same time that parents first notice symptoms of the disease (between 1-2 years) and the vaccine thus becomes an easy target for blame. Gerber and Offit go on to dispel the myths concerning thimerasol (an eythlmercury additive in some vaccines) and 'too many vaccines for children' causing autism in an equally convincing manner.

(2) Seasonal influenza vaccines can come in two forms: a trivalent (3 strains of flu), killed-vaccine and an orally administered attenuated vaccine.

• Trivalent killed vaccine comes in the form of an injection and contains killed flu virus elements from three strains (H3N2, seasonal H1N1, and B) which helps the body to produce antibodies to fight these strains if encountered. A killed vaccine cannot make a person sick with the flu. You have an equal chance of being killed by a dead person (yes, I know, what about zombie attack? I'll discuss that in another post).
  
• An attenuated vaccine is one where the virus has been weakened, but not killed. Attenuated vaccine for influenza is administered via an oral mist. It is possible, however unlikely, to get sick from an attenuated vaccine. As such, attenuated vaccines are not administered to children under 2, adults over 50, or to the immuno-compromised. For those to whom it can be administered, it most often provides a more robust immunological response, meaning better protection.
  

Do note that while your flu shot cannot make you sick with influenza, there is the possibility for side effects, depending on how the individual reacts to injections in general (redness, soreness, swelling at the point of injection) and in the case of certain allergies (flu vaccines are grown in chicken eggs). What everyone must consider is the fact that most people receive their flu shot between late September and mid-October, a period when a host of other respiratory ailments (such as the common cold) are beginning their high rate of circulation in the northern hemisphere. Much like autism and MMR, the percentage of individuals coming down with a respiratory ailment that is not actually influenza in the period immediately following vaccination is high enough to allow for this misconception to perpetuate.

So... get your shots.

*H1N1 vaccine will be discussed in the coming week(s)

A Manifesto on Marketplace Balance [Doesn't That Sound Thrilling?]

This is a response to a recent Op-Ed in the Wall Street Journal sent to me by a friend, along with a quote from a political science professor he once had that stated, "the number one goal of ANY bureaucracy is NOT to achieve it's goal but rather to perpetuate itself and grow." I ended up getting a bit carried away in my thoughts on the subject. Greg states that his life experience certainly validates this claim, and I think few in this country would be willing to take issue with that remark. Still, I think it provides an excellent framework to view the health care debate through in hopes of finding some reasonable middle ground, which sadly is some very scarce real estate right now...

I would agree with the notion that once created, bureaucracies, like any other organization (or organism for that matter) have a goal of sustaining themselves, and in many cases, growing. However, I would argue the point that none truly seek to achieve their goal. Do I feel that the people at the DMV are sitting there saying to themselves, "We must get these registrations processed! How dare these people be forced to wait!" - certainly not. But in institutions where there is a moral imperative (health care, for instance) I would say there is a great deal of passion for the work at hand. Having worked in such a bureaucracy at the Rhode Island Dept. of Health, I can say with firsthand experience that from top to bottom, most (certainly not all, but I what organization could claim this?) of the folks that I have had the pleasure of working with are passionate about what they do.

While I see a danger is bureaucracies growing without check, I also see a danger in the large corporations dominating our country growing without check. Were all insurers local, small businesses (or even regional, there is a certain economy of scale necessary in such a business) I would see less of a need for government to balance the odds. But when corporations grow to the extent where they dominate markets, and become their own private bureaucracies where people are just numbers and dollar signs (I'm not saying it would be any different for a government plan) I see the need for the government to offset this imbalance. Corporate dominance is just as, if not more frightening to me than big government. I have witnessed its effects very acutely in the last few years. The notion of a free-market America where entrepreneurs can flourish and passion and ideas abound is under serious threat from big business in this country. Corporate influence in Washington has exploded since the late 1970's and has reached a fever pitch in the last few years. Our country cannot expand into new industries and technologies because lobbyists block legislation required to make those new industries competitive (solar panel production comes to mind). When new ideas do break through, they're bought out and added to these companies portfolios to increase their market price.

