I’m Glad I don’t Live in the Burbs

My feeling about the burbs, and more so about the gated community, is that it’s where people like me go after they die if they’ve been very, very bad. The burbs are full of people who want to get away from all the problems of the city or escape the wildness of the country. They want everything to be nice. And square. And mowed.

Often when they get behind the gate they discover that their neighbors are not nice. And then they’re stuck. So they have to sue someone or call the cops. This is a pretty extreme case of calling in the authorities…

An 86-year-old man jailed for a week for not mowing high grass or cleaning trash from his yard has gotten help from prison staff hoping to keep him from going to the slammer again.

John Allen was sent to prison after being convicted of violating a Union Township law stating private property must be clear of junk, rubbish, garbage or unruly grass.

Union Township Police Chief Joseph Lombardo said Allen did not heed warnings to clean up his property, which neighbors complained was an eyesore. Allen also refused help from others in the neighborhood and from a group that assists the elderly, Lombardo said.

“I don’t want local people in my house,” Allen told the New Castle News when asked why he had turned down the help of friends and neighbors. “Ordinarily, I wouldn’t let you through the front door.”

I would have let the poor guy alone, I mean, how much longer would he have been a problem? But where the good neighbor policy failed, the prison guards knew what to do…

So, about a dozen corrections officers spent several days this week at the elderly man’s house. Working on their own time, they filled a garbage bin to the brim with old furniture and other household goods. They plan to get to the yard — including mowing the high grass — once the recent snow melts.

Allen, a World War II veteran who worked in the airline industry in California, praised the prison staff for treating him well when he was behind bars and for helping him stay out of more trouble.

So wishing all a Merry Christmas, and that’s my heartwarming story for this year.

Desperately Fighting Big Insurance

Sally Satel’s New York Times story about her search for a kidney donor and her conclusion that we should set up a process for selling organs led to a fascinating debate. (Check out the ‘comments’ section for ‘Desperately Selling a Kidney’.) Ms. Satel never addressed the role of health insurance, or lack of it.

Today’s ABC News brings a story of a young woman who had a matching donor for a liver transplant, had the medical team, and had insurance.

Nataline Sarkisyan, a 17-year-old from Glendale, Calif., died Thursday just a few hours after her insurer, CIGNA HealthCare, approved a procedure it had previously described as “too experimental.”

Nataline’s supporters, including a good number of nurses, took it public, which seems to have influenced the insurance company to change its decision.

Geri Jenkins of the California Nurses Association said the Sarkisyans had insurance, and medical providers felt comfortable performing the medical procedure. In that situation, the insurer should defer to medical experts, she said.

“They have insurance, and there’s no reason that the doctors’ judgment should be overrided by a bean counter sitting there in an insurance office,” Jenkins said.
Doctors at the UCLA Medical Center actually signed a letter urging CIGNA to review its decision.

Whether the delay was the cause of her death will probably be established in court.

In a free market you try to get the best deal, and the seller tries to get the best price. That’s fine when you’re shopping for a pair of shoes. When you’re sick your bargaining power is zip, and making critically ill people fight with insurance is a disgrace.

However, there is no perfect system. I agree with the nurses that the insurer should have let the doctors judge whether the transplant had a chance of success. A girl is dead because CIGNA denied, and then granted coverage when the publicity became an embarrassment. But there is no system we can construct that won’t have to use some form of triage.

Right now we cannot claim that we have a health care system that offers fairness and transparency. It’s a hopeless bureaucratic maze with multiple vendors all trying to make a buck and millions left with inadequate, or no coverage. Denying service brings rewards, promoting health is not a priority. It’s a screwed-up system that steers normally decent people into inhumane, immoral behavior.

Some of the people who oppose universal health insurance warn that we would lose ‘choice’ and that there would be ‘rationing’. Well, there already is rationing, and it’s not done on a fair or medically defensible basis. The Sarkisyan family paid their insurance and thought they had coverage, but found they had no recourse when time was of the essence. Nataline Sarkisyan was not the first and won’t be the last young person to die while we argue about how to make a health care system that works.

