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Maryland / Regional
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County may reopen enrollment in medical services plan for limited-income residents
(Baltimore Sun)
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Salmonella hits Maryland
(Baltimore Examiner)
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Budget Cuts Are Focus for Md., Va.
(Washington Post)
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National / International
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Director of Disease Control Centers Resigns (New York Times)
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Opinion
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Education could slow teen births
(Carroll County Times Editorial)
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Parallel crises in health care, higher education (Baltimore Sun
Commentary)
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We All Want Longer, Healthier Lives. But It's Going to Cost Us. (Washington Post
Commentary)
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The Dying of the Light
(Washington Post Commentary)
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County may reopen enrollment in medical services plan for limited-income
residents
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By Larry Carson
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Baltimore Sun
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Sunday, January 11, 2009
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Crafting a new way to extend medical services to uninsured residents has
proved tricky for county health officials.
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The health staff was initially overwhelmed in October, when 1,100 people
came to the East Columbia library during nine sessions to enroll in Healthy
Howard Inc. All but 66 turned out to be eligible for four existing insurance
plans for limited-income people.
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Now county health officer Dr. Peter Beilenson has come up with a new plan to
reopen enrollment while trying to counter criticism from County Council
member Greg Fox, a Fulton Republican. Fox argues that too few have been
enrolled in the program to justify the county's $500,000 contribution.
Healthy Howard offers a full range of health care for legal county residents
without insurance for at least six months for as little as $50 a month.
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Over the next few months, Beilenson wants to enroll more people in Healthy
Howard, while placing applicants eligible for other, existing programs on a
waiting list.
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"We are not going to be targeting all comers for the next several months,"
he said.
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Beilenson, who will present his revised strategy to the County Council
tomorrow, said that his staff is seeking people like part-time community
college instructors and students, state and county contractual employees,
small-business workers without benefits, residents in subsidized housing,
and the parents of children enrolled in a federally funded insurance program
for limited-income people.
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"We want to make sure we get our enrollment numbers up," Beilenson said, in
the hope that public support for the program doesn't wane.
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The original goal was to enroll up to 2,200 people in either Healthy Howard
or an existing program by October. That's about 10 percent of the estimated
number of county residents without insurance. The program, however, is
experimental and intended to be a source for research data to see whether
the program could be duplicated elsewhere.
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"I don't want to be concerned about people questioning using $500,000,"
Beilenson said. "Politically speaking, if we've got 1,500 [enrolled by
year's end] it's defensible. If we're serving 300, there is a real
question."
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So far, Beilenson has strong support from County Executive Ken Ulman and
other council members, including this year's chairwoman, Mary Kay Sigaty, a
west Columbia Democrat.
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"To me, I'm a bit bemused at this whole issue," Ulman said about Fox's
criticisms. "We've been able to get over 1,000 people. That's a huge
accomplishment. We always knew this would be a work in progress."
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Sigaty said she, too, supports the initiative.
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"It is what we should be doing," she said, calling the October enrollment "a
pretty good start."
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Fox argues that not enough research was done before the program's launch. He
has questioned the use of county funds, and ridiculed the questions the
program's health coaches would ask participants to promote healthier
lifestyles.
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"Is his goal to get most people insured or get people in his signature
program?" Fox asked.
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If so many people are eligible for existing programs, that should have been
the county's focus, he said.
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"This has been in the press since October," he said. "People should have
been banging down the doors."
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Asking people if they take walks or are following suggestions about changing
eating habits is silly, he suggested.
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"I think it's a joke if you're going to track how people do these things,"
Fox said, though he would not say that the program should be ended or county
funds withdrawn.
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Beilenson found Fox's criticism groundless.
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"We did a tremendous amount of research," he said.
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Beilenson said that 299 people the county enrolled in a Kaiser Permanente
insurance program also would have qualified by income for Healthy Howard.
Full insurance is better, though, Beilenson said. Healthy Howard is not
insurance and is only available inside the county.
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The effort for the next few months will target people with incomes of
roughly $20,000 to $30,000 for one person, or $40,000 to $63,600 for a
family of four, Beilenson said. People interested in enrolling can go to the
program's Web site, www.healthyhowardplan.org/apply, where they can fill out
a brief screening form.
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A program worker will call each applicant within two weeks, Beilenson said.
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He speculated that many who need health care still may not have read or
heard about Howard's unusual program. Ulman agreed with that.
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"It's hard to reach out to people," he said.
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Joanne Stato, a Baltimore resident who formerly taught English part time at
Howard Community College, said she and other adjunct professors had no
benefits.
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"I prayed for a health benefit program like this while I still worked
there," she said, adding that she later found a job with benefits in
Baltimore.
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Copyright © 2009, The Baltimore Sun
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Salmonella hits Maryland
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By Sara Michael
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Baltimore Examiner
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Sunday, January 11, 2009
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At least seven people in Maryland have been sickened by a strain of
salmonella sweeping the country.
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So far, 388 people in 42 states have become infected by Salmonella
typhimurium, according to the Centers for Disease Control and Prevention.
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People started getting sick between Sept. 3 and Dec. 29, and most of the
illnesses started after Oct. 1, the CDC said. Eighteen percent of the people
have been hospitalized.
