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			Friday, April 3, 2009 News Clipping Archives *Maryland / Regional* Smoking exemption (Baltimore Sun) Cigarette Tax Boost Prods Some to Quit (Washington Post) In Good Health - Health insurance options still open (Frederick News-Post) Public Defender Calls Venues Unconstitutional (Frederick News-Post) Cutting homelessness caseworkers considered, despite new agency (dcexaminer) *National / International* House passes bill giving FDA power over tobacco ads, sales (CNN.com) FDA Hasn't Intensified Inspections At Peanut Facilities, Despite Illness (Washington Post) CDC: Rocket fuel chemical found in baby formula (Washington Post) *Opinion* Stopping a killer (Baltimore Sun) Viewpoint: What happened to the 'care' in health care? (Baltimore Sun) *Maryland / Regional* Smoking exemption By Sam Sensa Baltimore Sun Friday, April 3, 2009 It is again legal to smoke cigarettes and cigars inside Ropewalk Tavern (1209 S. Charles St.). Last month, Ropewalk received an exemption from the statewide smoking ban. It's technically called an economic hardship waiver, and to get it, Ropewalk had to show sales losses of 15 percent over the course of two months. I went there last month and enjoyed a fine cigar, a fine beer and some fine company - just like the old days. But the McFaul clan, which runs the place, reinstated smoking in a smart way. Instead of allowing people to smoke on the first two floors, where it would stink up the whole place, they are only letting customers smoke on the isolated third floor. I didn't even know Ropewalk had a third floor. Come to find out, it's a pretty nice space, with leather sofas and chairs and Ronald Reagan memorabilia (Ropewalk is a Republican-themed bar). Oh, and I got a kick out of all the signs on the walls warning patrons about the smoke, too - as if it's some foreign thing. Ropewalk isn't the first cigar bar to get an exemption. The Havana Club (600 Water St.) received its waiver last June. Max's Taphouse (737 S. Broadway) reopened Max's Tobacco Company so patrons could smoke indoors. That means there are now about as many cigar bars in Baltimore as before the smoking ban started. Fancy that. Copyright 2009 Baltimore Sun. Cigarette Tax Boost Prods Some to Quit By David Brown Washington Post Friday, April 3, 2009; A06 For Tonette Lancaster, it just got to be too much one day -- the worry, the guilt and the money. "Cigarettes were $6 a pack, and now it's almost $7. It's like a bill," the 30-year-old, half-a-lifetime smoker said yesterday. "I just said, 'Enough is enough.' " So Wednesday night she slapped on a nicotine patch she got free, along with lots of information and encouragement, from the District government. She hopes it inaugurates a cigarette-free life. Lancaster, who is studying computer science at a downtown business college, is not alone in her newfound commitment to quit smoking. In recent weeks across the country, telephone "quit lines" have registered a jump in calls in advance of this week's biggest-ever increase in federal tobacco taxes. If the past is any guide, the sizable tax boost should have an immediate impact in getting many smokers to quit, and anti-smoking advocates were making the most of the moment yesterday. Much research has shown that smoking is an extremely "price sensitive" habit, with fewer people taking up cigarettes and more people putting them down every time a pack becomes more expensive. The 62-cent tax increase was adopted this year as a way to fund the expansion of the State Children's Health Insurance Program. On Wednesday, the day the increase took effect, the District's quit line got 131 calls, a record. The same day a week earlier, it had 44 calls; a month earlier, 19. "I'm in shock, quite frankly," said Debra Annand, director of health education services for the American Lung Association's District of Columbia office, which contracts with the local health department to provide smoking-cessation services. "Obviously something happened to drive that call volume up," Annand said. "Lots of research has shown the number one thing that helps people quit is increasing the price." "Several measures are proven to reduce tobacco use. Foremost is taxation," wrote the author of a report two years ago in the Morbidity and Mortality Weekly Report, a publication of the Centers for Disease Control and Prevention. A national telephone number, 1-800-QUITNOW, connects callers to programs in all 50 states and the District. In March, it registered 203,374 calls, more than twice February's 91,316. In January, it got 76,685. Normally, February and March have about the same number of calls, and fewer than January, which is a big month for quitting, said Linda A. Bailey, president of the North American Quitline Consortium. In Washington, the number of calls tripled in March, to 1,757, compared with February. The increases in Maryland and Virginia were more modest -- not quite doubling in March in both states. Various forces are at play in addition to the tax increase. Virginia recently enacted a law that will ban smoking in most restaurants starting in December. "That may be contributing to some of this," Phil Giaramita, spokesman for the Virginia Department of Health, said yesterday. Maryland's health department ran 