The Buck Stops There

I’m only a humble nurse, sitting here in my scrubs, with saggy white support hose on my legs and a cap shaped like a cupcake on my head. It may be presumptuous of me to say anything at all about the Governor’s chain of command. But what the heck…

When you come onto a unit to take charge there is a standard procedure. You and the nurse leaving the unit count the narcotics to be sure every pill is accounted for. Then you get the keys. Then you get a report on what happened to all the patients on the previous shift. The passing of the keys is an almost ritualistic passing of authority and responsibility. Any nurse who walks off shift with the keys in her pocket (it does happen) will be called at home and expected to return them right away. A good nurse doesn’t even leave the unit to eat lunch without passing the keys to another nurse. Everyone knows things can happen unexpectedly.

So why did the Governor leave the unit, I mean state, without informing the Lt. Governor? He did not give her report. He walked out with the keys in his pocket. Here’s from today’s Providence Journal

Although Roberts had pressed Carcieri’s staff to open the emergency operations center — where top officials from various agencies could have worked together and informed the public of their response — she said the governor’s staff turned her down. Gen. Bray also did not want to open the emergency operations center, said spokesman Lt. Col. Denis Riel.

If Donald Carcieri were a nurse he would have been written up.

This would have been his second write-up for the same mistake.

Nearly five years ago, there was another lieutenant governor in that position. When a major winter storm was predicted over President’s Day weekend in 2003, then-Lt. Gov. Charles Fogarty returned from a conference in Washington, D.C. Carcieri, a new governor, remained in Florida.

Fogarty said then-Adjutant Gen. Reginald Centracchio told him that the governor’s staff didn’t want to open the emergency operations center because they didn’t want to panic anyone. Fogarty said he called Carcieri to insist, and the governor agreed. The EOC opened…

After that, Fogarty said, Carcieri rarely told him when he’d be out of the state.

What is Carciei’s problem with handing over the keys? If he were a nurse he would have been expected to take responsibility, but he’s a Governor, so he tossed his emergency management executive director overboard instead…

Robert J. Warren’s firing from the $74,700-a-year job was immediate, according to a terse news release. The governor’s spokesman declined comment.

Maybe the Governor was doing a heckuva job and it was all Robert Warren’s fault, especially since the Governor was far from the scene of the debacle.

Carcieri said he was flying from Kuwait to Afghanistan and probably sleeping as the storm bore down on Rhode Island.

Maybe Warren was a lunkhead and we’ll be better of with Major General Robert T. Bray, the guy who refused to open the emergency operations center when the Lt. Gov. asked him to. But look at this…

Warren had been the first EMA chief with public safety experience in at least 20 years. He had retired as Cranston fire chief after 27 years with the department and 6 as the city’s EMA chief, when he’d been awarded EMA director of the year.

Carcieri tapped him to head the state EMA in August 2005, as Hurricane Katrina devastated the Gulf Coast. Under Warren, the state EMA produced its first hurricane plan within several months, its first statewide evacuation routes, and established an interoperable radio communications system meant to help officials from various state and local agencies communicate in a disaster. Warren restructured the agency, which had been used as a political dumping ground, and he used federal money to hire planners to work with the municipalities to improve their emergency response.

How did a good firefighter go bad? Was it because no one told him where the keys were?

Eventually it will emerge that there were many mistakes and failures among those who should have been responsible, you don’t have this big a mess without plenty of blame to go around. Lt. Governor Elizabeth Roberts has some very commonsense proposals for a meeting on Jan. 22, so let’s see if we come out with this with some organization and accountability, from the top down, so that we keep the state together when a real emergency comes.

