Archive for the ‘Gawande’ Category

Gawande and Kristof

May 31, 2007

Dr. Gawande says the ultimate measure of leadership is to take a health plan and persuede people to find common ground in it.  Mr. Kristof is in Weihai, China, writing on the rule of law in China.  Here’s Dr. Gawande:

As a surgeon, I’ve worked with the veterans’ health system, Medicare, Medicaid and private insurance companies. I’ve seen health care in Canada, Britain, Switzerland and the Netherlands. And I was in the Clinton administration when our plan for universal coverage failed. So, with a new health reform debate under way, what I want to tell you in my last guest column is this:

First, there is not a place in this world that is not struggling to control health costs while providing high-quality, easily accessible care. No one — no one — has a great solution.

But second, whether as a doctor or as a citizen, I would take almost any system — from Medicare-for-all to a private insurance voucher system — over the one we now have. Job-based insurance is bleeding away the viability of American businesses — even doctors complain about the cost of insuring employees. And it has left large numbers of patients without adequate coverage when they need it. In the last two years, for example, 51 percent of Americans surveyed did not fill a prescription or visit a doctor for a known medical issue because of cost.

My worry is less about what happens if we change than what happens if we don’t.

This week, Barack Obama released his health reform plan. It’s a puzzle how you are supposed to regard presidential candidates’ proposals. They are treated, by campaigns and media alike, as some kind of political G.P.S. device — gadgets primarily for political positioning. So this was how Mr. Obama’s plan was reported: it is a lot like John Edwards’s plan and the Massachusetts plan signed into law by Mitt Romney last year; and it has elements of John Kerry’s proposal from four years ago. In other words — ho hum — another centrist plan. No one except policy wonks will tell the proposals apart from one another.

Well, all this may be true. And if what you care about is which candidate can one-up the others, it is rather disappointing. But if what you care about is whether, after the 2008 election, we’ll be in a position to finally stop the health systems’ downward spiral, the similarity of the emerging proposals is exactly what’s interesting. I don’t think you can call it a consensus, but there is nonetheless a road forward being paved and a growing number of people from across the political spectrum are on it — not just presidential candidates, but governors from California to Pennsylvania, unions and businesses like Safeway, ATT and Pepsi.

This is what that road looks like. It is not single-payer. It instead follows the lead of European countries ranging from the Netherlands to Switzerland to Germany that provide universal coverage (and more doctors, hospitals and access to primary care) through multiple private insurers while spending less money than we do. The proposals all define basic benefits that insurers must offer without penalty for pre-existing conditions. They cover not just expensive sickness care, but also preventive care and cost-saving programs to give patients better control of chronic illnesses like diabetes and asthma.

We’d have a choice of competing private plans, and, with Edwards and Obama, a Medicare-like public option, too. An income-related federal subsidy or voucher would help individuals pay for that coverage. And the proposals also embrace what’s been called shared responsibility — requiring that individuals buy health insurance (at minimum for their children) and that employers bigger than 10 or 15 employees either provide health benefits or pay into a subsidy fund.

It is a coherent approach. And it seems to be our one politically viable approach, too. No question, proponents have crucial differences — like what the individual versus employer payments should be. And attacks are certain to label this as tax-and-spend liberalism and government-controlled health care. But these are not what will sabotage success.

Instead, the crucial matter is our reaction as a country when the attacks come. If we as consumers, health professionals and business leaders sit on our hands, unwilling to compromise and defend change, we will be doomed to our sliding global competitiveness and self-defeating system. Avoiding this will take extraordinary political leadership. So we should not even consider a candidate without a plan capable of producing agreement.

The ultimate measure of leadership, however, is not the plan. It is the capacity to take that plan and persuade people to find common ground in it. The politician who can is the one we want.

Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of the new book “Better.” He has been a guest columnist this month.

Here’s Mr. Kristof:

Every evening in a little village near this coastal city, peasants gather in a private home and do something that used to be dangerous. They pray.

They are Christians gathering in a little “house church,” reflecting a religious boom across China. But their story also underscores another trend: the way the legal system here offers hope of chipping away at the Communist Party dictatorship.

The tale begins a year ago when the authorities here in Shandong Province raided this house church and carted 31 Christians off to the police station. Such crackdowns are the traditional way the Communist Party has dealt with house churches in rural areas, and some Christians have even been tortured to death.

But this incident ended differently.

Tian Yinghua, a 55-year-old evangelical Protestant who runs the church in her living room, was outraged after she was ordered jailed for 10 days.

“We had done nothing wrong at all,” explained Ms. Tian. “We weren’t criminals.”

So Ms. Tian contacted a prominent Christian and legal scholar in Beijing, Li Baiguang, who traveled to Shandong Province to do something that once would have been unthinkable: Sue the police.

Even more unthinkable, Ms. Tian won. The police settled the case by withdrawing the charges. The police also formally apologized, paid symbolic damages of 1 yuan (a bit more than a dime) and promised not to bother the church again.

It was a historic victory for freedom of religion in China — and, even more important, for the rule of law.

“The police don’t bother us at all,” said another church leader, Wang Qiu. “They just stay away.”

That seems to be a growing pattern. The central government’s policy toward religion is much more relaxed than a few years ago, and in coastal areas the government usually lets people worship freely.

“In most places, it’s no problem today,” said Mr. Li, who himself was imprisoned for more than a month two years ago for his legal activism. “It’s just a problem in backward areas, or if you directly attack the Communist Party.”

Mr. Li, who enjoys a bit of protection because President Bush invited him to the White House last year, says that last year he filed suits like this one in eight provinces. The other he lost, but even in those cases the authorities were shaken enough that they have stopped harassing Christians, he says.

“On the surface we lost,” he said. “But in reality, we won in every case.”

