Posted on | May 20, 2016 | No Comments
“We are our geography’, as the saying goes. And nothing in current times illustrates this point more dramatically than Donald Trump’s proposed 1000 mile plus wall on our southern border. I won’t dwell on the oft repeated criticisms – the impossible logistics in radically reducing the numbers of 11 million immigrants (when we currently deport a maximum of 400,000 a year); the cost of such deportations pegged at $400 billion over 20 years; the cost of a 40 foot high, 10 foot deep (to avoid tunneling) wall of at least $26 billion, which doesn’t include ongoing maintenance; nor the shear embarrassment of living in a “free country” that chose to embrace such an embarrassing Soviet-style strategy (“Mr. Gorbackev, tear down this wall!”).
No. I will concentrate only on geography, most especially water. You see Mexico and the United States share more than a flow of citizens across our borders. We also share a flow of billions of gallons of water through the Rio Grande and Colorado Rivers, and their tributaries. As it turns out, our long standing treaties, which protect the flow, prohibit any kind of construction that would interfere with this flow – like a wall for example.
How this particular water flows, and who controls its use and distribution, has been a highly disputed issue for well over a century. But to the credit of both the U.S. and Mexico, we have managed to make peace, rather than war, over the sharing of this most vital resource. This has been especially noteworthy in recent years, as global warming induced droughts have decreased the flow. In fact, we just recently spent five years (2007 – 2012) successfully negotiating a treaty with Mexico that defines sharing into the future and agrees to the maintenance of dams, canals and water delivery systems derived from these two rivers.
Ken Salazar, 2012
Interior Secretary Ken Salazar said of the treaty in 2012, that the rivers, “in so many ways, makes us one people, and together we face the risk of reduced supplies in years ahead. More than ever, we are working together in times of drought as well as in times of abundance. We will cooperate to share, store and conserve water as needed.” Quite a different tone than the voice of the current Republican candidate for president, who my 5 year old grand-daughter, Luca, calls “Bob Trumpet”.
Let’s take a quick look at the geography of these two rivers. The Rio Grande (known in Mexico as the Rio Bravo del Norte) is nearly 2000 miles long, arising in the San Juan Mountains of southwest Colorado, and flowing south through New Mexico, a stone’s throw from Albuquerque, then turning southeast, forming the border between Texas and Mexico, bending hard at Big Bend National Park, and emptying into the Gulf of Mexico, in view of Brownsville, Texas and Matamoros, Mexico. Along this watery border, you’ll find many other paired towns like Laredo, Texas, and Nuevo Laredo, Mexico, and El Paso, Texas and Juárez, Mexico. Along the river, there are multiple dams and reservoirs, maintained and regulated by joint agreement, controlling for floods, and scarcity, and supporting vital agricultural needs on both sides of the river. Over four million Americans live and survive thanks to the Rio Grande watershed. The 2012 agreement sweetened the deal for the US, as drought made the prior sharing agreement problematic for our country.
If the Rio Grande joint stewardship is complex, the Colorado River system is monumental. This near 1500 mile waterway connects the Rockies in north central Colorado to the Gulf of California, or at least used to before drought and increased consumption dried up the last 60 miles of the descent. In 1922, we reached an agreement with seven US states and Mexico on the future allocation of the water. The Upper Basin (Wyoming, Colorado, Utah and New Mexico) received roughly 43% of the supply. The Lower Basin (Arizona, California and Nevada) was granted 49%. And Mexico was guaranteed 9%. While the allocations dating back to the 1944 treaty were based on a supply of roughly 21 billion cubic meters of water, 18 billion is the current estimate, with year to year variations of 6 billion to 25 billion.
The river’s behavior, and the storage and distribution of its water, and resultant hydroelectricity, involves the management of 20 major dams, including the 1936 Hoover Dam on the border of Nevada and Arizona, and resultant massive reservoirs like Lake Powell and Lake Mead. Internal water sharing is based on the principle of “useful purposing”, which helps explain why California agricultural fields receive 2/3’s of the supply, while golfing greens in Phoenix, Arizona may go wanting in the future.
The river supplies water to 1 in 8 Americans and irrigation for approximately 15% of all U.S. crops. But it also is a major supplier of municipal water to 17 million Americans in places like Los Angeles, San Diego, Las Vegas, Tucson, and Phoenix. As you might imagine, the management of this expensive and scarce resource is a delicate affair domestically, let alone adding Mexico to the mix. At the top of governance is the U.S. Bureau of Reclamation. But add to this separate state agencies, and then countess regional authorities.