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Seven cases with the same DNA fingerprint of this strain have been
identified in Maryland, and of those, two were hospitalized, according to
Dr. David Blythe, state epidemiologist at the Department of Health and
Mental Hygiene.
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"As we continue to look for Maryland cases, that number may change," he said
in a statement, adding that an average of 800 to 1,000 salmonella cases are
reported in Maryland each year -- 40,000 nationwide.
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CDC officials are working with local public health officials to identify the
contaminated product.
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Salmonella can cause fever, diarrhea and abdominal cramps, according to the
CDC. A small number of people with salmonella develop joint pain, irritation
of the eyes and painful urination, a condition called Reiter's syndrome,
which can last for months or years, and lead to chronic arthritis.
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This latest outbreak comes months after Salmonella saintpaul sickened 1,442
people -- 39 in Maryland. That outbreak, which ended in August, was linked
to jalape?o and serrano peppers from Mexico.
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baltimoreexaminer.com
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Budget Cuts Are Focus for Md., Va.
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Legislators Meet This Week Facing Major Shortfalls
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By John Wagner and Anita Kumar
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Washington Post
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Sunday, January 11, 2009; C01
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Maryland and Virginia lawmakers will return to work Wednesday with thousands
of bills to consider and one bleak reality hanging over their heads: If
anything costs money, forget it.
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With both states facing their worst financial crunches in decades,
legislators are hunkering down for sessions that will be dominated by deep
spending cuts and searches for creative ways to ease the pain -- and that
will feature virtually no discussion of initiatives that come with a price
tag.
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"You're going to be hard-pressed to go forward with anything new," said
Maryland Sen. Edward J. Kasemeyer (D-Baltimore County), vice chairman of the
Budget and Taxation Committee, which has signed off in recent years on
expanded funding for subsidized health insurance and cleanup of the
Chesapeake Bay. "The question will be what kind of things we put off and
don't do."
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In Maryland, the General Assembly will start its annual 90-day session
facing a budget shortfall of almost $1.9 billion for the fiscal year that
starts in July. In Virginia, lawmaker will return for a 45-day session
largely focused on cutting $2.9 billion from the two-year budget that took
effect in July.
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In both states, the magnitude of the shortfalls is prompting talk of
measures that would have seemed foreign in recent years, as lawmakers look
for ways to keep cuts to essential services, including education, health
care and public safety, from getting any deeper than necessary.
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Maryland lawmakers are considering freeing up money from their annual
capital budget -- typically reserved for construction of schools, prisons
and other projects -- to cover state operating expenses. Some legislators
want to hand off teacher pensions and other expenses to counties. And there
is serious talk about withdrawing money from the state's "rainy-day" reserve
fund, a step state leaders have been reluctant to take for fear of alarming
bond-rating agencies.
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Virginia will also be weighing a proposal to make the largest withdrawal
ever from its rainy-day fund, along with controversial plans by Gov. Timothy
M. Kaine (D) to offer early release to some prisoners doing time for
nonviolent offenses and to double the cigarette tax. Maryland lawmakers, who
passed multiple tax increases in 2007, have all but ruled out more hikes to
help close budget shortfalls this year.
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Virginia Del. Terry G. Kilgore (R-Scott) said House leaders have instructed
all 100 delegates to search for cuts and to look for ways to make government
spending more efficient.
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"Everyone needs to be concentrating on the budget this year," Kilgore said.
"The budget transcends everything."
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Other issues are expected to get an airing, of course.
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In Maryland, Gov. Martin O'Malley (D) has signaled that he will push a
package of anti-domestic violence laws, which would have no significant
effect on the state's bottom line. O'Malley has also asked lawmakers to take
another look at repealing the death penalty.
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And legislative leaders say they will take up bills affecting state police
surveillance policies, labor unions and land-use policies, among others.
None of those would have an immediate financial impact.
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"They're going to get attention, and some of them are going to get passed,"
said Maryland Senate President Thomas V. Mike Miller Jr. (D-Calvert).
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In Virginia, legislators are expected to debate a variety of non-money
issues, including a ban on text messaging while driving, the regulation of
companies that offer vehicle title loans and a handful of hot-button issues
that come up every year, including a smoking ban in restaurants and bars,
which Maryland has in place.
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Kaine will try to leave his imprint on the state by making energy and the
environment the focus of his fourth and final year in office through his
year-long "Renew Virginia" initiative, which aims to make the state a leader
in conservation.
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Robert Vaughn, staff director for the House Appropriations Committee, said
some policy issues that might not appear to cost money could actually have
financial impacts. Those include increasing penalties for crimes, which
could cost money to house inmates, and protecting consumers, which could
require additional staff members to enforce new laws.
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"At the end of the day, dollars drive every program and policy," Vaughn
said.
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Given the magnitude of the shortfalls, some lawmakers doubt that anything
but the budgets will generate much public attention.
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"The budget is going to suck 99 percent of the oxygen out of the State
House," said Maryland Sen. Brian E. Frosh (D-Montgomery), chairman of the
Senate Judicial Proceedings Committee. He said his panel, which deals with
legal issues, will probably have a lighter agenda than in recent years.