Han Dongfang, a Chinese labor activist now exiled to Hong Kong, says that he has also found that suing the authorities is often an effective way to increase labor protections. Mr. Han was a leader in the Tiananmen protests of 1989, but now he is trying to bring about change from within. “I believe this is the way to develop a civil society, not through a revolution,” he said.

Of course, the legal system is still routinely used to oppress people, rather than to protect them. China imprisons more journalists than any country in the world, and one of them is my Times colleague Zhao Yan. Judges never go against the Communist Party; what they can do is rectify local injustices where the higher party officials are indifferent.

Moreover, even when lawsuits are allowed to go forward, many Chinese police and judges are so corrupt that they sell themselves to the highest bidder.

A common saying, which I even saw in an illegal poster pasted on a government building in Beijing, goes: “The bandits used to hide in the hills. Now the bandits are in the courthouses.”

Still, the rule of law has gained immensely since the 1980’s, when a defense attorney was imprisoned for having the temerity to claim that the police had arrested the wrong man and that his client was innocent. If the Chinese government continues to nurture the rule of law, China could increasingly follow the path of South Korea and Taiwan away from autocracy toward greater democracy.

Easing the repression could also change the religious complexion of China. Estimates of the number of Chinese Christians vary widely, but the number may be approaching 100 million, many of them evangelical Protestants who aggressively recruit new believers. And with the more relaxed policy, the numbers are soaring.

“In 20 to 30 years China will have several hundred million believers,” said Mr. Li, the lawyer who helped the Shandong church. “That will make China the biggest Christian nation in the world, with more Christians than the entire U.S. population.”

You are invited to comment on this column at Mr. Kristof’s blog, www.nytimes.com/ontheground.

Gawande and Herbert

May 26, 2007

Dr. Gawande looks at the health care news from the four weeks he’s been a guest columnist, and Mr. Herbert says it’s time for the police to stop harassing minority people going about their daily business.  Here’s Dr. Gawande:

This is my fourth week as a guest columnist. Let’s take a look at the health care news that’s transpired in that time.

First, DaimlerChrylser sold off 80 percent of its Chrysler division for three pebbles and a piece of string. O.K., the cash payment was actually $1.35 billion. But for an 82-year-old company that built more than two million cars and trucks last year, took in $47 billion in revenue, and owns 64 million square feet of factory real estate in North America alone, that’s almost nothing. Yet analysts say that it was a great deal for Daimler. Why? Because the buyer, Cerberus Capital Management, agreed to absorb Chrysler’s $18 billion in health and pension liability costs.

Stop and think about this for a minute. The deal meant that the costs of our job-based health insurance system — costs adding $1,500 to each car Chrysler builds here, but almost nothing to those built in Canada or Europe — have so broken the automaker’s ability to compete that giving it away became the smartest thing Daimler could do. Chrysler’s mistake was to hang around long enough to collect retirees and an older-than-average work force. As a result, it now has less market value than Men’s Wearhouse, Hasbro, the Cheesecake Factory, NutriSystem, Foot Locker and Pottery Barn. Oprah is worth more than Chrysler. This is not good.

Meanwhile, officials at West Jefferson Medical Center outside New Orleans reported that the number of indigent patients admitted there has tripled since Hurricane Katrina. The uninsured are now 30 percent of their emergency room patients. Officials in Houston hospitals are reporting similar numbers. Conditions seem worse rather than better. Katrina caused a vicious spiral. Large numbers of people lost their jobs and, with them, their health coverage. Charity Hospital, the one state-funded hospital in New Orleans, closed. The few open hospital emergency rooms in the area have had to handle the load, but it’s put the hospitals in financial crisis. Four hundred physicians filed a lawsuit against the state seeking payment for uncompensated care, and massive numbers of doctors and nurses have left the area.

In Washington, a conference held by the American College of Emergency Physicians revealed that New Orleans may have it worst, but emergency rooms everywhere are drowning in patients. Mandated to care for the uninsured, they are increasingly unprofitable. So although the influx of patients has grown, 500 emergency rooms have closed in the last decade. The result: 91 percent report overcrowding — meaning wait times for the acutely ill of more than an hour or waiting rooms filled more than six hours per day. Almost half report this occurring daily.

A few days later, the Commonwealth Fund released one of the most detailed studies ever done comparing care in the United States, Australia, Canada, Germany, New Zealand and Britain. We’ve known for awhile that health care here is more expensive than anywhere and that our life expectancy is somehow shorter. But the particulars were the surprise.

On the good side, the study found that once we get into a doctor’s office, American patients are as likely as patients anywhere to get the right care, especially for prevention. Only Germans have a shorter wait for surgery when it’s needed. And 85 percent of Americans are happy with the care they get.

But we also proved to be the least likely to have a regular doctor — and starkly less likely to have had the same doctor for five years. We have the hardest time finding care on nights or weekends outside of an E.R. And we are the most likely (after Canadians) to wait six days or more for an appointment when we need medical attention. Half of Americans also reported forgoing medical care because of cost in the last two years, twice the proportion elsewhere.

None of this news, however, did more than lift a few eyebrows. So this is the picture of American health care you get after watching for a few weeks: it’s full of holes, it’s slowly bankrupting us and we’re kind of used to it.

That leaves two possibilities: (1) We’ve given up on the country; or (2) we’re just waiting for someone else to be in charge.

I’m pulling for No. 2.

Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of the new book “Better.” He is a guest columnist this month.

Here’s Mr. Herbert:

No one is paying much attention, but parts of New York City are like a police state for young men, women and children who happen to be black or Hispanic. They are routinely stopped, searched, harassed, intimidated, humiliated and, in many cases, arrested for no good reason.

Most black elected officials have joined their white colleagues and the media in turning a blind eye to this continuing outrage. And many black cops have joined their white colleagues in the systematic mistreatment.

