Discussing health care seriously

In my discussions with people on serious and controversial topics, I have some simple rules of thumb to tell me tell whether the discussion is worth pursuing or whether the other person is not serious and talking further is a waste of time.

For example, when discussing evolution, as soon as someone says something along the lines of Mel Gibson’s “If we descended from monkeys, then how come there are still monkeys? How come apes aren’t people yet?” then you know that you are dealing with someone who is either being willfully dishonest or is so ignorant of the basic facts of the topic under discussion that it is not worth continuing unless one is willing to spend a lot of time to bring that person up to speed. The wrongful use of the second law of thermodynamics is another example of a warning sign.

A similar situation applies to global warming when, during a cold or snowy spell someone triumphantly suggests that this has conclusively proven that global warming is a myth.

In discussing politics, the signal is when one makes a criticism of some action of the US government (such as its decision to ignore habeas corpus, or to invade Iraq, or its numerous covert destabilization actions in other countries) and the other person replies “If you don’t like it, then why don’t you go to Russia/France/China/Cuba/Sweden/(fill in the blank for whatever other country the speaker does not like)?”

In all these cases, the signs are clear that there has been no attempt by the other person to really engage with the issue and he or she has resorted to what he or she thinks is a clever debating point but in actuality has little or no content behind it.

In the case of the debates over the merits of a universal, government run, single-payer health care system, the signal that someone is not serious is when he or she trots out the waiting times for hip replacements in Canada as an argument about how the Canadian system is so terrible in comparison to the US. In the wake of the release of Michael Moore’s film Sicko, we can expect to see this being trotted out repeatedly, as indeed it already has.

As Kevin Drum pointed out a few months ago, the hip replacement argument is a sign of egregious cherry picking of data.

When comparing huge and complex systems like the health care or education systems in different nations, making point-to-point comparisons of isolated cases is of little use. No system is going to be better at every single thing, so this kind of debate results in each side selecting just those pieces of data to suit its purposes. There are probably some elective procedures for which there are longer waiting times in other countries than for those with high quality insurance plans in the US. It would not surprise me in the least if access to tests using expensive equipment like MRI machines is easier in the US (for those who have the requisite insurance coverage, of course) than it is for people in other countries. Health care in the US is aimed at servicing the well-to-do, because it is they who are the decision and policy-makers and as long as they are kept content, they are unlikely to want to make changes that reduce the profits of the health care industry, let alone eliminate them entirely, even if the changes benefit the general public.

One needs to look at aggregate measures to better compare quality and cost across nations. For example, the World Health Organization in 2000 put out The world health report 2000 – Health systems: improving performance in which it used the following measures for the comparison for health systems, using measures of both goodness and fairness:

  1. overall good health (e.g., low infant mortality rates and high disability-adjusted life expectancy);
  2. a fair distribution of good health (e.g., low infant mortality and long life expectancy evenly distributed across population groups);
  3. a high level of overall responsiveness;
  4. a fair distribution of responsiveness across population groups; and
  5. a fair distribution of financing health care (whether the burden of health risks is fairly distributed based on ability to pay, so that everyone is equally protected from the financial risks of illness)

Based on these criteria, according to the WHO study (p. 152), the US comes in at #37 in rank internationally, compared to France (#1), England (#18), Canada (#30), and Cuba (#39).

Michael Moore’s Sicko (which you should really see) points out that on measures like life expectancy at birth and infant mortality rates (i.e., the number of infants who die before reaching the age of one year for each 1,000 births), the US lags behind its developed world counterparts, even though its spends far more on health care as a fraction of its GDP (13.6% in 1998) than its nearest competitor Germany (10.6%). Per capita spending is also highest is the US ($4,178) with the next highest being Switzerland ($2,794).