All of which is to say that the 2012 agreement, which represented five complex years of negotiation, and at once acknowledged the need for careful management of an increasingly scarce resource, while committing ourselves and Mexico to a shared peaceful future – at least when it comes to water – strikes a wildly different tone then that bugled repeatedly by “Bob Trumpet”. Stated simply, we need to be building more bridges, and fewer walls.
Posted on | May 13, 2016 | No Comments
Posted on | May 11, 2016 | 2 Comments
From "Drops of Life". Mike Magee
In 2005, in a piece addressing the health of the “planetary patient”, I wrote, “Water – it’s movement, forms, availability, and transportability – has directly shaped and continues to define the future of this planet and all of its inhabitants…As we have grown in numbers and in concentration; as we have built and infiltrated among, and at times, in opposition to other life forms, we have created future health challenges that must now be addressed.”
At the time, I saw water – its scarcity and unequal distribution and inaccessibility – as the most important planetary health issue of the day. I hit the road with a traveling show called “The Drops of Life”, a multimedia program prepared with the help of the Duarte Group which had produced Al Gore’s “An Inconvenient Truth”. What I discovered is that most health professionals considered the issue a low priority. Water was as inconvenient as global warming.
I began focusing on other issues, and “Healthy Waters” lay dormant. Then recently, I was in Syracuse, NY, to talk to 150 PA students of Dept. Chair Mary Springston and faculty at LeMoyne College. I spoke on leadership and change. In the address I touched on the case of three chemical engineering PhD students at Virginia Tech, who, with the support of their professor, uncovered and revealed the Flint, Michigan, poisoning of public waters with lead. Some months later, they published their story, citing the engineering code of ethics which pledges a commitment to societal responsibility, and to protecting individuals above all else.
After the address, over lunch, Dr. Beth Mitchell, the Department Chair of Biological Sciences, asked me what had become of the Healthy Waters movement (the site was down). I explained that I had tried, but there had been little traction. She gently suggested, in the wake of Flint, Michigan, that I might try again.
As I was preparing to relaunch the new site, President Obama visited Flint, just as air filled with smoke and carbon-laden soot was beginning to approach the Midwest from fires in Fort McMurray, in northern Alberta. The juxtaposition nicely illustrates the urgent need for each of us to be better informed on our planetary health and critical issues like water. Let me explain.
By now, we all know that the lead in Flint’s water leached out of ancient pipes, made vulnerable by an engineering mistake. Less known is that 2000 other water systems in the US currently have dangerous lead levels. Cause and effect are clear. The will and resources to rebuild ancient infrastructure is less visible. It seems part of our populace would prefer to build a wall.
The situation in Alberta, Canada, is more convoluted, but inter-connected with planetary health and water as well. A few facts:
1. Alberta, Canada, is part of a heavily forested area in the Northern Hemisphere known as the Boreal (Northern) Forest, a belt of evergreens just below the Arctic Circle which includes Alaska, Canada, Scandinavia and Russia. The forest is made up of mostly resin producing, cone-bearing trees
2. For two decades, scientists have been predicting large scale fires and loss due to drying trees caused by increased temperatures, early snow melt, and secondary insect infestations. Temperature rises are greater in this Northern hemisphere belt than anywhere else on Earth.
3. The Boreal Forest represents 1/3 of all tree cover on Earth, and its capacity to absorb carbon is enormous.
4. In the last three years, both Russia and Alaska have had record breaking forest fires. The fires secondary impact, the deposition of heat absorbing soot onto the Greenland ice sheet, has accelerated the sheet’s disintegration. If we lose it, sea levels will rise 20 feet.
5. These are also heavy mining regions. As with Fort McMurray, mining leads to settlements, and their inhabitants carry an increase risk of accidental forest fires. These outposts generally do not have adequate forest fire fighting equipment or personnel, nor adequate exit plans. In Fort McMurray, 90,000 inhabitants had to be evacuated on a single highway.
Scientists see in the Boreal Forest multiple layers of vulnerability. Loss of the forests eliminates a critical carbon sink, while also acutely releasing large amounts of carbon into the atmosphere. The soot itself can magnify surface warming. The mining interests pollute surface and ground water reserves, while raising the risk of human caused fires, without adequate infrastructure to manage the calamity.