Last Monday in the Bushwick section of Brooklyn, about three dozen grieving young people on their way to a wake for a teenage friend who had been murdered were surrounded by the police, cursed at, handcuffed and ordered into paddy wagons. They were taken to the 83rd precinct stationhouse, where several were thrown into jail.

Leana Matia, an 18-year-old student at John Jay College, was one of those taken into custody. “We were walking toward the train station to take the L train when all these cops just swooped in on us,” she said. “They cursed us out and pushed the guys. And then they handcuffed us. We kept asking, ‘What are you doing?’ ”

Children as young as 13 were among those swept up by the cops. Two of them, including 16-year-old Lamel Carter, were the children of police officers. Some of the youngsters were carrying notes from school saying that they were allowed to be absent to attend the wake. There is no evidence that I’ve been able to find — other than uncorroborated statements by the police — that the teenagers were misbehaving in any way.

Everyone was searched, but nothing unlawful was found — no weapons, no marijuana or other drugs. Some of the kids were told at the scene that they were being seized because they had assembled unlawfully. “I didn’t know what unlawful assembly was,” said Kumar Singh, 18, who was among those arrested.

According to the police, the youngsters at the scene were on a rampage, yelling and blocking traffic. That does not seem to be the truth.

I spoke individually to several of the youngsters, to the principal of Bushwick Community High School (where a number of the kids are students), to a parent who was at the scene, and others. Nowhere was there even a hint of the chaos described by the police. Every account that I was able to find described a large group of youngsters, very sad and downcast about the loss of their friend, walking peacefully toward the station.

Kathleen Williams, whose son and two nieces were rounded up, was at the scene. She said there was no disturbance at all, and that when she tried to ask the police why the kids were being picked up, she was told to be quiet or she would be arrested, too.

Capt. Scott Henderson of the 83rd Precinct told me that the police had developed a “plan” to deal with youngsters going to the wake because they suspected that the murder was gang-related and there had already been some retaliation. He said he had personally witnessed the youngsters in Bushwick behaving badly and gave the order to arrest them.

Many of the kids were wearing white T-shirts with a picture of the dead teenager and the letters “R.I.P.” on them. The cops cited the T-shirts as evidence of gang membership.

Thirty-two of the youngsters were arrested. Most were charged with unlawful assembly and disorderly conduct. Several were held in jail overnight.

Police Commissioner Ray Kelly did not exactly give the arrests a ringing endorsement. He said, in a prepared statement, “A police captain who witnessed the activity made a good-faith judgment in ordering the arrests.”

A spokesman for the Brooklyn district attorney, Charles Hynes, said, “It wouldn’t be unusual for a lot of this stuff to get dismissed.”

The principal of Bushwick Community High, Tira Randall, said, “My kids come in here on a daily basis with stories about harassment by the police. They’re not making these stories up.”

New York City cops stopped and, in many cases, searched individuals more than a half million times last year. Those stops are not happening on Park Avenue or Fifth Avenue in Manhattan. Thousands upon thousands of them amount to simple harassment of young black and Hispanic males and females who have done absolutely nothing wrong, but feel helpless to object.

It is long past time for this harassment of ethnic minorities by the police to cease. Why it has been tolerated this long, I have no idea.

Gawande and Kristof

May 24, 2007

Dr. Gawande on rethinking old age, and Mr. Kristof says that China has thrived thanks to “traditional American values.”  Here’s Dr. Gawande:

At some point in life, you can’t live on your own anymore. We don’t like thinking about it, but after retirement age, about half of us eventually move into a nursing home, usually around age 80. It remains your most likely final address outside of a hospital.

To the extent that there is much public discussion about this phase of life, it’s about getting more control over our deaths (with living wills and the like). But we don’t much talk about getting more control over our lives in such places. It’s as if we’ve given up on the idea. And that’s a problem.

This week, I visited a woman who just moved into a nursing home. She is 89 years old with congestive heart failure, disabling arthritis, and after a series of falls, little choice but to leave her condominium. Usually, it’s the children who push for a change, but in this case, she was the one who did. “I fell twice in one week, and I told my daughter I don’t belong at home anymore,” she said.

She moved in a month ago. She picked the facility herself. It has excellent ratings, friendly staff, and her daughter lives nearby. She’s glad to be in a safe place — if there’s anything a decent nursing home is built for, it is safety. But she is struggling.

The trouble is — and it’s a possibility we’ve mostly ignored for the very old — she expects more from life than safety. “I know I can’t do what I used to,” she said, “but this feels like a hospital, not a home.” And that is in fact the near-universal reality.

Nursing home priorities are matters like avoiding bedsores and maintaining weight — important goals, but they are means, not ends. She left an airy apartment she furnished herself for a small beige hospital-like room with a stranger for a roommate. Her belongings were stripped down to what she could fit into the one cupboard and shelf they gave her. Basic matters, like when she goes to bed, wakes up, dresses, and eats were put under the rigid schedule of institutional life. Her main activities have become bingo, movies, and other forms of group entertainment. Is it any wonder most people dread nursing homes?

The things she misses most, she told me, are her friendships, her privacy, and the purpose in her days. She’s not alone. Surveys of nursing home residents reveal chronic boredom, loneliness, and lack of meaning — results not fundamentally different from prisoners, actually.

Certainly, nursing homes have come a long way from the fire-trap warehouses they used to be. But it seems we’ve settled on a belief that a life of worth and engagement is not possible once you lose independence.

There has been, however, a small band of renegades who disagree. They’ve created alternatives with names like the Green House Project, the Pioneer Network, and the Eden Alternative — all aiming to replace institutions for the disabled elderly with genuine homes. Bill Thomas, for example, is a geriatrician who calls himself a “nursing home abolitionist” and built the first Green Houses in Tupelo, Miss. These are houses for no more than 10 residents, equipped with a kitchen and living room at its center, not a nurse’s station, and personal furnishings. The bedrooms are private. Residents help one another with cooking and other work as they are able. Staff members provide not just nursing care but also mentoring for engaging in daily life, even for Alzheimer’s patients. And the homes meet all federal safety guidelines and work within state-reimbursement levels.