67 quit-smoking spots on two Baltimore television stations in early March, and "we did see a bump" in calls after that, said Sara Wolfe, the state's quit-line coordinator. Washington also has an advertising campaign underway. A TV spot featuring former Redskin Darrell Green drove Tonette Lancaster to the 800 number. But the price of cigarettes appears to be the main driver of the recent rise in people seeking help. Philip Morris raised the price of some brands more than a month ago, and some experts believe it was an attempt by the company to get some profit out of the unavoidable price bump ahead. "More so than people not being able to smoke indoors, I am now getting calls from people who say they just can no longer afford to smoke," said Dana Lefko, manager of mission services and advocacy at the American Lung Association's Maryland office. Although the 62-cent increase is the steepest step-up in federal taxes, it is not the biggest tax increase ever. New York City increased its local tobacco tax from 8 cents to $1.50 in July 2002, the biggest single jump by any U.S. jurisdiction. Last year, New York state increased its tax on cigarettes to $2.75 a pack. In 2002, 21.5 percent of New Yorkers smoked -- a proportion that had not changed in a decade. In 2006, after the first tax increase and an ad campaign that graphically described the hazards of smoking, the smoking rate fell to 17.5 percent. Yesterday afternoon, at a news kiosk near Central Park in Manhattan, a pack of Marlboros was a flat $10. Cigarette sticker shock tends to fade after a few years, causing the price-driven decline to flatten out. At the lung association's rowhouse office on Seventh Street SE, however, the shock is now in full force, said counselor Robert Wright. Normally, three or four people wander in off the street each week to ask for help quitting. This week, it's been that many each day. "I just got a young guy who said he was told a pack cost $8, and he said, 'No way!' " Wright said. District residents who call the 1-800-QUITNOW number are referred to Wright if they want to enroll in a program. The office follows a strict, evidence-based protocol and provides 10 weeks of nicotine-replacement therapy -- patches or lozenges -- to those who want it. Nationwide, 28 jurisdictions provide nicotine replacement free. In Washington, clients have to pick up their first two-week supply, and their second, in person. Which means they need to talk to Wright, a man on a mission. His business card has his cellphone number on it. Most of his clients are low-income -- 60 percent from Wards 7 and 8 -- and he regularly agrees to counsel some at night when their mobile minutes are free. His required in-person counseling lasts 15 to 30 minutes and includes a carbon monoxide breath test. Lancaster's test registered 18 parts per million (normal is less than 6) -- enough to tell her that "my lungs aren't operating like they should be," she said, but far below the 63 ppm that one of Wright's clients tested. By the second visit, if a client does not smoke, the number is back down to normal. "That is the greatest motivating part right there. They are overjoyed -- and so am I," Wright said. But of course that's not the end. Vigilance is also necessary. In 2007, just 29 percent of people who went through the program quit for good. Also yesterday, the House approved a measure that would give the federal government the power to regulate tobacco for the first time. The bill, which passed 298 to 112, allows the Food and Drug Administration to regulate some of the ingredients in cigarettes and other tobacco products, along with the products' marketing, but stops short of allowing the agency to ban tobacco. Debate will now move to the Senate. Staff writers Lyndsey Layton in Washington and Keith Richburg in New York contributed to this report. Copyright 2009 Washington Post. In Good Health - Health insurance options still open By Ashley Andyshak Frederick News-Post Friday, April 3, 2009 There's plenty of talk about developing new health insurance programs to cover those in "the gap": those who can't afford private insurance but make too much money to qualify for government assistance. Ideas are taking root here in Frederick County (i.e. the Frederick County Health Access Program I wrote about earlier this month), but state officials say assistance programs for low-income residents are still underenrolled. The Frederick County Health Care Coalition held a training session at Frederick Memorial Hospital on Friday afternoon. Classrooms were packed with social workers and others learning where to direct their lower-income clients for help. The state offers several options for those who meet income guidelines: * Primary Adult Care (PAC) covers adults 19 and older without dependent children and who are not eligible for Medicare. * Medical Assistance for Families covers primary and specialty care and other services for parents or caregivers with dependent children. * The Maryland Children's Health Insurance Program (MCHIP) covers children under 19 and pregnant women and includes doctor visits, vision and dental care, and prescriptions. MCHIP Premium covers children whose parents make too much to qualify for regular MCHIP; families must be willing to pay a monthly premium. If you