The reason the US gets so much less for the money it spends on health care is because of the vast amounts siphoned off to the insurance and drug companies, partly due to profits and partly due to a huge bureaucracy to handle the complex billing and processing process involved with private health insurance. Such costs account for between 19.3 and 24.1% of health care spending in the US compared with between 8.4 and 11.1% in (say) Canada.

image001.pngThere is a strong (negative) correlation between infant mortality and life expectancy, as can be seen from this graph, where each dot represents the data for a country, along with a linear regression line. The implication is clear that the best way to improve life expectancy is to reduce infant mortality. The reason that many developing countries have high infant mortality rates and resulting low life expectancy is that lack of access to clean water results in diarrhea and this leads to dehydration, which is often fatal for infants. (As an aside, the international conglomerate Nestle deserves widespread condemnation for its policy of marketing infant formula in the developing countries, despite the lack of easy access to clean water to prevent infection. Breastfeeding is always preferred except in exceptional cases, but because of the Nestle marketing campaign became perceived as inferior to formula.)

But when comparing the US to the rest of the developed world, access to clean water is not the main issue, so widespread access to health care emerges as the prime suspect for its low ranking. For example, infant mortality rates for non-whites in US cities are two to three times as high as the national average.

What really irks many people in the US about Moore’s film is perhaps not so much the adverse comparison with Canada, England and France. People who for some reason are enamored of the system here will complacently trot out once again hip replacement waiting times to claim a spurious superiority. It is the fact that among the 221 countries listed, Cuba’s infant mortality rate (6.04, rank 40) and life expectancy rates (77, rank 56) are almost identical with the US infant mortality (6.37, rank 42) and life expectancy (78, rank 45) that really rankles.

The US government’s implacable animosity to Cuba, trying to strangle its economy with boycotts and embargos and repeated attempts at destabilization and even assassination of its leaders, has to be one of the cruelest policies ever implemented towards a country that is not a threat to its security. And yet despite that deliberate attempt at destroying the Cuban economy, Cuba has managed to create a public health system that is a model for third world countries, and produces results in key indices that are comparable with the US. Cuba is legendary among third world countries in its generosity, sharing its medical personnel and expertise around the world.

Kevin Drum wonders if Moore’s use of Cuba in his film was a clever public relations strategy, knowing that it would trigger the almost reflexive anti-Cuba venom that exists in certain quarters in the US and that they would make a huge fuss, thus giving him free publicity. “Moore’s brilliance at getting his mortal enemies to do all his publicity for him is unparalleled.”

Drum may be right. In the weird media world we live in, it is not enough for Moore to accurately portray the scandal that is the US health system compared to its peer countries. That information has been out there for a long time, and ignored by the power elites. He had to create a fuss and by going to Cuba, he did so.

POST SCRIPT: This Modern World

Cartoonist Tom Tomorrow sums up the predictable responses to Sicko by the apologists for the US health care industry.

Defending the right of free speech and Dennis Kucinich

Since today is a holiday, there will be no original post today. Instead, here are some video clips.

One is of the late Frank Zappa of the group Mothers of Invention on Crossfire talking about the right of free speech.

It is always fun when someone appears on these idiotic talk/yell shows and simply says what he thinks. In this clip from 1986, Zappa drives the person from the Washington Times crazy with his quick-witted defense of free speech and his sardonic sense of humor.

Also, here is an interview of Dennis Kucinich on David Letterman’s show. Kucinich is the only candidate for president who takes the correct stands on the two most fundamental issues facing the US: The Iraq war and the need for single-payer universal health care.

Film review: Sicko

When I was just six years old, I became gravely ill with polio. Although Sri Lanka had first-rate doctors, they felt at that time that they did not have the specialized services to provide the kind of treatment that was best for me and recommended that, if at all possible, my family take me to England. We were not wealthy, just middle class, and did not have the kind of money that would enable my parents to afford this. But by an incredible stroke of luck, my father just happened to work for the Sri Lankan state bank that just happened to have a branch in England. It was the bank’s practice to rotate their officers to that branch and my father was due to go in few years but because of the urgency of my illness, his bosses quickly arranged for him to be immediately transferred to the London branch. As a result we arrived in England and simply by virtue of the fact that we now lived there, I was able to get health care through the British National Health Service.
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The mixed views of candidate Ron Paul

If anyone had any doubts that the US is ruled by a single pro-war, pro-business party, recent Congressional action should dispel them. It is clear that the wheels are already being oiled for starting a war with Iran, and the Democrats are complicit in this pre-war demagoguery, just as they were before the war with Iraq, when many voted for the Iraq war authorization resolution.
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“So, do you support the troops?”