They have been a great success. Dr. Thomas is now building Green Houses in every state in the country with funds from the Robert Wood Johnson Foundation. Such experiments, however, represent only a tiny fraction of the 18,000 nursing homes nationwide.

“The No. 1 problem I see,” Dr. Thomas told me, “is that people believe what we have in old age is as good as we can expect.” As a result, families don’t press nursing homes with hard questions like, “How do you plan to change in the next year?” But we should, if we want to hope for something more than safety in our old age.

“This is my last hurrah,” the woman I met said. “This room is where I’ll die. But it won’t be anytime soon.” And indeed, physically she’s done well. All she needs now is a life worth living for.

Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of the new book “Better.” He is a guest columnist this month.

Here’s Mr. Kristof, writing from Dongguan, China:

This is a city you’ve probably never heard of, yet it has a population of 10 million people who fill your dressers and closets. By one count, 40 percent of the sports shoes sold in the U.S. come from Dongguan.

Just one neighborhood within Dongguan, Dalang, has become the Sweater Capital of the World. Dalang makes more than 300 million sweaters a year, of which 200 million are exported to the U.S.

Keep towns like this in mind when American protectionists demand sanctions, after the latest round of talks ending yesterday made little progress. Some irresponsible Democrats in Congress would have you believe that China’s economic success is simply the result of currency manipulation, unfair regulations and pirating American movies.

It’s true that China’s currency is seriously undervalued. But places like Dongguan have thrived largely because of values we like to think of as American: ingenuity, diligence, entrepreneurship and respect for markets.

The people in Dalang, the Sweater Capital, used to be farmers, until a Hong Kong investor opened a sweater factory at the dawn of the 1980’s. After a few years, the workers began to quit and open their own factories, and both the bosses and the staff work dizzyingly hard. One factory worker here in Guangdong Province told me that she works 12-hour shifts, seven days a week, 365 days a year, not even taking time off for Chinese New Year. She chooses to work these hours to gain a better life for her son. If protectionists want somebody to criticize for China’s trade success, blame that woman and millions like her.

Remember that China isn’t like 1980s Japan, which had a sustained huge surplus with nearly everybody. China’s global surplus has surged in the last five years, but traditionally its global trade position has been close to a balance, and it still has a trade deficit with many countries.

China imports components, does the low-wage assembly, and then exports the finished products to the U.S. — so the whole value appears in the Chinese trade surplus with the U.S., even though on average 65 percent of the value was imported into China. When a Chinese-made Barbie doll sells in the U.S. for $9.99, only 35 cents goes to China.

Sure, China pirates movies and software — but the U.S. was even worse at this stage of development (when we used to infuriate England by stealing its literary properties without paying royalties). Pirated DVDs are sold openly on the streets of Manhattan, while sellers in China can be far more creative. A couple of days ago, I dropped into a small DVD shop in Beijing to check its wares. Everything seemed legal.

Then the two saleswomen asked if I wanted to see American movies — and tugged at a bookshelf, which rolled forward on wheels. Behind was a door; one of the saleswomen whisked me into a secret room full of pirated DVDs. That’s piracy — but also capitalism at its harshest and hungriest. There are plenty of reasons to put pressure on China, including its imprisonment of journalists and its disgraceful role in supplying the weaponry used to commit genocide in Darfur. But whining about the efficiency of Chinese capitalism is beneath us.

All that said, the Chinese development model is running out of steam.

Labor shortages are growing and pushing up wage costs. Factories are having to spend more money to improve worker safety and curb pollution. The environment is such a disaster that 16 of the world’s most polluted cities are now in China.

China will also be forced to appreciate its undervalued currency, further pushing up costs. The “China price” will no longer be the world’s lowest, and millions of jobs making T-shirts and stuffed toys will move to lower-wage countries like Vietnam and Bangladesh.

So if China is going to continue its historic rise, it will have to move up the technology ladder and shift to domestic consumption as its economic engine. Yet the share of consumption in China’s economy has fallen significantly since 2000.

So as one who has been profoundly optimistic about China for the last 25 years, I think it’s time to sober up. President Hu Jintao is China’s least visionary leader since Hua Guofeng 30 years ago, and China has the burden of unusually weak leadership as it navigates a transition to a new economic model as well as a political transition to a more open society.

I’m betting China will pull it off, but I don’t think the world appreciates the risks and challenges ahead.

You are invited to comment on this column at Mr. Kristof’s blog, www.nytimes.com/ontheground. Also, Mr. Kristof has been filing regular video reports from his journey across China. The latest video, “Factory of the World,” is from his visit to a sweatshop in Guangdong Province.

Gawande and Herbert

May 19, 2007

Dr. Gawande does a piece on sex ed, with the four facts that everyone needs to know about sex and contraception, and Mr. Herbert writes about being young, ill and uninsured.  Here’s Dr. Gawande:

One statistic seems to me to give the lie to all the rhetoric about abortion, and it’s this: one in three women under the age of 45 have an abortion during their lifetime. One in three. All politicians — Democrat and Republican — say they want to make abortion at least rare (as Giuliani did in Wednesday’s debate). On, this they could reach agreement. But it’s clear they haven’t been serious; the U.S. has 1.3 million abortions a year.

Reducing unintended pregnancy is the key — half of pregnancies are unintended, and 4 in 10 of them end in abortion. For a while now, we’ve had solid evidence about how to effectively do this. But it requires getting specific about two subjects that are perilous in politics: sex and contraception. That, politicians won’t do. So let me try to help with four facts everyone needs to know.