The true America, the independent America, middle-class America is being choked and squeezed for all its worth by a multitude of corporations, and the government in turn responds in its typical manner of expansion and regulation. This game has been played throughout history, but only this decade on such a grand scale.

My liberal leaning acknowledged, in the wake of a catastrophic financial collapse brought on by deregulation, my trust is won only marginally by a public option for health care. In my mind, while concern over government expansion is legitimate, the government nevertheless still answers to us, the voters. Corporations answer only to shareholders, whose primary interest is only profit.

There is a classic and historic concern for checks and balances in government, but we have reached a point where government must weigh as a balance to business. I do not support the one-sidedness of a single-payer, fully-nationalized system such as the British NHS, rather a system more modeled on that of France, but with greater market freedoms that will ensure the U.S. can continue to do what it does best, namely advancing the use of medical technology. Yes, France, that friend that everyone loves to hate. The inspiration for 'Freedom Fries' and other Euro-phobic nonsense. Their health care system is arguably the best in the world. Does this mean we should mimic it? Certainly not, but I feel that we can take a cue from our brie-eating friends across the pond and adapt their system to meet our needs.

Despite the constant fear of a 'government takeover', this takeover would impinge upon only an estimated 5% of the current 'corporate takeover' that we now enjoy. The public option is just that, an option. The key is balance, because in the escalating battle between big business and big government, my biggest fear is either one declaring victory.

Facemask, please...

Yesterday Newsweek dared to challenge conventional wisdom by publishing an article that called into question the effectiveness of hand-washing in regards to reducing the spread of influenza, including H1N1. Blasphemy!

Maybe not...

This debate is one that has been ongoing here at UC Berkeley. Just a couple of days ago I tweeted a NYT article citing a study performed here claiming quite the contrary.

The primary impetus behind Newsweek's article is Dr. Art Reingold (my epidemiology professor this semester). Dr. Reingold has not only worked at the CDC and is now chairing Berkeley's epidemiology department, but is involved in the Center for Global Public Health here on campus, the Center for Infectious Disease and Emergency Readiness, and the California Emerging Infections Program (Co-Director). He argues that there is no substantive evidence to prove that humans can become infected with influenza from microbes on their hands, rather, he argues that infection primarily results from inhaled microbes.

There is much evidence to link hand sanitation with prevention of rhinovirus (common cold), certain respiratory ailments, and many gastrointestinal infections, but Dr. Reingold is correct in his assertion that there is no evidence to link it with flu prevention. Much of the CDC's recommendations are based on 'general' respiratory infection guidelines.

Hand-washing is certainly an important public health practice, and fear of H1N1 acting as a motivator (however dubious) for the public to wash their hands more often can be a good thing. The concern however lies in the fact that with health departments nationwide prescribing hand hygiene as a primary barrier to flu infection, other more effective measures, such as facemasks, will be underutilized, if not ignored.

For my part, I've got a stash of 3M N95 respirators in my first aid kit, and I certainly won't hesitate to use them. [Don't get suckered into buying them for $500.00 on ebay, they're cheap, and not that scarce]

I'm still washing my hands though.

[Eduardo the H1N1 mascot working alongside me in the RI Dept of Health's 'Operations Center']

This is Why We Vaccinate...

No I didn't steal this image 28 Days Later, that's Al Davis, owner and general manager for the Oakland Raiders, my neighborhood pro football team.

As I embark on a research project exploring potential infectious etiologies of Autism and am thus forced to wade through articles advocating the now-thoroughly debunked notion that vaccinating children leads to this heartbreaking disorder, I would like to remind everyone to get your shots.

If you don't believe me, see what Dr. Paul Offit has to say...