In 2005, in addition to the focus on integrated water cycles, I addressed the Water Crisis, Water and Health, Water and Agriculture, Water and Industry, Water and Energy, Water and Cities, and Natural Water Disasters. My timing was off. Healthy-Waters.org is again live, and “Drops of Life” has been updated. Whether we are ready or not, what recent events dramatically demonstrate, these issues are urgent and demand every citizen’s attention.
Posted on | May 7, 2016 | No Comments
The science was clear in 2007. It hasn’t changed in the decade since. But deniers persist.
Posted on | May 3, 2016 | No Comments
The AMA’s vigorous opposition this week to the FDA’s consideration of mandating training for opioid prescribers to curb the current opioid epidemic (which the AMA’s liberal policies toward specialty designation and pharmaceutical underwriting helped create), called to mind the words in 2009 of Gundersen-Lutheran neonatologist and CEO, Jeff Thompson in an interview with John Iglehart. They said:
IGLEHART: “One thing that has always struck me about physicians, and I suppose I’m particularly sensitive to it having written for a medical journal, the New England Journal of Medicine, for many years, is that physicians are generally leading citizens in the communities where they practice. They are respected, they bring authority and credibility to their tasks as doctors. Yet when physicians have gathered in various collections, whether it’s the American Medical Association or countless other medical organizations, when they gather in Washington and try to harness their authority and respect, it just breaks down, and it mostly breaks down because the issues that they bring to Washington are largely economic and pertain to their incomes. This has always struck me as odd and perhaps presents a challenge for organized medicine to figure out a different model of advocacy that would not only serve their own interests but those of the larger community and society. Do you also see a disconnect here?”
THOMPSON: “That’s a great observation, John. Here’s my answer back to you in a question. Why is it that 85 or 90 percent of pediatricians belong to the American Academy of Pediatrics, but probably less than 15 percent of practicing physicians belong to the American Medical Association?… I have always been a member of the American Academy of Pediatrics for the very reason that you state, because I knew where their priorities were. The AMA by contrast has been so embarrassing at so many times, it’s why at my age and behind me, the percentage of people that have engaged and paid dues has been tiny. Time after time the AMA has screamed about their finances and so they have lost their credibility in Washington and with the public.”
Posted on | April 29, 2016 | 1 Comment
Would you be willing to subject yourself to a 3.3% payroll tax (and your employer to a 6.7% payroll tax) to gain access to reliable simple universal health coverage – one that provided choice in and out of network, one that would cover all citizens, and one that has drawn the active opposition of health insurers? That’s the $38 billion dollar question facing Colorado voters in the near future.
Colorado supporters have arrived at this point through a rational process that began with advantaging Obamacare with the expansion of state Medicaid rolls, and navigating bronze, silver, gold and platinum options. But in the end, as the system attempted to move toward low cost/high quality goal posts, which contractually continued to include insurer middle-men draw downs and embargoes on drug price negotiation, all roads led toward universal care and universal management as simpler, better, and (for almost everyone) cheaper in the long run approach, supporters said.
A similar process was proposed this week in a JAMA article titled, “Toward an Integrated Federal Health System”. In it, the authors review the facts, including:
- The federal government spends $1.3 billion a year (40% of all health care spending), on health care.
- This budget funds coverage through the departments of Health and Human Services, the Department of Defense, Veterans Administration, and the Department of Homeland Security.
- The payments channel through a bewildering array of mechanisms and middle men – through private insurers, private health professionals and organizations, and direct services to covered patients.
- The complexity is mind-boggling. For example, 42 programs exist across 6 federal agencies for ambulatory transportation of the elderly and disabled, each with their own rules.
- Drug payment levels vary widely. DOD pays 67% more for generic drugs than the VA for example.
- Double payments are not uncommon. Approximately one million citizens are now simultaneously tapping in to both VA and Medicare Advantage payments with losses estimated at $3 billion a year.
- Brick and mortar duplications, and in-patient underutilization is legendary.
- The DOD and the VA electronic medical records are moving forward toward integration this year – which should allow inter-operability and mobility/virtual choices for services to proceed.
- HHS expects that 50% of Medicare payments will have been converted from fee-for-service to “value-based models” (bundled payments with quality performance incentives) by 2018. Seven states will apply this approach to their Medicare Advantage plans beginning in 2017.
If all of this sounds complicated, multiply it by 50 states, and you begin to understand why supporters in a state like Colorado are seriously considering pulling the plug and going with a simpler universal solution.