Narragansett Spoken Here

I remember the good old days in the hospital. We didn’t have interpreters, we just called Luis in maintenance. Luis was a kindhearted guy who was willing to help out with the Spanish-speaking patients and still get his own work done before his supervisor got all over him. If Luis wasn’t working that night we could always nudge the patient to grab someone from the waiting room to interpret, or else we would talk through their children. This was before the HIPPA privacy act, and you can bet there was nowhere to hide. We were not insensitive, we were just trying to get by. I want to thank Luis, and Faina and Pakyaphet and Celeste and all the other well-meaning people in maintenance who were willing to help, and I want to thank all the people who worked to pass laws that ensure that hospitals provide real interpreters.

I don’t miss the chaotic, confusing, dangerous old days.

When I worked in a community clinic I found myself calling maintenance again, as more and more of our patients were Spanish-speaking. We nurses began to acquire some basic Spanish skills, and thought we were getting by. But we really began to reach our patients when we hired Ana. Ana interpreted Spanish and taught us some of the norms of Dominican culture. She did so much more than just translating. She got to know the patients and the clinic staff, learned the standard procedures, what information needed to be obtained and what every patient needed to know. With one consistent interpreter we were able to build relationships and give better care more efficiently.

Like many small grant-funded programs, the clinic closed, and the patients were referred to a network with more resources, including bilingual staff.

Recently I worked for a home care agency and had a Spanish-speaking patient. She understood some English, studied books, listened to tapes, she really tried. She was far more comfortable in Spanish. My agency sent out a Spanish-speaking nurse’s aid, which was a great help. As the patient and I got to know each other better I felt comfortable falling back on my limited Spanish and my patient’s limited English. As a safeguard, I called the AT&T Language Line at the end of each visit to review what we had discussed.

The Language Line had helpful, courteous staff and was easy to access, but not easy to use. You lose a great deal when you have to communicate through a voice on the phone. I had to think carefully how to word my questions and instructions so that there was no ambiguity. I then had to get the patient to repeat the information through the translator so I knew she understood. It was laborious and time-consuming. The Language Line charges by the minute.

When you need interpreters infrequently, or you need a language that is uncommon, the Language Line is a good option. But when you are going to serve a large number of people who speak the same language it’s much better to have an interpreter, more efficient and less expensive. If you have a member of your team who is full-time and experienced, they do more than translate. They facilitate. They are a mediator between the organization and the client.

Governor Carcieri has laid off three interpreters from the Department of Human Services. He proposes to find private contractors. If he’s planning to use a service like the Language Line it will be very expensive and slower, with more potential for error. If he can get people to come on site, they will not have the familiarity with DHS and its clients that the full-time employees have. We will end up paying more but getting less.

A lot of serious foul-ups in medicine start with miscommunication. It takes longer to straighten out a mess than to get it right the first time. I’m sure that is true in social services and the rest of the universe. If the Governor is trying to make political points by firing interpreters, he is taking apart a system that works and trying to replace it with a less efficient one. If the press lets it go by, the Governor may win with the anti-immigrant crowd, but this budget cut will hurt the people most in need and end up costing the state more money. Remember the brilliant idea of putting 17-year-olds in the adult prison? We’ll be cleaning up that mess for awhile.

Narragansetts excepted, we all came from somewhere else. What Cheer, Netop?

Desperately Selling a Kidney

It was a strange experience reading Sally Satel’s essay, Desperately Seeking a Kidney in last Sunday’s New York Times. The writer, a resident scholar at the conservative think tank, American Enterprise Institute, needed a kidney transplant. She offers her personal narrative, and then some proposals for inducing the poor to sell their bodies in a free market.

Ms. Satel begins with her experience as a woman suddenly faced with a life-threatening illness…

Three days a week, for four debilitating hours at a time, I would be tethered to a blood-cleansing machine. Even simple things like traveling to see friends or to give talks would be limited. This would very likely continue for at least five years until my name crawled to the top of the national list of people waiting for kidneys from the newly deceased. On average, 12 names, the death toll from the ever-growing organ shortage, would be scratched off the list each day.