My point being, you don't want your children to end up looking like Mr. Davis up there, who despite being wealthy enough to own a pro sports team, still looks like he just crawled out of the grave and may drag you back there with him. Get your vaccinations!

H1N1: Antiviral Resistance, Vaccine Supply Doubles

Two of the latest ProMED reports to reach my inbox (V2009 #425 & #427) have brought to light two potentially serious concerns relating to the current H1N1 influenza pandemic now sweeping across college campuses in United States.

The first report confirms what many doctors have been seeing for months, in that according to a study published by the journal Nature Biotechnology, laboratory tests have confirmed that, "Seasonal strains of flu attach themselves almost exclusively to cells found in the nose, throat and upper airway, producing some of influenza's signature symptoms: a runny nose, scratchy throat and a dry cough. But the research shows that [influenza pandemic (H1N1) 2009 virus] -- by sticking to a greater range of receptors -- can also reach cells deep in the lungs."

Essentially what this is saying is that the potential for serious complications from H1N1 are much greater than from seasonal flu. Those persons who are identified as among the top risk groups (pregnant women, infants and small children, individuals who are immuno-compromised) should take care to avoid exposure at all costs. Even for those with healthy immune systems, H1N1 promises to bring you a week filled with cough, sore throat, and fever... it really will knock you on your ass. As thoughtful human beings, anyone who suspects they are infected should stay home for the week to reduce the spread of the disease.

Perhaps an even more worrying report comes this week from a summer camp in North Carolina, where two out several hundred campers and camp staff being given chemoprophylaxis (antiviral medication) to help treat H1N1 clearly displayed signs that strains of the virus are developing resistance to oseltamivir, one of the two most commonly used antivirals used to treat influenza. Oseltamivir is sold under the brand name Tamiflu. The virus is still shown to be susceptible to the other common antiviral drug, zanavimir (Relenza). The full report can be access via CDC's Mobidity & Mortaility Weekly Report.

A quick rundown on antivirals vs. vaccines...

Tamiflu and Relenza are two of the most common and effective antiviral drugs used to combat influenza, and stockpiles of both are common in doctors offices, hospitals, and state and federal warehouses (I have personally stocked more boxes of these medications than I could ever count - thanks CDC). These medications do not cure the flu, rather they enhance the body's immune response to the virus, hopefully making symptoms less severe, and reducing the overall time of infection. Antivirals can be taken in advance of expected exposure or soon after suspected infection.

These antivirals stand in contrast to vaccines (of which there are several for other strains of flu) that are currently being developed to protect the population against H1N1. Without going into too much detail, the production process for an H1N1 vaccine, while being implemented rather rapidly, is nevertheless complicated by the need to simultaneously produce and administer seasonal influenza vaccine. Seasonal influenza vaccine production has more or less been completed, and the public can expect to see seasonal influenza vaccination clinics by the end of this month. H1N1 vaccine will likely not be widely available until mid-to-late October (which may miss the virus' peak), but as some have suspected, it is now being reported that protection from H1N1 can be achieved through one shot, rather than two, essentially doubling the vaccine supply.

The best advice remains the tried and true advice being repeated by public health practictioners for the past several months: cough into your elbow, wash your hands frequently, and stay home if you're sick. It's not the magic bullet that the public wants, but these practices can make the most difference in rates of infection.

This is Berkeley...

A brief photo tour of my new home, Berkeley, CA...

Berkeley Bowl... no its not a bowling alley. Its a grocery store and their produce section (as you can see) is enormous. Having dirt cheap produce only 4 blocks from my house gets two thumbs up.

Cal has a football team. And a 72,000 person stadium. And a Heisman contender (Jahvid Best). Oh, and they're No. 10 in the country right now. I got season tickets.

It took me a few days to realize what the sign I often lock my bike to actually meant... 'NL' stands for Nobel Laureate, and yes, there are multiple parking spots.

Speaking of bikes, trying to find a spot at a bike rack here is like trying to find a place to park your car at on the URI campus, meaning if its past 10am, forget about finding anything convenient.