Fact one is that, with children, parents do matter. Reviews of multiple studies have shown that parents who maintain a close relationship with their teenage children, monitor them carefully, and send a certain message about sex actually do reduce unintended pregnancies. That message, when most effective, is neither permissive about sex nor focused only on abstinence, but instead combines two components. First, it emphasizes throughout high school that teenagers should wait until they’re older to have sex (because the majority regret not waiting; because having a child as a child wrecks their lives); and second, it makes it clear that when they ultimately have sex, they should always use protection.

More children are, in fact, getting this message. Pregnancies at age 15 to 17 are down 35 percent since 1995, according to federal data; one-fourth of the drop is from delaying sex, and three-fourths is from increased use of contraceptives. Today, just 7 percent of abortions occur in minors.

Fact two follows from this: Abortion is mainly an adult problem. Forty-five percent of abortions occur in adults ages 18 to 24; 48 percent occur after age 25. Most are in women who have already had a child. The kids are all right. We are the issue.

Fact three is that our biggest problem is not using contraception properly: 92 percent of abortions occur in women who said they used birth control. Six in 10 used contraception the month they got pregnant. The others reported that they had used birth control previously but, for one reason or another, not that month. (Many, for example, say they didn’t expect to have sex.) The trouble appears to be blindness to how easy it is to get pregnant and what it takes to make birth control really work.

Oral contraceptive pills, for example, are nearly 100 percent effective when used consistently. But in the real world, they fail 8 percent of the time — that is, 8 in 100 women on the pill get pregnant in a year. The lower dose hormone formulations used nowadays have fewer side effects, but missing a dose by even six hours puts a woman at serious risk. (One should add condoms for that whole month, experts say.) Miss two days and one is effectively not on birth control at all. Anyone prone to missing really needs to consider switching methods.

Birth control requires constancy, and most people overestimate how constant they can be. Fifteen percent of women who rely only on condoms get pregnant in a year, largely from inconsistency in using them. Withdrawal is even more dicey — it has a 25 percent failure rate.

The most effective methods are long-lasting: I.U.D.’s are safe and nearly 100 percent effective in actual practice. So is Implanon (the under-the-skin implant which replaced Norplant) and surgical contraception. But no method is perfect. Each has downsides — costs, risks, side effects. Every woman must weigh them. A few good Web sites have the details. WebMD is one, for example. But this is where you come to the last fact.

Fact four: you have to educate yourself. The details matter. An effective national campaign would provide the details — on television, on billboards — and actively use what evidence shows works best to cut our massive rate of unwanted pregnancies. But politics precludes this. There’s not going to be such a campaign anytime soon.

Nonetheless, there’s no reason you have to join the one in three — or as a male, contribute to it. You just have to understand: the effort is strictly Do-It-Yourself.

Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of the new book “Better.” He is a guest columnist this month.

Here’s Mr. Herbert:

Fourteen-year-old Devante Johnson deserved better. He was a sweet kid, an honor student and athlete who should be enjoying music and sports and skylarking with his friends at school. Instead he’s buried in Houston’s Paradise North Cemetery.

Devante died of kidney cancer in March. His mother, Tamika Scott, believes he would still be alive if bureaucrats in Texas hadn’t fouled up so badly that his health coverage was allowed to lapse and his cancer treatment had to be interrupted.

Ms. Scott, who has multiple sclerosis, understood the grave danger her son would be in if he were somehow to be left without the Medicaid coverage that paid for his chemotherapy, radiation and other treatment. She submitted the required paperwork to renew the coverage two months before the deadline.

“I was so anxious to get it processed,” she said, “so we wouldn’t have a lapse of coverage.”

In Texas, as in many other states, there is a concerted effort to undermine programs that bring government-sponsored health care to poor and working-class children. It is not an environment in which bureaucrats are encouraged to be helpful, not even when lives are at stake.

“They kept losing the paperwork,” Ms. Scott told me, her voice quivering with grief. She submitted new applications, made dozens of phone calls and sent off a blizzard of faxes. Despite her frantic efforts, the coverage was dropped.

When the coverage lapsed, the treatment Devante had been receiving ceased. “They put us on clinical trials,” Ms. Scott said. “They changed his medicine, and he started getting sicker and sicker. After awhile it was like his body was so frail and he was so weak he could barely walk on his own.”

Four months after the Medicaid coverage lapsed, the mistakes were finally corrected and the coverage was reinstated. By then, there was no chance to save Devante.

“I believe he would be with me now if they hadn’t let his insurance lapse,” said Ms. Scott.

Across America children by the millions are being denied the health care they need and deserve — and some are dying — because the U.S. has no coherent system of health coverage for children.

Stories like Devante Johnson’s are not unusual. Three months ago a homeless seventh grader in Prince George’s County, Maryland, died because his mother could not find a dentist who would do an $80 tooth extraction. Deamonte Driver, 12, eventually was given medicine at a hospital emergency room for headaches, sinusitis and a dental abscess.

The child was sent home, but his distress only grew. It turned out that bacteria from the abscessed tooth had spread to his brain. A pair of operations and eight subsequent weeks of treatment, which cost more than a quarter of a million dollars, could not save him. He died on Feb. 25.

There’s a presidential election under way and one of the key issues should be how to provide comprehensive health coverage for all of the nation’s children, which would be the logical next step on the road to coverage for everyone.

That an American child could die because his mother couldn’t afford to have a diseased tooth extracted sounds like a horror story from some rural outpost in the Great Depression. It’s the kind of gruesomely tragic absurdity you’d expect from Faulkner. But these things are happening now.

“People don’t understand the amount of time and stress parents are going through as they try to get their children the coverage they need, in many cases just to stay alive,” said Marian Wright Edelman, president of the Children’s Defense Fund and a tireless advocate of expanding health coverage to the millions of American children who are uninsured or underinsured.

Medicaid and the State Children’s Health Insurance Program provide crucially important coverage, but the eligibility requirements can be daunting, budget constraints in many jurisdictions have led to tragic reductions in coverage, and millions of youngsters simply fall through the cracks in the system, receiving no coverage at all.