think you may qualify for any of these programs, call the Frederick County Health Department at 301-600-3348. If you don't qualify for state programs, you can e-mail Leigh Joos at leigh.joos@hotmail.com to be put on a waiting list for participation in the Frederick County Health Access Program. Other community agencies and providers also offer free or low-cost medical care and prescription assistance. For a full list, visit www.co.frederick.md.us/index.asp?NID=1936 or call the number above. Copyright 1997-09 Randall Family, LLC. All rights reserved. Public Defender Calls Venues Unconstitutional Defendants in So-Called Problem-Solving Courts Denied Due Process, Official Says By Henri E. Cauvin Washington Post Friday, April 3, 2009; B03 Drug courts, a forum designed to give addicted offenders a second chance, are under attack in Maryland -- and not by prosecutors. The state's public defender says Maryland's drug courts give judges too much power and defendants too little protection, and yesterday she argued to the state's high court that the tribunals are not constitutional. Public Defender Nancy S. Forster told the Court of Appeals that judges should not shed impartiality by sitting down with prosecutors, social workers and defense attorneys to try to help a defendant. She argued that judges should not be permitted to send a defendant to jail again and again without a full hearing each time, as she said judges in the drug courts do. "There is no due process in drug treatment court," she said. The case is the first legal challenge to the state's drug courts, and the arguments spurred a lively exchange about so-called problem-solving courts, which have become common in Maryland and across the country, with 41 in Maryland and more than 2,000 nationwide. The state attorney general's office, which represents the courts, says they do not infringe on drug court defendants' individual rights. Started in Florida two decades ago and rooted in the idea that providing treatment to some defendants may be better for them and for the community, drug courts have spawned similar courts for everything from truancy to mental illness. Where ordinary criminal courts are adversarial, proceedings in problem-solving courts are supposed to be collaborative. Judges, prosecutors, social workers and defense lawyers work together to determine what's best for the defendant and the community. Defendants volunteer to have their cases handled in such courts rather than in ordinary courts; the charges that make a defendant eligible vary from jurisdiction to jurisdiction. Maryland's first drug court was established in Baltimore in 1994. Calvert, Charles, Montgomery, Prince George's and St. Mary's counties have juvenile drug courts, and Montgomery and Prince George's have drug courts for adults as well. In the appeals case, Robert Calvin Brown III pleaded guilty in a Baltimore drug court to heroin charges and was sentenced to 20 years in prison, almost all of which was suspended. The judge placed Brown on probation for three years and ordered him into drug treatment as a condition of probation. After being bounced from several treatment programs and being sanctioned with jail stays of 14 and 35 days, the judge decided that Brown wasn't complying with the drug court agreement. He revoked Brown's probation and sentenced him to eight years in prison. The issue of the rights of individual defendants in drug courts drew more pointed questions from several of the judges. Judge Joseph F. Murphy Jr. noted that a judge's talking to one party without the other party being present, which might happen in a drug court case, has raised due-process concerns in other sorts of criminal proceedings. "Can you do that without violating the defendant's rights?" he asked Assistant Attorney General Michelle W. Cole. As they have become more common, drug courts and problem-solving courts have faced questions about their effectiveness and about defendants' rights and judges' roles. "They are trying to move into the mainstream and become more institutionalized," said Greg Berman, a proponent of problem-solving courts and director of the Center for Court Innovation in New York. "As that happens, you're naturally going to attract more attention and more of these questions." For critics of such courts, the challenge in Maryland is welcome. "It's about time," said Mae C. Quinn, a University of Tennessee law professor and a former public defender in New York who has written extensively about drug courts. "These courts have been operating largely between the cracks of the law for a long time." Copyright 2009 Washington Post. Cutting homelessness caseworkers considered, despite new agency By William C. Flook dcexaminer Friday, April 3, 2009 Fairfax County officials are weighing whether to cut nine caseworkers who aid hundreds of the county’s homeless, while creating an agency to combat homelessness with a director salaried at $125,000. The nine positions, all but two of them mental health therapists, are among the hundreds of jobs eliminated under County Executive Anthony Griffin’s proposed budget, which seeks to close a $648 million shortfall for the coming fiscal year. The cuts would result in fewer on-site visits to 468 homeless people in shelters, according to budget documents, and