She is a psychiatrist, working in a methadone clinic, and she knew from her medical training what dialysis involves. She dreaded it so much that she chose not to wait on the transplant list, opting instead to search for a live donor. She writes honestly and unsparingly of her failed negotiations with two friends, then with a man she met online. Finally she received an offer from an acquaintance, Virginia Postrel, a fellow conservative writer, and the transplant was successful.

While Ms. Satel calls the gift she received, ‘altruism’  she has a different definition when applied to people outside her circle.

We must be bold and experiment with offering prospective donors other incentives for giving, not necessarily payment but material reward of some kind– perhaps something as simple as offering donors lifelong Medicare coverage. Or maybe Congress should grant waivers so that states can implement their own creative ways of giving something to donors: tax credits, tuition vouchers or a contribution to a giver’s retirement account.

This is the kinder, gentler version. She is not ignorant of how desperate things can get for the poor in this world…

I flirted with the idea of becoming a ‘transplant tourist’  in Turkey or the Philippines, where I could buy a kidney. Or going to China, where I would have to face the frightful knowledge that my kidney would probably come from an executed prisoner. Grim choices, but I was afraid I could die on dialysis if I didn’t do something to save myself.

In all of this long essay Ms. Satel never wonders what would have happened if she were poor and uninsured. She seems to live in a bubble where the only problem is a lack of donated organs. And she downplays, almost callously, the risk to the donor.

The operation is done by laparoscope, leaving only a modest three-inch scar. She would have been out of the hospital after two or three nights. Most important, the chance of death is tiny–2 in every 10,000 transplants– and the long-term health risks are generally negligible.

This kind of reasoning explains a lot about why conservatives can be persuaded that whatever works for them is just peachy. There is a reason nature gave us two kidneys, a woman with chronic renal failure should be able to figure that out. If you lose one, as did my aunt, to a tumor, or my friend, to a motorcycle accident, you have a spare. And I’m not so casual about the long-term health risks — we haven’t been doing these transplants for all that long. Not to mention the risk of post-surgical infection as antibiotic resistant germs increase. Myself, I would gladly take this risk for love, but god grant I never have to for money.

But back to the kinder, gentler. The mother who sells a kidney so her son can go to college ( no pressure, Sonny), or the eighteen year old who needs cash and feels invincible. Or the man who needs insurance and can’t get accepted on an affordable plan. David Holcberg, of the Ayn Rand Institute puts it a little more frankly. This was printed on the Journal’s editorial page —

A person may reasonably decide, after considering all the relevant facts (including the pain, risk and inconvenience of surgery), that selling an organ is actually in his own best interest. A father, for example, may decide that one of his kidneys is worth selling to pay for the best medical treatment available for his child…

Opponents of a free market in organs argue as well that it would benefit only those who could afford to pay–not necessarily those in most desperate need. This objection should also be rejected. Need does not give anyone the right to damage the lives of other people, by prohibiting a seller from getting the best price for his organ, or a buyer from purchasing an organ to further his life. Those who can afford to buy organs would benefit at no one’s expense but their own. Those unable to pay would still be able to rely on charity, as they do today. And a free market would enhance the ability of charitable organizations to procure organs for them.

Just think, all those deadbeats sitting in the waiting room at Hasbro with their sick kids, they could be persuaded to put out if they want ‘the best medical treatment for their sick child’.

But don’t consider giving free medical care to needy children, or scholarships to hardworking poor students. That would be immoral.

We are really on the edge of a class disparity that is not only about money but blood. We already pay lip service to ‘serving our country’ while dangling cash and scholarships in front of the kids at Central and Hope High. The recruiters know where to go.

No matter how well written, and no matter how much natural sympathy one feels for anyone who goes through a dangerous illness, Sally Satel’s essay is horrible. In countries where desperate people sell their kidneys, you can be sure there will be many who die prematurely when their remaining kidney gives out, and there will be no help for them. I wonder where in the Libertarian scheme of things you put the person who sold a kidney, and now needs one. Do you chalk it up to ‘bad choices’ ? We will be going down a very dark road if we give up the principle of taking care of our own, rich or poor, and instead let the rich use the poor for spare parts.