Are we approaching some consensus? Will integration morph eventually into universal and cut the middle men out of the deal? Where are the consensus points emerging? Here are four areas:
1. Eliminate “fee-for-service” payment methodologies.
2. Move toward universal coverage, eliminating low benefit scam plans.
3. Integrate patient-focused EMR’s regionally, then nationally.
4. Favor non-profit solutions, and integrated delivering systems whose mission incorporates individual, population and community health.
Posted on | April 23, 2016 | No Comments
The medical journals these days are replete with analyses of the latest health reform measures, and their negative impact on the physician psyche. It would be easy to simply connect the dots, and say that physician discontent is the result of ill-advised organizational changes. But, in reality, this problem has plagued the profession for some time, and is existential in nature.
Over the past two decades, our health care system in the United States has been actively transforming. Health is rapidly becoming synonymous with reaching full human potential. Health care provision is increasingly being redefined as a right carrying with it responsibilities for individuals, families and community. Provision of care is now a collaborative effort with individual providers giving ground to health care teams, and consumers joining hands with providers in strategic health planning and mutual decision making.
The role of ‘professionalism’ in training of physicians and in the delivery of care has been heralded by major scientific bodies including the AAMC, Institute of Medicine, the ACGME and the ABMS. Their listing of desirable attributes in health care professionals is helpful. But absent the context of rapid environmental change, the modeling of new approaches to care that are emerging from both the consumer and provider side, and the integration of the latest social science concepts which impact human planning, development and potential, physicians will predictably under perform in the modern world and not fully realize either the professionalism they desire or their full leadership potential in the future.
As a Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC) in 2002, Dr. Thomas S. Inui opened his mind and heart to try to understand whether and how professionalism could be taught to medical students and residents. His thoughts on the topic, published under the title “A Flag In The Wind: Educating For Professionalism In Medicine”, are highly relevant to today’s medical educators and our nation’s health professional community.
After listing the profession’s ideal values and character qualities, he states:
“While we in medicine might see these as our lists of the desirable attributes of professionalism in the physician, as the father of an Eagle Scout I know that Boy Scout leaders use a very similar list to describe the important qualities of scouts: ‘A Scout is trustworthy, loyal, helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean, reverent (respecting everyone’s beliefs).’ I make this observation not to descend into parody, but to make a point. These various descriptions are so similar because when we examine the field of medicine as a profession, a field of work in which the workers must be implicitly trustworthy, we end by realizing and asserting that they must pursue their work as a virtuous activity, a moral undertaking.”
Later in the report, he shares: “The processes of formation include experience and reflection, service, growth in knowledge of self and of the field, and constant attention to the inner life as well as the life of action. ‘Who am I becoming as I move towards this life of service?’ is a critical question in formation, as disciplinary acculturation and expertise increases. Acknowledging that the educational process in medicine changes – in some substantive sense – who we are as well as how we relate to others, may be the key to understanding why we need to be mindful, articulate, and reflective about the process.”
“Who am I becoming?” is the right question. But equally important (perhaps more) is “Why am I becoming that?” In the same year when Dr. Inui was doing his AAMC fellowship, John Inglhart, founding editor of Health Affairs, interviewed Steven Schroeder, who had announced his coming retirement as CEO of the Robert Wood Johnson Foundation. Schroeder said, “If physicians and nurses, who are central to the operation of the system, however care is financed, are dissatisfied and feel undervalued, I grieve for that system because that is a system in trouble.” Here we see a shift, away from “I” to “it”. It is the “system”, not an individual or even an individual’s teachers, that is “in trouble”. “Bad people or bad design?”, Deming, the father of re-engineering systems, might ask.
But increasingly, I believe that the systems that are evolving are largely a reflection of the current values of physicians and the organizations that represent physicians. Eli Ginzberg predicted this outcome thirty years ago in his classic article, “The Monetarization of Medical Care”. The recent manmade opioid epidemic, made possible in part by the AMA Federation’s liberal approval policies of “specialty organizations” in “pain management”, as well as the rapid fire prescribing of oxycontin by the nations doctors and dentists, is proof positive that we have wandered far afield of our original mission, into a positioning that is so deeply conflicted by our own and others business interests that our identities as physicians and self-regulating ethical professionals have become fundamentally compromised. To my mind, the “Medical-Industrial Complex” now largely owns the soul of medicine. And for physicians to regain possession of their professional values, and quiet our inner voices of discontent, we will be required to do some serious soul searching, and exhibit a bit of backbone as well.keep looking »