would save the county $673,819. The Board of Supervisors may scale back that reduction before it adopts the budget later this month. Meanwhile, in a rare expansion amid the belt-tightening, county leaders have established the Office to Prevent and End Homelessness, consisting of former Freddie Mac Foundation manager Dean Klein and a small staff, with a goal of helping carry out the board’s mission of ending the problem by 2016. Fairfax’s homeless population tends to hover around 2,000. The office’s creation drew the rancor of Republican supervisors in February, and the proposed elimination of caseworkers has fanned that anger. “Staffing up a half-a-million-dollar office that provides no direct services to the homeless at the same time you’re cutting people that interact with the actual homeless is insanity,” said Springfield District Supervisor Pat Herrity. The office was given a $500,000 budget for the current fiscal year and a $309,000 budget for the year beginning in July, according to documents. The nine caseworkers, part of a team of 16, work within the Fairfax-Falls Church Community Services Board, which handles mental health, mental retardation and substance abuse services for the county. Four of the positions could be restored should additional revenue become available, CSB Executive Director George Braunstein said. The caseworkers provide homeless people, many of whom have mental health and substance abuse problems, with counseling and assessments, and ensure that they receive available services, Braunstein said. They will receive help under the cuts, just not “as adequate as it could be.” He also took issue with the GOP objections to creating the anti-homelessness agency. “The fact of the matter is if you were to eliminate the homelessness office as it’s currently configured, you’re going to have an immediate savings, but then you’re going to end up in a static position in the long run,” he said. wflook@dcexaminer.com Find this article at: http://www.washingtonexaminer.com/local/Cutting-homelessness-caseworkers-considered-despite-new-agency-42364052.html Copyright 2009 dcexaminer. *National / International* House passes bill giving FDA power over tobacco ads, sales CNN.com Friday, April 3, 2009 WASHINGTON (CNN) -- The House of Representatives passed a bill Thursday that would give the Food and Drug Administration the authority to regulate the advertising and sale of tobacco products in the United States. The measure passed by a vote of 298-112. Only eight Democrats voted against the bill; a majority of Republicans opposed it. The Family Smoking Prevention and Tobacco Control Act, which now moves to the Senate for further consideration, would allow the FDA to restrict the marketing of tobacco and ban candy-flavored cigarettes. It would also allow the agency to regulate nicotine and other ingredient levels, as well as force greater disclosure of the contents of tobacco products. Among other things, it would give the FDA the authority to require the posting of larger warning labels on cigarette cartons and other tobacco products. Tobacco companies could be barred from running ads implying, critics say, that "mild" or "low-tar" cigarettes are less harmful. "This legislation is a major victory for those of us who prize the health of this nation over the profits of tobacco companies," J. Randall Curtis, the incoming head of the American Thoracic Society, said in a written statement. "We applaud the House for passing the bill and hope that the Senate will move it through quickly so that President Obama can sign it into law as he has already indicated he would. Swift action could prevent tens of thousands of future deaths." North Carolina Sens. Richard Burr and Kay Hagan have introduced separate legislation in the Senate that would create a new agency to oversee the tobacco industry. Critics say such an agency would do a less effective job regulating tobacco products. "It's a legal product," Hagan said in a recent interview with the Charlotte Observer. "I don't want to do anything that would harm the industry in North Carolina." According to the North Carolina Department of Agriculture, the state is the biggest tobacco producer in the nation. Find this article at: http://www.cnn.com/2009/POLITICS/04/02/tobacco.regulation/index.html?eref=rss_topstories 2008 Cable News Network. FDA Hasn't Intensified Inspections At Peanut Facilities, Despite Illness By Lyndsey Layton Washington Post Friday, April 3, 2009; A04 Despite four outbreaks of salmonella illness from peanut products in the past three years, the federal government has not changed the safety measures required of peanut companies or instructed its inspectors to test for the bacteria. In all, the outbreaks have killed nine people and sickened more than 1,400. Although officials at the Food and Drug Administration promised to intensify inspections after a salmonella outbreak caused by Peter Pan peanut butter in 2007 sickened 628 people, the agency did not increase checks or require microbial testing at peanut plants, officials have acknowledged in congressional hearings. That is still true today, even after Congress and President Obama sharply criticized the FDA for oversight failures leading to the recent outbreak of salmonella illness linked to products