For another, less temperate, take on this, check out Daily Kos. And yes, I’ve signed a donor card, but they’re not getting them until I’m dead.

Blizzards & Hurricanes

I know I’m not the only Rhode Islander who sat in a traffic jam on Thursday wondering what on earth would happen in a real disaster. If a few inches of snow shut everything down what will happen when the next hurricane hits our coast? Was the Governor was more focused on politics than public safety? He left town without bothering to tell Lt. Governor Elizabeth Roberts he was in Iraq, and he took all the keys with him. It reminds me of the shabby treatment Gov. Kathleen Blanco suffered when she was falsely accused of not declaring a state of emergency prior to Hurricane Katrina. News outlets, including the Providence Journal editorial page (Questions after Katrina 9/8/05 p.B4) repeated that slander and few bothered to print a retraction.

We began to see some of these attacks over the weekend. Sunday’s Washington Post cited an anonymous Bush administration official who explained that one reason that the federal government didn’t intervene more quickly in Louisiana was because Kathleen Blanco, the state’s Democratic governor, failed to declare a state of emergency there, a necessary step for federal help to flow. An article in Newsweek repeats the same claim.

But there’s a problem with the White House’s excuse: It’s patently false. As Josh Marshall points out, Blanco declared a state of emergency on Aug. 26 — a day before Bush declared a federal emergency in Louisiana.

Reading the Journal’s M.Charles Bakst I got a feeling of deja vu.

Roberts groused that Carcieri administration officials rebuffed her offers of assistance and her advice that the state Emergency Operations Center be activated.

She said, “This is New England. We have snow. I understand we can’t control nature. The timing of the storm was difficult. But we should be able to respond to a situation like this more effectively.�

You perhaps thought Carcieri’s Iraq/Kuwait trip made Roberts acting governor. But a 1992 constitutional amendment deleted wording that put the lieutenant governor in charge whenever the number one was out of state. Indeed, Roberts said she hadn’t known Carcieri was going away until she saw news accounts that he was already abroad.

The Lt. Governor is a Democrat, and a woman, and clearly didn’t get invited to the important meetings. Reading Kiersten Marek’s ‘Partisanship Putting Everyone in Danger’ is enough to give you heartburn — especially the absurd excuse that the Lt.Gov. was kept out of the loop for security reasons. Yeah, I feel more secure now that Gov. Carcieri went to Iraq and got his picture taken.

But I’m not interested in watching various officials throw blame around. I just want to see them start working together and come up with a better plan so this doesn’t happen again.

Partisanship Putting Everyone in Danger

There is a very concerning aspect to Carcieri spokesperson Jeff Neal’s comment about why Elizabeth Roberts, the Lieutenant Governor, was not informed that the Governor was going out of the country. According to Ian Donnis’s post on the lack of communication between the Governor and Lieutenant Governor:

Neal said he would have to check with the Department of Defense on the specifics of Carcieri’s Iraq trip, “but my understanding is that we were not permitted to share that information [in advance] outside this office.”

So national security now requires not communicating with your own Lieutenant Governor? This is where we have to really wonder if our national security protocols are actually causing more problems than they are preventing. If this is really true (and I doubt that it is) we are going to have real issues with emergency management, if we are wondering whether every piece of information we share outside of our office is going to go directly into the hands of “the enemy.” Come on, Mr. Neal. The Governor was not supposed to tell “anyone outside his office?” Whatever the rules may be, common sense also needs to be exercised. Shouldn’t the Governor of a state tell his successor when he is going to be out of the country, particularly as he is going into a war zone and may be at risk for being caught in the crossfire?

This is partisanship at its worst. And the results were abundantly clear in the ways the city of Providence and the State of Rhode Island could not respond to the needs of the community by enacting emergency management communication on Thursday.

We are lucky to have gotten a “test-drill” and not an even worse emergency with major power outages. Let’s hope we can learn from Thursday’s experience and improve our communication in this divided state.