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Virginia House Majority Leader H. Morgan Griffith (R-Salem) said his state's
session might feel like a throwback to earlier short sessions. Virginia's
shorter session, held every other year, had traditionally been used solely
to tweak the state budget and approve emergency legislation. Over the years,
the 45-day sessions have mushroomed to include consideration of thousands of
bills.
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"The serious economic situation is going to force us to focus," Griffith
said.
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Both states have taken measures to start coping with shortfalls that
expanded rapidly amid the national economic downturn.
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In an effort to balance its two-year, $77 billion budget, Virginia is
starting to eliminate thousands of jobs, slash agencies' spending by 15
percent and trim $800 million from K-12 education and Medicaid, which helps
cover medical needs for the indigent, elderly and disabled.
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But legislators will have to consider some of Kaine's financial proposals,
including the cigarette tax increase, early release plan and borrowing $490
million from the state's rainy-day fund.
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Senate leaders support many of Kaine's proposals, but House leaders,
including Speaker William J. Howell (R-Stafford), are opposed to some,
including raising taxes.
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In Maryland, lawmakers are not scheduled to get a budget proposal from
O'Malley for the coming fiscal year until late this month. He is also
grappling with a shortfall of about $400 million in the current year's $15
billion budget.
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O'Malley has ordered furloughs for state workers and is considering scaling
back a number of initiatives begun during his term, including a program that
provides additional school funds for counties where the cost of education is
more expensive. Montgomery and Prince George's are beneficiaries of the
program.
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O'Malley and other state leaders are also exploring ways to redirect money
from other state funds to help close the shortfall in its primary operating
budget, known as the general fund.
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Last week, for example, O'Malley and Comptroller Peter Franchot (D) floated
the idea of taking up to $367 million out of an obscure reserve fund that
has been set aside to pay refunds owed on county income taxes. Franchot
aides say the fund is not needed because refunds are paid out of
current-year collections.
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Leaders in both states, meanwhile, are watching anxiously to see what help
Washington will provide in the form of a federal stimulus package.
Additional Medicaid funding could help ease budget shortfalls in Maryland
and Virginia.
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"We're hopeful the Obama administration steps up," said Maryland House
Speaker Michael E. Busch (D-Anne Arundel). "The state really doesn't have a
whole lot of options if there's not help from the federal government."
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© 2009 The Washington Post Company
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Director of Disease Control Centers Resigns
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Associated Press
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New York Times
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Sunday, January 11, 2009
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ATLANTA (AP) — Dr. Julie L. Gerberding has resigned as director of the
Centers for Disease Control and Prevention and will be replaced on an
interim basis by a deputy as of Jan. 20, the day President-elect Barack
Obama is inaugurated.
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Her resignation was announced in an e-mail message to employees on Friday
night.
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Dr. Gerberding, the first woman to direct the agency, led the C.D.C. through
a post-Sept. 11 world of bioterrorism fears and was considered an effective
communicator with legislators and the public.
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In a November e-mail message to staff members, Dr. Gerberding said she
expected that she might leave the post after the Bush administration left
office. But colleagues said she had quietly held out hope that she would be
allowed to stay on.
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A spokesman for the agency, Glen Nowak, said Dr. Gerberding was traveling in
Africa on agency business and was not available for comment.
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Mr. Nowak said in a prepared statement that the Bush administration, “as
part of the transition process,” had requested resignation letters from “a
number of senior-level officials, including Dr. Julie Gerberding. This week,
the administration accepted Dr. Gerberding’s resignation, effective Jan.
20.”
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The agency investigates disease outbreaks, researches the cause and
prevalence of health problems, and promotes illness prevention efforts. In a
2007 Harris Poll, the C.D.C. was rated the government agency that does the
best job.
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Dr. Gerberding is also head of the sister agency to the C.D.C., the Agency
for Toxic Substances and Disease Registry. The two have a combined budget of
about $8.8 billion and more than 14,000 full-time, part-time and contract
employees.
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Dr. Gerberding receives a total compensation of $202,200.
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Dr. Gerberding, 53, was named director in July 2002. She had been an
infectious diseases specialist at the University of California, San
Francisco, and joined the disease centers in 1998 to lead a patient safety
initiative.
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Copyright 2009 The New York Times Company
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Education could slow teen births
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Carroll County Times
Editorial
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Sunday, January 11, 2009
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The more than 425,000 births to mothers ages 15 through 19 in the latest
Centers for Disease Control and Prevention vital statistics report
underscores the need for increased sex education and discussion in our
schools and between family members at home.
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The CDC last week released its final report on birth data from 2006. The
final data confirms what the agency noted a year ago with preliminary
numbers: the number of youngsters having children is on the rise for the
first time in about 15 years.
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According to the report, teen birth rates increased in 26 states. In
Maryland, the rate increase from 31.8 per 1,000 births in 2005 to 33.6 per
1,000 births in 2006. The increase followed years of decline since 1991,
when the number was 54.1.
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Part of the increase likely is attributable to an overall increase in births
across the board. According to the CDC, births increased 3 percent from 2005
to 2006, and most of the statistical groups saw increases. The 4,265,555
births was the largest number seen since 1961.