sold by Peanut Corporation of America. That outbreak, which began in September and is slowing, has sickened more than 690 people, killing nine, and triggered the largest food recall in U.S. history. During its investigation of the Peanut Corporation case, the FDA discovered about 20 additional facilities that have been making peanut products without the knowledge of federal regulators. It learned about the facilities because they were buying peanuts from PCA, said Michael Herndon, an FDA spokesman. The agency will not name the 20 facilities or say where they are located, he said, adding that FDA inspectors are planning to visit each site shortly. "It's a little depressing, but not surprising, that they found another 20 facilities they didn't know about," said Jean Halloran, director of food safety for Consumers Union. She pointed to the fact that unknown to federal regulators, one of Peanut Corporation of America's three facilities had operated in Plainview, Tex., for four years until the outbreak. Salmonella is the most common food-borne bacteria in this country, with 2,500 strains. Contaminated foods are often of animal origin and moist, such as beef, poultry, milk and eggs. But as early as 1994, federal health officials began to see outbreaks of salmonella illness in people who ate nuts. In 2006, the Centers for Disease Control and Prevention counted three such outbreaks traced to peanuts. "That's a red flag," said Caroline Smith DeWaal, food safety director at the Center for Science in the Public Interest, a Washington-based health advocacy group, adding that the increase in illnesses from peanuts should have prompted regulators to reexamine whether a threat had emerged in a food previously considered relatively safe. Every year, approximately 40,000 cases of salmonella illness are reported in the United States. Because many milder cases are often not diagnosed or reported, epidemiologists believe the number of infections may be 30 or more times greater. And while healthy adults usually recover within a few days, the illness can be deadly for children, the elderly and people with weakened immune systems. The FDA, which lacks enough inspectors to regularly visit food manufacturing facilities nationwide, inspects some peanut processing facilities and contracts with dozens of states to perform inspections on its behalf. FDA inspectors and state officials under contract are now "being encouraged to look for every opportunity to conduct environmental sampling" of peanut processing facilities to test for bacteria, FDA's Herndon wrote in an e-mail. They are being told to consider testing the facility or a sample of the product when they observe physical conditions that suggest potential contamination, such as "moisture or pooled water, evidence of cross-contamination, improper cleaning and sanitization practices, a history of positive product samples, recent construction, cracks in floors around processing areas, and evidence of roof leaks above food handling areas," Herndon wrote. Routine testing is not required, and the decision whether to test is left to the inspector, he said. Food safety advocates said that microbial testing should be part of regular FDA inspections, and that the agency should mandate that every nut processor develop plans that identify specific contamination risks, spell out the ways it will reduce those risks, and then document those efforts, creating a record available to government regulators. The FDA requires this of seafood and juice producers, a step the agency took in the 1990s after several high-profile contamination cases. "They definitely should be doing salmonella testing in the environment and in the product," Halloran said. Last month, the FDA issued "guidance" to food companies suggesting that manufacturers that use peanuts should buy them from processors that have systems to reduce the risk of salmonella. The guidance is only advice and does not carry the legal weight of a regulation. Issuing guidance to industry does little, DeWaal said. "It's a feel-good exercise for the agency which doesn't obligate anyone to do anything," she said. About half a dozen food safety reform bills are pending on Capitol Hill. Observers say a bill introduced by Sen. Richard J. Durbin (D-Ill.) has the best chance of passing this session. It would require all manufacturers to develop food safety plans, use federally approved laboratories to test for pathogens, and send those results to the FDA. The bill would also require the FDA to annually inspect facilities that produce "high risk" foods. Copyright 2009 Washington Post. CDC: Rocket fuel chemical found in baby formula Associated Press By Mike Stobbe Washington Post Friday, April 3, 2009 ATLANTA -- Traces of a chemical used in rocket fuel were found in samples of powdered baby formula, and could exceed what's considered a safe dose for adults if mixed with water also contaminated with the ingredient, a government study has found. The study by scientists at the U.S. Centers for Disease Control and Prevention looked for the chemical, perchlorate, in different brands of powdered baby formula. It was published last month, but the Environmental Working Group issued a press release Thursday drawing attention to it. The chemical has turned up in several