That was the question asked by the perky young female TV news reporter holding the microphone near my face.

I must admit that I was surprised by the question. It seemed like such a non sequitur.

Perhaps I should back up a bit and explain how it got to that point. This happened to me four years ago but I was reminded of it during the recent discussions in congress concerning the supplemental appropriations for funding the war in Iraq when those who opposed it were accused, as usual, of not supporting the troops.

Back in 2003, just before the invasion of Iraq was launched, a group of students, faculty and staff at Case Western Reserve University opposed to the war had been holding weekly public vigils in Cleveland, Ohio. March 5th, 2003 was the day of the worldwide student moratorium against the war and on that bitterly cold, windy, dreary day, we were standing at a busy intersection holding up signs and urging people to honk their horns to show opposition to the war, which many obligingly did. The media news crews were present, looking for sound bites.

My colleague and I were holding a “Not in my name” banner as the reporter and her cameraman approached and asked me why I opposed the war. That was an easy question. Although not too media savvy, I knew enough not to try and give a lengthy, complex, or subtle answer.

“Because I believe a war is justified only in self defense or in the case of imminent threat and neither condition holds with respect to Iraq” I replied.

I waited for the next question, expecting a follow-up, maybe asking for clarification or elaboration or justification or even challenging my assertion. All those would have been natural continuations of the dialogue.

Instead I got the “So, do you support the troops?” question.

I paused. “What do you mean?” I eventually asked, looking into her eyes to see if I could decipher the train of thought that had caused her to ask a question that had little relationship to my response. All my years of teaching has helped me realize that behind the seemingly random questions and comments that a student would sometimes make, there usually lay some complicated but relevant train of that that could, under careful questioning, be brought to the surface. The student and I both learned something from that process of intellectual excavation.

So my question to the TV reporter was the first step in that process of deeper understanding. But she looked blankly at me, as if my question made no sense to her.

It then dawned on me what was going on. This was not the kind of dialogue I was used to with students. She already had in her mind a set of questions that, to her, represented journalism. And in that fixed mental template, to be against the war was to undermine the troops.

Just a little reflection (and comparative analysis) should persuade anyone that this is just plain silly. Suppose that we had been protesting the President’s tax policies. Would anyone think to ask us “So, do you support the government’s accountants?” If we were protesting the government’s welfare policies, would the media ask us “So, do you support the administrators in the welfare departments?” The “Do you support the troops?” question has the same lack of logic. Troops are just the agents that the government uses to implement its war policy. Opposing the policy has nothing to do with one’s attitude towards the agents who have no choice concerning it.

But it is too much to expect the media to appreciate this. They will continue to ask the question and those of us opposed to the slaughter in Iraq had better be prepared to answer it.

So this is the answer that I gave the TV reporter then. “I don’t want the troops to die and I don’t want them to be made into killers in an unjustified war. I would like them to be brought home.”

Is this a good answer? I don’t know. Did it make it into the five-second clip that would be shown on the evening news? I don’t know that either because I long ago gave up watching TV news, especially the local ones. The encounter with the reporter reminded me why.

POST SCRIPT: Ron Paul interviewed by Bill Maher

Rudy Giuliani may have done congressman Ron Paul a big favor when, during the first Republican candidates debate, he tried to bully Paul into withdrawing his statement that the attacks of 9/11 were a consequence of resentment over US foreign policies. As a result of that exchange, Paul has gone from being an obscure congressman to receiving a lot of media attention, most recently being interviewed by Bill Maher.

In this interview, Paul comes across as a soft-spoken, thoughtful, and well-read person who actually knows history. He says that the goal of the US should not be to be loved or hated around the world but to be respected, and that would be achieved if it sets its own house in order by restoring liberties at home and avoiding interfering in other countries.

Is the Republican party ready for such a person as its presidential nominee?