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If there was any good news to glean from the report it is that births to the
youngest age group, 10- to 14-year-olds, declined to 0.6 per 1,000. But the
rate for 15- to 17-year olds, which has decreased 45 percent since 1991,
rose 3 percent between 2005 and 2006. And births to 18- and 19-year-olds,
which decreased 26 percent since 1991, rose 4 percent between 2005 and 2006.
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Youngsters are bombarded with sex everywhere they turn every day. From
television shows and movies to Madison Avenue ad campaigns that use sex to
sell products, youngsters learn early on that sex and society are closely
intertwined.
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Add in high-profile teen pregnancies, such as the hype surrounding Jamie
Lynn Spears and her pregnancy at age 16, and too often we are sending the
wrong message to youngsters about the responsibilities that come with
parenthood.
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But talking to kids about sex is still too uncomfortable for some parents.
And some don’t want schools to broach the subject either unless the
conversation is limited to abstinence.
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This line of thinking is difficult to understand given the successes that
have been seen in other areas — such as drugs and drug abuse — where
increased awareness and education has brought about positive results.
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When one in 10 babies is born to a mother age 15 to 19, clearly there is a
need to do more.
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Copyright © 2009 Carroll County Times
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Parallel crises in health care, higher education
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By Patrick Callan and Andrew L. Yarrow
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Baltimore Sun
Commentary
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Sunday, January 11, 2009
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While America's deepening economic woes cast a pall over the nation,
long-term U.S. fortunes are profoundly threatened by parallel crises of
cost, quality, access, and equity in health care and higher education.
Once-proud symbols of national greatness, these sectors no longer deliver
world-class results, are increasingly inequitable, and elicit growing
discontent from many Americans.
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The U.S. health care bill is $2.3 trillion, 16 percent of gross domestic
product - roughly double the percentage for Western Europe, Canada, Japan,
and other rich countries. Spending is rising by 7 percent a year, with
Medicare increasing by 13 percent in 2007. Escalating health-care costs are
the leading cause of personal bankruptcy and are why America's $10.6
trillion national debt is projected to soar. Waste is a major culprit,
manifested in such problems as vast overhead costs, overuse of medical
services, insufficient competition and lack of information about
cost-effective practices.
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The United States also spends about 3 percent of GDP on higher education -
again, roughly twice the percentage of virtually every other developed
country. While health-care costs have risen 2.5 percentage points faster
than economic growth, higher education costs have increased about 3.5
percentage points faster than GDP growth for the last several decades.
Exploding higher education costs have caused real student loan debt to more
than double in a decade.
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Government support through Pell Grants and other student assistance has
risen, but cost increases have outpaced public investment in financial aid.
Reasons for this cost growth include the knowledge-based global economy and
rising aspirations creating a seller's market for college; an "arms race"
among colleges to have the fanciest facilities; and weak financial
accountability and few incentives for controlling costs.
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The problem would be bad enough if it were just a matter of cost. But it's
not. Not long ago, the United States was arguably tops in both higher
education and health care. No more. To make matters worse, a nation whose
cherished ideals of equality were advanced immeasurably during the 20th
century by the diffusion of high-quality health care and higher education
now has become troublingly inequitable in both.
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The World Health Organization reports that about three dozen other nations
have better aggregate health-care outcomes than America, and the RAND
Corporation finds that barely half the treatments Americans receive are
considered "best practices." Similarly, the United States is no longer the
world leader in college access, and is in the bottom half in Organization
for Economic Cooperation and Development rankings in college completion
rates and 10th in the proportion of its 25-to-35-year-old population that is
college-educated.
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Higher education increasingly reflects and reinforces inequities in American
society. Large gaps in college access associated with race and income have
not narrowed for decades. The wealthy can afford Ivy League tuitions, the
upper middle class falls into debt to attend flagship state universities,
the lower middle class also borrows heavily to enroll in regional state
colleges and community colleges, and poor Americans simply lack college
opportunity. What's more, the quality of much of higher education itself has
declined, sliding behind both earlier U.S. standards and those of many other
countries.
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At the same time, nearly 50 million Americans lack health insurance, tens of
millions have limited medical coverage, and millions more may lose coverage
due to the current economic crisis. Access to good care varies tremendously
by income. A sizable population faces the triple whammy of inadequate
insurance coverage, poor health behaviors, and lower-quality health
providers - compared to a decently covered middle class and a
health-conscious elite with access to the world's best medicine. This has
created a trifurcation of American health care equivalent to a beat-up
Chevy, a new Toyota and a Rolls-Royce.
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Few Americans are satisfied with their medical care. The once-friendly and
admired image of a selfless corps of Marcus Welbys has given way to a more
widespread belief that doctors, hospitals, and pharmaceutical companies are
greedy, insensitive, incompetent and dishonest.
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Likewise, three-fourths of Americans are worried about college costs and
debt. Barely half think that students get a valuable return on higher
education. Half believe that colleges "mainly care about the bottom line."
And three-fifths think that talented students lack the opportunity to attend
college; among African-Americans and Hispanics the proportions are even
higher.
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The danger to a prosperous, optimistic American future is enormous. Serious
cost control, accountability for high-quality outcomes, and greater equity
are desperately needed. Systemic overhaul of health care and higher
education requires an outcry from the public and the business community, as
well as political champions who understand that larger public subsidies
without substantial reforms will not suffice; greater engagement by
health-care and higher-education leaders; and public-policy intervention
that recognizes the failure of market mechanisms to yield quality,
affordability and access.