cities' drinking water supplies. It can occur naturally, but most perchlorate contamination has been tied to defense and aerospace sites. No tests have ever shown the chemical caused health problems, but scientists have said significant amounts of perchlorate can affect thyroid function. The thyroid helps set the body's metabolism. Thyroid problems can impact fetal and infant brain development. However, the extent of the risk is hard to assess. The government requires that formula contain iodine, which counteracts perchlorate's effects. The size of the infant and how much formula they consume are other factors that can influence risk. The study itself sheds little light on how dangerous the perchlorate in baby formula is. "This wasn't a study of health effects," said Dr. Joshua Schier, one of the authors. The largest amounts of the chemical were in formulas derived from cow's milk, the study said. The researchers would not disclose the brands of formula they studied. Only a few samples were studied, so it's hard to know if the perchlorate levels would be found in all containers of those brands, a CDC spokesman said. Earlier this year, the U.S. Environmental Protection Agency said it was considering setting new limits on the amount of perchlorate that would be acceptable in drinking water. A few states have already set their own limits. The EPA has checked nearly 4,000 public water supplies serving 10,000 people or more. About 160 of the water systems had detectable levels of perchlorate, and 31 had levels high enough to exceed a new safety level the EPA is considering. CDC:http://www.cdc.gov/ © 2009 The Associated Press. *Opinion* Stopping a killer By Carole Mitnick Baltimore Sun Commentary Friday, April 3, 2009 China has called an urgent meeting that could affect your life, and it's not about the global economic crisis - or global warming. Instead, it's about a quiet global health threat that is more disturbing than you probably assume: the silent spread of multidrug-resistant tuberculosis (MDR-TB) around the world. Many global health leaders are in Beijing this week trying to draw attention to the danger, including Bill Gates, whose foundation has given billions of dollars to fight diseases; Margaret Chan, the director-general of the World Health Organization; and senior representatives from more than two dozen nations, including the United States. MDR-TB - an acronym to burn into your brain - is a killer of unknown dimensions, moving in unknown directions. It passes in the air, through a cough or a sneeze. You thought SARS (severe acute respiratory syndrome) was dangerous? SARS killed 800 people overall; MDR-TB kills 800 every two days, maybe many more. And in our attempts to protect people around the world, including the American public, those of us in public health stand in the path of this deadly infectious bug holding just crude, cruel and scarce tools. Crude, because the main diagnostic test for TB is 127 years old and can't detect resistance; the only vaccine is 85 years old and doesn't prevent the most common form of TB; and the last antibiotic, anti-TB medicine was discovered more than 40 years ago and is useless in the treatment of MDR-TB. Cruel, because the drugs we give to people with MDR-TB can make them anxious, nervous, psychotic and physically ill for hours and makes their skin burn. And this must go on for up to two years of daily doses of the toxic medicines, with a 50 percent to 80 percent hope that they will be cured. Scarce, because of the 1 million to 2 million cases of MDR-TB that occur each year, the World Health Organization reports that less than 1 percent will receive high-quality treatment. All this means that Mycobacterium tuberculosis, the bug that causes TB, has room to run because we don't have new ammunition needed to stop it. Those gathering in Beijing will call for a major global response to halt the spread of MDR-TB and even worse strains of TB bacterium, such as extensively drug-resistant TB, known as XDR-TB. They will call for more funding, tailored national responses to fight the disease, and a renewed commitment to treat TB well the first time so that resistance to the drugs does not develop. All of that is urgently necessary. But one message rarely highlighted is just as critical: More funding is needed for tuberculosis research specifically and global health research in general. But that's not happening. The world's 40 largest donors invested $482 million in TB research and development in 2007, according to a report released last month. That is less than one-fourth the amount recommended by the WHO and the Stop TB Partnership, and only one-tenth the amount recommended by Treatment Action Group, which released the report. We desperately need an infusion of global health research funding so that in the TB fight we will have better diagnostic tools, but that research in 2007 received just $42 million globally. We need a new TB vaccine (just $71 million spent in 2007) and new TB drugs (just $170 million). And we need improved delivery systems to get these tools to those who need them most (just $37 million spent in 2007). Despite all of this, we have a strong, committed group of practitioners and researchers who, given better tools and drugs, can get on the right track to