Sunset over the Pacific, taken from Highway 1 on the ride back from Santa Cruz...

Stressed?

No Rep. Joe Wilson of South Carolina, you lie... Get your facts straight.

Thumbs up Obama, way to chide all of Congress in their own house, in prime time. Here's a few of my favorite lines, before things blow up in the media tomorrow and the debate quickly clouded again...

"I am not the first president to take up this cause, but I am determined to be the last!"

[Referring to people losing health care coverage] "That is heartbreaking, it is wrong, and no one should be treated that way in the United States of America."

"Our health care problem is our deficit problem... nothing else even comes close."

"The time for bickering is over, the time for games has passed. Now is the season for action. Now is when we must bring the best ideas of both parties together and show the American people that we can still do what we were sent here to do. Now is the time to deliver on health care!"

"But know this: I will not waste time with those who have made the calculation that it's better politics to kill this plan than to improve it. I won't stand by while the special interests use the same old tactics to keep things exactly the way they are. If you misrepresent what's in this plan, we will call you out. And I will not... And I will not accept the status quo as a solution. Not this time; not now."

See the full text of Obama's speech...


**Sidenote: Prime time on the West Coast is strange, watching that speech at 5pm... Not looking forward to NFL games at 10am.

Health Care Reform: The Breakdown

So, its been pointed out to me recently that less than a year ago 70% of Americans favored a public option for health care... my oh my, how a worthless media establishment, pissy obstructionist Republicans, corporate-beholden Blue Dog Democrats, pushy liberal-zealot Democrats, and a President that thought he could get these fools to compromise have shifted the debate so far from where it should be is just downright depressing. And the insurance companies and their shareholders are laughing all the way to the bank.

WAKE UP AMERICA!

If you do not favor health care reform I really want to know why. I can fathom people's arguments about not wanting a public option, I may not agree, but there are arguments against it that are based in logic (mentioning the establishment of death panels or a mysterious government bureaucrat getting between you and your doctor discounts any logic you think your argument might have). Death panels? Seriously? And anyone with private insurance who gets to spend good quality time with their doctor, I assure you, you are a rarity. Most people go through doctor's offices like they were in line at the deli. Health care reform is much bigger than a public option. Sure thats a big component of what some would like to see pass, but there's a lot more that will have a huge impact on the current system.

I'm looking forward to Obama's speech (in ~20 minutes) tonight because I hope that he'll be able to use his deft ability to orate to clear the air and put this debate back on track. Key word here being 'debate'. Senator Mitch McConnell's (R-KY) proposal to 'skinny this thing down' (referring to the large text of the legislation currently proposed) and Rep. John Boehner's (R-OH) assertion that “It appears that the president is going to double down tonight and try to put lipstick on this pig and call it something else," do nothing to contribute to debate... and these are the Senate and House minority leaders! If Republicans are so adamnt about killing this legislation, I'd like to see what they propose instead, because if they're ok with the status quo, there's something terribly wrong.

As many (including an article in the New York Times today) have argued, if Republicans shifted from being simply obstructionist (with the exception of a few, thanks Olympia Snowe!) to actually showing a willingness to compromise, they could actually get some of their proposals into legislation, and it would give Obama leverage against the more liberal members of the Democratic Party, who at this point, are Obama's only hope to get anything passed.

Seems like a no-brainer to me... deny liberal Dems their communist agenda AND have a say in what has the potential to be one of the most historic pieces of legislation of a generation? Come out and play Republicans!

Never thought I'd be saying that...

I was going to break down all the different elements of proposed legislation, but I think that will be better done tomorrow once the air clears and we see where things really stand in this debate.

A Preamble to the Healthcare Debate

I've got big plans to break down current proposed health care reform legislation and make it palatable to the average American, who would rather not wade through hundreds of pages of legalese... this, however, is still in the works. But I did want to set the stage for discussion on health care by bringing up a point that I feel is lost in the current debate taking place. Keep in mind that this is a moral argument, not a practical one.