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Higher education needs substantial rethinking about delivery and financing.
Can online instruction be adapted and broadened to strengthen learning and
reduce costs? Can colleges work collectively with high schools to identify
readiness standards? Can transfer of credits among two- and four-year
colleges become seamless, reducing costly and redundant course repetition?
Can state finance and accountability systems increase college access and
completion? Do four-year colleges need to look like swank corporate
conference centers? And should scarce financial aid now used to compete for
gifted - but less needy - students be refocused to qualified students
strapped for resources?
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How to control health-care costs is an even tougher nut to crack. Universal
insurance - with government premium support, combined with some "managed
competition" among insurance providers and greater cost-sharing - are
important. Increased regulation of health-care providers and their costs,
greater emphasis on public health and prevention, medical malpractice
reform, some rationing of care, and use of information technology to
disseminate best and most-cost-effective practices and maintain a national
medical records database also could help.
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Without such changes, even with additional public investments proposed by
President-elect Barack Obama and others, America will be less and less
likely to be healthy, wealthy or wise.
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Andrew L. Yarrow, vice president and Washington director of Public Agenda,
is author of the new book, "Forgive Us Our Debts: The Intergenerational
Dangers of Fiscal Irresponsibility" and teaches U.S. history at American
University. His e-mail is ayarrow@publicagenda.org. Patrick M. Callan is
president of the National Center for Public Policy and Higher Education.
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Copyright © 2009, The Baltimore Sun
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We All Want Longer, Healthier Lives. But It's Going to Cost Us.
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By David Brown
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Washington Post
Commentary
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Sunday, January 11, 2009; B01
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Over the next few months, this country will engage in the first serious
national discussion on health care in 15 years. Most of the talk will be
about ways to make medical insurance available to all U.S. citizens. There
will be a fair amount, too, about the need to make the hodgepodge "system"
of American health care safer, better and more efficient. What we're
unlikely to hear, though, is something like this:
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Arresting the growth of health care spending in the United States is
impossible. The policies and programs we're suggesting will either
accelerate the upward trend or slow it temporarily, but they won't stop it.
Health care costs will go up year by year until you die, and probably until
your children die, too.
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This difficult truth, which has emerged over the past half-century, is
leading the United States and the rest of the industrialized world into a
new era of humankind.
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We are on a collision course between our wish to live longer, healthier
lives and our capacity to pay for that wish. Whether we can somehow avoid
the collision is perhaps the most important domestic issue of this century.
From now on, health care costs will be up there with globalization,
terrorism and climate change as a force shaping our world.
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For most of recorded history, food production was the chief goal of human
labor. In the United States, that time is long gone. We spend a little less
than 10 percent of our income on food, down from 25 percent in 1930. We
spend twice as much -- 21 percent -- on shelter. But health care -- that's
where we really get our wallets out.
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Last year, 16 percent of the nation's gross domestic product went for health
care, about $7,600 per person. In terms of human effort, health care is the
new food. By 2016, when it reaches 20 percent of GDP, it will be the new
shelter. If it grows at its present rate through the first three-quarters of
this century, it will consume 38 percent of GDP by 2075. It will then be the
new food and shelter.
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This isn't a mistake. If it were, we might have a chance of stopping it.
It's success -- the way things are supposed to be, and the way we want them
to be.
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"At the end of the day, when it comes to controlling health care costs, the
enemy is us," said Drew Altman, head of the Henry J. Kaiser Family
Foundation. "Americans want the latest and best in health care technology,
and we want it down the street, and we want it now."
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Medicine lies at the intersection of two profound forces. One is the desire
to survive, which motivates all living things. The other is the ability to
make things, which distinguishes humans from other animals.
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Crowding that intersection are thousands of opportunities for avoiding or
curing an illness, feeling better, living longer and being happier than our
grandparents ever could have imagined. These opportunities take the form of
implantable defibrillators, replacement knees, periodic colonoscopies,
weight-loss surgery, life-long antidepressants, anti-retroviral medicines,
breast tumor gene scans, biologically targeted chemotherapy, heart-lung
transplants and prenatal tests for dozens of dread diseases.
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These are just a few of the fruits of our desire to survive and our capacity
to create -- and there's lots, lots more right around the corner.
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All these things, of course, haven't come for free. Health care spending has
grown faster than the economy, by an average of 2 to 3 percent a year, at
least since the end of World War II. In the first five years of this decade,
it averaged 6.9 percent a year.
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Medicare, the federal government's insurance program for the elderly and
disabled, provides an especially dramatic snapshot of health care's growing
claim on our wealth and labor. In 1970, Medicare was 0.7 percent of GDP --
70 cents of every $100 the country produced. By 2005, it was 2.7 percent.
Last year, it was 3.2 percent, according to the Medicare trustees' annual
report. In 2082, the program is projected to be 10.8 percent of GDP. Over
the past half-century, total federal income tax receipts have averaged 11
percent of GDP per year. So unless something changes, in about 75 years,
Medicare alone will cost as much as the sum of all our federal income taxes.