It is time for all that to end. American children should be guaranteed nothing less than comprehensive health coverage from birth through age 18. This can be achieved if an effort is mounted that is comparable to that which led to the first moon shot, or the Marshall Plan, or the postwar G.I. bill.

Keeping American children alive and healthy should be at least as important as any of those worthy projects.

Gawande and Kristof

May 17, 2007

Dr. Gawande points out that most doctors feel a moral obligation to treat the poor and says it’s time for more pharmaceutical companies to realize their moral obligations.  Mr. Kristof says that as Wolfie is to the World Bank the United States is becoming to the world.  Here’s Dr. Gawande:

It’s one of those questions no one tells you about when you enter medical practice. What do you do when patients come who can’t pay? Some doctors decline to see them. I have expenses to pay and a family to feed, they’ll argue.

But I grew up in a rural part of Ohio where an inordinate number poor people live. My mother is a pediatrician there, and from the start, she could not imagine turning children away. Up to 20 percent of her patients have been without insurance, and more than half were on Medicaid, which paid terribly and was refused by other doctors. Some patients were not very grateful. Some were not as poor as they claimed. But we could count on my father’s better-paying urology practice to cross-subsidize. So that’s what she did.

The message from my parents was straightforward: We are in medicine and that comes with certain moral obligations. So I’ve understood that part of my job is to see those who can’t pay — even if sometimes it hurts.

I’ve been thinking about this as I’ve watched the arguments unfold about what pharmaceutical companies should charge in the developing world. The history of H.I.V. drugs has not been pretty. First, for almost a decade, we in the West ignored the possibility that antiretroviral drugs could be used in the developing world. (Remember the 2001 claim of U.S. government officials that Africans couldn’t learn to take the drugs on time because they didn’t have watches?) Then, under international pressure, drug companies made some discounts, but they were not deep enough. (A year’s supply was still more than $1,000 per patient.) Only when an Indian generic manufacturer provided a copycat three-drug regimen for $150 per year and major donors stepped forward did distribution effectively reach poor countries.

We’re now in the throes of another round of H.I.V. drug battles, this time over advanced, but even more expensive drug regimens from Merck and Abbott Laboratories. Last week, the Clinton Foundation endorsed decisions by Thailand and Brazil to break the companies’ patents and purchase cheaper, copycat versions of the drugs. Abbott retaliated by withholding seven new drugs from Thailand, including an antibiotic, a painkiller, and a medication for high-blood pressure. The fight has become vicious.

In a way, it’s hard to see how the confrontation could be avoided. The cost of developing a new drug now approaches $1 billion, and companies do need profit margins to recoup that cost and encourage new innovation. Yet, once a life-saving discovery is made, it is clearly grotesque to make millions suffer or die while waiting for a 20-year patent to expire.

The experience with H.I.V. drugs is oddly heartening, though. There is, in fact, a spectrum of behavior among pharmaceutical companies — just like with doctors. Gilead Sciences has granted licenses to generic manufacturers to supply its blockbuster H.I.V. drug, Viread, to the world’s hundred poorest countries at the reasonable royalty rate of 5 percent of sales. Bristol-Meyers Squibb licensed its second-line drug, Reyataz, completely free of royalties to generic manufacturers for India and southern Africa. And through the World Health Organization’s bulk vaccine purchasing arrangements, manufacturers have been able to make significant profits selling vaccines at low cost but large volumes. This is the progress we want to build upon.

Pressure to broaden these efforts will grow, and it should. Agreement on regional pricing tiers and distribution networks for H.I.V. drugs show likelihood of solidifying in ways that make drugs available and support innovation, but we have nothing like it for drugs for heart disease, lung disease, or cancer. Meanwhile, the world is changing. The No. 1 cause of death in India, China, and Vietnam is not H.I.V. It’s heart disease. Cancer is in the top 10. Their people need clot-busting drugs, chemotherapies, and EKG machines just like everyone else. Manufacturers need to show the same willingness to make these life-saving technologies available to the poor.

Some will argue, hey, companies just invent this stuff; it isn’t their job to make sure every country gets some. But that’s not right. As Arthur Caplan, the bioethicist, points out, “You aren’t manufacturing pantyhose when you’re in health care. There are special moral duties attached.”

And one of them is: If you’re building a lifeboat, you have to think about how many you can get inside.

Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of the new book “Better.” He is a guest columnist this month.

And now here’s Mr. Kristof:

As Paul Wolfowitz is to the World Bank, the U.S. is becoming to the world.

We should look at the battle unfolding at the World Bank not as the story of one man falling to earth, but as a moral tale of the risks the U.S. faces unless the Bush administration spends more time rebuilding bridges it has burned all over the world.

Mr. Wolfowitz genuinely aspired to help Africa develop, but he ended up isolated, friendless and vulnerable; receiving no credit for his genuine accomplishments; and unable to make progress on the issues he cares about. And the U.S. is in a similar position today.

The similarity arises in part because although President Bush’s best-known role has been as a conservative hawk — and everything he has done in that role has been a disaster — he has also aspired to fight poverty and help Africa. And Mr. Bush has genuinely scored some major accomplishments as a humanitarian.

O.K., pick yourself off the floor: It’s true. In the world of foreign aid, Mr. Bush has done better than almost anyone realizes — or gives him credit for. It’s his only significant positive legacy, and it consists of four elements.

First and most important, Mr. Bush started Pepfar, his Emergency Plan for AIDS Relief in Africa — the best single thing he has done in his life. It’s a huge increase over earlier programs and will save more than 9 million lives. Granted, it has been too ideological about promoting “abstinence only” programs, but at the grass-roots level it is increasingly pragmatic (don’t tell the White House, but the U.S. still gives out far more condoms than any other country).