halt the devastation of drug-resistant TB. Those in Beijing are trying hard to make you aware of MDR-TB. But the disease itself is emerging, and in more dangerous forms, both here and abroad. We should put our best scientists on this problem - fast. Carole Mitnick is an assistant professor in global health and social medicine at Harvard Medical School and a Paul G. Rogers Society for Global Health Research Ambassador. Her e-mail is carole_mitnick@hms.harvard.edu. Copyright 2009 Baltimore Sun. Viewpoint: What happened to the 'care' in health care? By Ellen Goodman Baltimore Sun Commentary Friday, April 3, 2009 BOSTON - I was tickled to hear that the insurance industry is beginning to commence to start to think about lifting bans on the pre-existing conditions that keep a slew of Americans from getting health coverage. This has always been on the deep end of a pretty wacky system. But there is a pre-existing condition that hasn't garnered nearly as much attention in the health care debate. It's the condition we all share: being a human being. As opposed to, say, being an organism subdivided into parts and scattered over the medical landscape from neurology to podiatry. Health care reform has focused, rightly enough, on the 50 million uninsured people in this country. Reformers are homing in on price tags that are off the (medical) charts. We are told of financial fixes and electronic records that will save the day, or at least the budget. But speaking as the CEO of a wholly owned body, I don't think we're talking enough about the care in health care. Consider the erosion of primary care doctors. A half-century ago, we had an equal number of generalists and specialists. Today, there are two specialists for every generalist. In clear view and with all undeliberate speed, we developed a system that rewards procedures over primary care. As analyst Robert Blendon puts it bluntly, "It's absolutely clear that payment systems have been negotiated that reward specialty time and use of equipment." The incentives tip toward the kind of medicine that is performed with hands, tools and technology over the medicine that is practiced with eyes, ears and mind. The average generalist now earns 55 percent less than the average specialist. Many students apply to medical school to connect with and take care of sick people. They graduate to become what one doctor slyly calls "proceduralists." They enter with a strong desire to look after families and exit with a ticket to X-ray femurs. It was this business model that produced both runaway costs and discontent. Now we are told that a business model can fix it. But this is by no means certain. As Drs. Jerome Groopman and Pamela Hartzband wrote in a thoughtful New England Journal of Medicine piece on the changing culture of their profession, medicine is about more than metrics. It is both a "market relationship," where you provide goods for services, and a "communal relationship," built on a family model, where doctors are expected to help when help is needed, regardless of money. "Assigning a monetary value to every aspect of a physician's time and effort," they write, "may actually reduce productivity, impair the quality of performance and thereby even increase costs." All while undermining the communal relationship. More to the point, the business models don't touch the basic problem of an out-of-kilter system favoring CT scans over human connections. "The really hard conversation is not going on," says Dr. Groopman about health care reform. "The hard conversation involves what we value as a society and what translates into the kind of care we all want." The "kind of care we all want" includes a known doctor who can diagnose, manage, coordinate and comfort. This is especially important in an aging society. "I can't see an 88-year-old man for 15 minutes and find out what's wrong," says Dr. Groopman. He compares the difference between high-tech and "cognitive medicine" to the difference between CSI and Sherlock Holmes. Spending time with a patient "isn't about having a beer together. It's about getting a story and figuring out the treatment that makes sense." There is nothing entirely new in the discontent of doctors and patients, the shredding of personal relationships, or the shrinking pool of primary care doctors. It's been chronicled in conversations and commissions dating back as far as Richard Nixon. Yet it has continued unabated. President Barack Obama passed a glancing eye at the problem during his recent news conference when he said, "Let's reimburse on the basis of improved quality, as opposed to simply how many procedures you're doing." Rebuilding the culture of medicine and recruiting a new cohort of primary care doctors are, in themselves, part of that improved quality. Speaking for my pre-existing condition of being human, it's the family doctors, the primary caregivers, who put the care in health care. Yet we talk of finance and efficiency, and the designated superhero is the electronic record keeper. Are we to pin our hopes on that? Take two aspirin and call your computer in the morning. Ellen Goodman is a columnist for The Boston Globe. Her e-mail is ellengoodman@globe.com. Copyright 2009 Baltimore Sun. BACK TO TOP


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