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This kind of growth doesn't come just from jacked-up prices, a bureaucratic
and inefficient delivery system or increasing numbers of sick and old
people. Something else has to be going on to explain such steady,
predictable, relentless growth.
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That something is innovation. Various health economists have estimated that
somewhere between 40 and more than 65 percent of the growth in per capita
health care spending since 1940 can be attributed to advances in medical
care. Each year, there's more that can be done and more that's judged worth
doing.
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And the effect has been profound. Consider heart disease, the leading cause
of death in the United States. From 1980 to 2000, deaths from heart disease
fell 40 percent. If the 1980 death rate from heart attacks had held in 2000,
about 342,000 more Americans would have died in that year alone. A team of
researchers recently calculated that 47 percent of those lives were saved by
better medical care -- involving such developments as clot-dissolving drugs,
coronary stents and medicines to prevent congestive heart failure. About 44
percent were saved because people had reduced their risk factors -- quit
smoking, lowered their cholesterol and gotten their blood pressure under
control, with many of those improvements also the effect of better drugs and
medical care.
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Two years ago, another group of researchers, led by Harvard economist David
M. Cutler, looked at the money spent on health care from 1960 to 2000 and
asked the crucial question: What did it get us? Their answer: Plenty -- but
improvements are costing more all the time.
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Their study found that over those 40 years, the life expectancy of people of
all ages had increased. Not surprisingly, investments in the health of
children were more cost-effective than investments in 60-year-olds. What's
more interesting is that extending life cost more as the 20th century
progressed, even taking inflation into account. In the 1970s, it took
$46,870 to add a year to the life expectancy of 65-year-olds. By the 1990s,
it cost $145,000.
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As we become healthier, it takes more effort to extend our lives than it did
in a time when we were less healthy (and dying prematurely). Fifty years
ago, American medicine picked the low-hanging fruit of life-extension as
clean water, vaccines, antibiotics, insulin and other cheap innovations
became available to everyone. Now, we're going after the higher and more
expensive stuff.
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Take implantable cardioverter-defibrillators, or ICDs. These "ambulances in
the chest" shock hearts out of the fatal rhythms that are a major hazard for
people who survive large heart attacks. Vice President Cheney has one wired
into his heart.
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Three years ago, a team of researchers calculated that putting an ICD into a
heart-attack survivor added one to three years to the person's life
expectancy. The cost? Between $30,000 and $70,000 for every year of life
gained. In the world of "cost-effectiveness analysis," that's judged to be
worth it, the convention being that a treatment that buys an extra year of
life for $50,000 or less is "affordable."
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Medicare estimates that about 500,000 Americans now qualify for an ICD on
medical grounds. Undreamed of when our parents and grandparents were having
heart attacks, these devices are keeping or will keep thousands alive.
Sowho's going to give one up in the interest of slowing the growth of health
care spending? Not I. And I suspect not you, either.
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Of course, there are ways to save money.
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Administrative costs consume 24 percent of health care spending, according
to one often-quoted estimate. Establishing a more unified health care system
could probably cut that in half. There is also tremendous regional variation
in medical care in the United States, so bringing everybody into line will
reduce costs.
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Then there's prevention, a favorite money-saving ace in the hole. The
trouble is that prevention also costs money. A study that got front-page
coverage nationwide in the week after the election not only demonstrates
that but also shows how much we value small improvements in health. A group
of researchers in Boston found that if you prescribe cholesterol-lowering
drugs to people whose cholesterol levels are normal but who have evidence of
mild body-wide inflammation, you can reduce their chances of developing
cardiovascular disease by about half. "It's a breakthrough study," effused
the head of cardiology at the Cleveland Clinic. "These are findings that are
really going to impact the practice of cardiology in this country," said the
head of the National Heart, Lung and Blood Institute at the National
Institutes of Health.
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What few stories pointed out was how little bang you actually get for this
prevention buck. You have to treat 95 people for two years to prevent one
"event" -- death, heart attack, stroke. At a cost of up to $1,200 a year for
the drug, Crestor, that's a big investment to make year after year to help a
few people. Given the response to the study, however, I suspect it's an
investment we'll soon start making routinely.
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Furthermore, there's little evidence that preventing disease reduces health
care costs over the long run, although it obviously extends lives and
prevents misery.
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So what's likely to happen?
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Over the short term, many experts say, there will be the sort of adjustments
that humans make whenever necessities -- food, heat, shelter -- become
scarce. We'll pay more for health care. We'll give up small things in favor
of it. We'll cut corners. We'll complain. And then we'll find other corners
to cut and reluctantly pay still more. Of course, the "we" may not include
all of us; some Americans pay little or nothing for their health care. But
as a society, we'll all pay more.
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In the longer term, however, not just the United States but the entire
industrialized world is facing a conundrum resembling a famous one of 200
years ago. In 1798, an English parson named Thomas Malthus published "An
Essay on the Principle of Population as It Affects the Future Improvement of
Society." He laid out a chilling scenario in which population growth
outstrips food production and produces a cycle of famine, catastrophic
population decline, recovery, famine and catastrophic decline, over and
over.
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This was the so-called Malthusian Spectre. It was a hugely influential --
and horribly frightening -- idea. It kept members of Parliament awake at
night. But it never came to pass because of two as-yet-undiscovered truths
that Malthus never imagined.