Second, Mr. Bush started a major new foreign aid program, the millennium challenge account. This involves giving large sums to countries selected for their good governance and from top to bottom reflects smart new approaches to foreign aid.

Third, the Bush administration elevated sex trafficking on the international agenda. Mr. Bush spoke about it to the U.N., and he appointed a first-rate ambassador for the issue, John Miller, who until his resignation late last year hectored and sanctioned foreign countries into curbing this form of modern slavery. (Alas, since Mr. Miller left, the administration’s anti-trafficking efforts have faltered.)

Fourth, Mr. Bush has begun to focus attention and funds on malaria, which kills more than 1 million people a year in poor countries and imposes a huge economic burden on Africa in particular.

So why doesn’t Mr. Bush get any credit for these achievements? Partly, I think, because he never seems very interested in them himself. And partly because, like Mr. Wolfowitz, Mr. Bush’s approach to governing is to circle the wagons rather than build coalitions; they both antagonize fence-sitters by coming across as unilateralist, sanctimonious, arrogant and incompetent.

In December, the White House held an event to call attention to malaria. But Mr. Bush’s staff barred me from attending: They apparently didn’t want coverage of malaria if it came from a columnist they didn’t like.

I can’t recall an administration as suspicious and partisan as this one, one so disinclined to outreach, one that so openly adheres to the ancient Roman maxim of Oderint dum metuant: Let them hate, so long as they fear.

So Mr. Bush, unwilling to concede any error, unwilling to reach out, unwilling to shuffle his cabinet, staggers on. And the U.S. itself has been tainted by the same haughtiness; long after Mr. Wolfowitz has gone, and even after Mr. Bush has gone, the next president will have to detoxify our relations with the rest of the world.

Moreover, even in those areas where Mr. Bush has done well, like foreign aid, our strained relations with the rest of the world have undermined our ability to succeed. Indeed, Bill Clinton (who wasn’t nearly as generous with foreign aid as Mr. Bush when he was in the White House) has shown in recent years how much can be accomplished when a leader cooperates with partners on issues like AIDS and development. If Mr. Clinton were pursuing Mr. Bush’s development agenda, it would be in a flurry of meetings and visits and multilateralism that would be far more effective in seeing that agenda put in place.

But instead the international stage is riven in ways that mirror the World Bank itself. And it looks as if we’re drifting toward the end of a failed presidency of the United States that parallels Mr. Wolfowitz’s failed presidency of the World Bank.

You are invited to comment on this column at Mr. Kristof’s blog, www.nytimes.com/ontheground.

Gawande and Herbert

May 12, 2007

Dr. Gawande is concerned about how bad medicine and medical products creep in, driving out good medicine.  Mr. Herbert discusses the fact that more Americans are poor than the government statistics indicate.  Here’s Dr. Gawande:

As I read about the melamine-tainted pet food, and about the hundreds in Panama killed by phony glycerin from China, I remembered a patient I once saw. She was a dancer in her 40s who had hobbled into the emergency room one October night with a painful, bulging mass in her groin. I gently put my fingers to it. It was beet-sized and firm. When I placed my stethoscope on it, I heard gurgling. This was, I told her, a strangulating hernia — a rent in her abdominal wall had trapped a loop of intestine. The swelling was the knot of bowel; the gurgling, the fluid inside.

She was at risk of gangrene and agreed to an emergency hernia operation. It’s not a complicated procedure. But there are still plenty of ways it can go wrong. Inside her, I found the hernia defect — a one-inch gap in her muscle wall — and, protruding through it, a choked-off, purple, six-inch length of bowel. I opened the gap wider, pushed the bowel back in, and thankfully it pinked back to life. We’d gotten there in time. I closed the hernia with a polypropylene mesh cut to size. It was like sewing a patch onto a torn couch cushion. The next day, she went home. I saw her two weeks later. No infection. No troubles. She’d done beautifully.

Then I got an e-mail notice. The mesh manufacturer, Johnson & Johnson, was reporting that the mesh I’d put in was counterfeit. It was fake.

Someone had infiltrated the supply chain somewhere between Sherman, Tex., where the authentic mesh was manufactured, and Boston, where I’d operated on the patient. Apparently, mesh can travel through many hands. The original lot had gone to a Memphis warehouse, and then through at least two hospital goods distributors, which sell and trade medical supplies on what turns out to be a worldwide market, like oil. Somewhere along the way a counterfeiter replaced the lot with fake mesh packaged exactly like Johnson & Johnson’s, right down to the lot number. It is believed this happened someplace in Asia. But no one really knows.

The material looked like ordinary mesh to me. But according to the alert from the Food and Drug Administration, it wasn’t sterile. And although it seemed to be polypropylene, the fibers and weave were different from the manufacturer’s. It wasn’t clear what should be done. I called the patient to come see me.

I also began to wonder how I could trust anything I use. My sterile gloves come from the Philippines, surgical sponges from China, devices and instruments from Taiwan to Texas. The ingredients for medications come from all over the world.

This is how it is now. That’s not bad, I know. But it’s not all good, either. In the effort to get the best possible results for people, it seems hard enough make sure one’s decisions are right. I’d never considered that I had to worry about my supplies, too.

So what to do?

In the name of safety and simplicity, we could try to restrict medical manufacturing and distribution networks to our borders. This is, for example, the argument for blocking the sale of medications from Canada. It’s folly, though. Medicine’s success and affordability already critically depend on materials and distribution from around the globe. Yet market forces aren’t weeding out the shady operators, either.

So we’re left only with vigilance — police work. Put enough F.D.A. inspectors on the ground and tracing technology on the goods and we actually could block those who would put an industrial solvent in children’s cough medicine and fake, unsterile material in our surgical supplies.

This we don’t do, though. The number of F.D.A. inspectors has actually been cut — partly because of small-government ideology and partly because of tight budgets. And still they’re finding more cases than ever. (In recent years, they’ve found counterfeit Lipitor, Viagra, Botox, Zyprexa and birth control pills, among others.) We need many times more inspectors. But nothing like it has been considered. That is no longer acceptable.