The power pendulum

It has been some time since I wrote about John Rawl’s ideas in his book The Theory of Justice but the more I see how political developments are evolving both in the US and in the world, the greater the value of implementing his ideas.

The key idea that he proposed was that when creating a system or structure for anything, we should work under a ‘veil of ignorance’ in which we do not know which particular individual or group characteristic we ourselves will have once the system is underway. What this insures is that we will try and create a system that is as fair as possible for everyone.
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Presidential candidates Ron Paul and Dennis Kucinich

In the Republican and Democratic primaries, Reps. Ron Paul (R-Texas) and Dennis Kucinich (D-Ohio) are the only ones who opposed the Iraq war authorization act in 2002 and both have been calling for US troops to be withdrawn and closing of the bases.

In the latest debate amongst the Republican presidential candidates on May 16, Paul was asked about his position.

MR. WALLACE: Congressman Paul, you’re one of six House Republicans who back in 2002 voted against authorizing President Bush to use force in Iraq.

REP. PAUL: Right.

MR. WALLACE: Now you say we should pull our troops out. A recent poll found that 77 percent of Republicans disapprove of the idea of setting a timetable for withdrawal. Are you running for the nomination of the wrong party? (Scattered laughter.)

REP. PAUL: But you have to realize that the base of the Republican Party shrunk last year because of the war issue. So that percentage represents less people. If you look at 65 to 70 percent of the American people, they want us out of there. They want the war over.

In 19- — 2002, I offered an amendment to International Relations to declare war, up or down, and it was — nobody voted for the war. And my argument there was, if we want to go to war, and if we should go to war, the Congress should declare it. We don’t go to war like we did in Vietnam and Korea, because the wars never end. And I argued the case and made the point that it would be a quagmire if we go in.

Ronald Reagan in 1983 sent Marines into Lebanon, and he said he would never turn tail and run. A few months later, the Marines were killed, 241 were killed, and the Marines were taken out. And Reagan addressed this subject in his memoirs. And he says, “I said I would never turn tail and run.” He says, “But I never realized the irrationality of Middle Eastern politics,” and he changed his policy there.

We need the courage of a Ronald Reagan.

Later, he took on the myth that the reason for the 9/11 attacks was that “they hate us for our freedoms” and in the a subsequent exchange refused to bow down to Giuliani’s grandstanding on this issue. (You can see the video of that clip here.)

MR. GOLER: Congressman Paul, I believe you are the only man on the stage who opposes the war in Iraq, who would bring the troops home as quickly as — almost immediately, sir. Are you out of step with your party? Is your party out of step with the rest of the world? If either of those is the case, why are you seeking its nomination?

REP. PAUL: Well, I think the party has lost its way, because the conservative wing of the Republican Party always advocated a noninterventionist foreign policy.

Senator Robert Taft didn’t even want to be in NATO. George Bush won the election in the year 2000 campaigning on a humble foreign policy — no nation-building, no policing of the world. Republicans were elected to end the Korean War. The Republicans were elected to end the Vietnam War. There’s a strong tradition of being anti-war in the Republican party. It is the constitutional position. It is the advice of the Founders to follow a non-interventionist foreign policy, stay out of entangling alliances, be friends with countries, negotiate and talk with them and trade with them.

Just think of the tremendous improvement — relationships with Vietnam. We lost 60,000 men. We came home in defeat. Now we go over there and invest in Vietnam. So there’s a lot of merit to the advice of the Founders and following the Constitution.

And my argument is that we shouldn’t go to war so carelessly. (Bell rings.) When we do, the wars don’t end.

MR. GOLER: Congressman, you don’t think that changed with the 9/11 attacks, sir?

REP. PAUL: What changed?

MR. GOLER: The non-interventionist policies.

REP. PAUL: No. Non-intervention was a major contributing factor. Have you ever read the reasons they attacked us? They attack us because we’ve been over there; we’ve been bombing Iraq for 10 years. We’ve been in the Middle East — I think Reagan was right.