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The first was that scientific agriculture would eventually double, triple
and quintuple crop yields. The second was that when industrialization pulled
huge numbers of people out of poverty, infant mortality fell, women became
more educated, and the value of their labor rose. The net result was a huge
decline in birth rates. This is known as the "demographic transition," and
virtually every region of the planet has gone through it.
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We will need something like the revolution of scientific agriculture and the
demographic transition to rescue us from the Malthusian Spectre of health
care spending.
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What it might be -- ah, that's what nobody knows.
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David Brown is a medical doctor and a health and science reporter for The
Washington Post.
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© 2009 The Washington Post Company
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The Dying of the Light
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The Drawn-Out Indignities of The American Way of Death
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By Craig Bowron
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Washington Post
Commentary
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Sunday, January 11, 2009; B01
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It's January, and with the holidays behind us, here in Minnesota the deep
psychosis of winter settles in. The cold has a sharper edge; the darkness of
night seems more penetrating and brittle. We'll take the ornaments off the
tree but leave the lights on and keep watering it until it gives up its
photosynthetic ghost. The green must be cherished until life returns in
earnest in the spring.
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I'm a physician in a large hospital in Minneapolis, where I help care for
patients struggling through the winter of their lives. We've got a lively
spring unit, an obstetrical ward where fresh-faced tulips are popping up at
all hours, but that's not my specialty. As a hospitalist, I see adult
patients of all ages and complexities, most of whom make good recoveries and
return to life as they knew it. But taking care of the threadworn elderly,
those facing an eternal winter with no green in sight, is definitely the
most difficult thing I do.
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That's because never before in history has it been so hard to fulfill our
final earthly task: dying. It used to be that people were "visited" by
death. With nothing to fight it, we simply accepted it and grieved. Today,
thanks to myriad medications and interventions that have been created to
improve our health and prolong our lives, dying has become a difficult and
often excruciatingly slow process.
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Take one of my patients. She started dialysis six months ago at the tender
age of 85, and the diabetic vascular problems that put her kidneys in the
tank persist. One leg has been amputated above the knee, and several toes on
her remaining foot have succumbed to gangrene. Robbed of blood, they appear
dry, black and tenuously connected, like an ash dangling off a cigarette.
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This patient was brought in for a decreased level of consciousness and low
blood pressure, but she has been having periods of nausea, and her appetite
seems to have died with her kidneys. The initial workup revealed little,
perhaps a low-grade bladder infection, but treating it and her low blood
pressure doesn't seem to make much of a difference. She is withdrawn; food
goes into her mouth, but she won't chew and swallow unless her children
instruct her to. She intermittently refuses pills. There's a language
barrier, but her children are there to interpret for her. Translation: She
feels exhausted and weak, and she feels that way most of the time.
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This woman is suffering from what we call "the dwindles," characterized by
advancing age and illness. Although dialysis is a miraculous technology --
she'd be dead without it -- it exacts a heavy toll from someone her age or
with her medical problems. Three days a week are spent in dialysis, and the
other four are spent recovering. It is extending her life, but she's
miserable.
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Her family has designated her "full code," meaning that if her heart stopped
or she were to cease breathing, we would do CPR to revive her, even though
there would be a very slim chance of success -- and even though it would be
God's or the universe's way of giving her an easy way out.
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Another patient is in even worse shape. He's 91 and still a very big man.
When I enter his room to examine him, he seems like a giant oak felled into
a hospital bed, stiff and rigid, with swollen arthritic joints. A stroke
four months earlier paralyzed his right side and left him bed-bound and
nearly helpless, with pressure sores on his heels. He is mildly demented,
and the pain pills aren't helping. He was brought to the ER because he was
thought to be having another stroke, though these new symptoms quickly
resolved.
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Talking with this patient, I recognize his face and the Cajun accent; I'm
certain that I took care of him sometime in the past, but he is not the man
he was then. Staring at his 230 pounds stretching the length of the bed, I
wonder how difficult it must be to care for him. To transfer him to a toilet
or a chair requires the use of a Hoyer lift, a gigantic sling that's wrapped
around the patient and attached to a mobile mini-crane. Fully suspended, he
looks like a massive baby being delivered by a giant stork. The contortions
and gymnastics of getting him slung up and moved must drive him wild with
arthritic pain.
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Though I reviewed the patient's chart before going into his room, I can't
recall seeing what nursing facility he had come from. So I ask the nurse.
She tells me, unbelievably, that he has come from his home, where his son
cares for him. Later in the day I place a call to this Clark Kent, this
Superman in disguise.
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The son answers with soft echoes of his father's Louisiana brogue, and I ask
him how in the world he manages to take care of his dad. He replies that for
one, it's all he does, a full-time job, and moreover, his experiences in
Vietnam numbed him to some of the intimacies of caring for another human
being. "Once you've shoved some guy's guts back into his stomach, you know,
you can get used to the rest of it," he says.
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He tells me that his father is wearing out and that it's hard to watch. The
arthritis has become quite painful, and sometimes his dad just weeps. Some
nights he needs a couple of Vicodin to be able to sleep through the pain.