Can we all step back a moment and look at our health care system with fresh eyes? I think that everyone - Democrat, Republican, independent, and apathetic alike - can manage this, but it truly does take a stretching of the imagination. It is exceedingly difficult to detach oneself from the constant media onslaught (both wanted and unwanted) that penetrates the psyche via television, newspapers, Facebook, Twitter, and is then recycled via word-of-mouth.

But imagine that you had no preconceptions of how health care in this country should function... how would you set it up? Now, we don't live in a moralistic society, though some would like to pretend we do when it suits their political purposes (more on that later). So let us be practical in our aspirations for establishing our brand-new, first-ever health care system. Lets go with the assumption that at least a slight majority of Americans don't really trust the government (I think that's a safe bet) and that being a capitalistic, free-market economy, we're more comfortable with creating some private health insurance companies... Done.

These companies need workers, they have overhead to pay, and of course, they have to pay the medical bills for all their consumers. They hire some brilliant mathematicians and actuaries and find out what they need to charge their customers to stay financially viable. Sounds pretty reasonable to establish rates that will bring in at least a bit of profit.

So why is it that health insurance companies have, on average, increased premiums by 87% in the past six years, while profits from the 10 largest publicly-traded companies has risen 428% between 2000 and 2007. Why have the over 400 corporate mergers involving health insurance companies in the past 13 years, that have resulted in 94% of insurance markets becoming highly-concentrated (re: near monopoly), according to the American Medical Association, been allowed to take place? Mergers resulting in an anti-competitive marketplace where companies can thrive and shareholders can demand that profits continue to increase doesn't sound like free-market America.

So I ask, why is it that we allow insurance companies to be publicly traded at all? Stepping back to our newly-created health insurance company scenario, why can't this company function at a level where it earns steady, moderate profits? Why do we have to introduce investors to an industry that has the power decide between life and death? Why do we resist reforming a system that is set up to reward those who deny medical coverage to sick people? Shareholders in any company want to see employees cut costs and increase profits... cutting costs in the health insurance industry means killing human beings. Perhaps that seems like a harsh statement, but perhaps most of the people working at these companies are too far removed to truly grasp the consequences of their actions... Wendell Potter would agree.

An estimated 18,000 people die every year because they do not have health insurance. And while that may not be the cause of death listed on their death certificate, it is certainly the reason. Living without health insurance is the socio-economic equivalent of living with the AIDS virus. No one dies of AIDS, they die because AIDS has so utterly destroyed their immune system that opportunistic infections, be they pneumonia, tuberculosis, any other number of ailments can kill them almost instantly. People without health insurance are some of the most vulnerable. When you know a simple visit to the dentist for a toothache, or a trip to the ER to have a dislocated shoulder properly set, is far beyond your means, you simply don't go.

This is why our health care system is as costly as it is. Anyone working in the health care field (and most people with a little common sense) will agree that preventative care is the cheapest, most efficient way to keep our country healthy. When 46 million people don't have that option, things get awfully expensive.

Its A Small World After All

So I've started this blog... My original idea was to write about what I was up to out here in Berkeley, CA so all my East Coast friends and family could keep track of my exploits (and hoping that I would be able to keep from having to repeat the same stories over and over). Before I even started writing though, I realized that as a topic, my day-to-day life in Berkeley is going to be a pretty boring read, and probably even more dreadful to write about. So I'm going to refrain from chronicling my life out here.

There will be a sampling of life in Berkeley and my adjustment to the West Coast, but I'm going to stick mostly to public health issues, two of the hot items right now being H1N1 (one of the few things I can call myself an expert on) and health care reform (currently honing my expertise).

This first post will refrain from health issues to make one point: despite being a tiny dysfunctional speck of planet earth, Rhode Island seems to reach even the West Coast with relative ease, I'll explain...