We don’t understand the irrationality of Middle Eastern politics. So right now we’re building an embassy in Iraq that’s bigger than the Vatican. We’re building 14 permanent bases. What would we say here if China was doing this in our country or in the Gulf of Mexico? We would be objecting. We need to look at what we do from the perspective of what would happen if somebody else did it to us. (Applause.)

MR. GOLER: Are you suggesting we invited the 9/11 attack, sir?

REP. PAUL: I’m suggesting that we listen to the people who attacked us and the reason they did it, and they are delighted that we’re over there because Osama bin Laden has said, “I am glad you’re over on our sand because we can target you so much easier.” They have already now since that time — (bell rings) — have killed 3,400 of our men, and I don’t think it was necessary.

MR. GIULIANI: Wendell, may I comment on that? That’s really an extraordinary statement. That’s an extraordinary statement, as someone who lived through the attack of September 11, that we invited the attack because we were attacking Iraq. I don’t think I’ve heard that before, and I’ve heard some pretty absurd explanations for September 11th. (Applause, cheers.)

And I would ask the congressman to withdraw that comment and tell us that he didn’t really mean that. (Applause.)

MR. GOLER: Congressman?

REP. PAUL: I believe very sincerely that the CIA is correct when they teach and talk about blowback. When we went into Iran in 1953 and installed the shah, yes, there was blowback. A reaction to that was the taking of our hostages and that persists. And if we ignore that, we ignore that at our own risk. If we think that we can do what we want around the world and not incite hatred, then we have a problem.

They don’t come here to attack us because we’re rich and we’re free. They come and they attack us because we’re over there. I mean, what would we think if we were — if other foreign countries were doing that to us?

Paul is quite right on the facts about the reasons for the attacks. Bin Laden published a fatwa in 1996 outlining his reasons for ‘declaring war’ on America. The pundits were surprised when in an (unscientific) Fox News poll on who won held immediately after the debate, Paul polled second (with 25%) to Romney’s 29%, after having even led at one point.

What was appalling was the enthusiastic response that some in the crowd gave when Giuliani and Sam Brownback and Mitt Romney and Duncan Hunter implicitly but enthusiastically supported torture and the denial of due process.

You can see Dennis Kucinich express his views on Bill Maher’s show and also see former Alaska governor Mike Gravel (also seeking the Democratic nomination) challenge strongly the bipartisan consensus on the war.

There have been rumors that Paul and Gravel may not be invited to future debates. That would be a travesty because it is only people like them who are really challenging the banalities uttered by the so-called leading candidates, since the media has abandoned that role.

How the Iraq war was sold

If you missed the excellent special episode of Bill Moyer’s journal Buying the War: How did the mainstream press get it so wrong? that was broadcast on PBS on Wednesday, April 25, 2007, you can see the 90-minute program online.

I would strongly urge that you watch the program. Those of us who followed the run-up to the war closely will not find any startling new revelations in the program but by assembling the information into one narrative, Moyers shows dramatically how the administration and Congress and the media colluded in misleading the country into the disastrous Iraq war. (See Justin Raimondo’s review of the program which adds useful information.)
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The Virginia Tech tragedy

What was your reaction when you first heard the news of the shootings at Virginia Tech? When someone in my office told me around noon on Monday that about twenty people had been shot dead on that campus, my first reaction was that this was probably another case of someone snapping under the pressure of something or other and setting off on a killing spree.

One thing that did not occur to me, despite the fear-mongering that has gone on under the guise of the so-called ‘war on terror’, was the possibility that this was a terrorist attack. After all, these kinds of killings happen periodically in America, though admittedly this was on a larger scale than usual. Although I checked the internet for news, I have long realized that you should never take seriously the initial news reports that emerge from such chaotic and fast-moving situations.
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Iran and the captured British sailors

One cannot view the reaction of the British and US governments and media to the capture of 15 British naval personnel by Iran without feeling even more cynical about the double standards that are now taken for granted.

It is being simply assumed here that the British government’s claim that their people were not in Iranian waters is true, without any further discussion. Bush, itching for a reason to bomb Iran, has even called them ‘hostages.’ He says this with a straight face even as the fate of five Iranian officials captured by the US January 11, 2007 remain unknown:
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