The old man is also spending a lot more time thinking about his wife, who
passed away before him. His son thinks he may be ready to die.
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Nothing in my medical training qualifies me to judge what kind of life is
satisfying or worth living. Many would say that if we were to become
paralyzed in an accident, just let us die. But many quadriplegics, once
they've gone through an initial period of adjustment, find their lives very
satisfying. Patients can and do make enormous efforts and fight precipitous
odds to get back to life as they knew it, or even just to go on living. But
the difference for many elderly is that what's waiting for them at the end
of this illness is just another illness, and another struggle.
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Another patient of mine has 86 years behind her and was brought to our
hospital from a nursing home in the wee hours of the morning. Her diabetes
has become very brittle and difficult to control; the day before, paramedics
were called because her blood sugar had dipped so low that she was becoming
unresponsive. She also has dementia, and a couple of months ago, she fell
and broke a hip. Although it was repaired and she completed rehabilitation,
she has wound up essentially bedridden. Strictly speaking, losing your mind
won't kill you: It's the falling, the choking, the weakness, the bed sores.
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This patient was brought in because the nursing home staff thought that she
might have aspirated some food or secretions and developed pneumonia. She
thinks it's 1982 and is, as we say, "pleasantly confused." She denies any
and all symptoms, and her breathing looks comfortable. A review of her chart
shows no fever and a normal white blood cell count. Her chest X-ray shows
perhaps a subtle pneumonia but also a compression fracture of one of her
vertebrae, which has gone from being 50 percent to 90 percent collapsed. Her
dementia has mercifully spared her a lot of pain from the fracture, but it
also keeps her from recognizing members of her extended family. Sometimes
she doesn't recognize her own son, who drove to the hospital to be with her
at this early hour.
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He and I discuss what brought her in, and then we talk about her code
status, which he confirms is Do Not Resuscitate. "She wasn't supposed to be
brought to the hospital in the first place," the son tells me, and puzzled,
I ask him to say that again. She was never supposed to be hospitalized:
Whatever troubles arrived, the plan was to deal with them in the nursing
home. His mother had made that decision herself, several years prior to this
hospitalization, before the dementia really set in.
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Later that day, I meet with the son and a few other close family members.
They want to continue the medications that would bring their mother comfort
and discontinue all the rest. They aren't looking to end her life, but they
aren't looking to prolong it, either. They can see that she is moving away
from them in both body and mind, and they are ready to let her go.
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To be clear: Everyone dies. There are no life-saving medications, only
life-prolonging ones. To say that anyone chooses to die is, in most
situations, a misstatement of the facts. But medical advances have created
at least the facade of choice. It appears as if death has made a
counter-offer and that the responsibility is now ours.
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In today's world, an elderly person or their family must "choose," for
example, between dialysis and death, or a feeding tube and death. Those can
be very simple choices when you're 40 and critically ill; they can be
agonizing when you're 80 and the bad days outnumber the good days two to
one.
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It's not hard to identify one of these difficult cases in the hospital.
Among the patient-care team -- nurses, physicians, nursing assistants,
physical and occupational therapists, etc. -- there is often a palpable
sense of "What in the world are we doing to this patient?" That's "to" and
not "for." We all stagger under the weight of feeling complicit in a
patient's torture, but often it's the nurses who bear most of that burden,
physically and emotionally. As a nurse on a dialysis floor told me, "They'll
tell us things that they won't tell the family or their physician. They'll
say, 'I don't want to have any more dialysis. I'm tired of it,' but they
won't admit that to anyone else."
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This sense of complicity is what makes taking care of these kinds of
patients the toughest thing I do. A fellow physician told me, "I feel like I
am participating in something immoral." Another asked, "Whatever happened to
that 'do no harm' business?"
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If we can be honest and admit that we have no choice about dying, then the
only thing we do have a say in are the circumstances. Like many nursing home
patients, Dorothy was on the cholesterol-lowering medication Lipitor. Why?
So that she wouldn't die of a heart attack or a stroke. But don't we all die
of something?
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Everyone wants to grow old and die in his or her sleep, but the truth is
that most of us will die in pieces. Most will be nibbled to death by
piranhas, and the piranhas of senescence are wearing some very dull
dentures. It can be a torturously slow process, with an undeniable end, and
our instinct shouldn't be to prolong it. If you were to walk by a
Tilt-A-Whirl loaded with elderly riders and notice that all of them were
dizzy to the point of vomiting, wouldn't your instinct be to turn the ride
off? Or at the very least slow it down? Mercy calls for it.
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This isn't about euthanasia. It's not about spiraling health care costs.
It's about the gift of life -- and death. It is about living life and death
with dignity, and letting go.
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In the past, the facade of immortality was claimed by Egyptian kings,
egomaniacal monarchs and run-of-the mill psychopaths. But democracy and
modern medical advances have made the illusion accessible to everyone. We
have to rid ourselves of this distinctly Western notion before our nation's
obesity epidemic and the surge of aging baby boomers combine to form a
tsunami of infirmity that may well topple our hospital system and wash it
out to sea.
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At some point in life, the only thing worse than dying is being kept alive.
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Craig Bowron is a hospital-based internist and a writer in St. Paul, Minn.
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© 2009 The Washington Post Company
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