Instance 1: My thankfully uneventful plane trip was made at least slightly interesting by the commonalities I discovered between myself and the middle-aged couple sitting to my right on board our Boeing 757 from Boston to San Francisco. Carol happened to ask if I was 'coming or going', I replied that I was going... for quite some time... and explained how I was starting an MPH degree at UC Berkeley. Upon hearing that I attended URI, Carol and her husband Neil inquired if I knew Professor Manchester... "well there is no professor Manchester at URI [to my knowledge] but I know a Margaret Manchester that teaches at Providence College," I replied, "and she happens to be a close family friend." 'Yes, thats it! We know the Frees... I teach with Scott at Berkley [School of Music]' replied Neil. The Frees lived next-door to the Manchesters for years as I was growing up in Barrington, RI, and both families were close friends of my own family, as most of us kids were around the same age. The Olmsteads (Neil and Carol) had been to the same beach houses in the summer and met many of the same folks I knew as I was growing up. I hope they enjoyed their vacation in San Francisco.

Instance 2: After arriving in Berkeley and moving into my apartment on Tuesday (Aug 18th), my roommates and I split up to hit all the yard sales in Berkeley that Saturday. Alex and I took his Subaru wagon around south Berkeley, while Bobby and Doug took the north. After getting a 'New England Discount' on a set of chairs for our dining room from a woman wearing a UMass sweatshirt (Alex is from Western Mass), our second stop was looking much less interesting. We did however find a functioning iron for $1, so I we happily made the purchase from the couple staffing the yard sale. When they inquired where we were from (I think my Rhode Island Ultimate sweatshirt gave it away) and I responded with 'Rhode Island'. They happily informed me that they too, were both from the Ocean State. Upon further discussion I found that Janet had worked as an RN at Rhode Island Hospital for quite some time (and of course knew a couple colleagues of mine at the RI Dept of Health) and was now the immunization coordinator for the city of Berkeley. When I informed her of my concentration at Cal in Infectious Disease, and my work on H1N1 back in Rhode Island, she gave me her business card. I'm excited to put it to use.

[Update: I'm currently in conversation with Janet working the logistics of having the Association of Public Health Infectious Disease Students (APHIDS) help staff flu vaccination clinics]

Instance 3: Three days later I was attending the 'Center for Public Health Practice' leadership day prior to the start of class. As they were busy pumping us full of accolades and promises of the many opportunities that lay ahead of us, I asked the other students of the table I was sitting at where they were from... Virginia, California, North Carolina...RHODE ISLAND!? I had certainly expected myself to be the only one at my table (indeed, in the whole auditorium) to be uttering that state name. It turns out the Divya, a 1st year Epidemiology MPH student, graduated from East Greenwich high school the same year that I graduated from Barrington High. She had been my college roommate's square dancing partner in Jr. High, she knew a co-worker of mine from the kayak shop in Wickford, and knew my friend Sushil (now a law student here at Cal) and highschool classmate Nick Bauer from when they attended Brown University. I had wondered if my immediate high-five to her for both being from RI was a little over the top, but apparently she has just as much pride in our tiny state as I do. The only people a bit perplexed were the rest of the students at our table... I guess you don't get quite as excited when you meet someone else from North Carolina.

Instance 4: Last but not least is Andrew, the sandwich shop counter attendant where Divya and I went to get lunch between classes. He happened to comment ('hey, nice shirt') on the Narragansett Little League t-shirt I was wearing, obtained from when Maria worked at their Parks and Recreation department. I was of course confused, because it is not a nice shirt. Seeing my confusion, he explained that he graduated from Narragansett High in 2000. Of course he knew both Toby Johnson and Carris Transue, Narragansett natives whom I worked with at summer camp.

It is indeed a small world. The one-degree-of-separation rule holds strong for Rhode Islanders, even ones transplanted to the West Coast. Every RI native I've met has had more than one mutual aquaintence. I take it as a sign that I'm on the right path...