I saw my patient and told her about the fake mesh. She was stunned. We then considered what to do. It wasn’t clear the mesh would hold; and in many other patients, it became infected and had to be removed. But she’d done all right so far, and redoing the repair is major surgery. So she decided to wait and see what happened.

Given the alternative, doing nothing and hoping for the best was a wise choice for her. But it’s a bad choice for the rest of us.

Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a New Yorker staff writer, is the author of the new book “Better.” He is a guest columnist this month.

Here’s Mr. Herbert:

The United States may be the richest country in the world, but there are many millions — tens of millions — who are not sharing in that prosperity.

According to the most recent government figures, 37 million Americans are living below the official poverty threshold, which is $19,971 a year for a family of four. That’s one out of every eight Americans, and many of them are children.

More than 90 million Americans, close to a third of the entire population, are struggling to make ends meet on incomes that are less than twice the official poverty line. In my book, they’re poor.

We don’t see poor people on television or in the advertising that surrounds us like a second atmosphere. We don’t pay much attention to the millions of men and women who are changing bedpans, or flipping burgers for the minimum wage, or vacuuming the halls of office buildings at all hours of the night. But they’re there, working hard and getting very little in return.

The number of poor people in America has increased by five million over the past six years, and the gap between rich and poor has grown to historic proportions. The richest one percent of Americans got nearly 20 percent of the nation’s income in 2005, while the poorest 20 percent could collectively garner only a measly 3.4 percent.

A new report from a highly respected task force on poverty put together by the Center for American Progress tells us, “It does not have to be this way.” The task force has made several policy recommendations, and said that if all were adopted poverty in the U.S. could be cut in half over the next decade.

The tremendous number of people in poverty is an enormous drag on the U.S. economy. And one of the biggest problems is the simple fact that so many jobs pay so little that even fulltime, year-round employment is not enough to raise a family out of poverty. One-fifth of the working men in America and 29 percent of working women are in such jobs.

Peter Edelman, a Georgetown law professor who was a co-chairman of the task force, said, “An astonishing number of people are working as hard as they possibly can but are still in poverty or have incomes that are not much above the poverty line.”

So the starting point for lifting people out of poverty should be to see that men and women who are working are adequately compensated for their labor. The task force recommended that the federal minimum wage, now $5.15 an hour, be raised to half the average hourly wage in the U.S., which would bring it to $8.40.

The earned-income tax credit, which has proved very successful in supplementing the earnings of low-wage working families, should be expanded to cover more workers, the task force said. It also recommended expanded coverage of the federal child care tax credit, which is currently $1,000 per child for up to three children.

A crucial component to raising workers out of poverty would be an all-out effort to ensure that workers are allowed to form unions and bargain collectively. As the task force noted, “Among workers in similar jobs, unionized workers have higher pay, higher rates of health coverage, and better benefits than do nonunionized workers.”

In a recent interview about poverty, former Senator John Edwards told me: “Organizing is so important. We have 50 million service economy jobs and we’ll probably have 10 or 15 million more over the next decade. If those jobs are union jobs, they’ll be middle-class families. If not, they’re more likely to live in poverty. It’s that strong.”

The task force made several other recommendations, including proposals to ease access to higher education for poor youngsters, to help former prisoners find employment, to develop a more equitable unemployment compensation system, and to establish housing policies that would make it easier for poor people to move from neighborhoods of concentrated poverty to areas with better employment opportunities and higher-quality public services.

Mr. Edelman, an adviser on social policy in the Clinton administration, stressed that there is no one answer to the problem of poverty, and that in addition to public policy initiatives, it’s important to address the “things people have to do within their own communities to take responsibility for themselves and for each other.”

But he added, “It is unacceptable for this country, which is so wealthy, to have this many people who are left out.”

Gawande and Kristof

May 10, 2007

Dr. Gawande has some ideas on curing the health care system, and Mr. Kristof explains what will motivate people to help save Darfur — a puppy.  Here’s Dr. Gawande:

The American health insurance system is a slow-creeping ruin, damaging people and increasingly the employers that hire us. Yet there is another truth as well: the vast majority who have decent coverage are happy with the care we get — I am writing this, for instance, as I sit with my 11-year-old son waiting for an M.R.I. to check the cardiac repair that has saved his life for a decade. So most have resisted large-scale change, fearing that it could make some lives worse, even as it makes others better.

And the truth is it could.

There are two causes of human fallibility — ignorance and ineptitude — and health system change is at risk of both. We could err from ignorance, because we have never done anything remotely as ambitious as changing out a system that now involves 16 percent of our economy and every one of our lives. And we could err from ineptitude, underestimating the difficulties of even the most mundane tasks after reform — like handling all the confused phone calls from those whose coverage has changed; ensuring that doctor’s appointments and prescriptions don’t fall through; avoiding disastrous cost overruns.

Health systems are nearly as complex as the body itself. They involve hospital care, mental health care, doctor visits, medications, ambulances, and everything else required to keep people alive and healthy. Experts have offered half a dozen more rational ways to finance all this than the wretched one we have. But we cannot change everything at once without causing harm. So we dawdle.

We don’t need to, though. It is possible to alter our system surgically enough to minimize harm while still channeling us onto a path out of our misery.

Option 1 is a Massachusetts-style reform, which follows a strategy of shared responsibility. Enacted statewide last year, the law has four key components. It defines a guaranteed health plan that is now open to all legal residents without penalty for pre-existing conditions. Using public dollars, it has made the plan free to the poor and limited the cost to about 6 percent of income for families earning up to $52,000 a year. It requires all individuals to obtain insurance by year end. And it requires businesses with more than 10 employees to help cover insurance or pay into a state fund.

The reform gives everyone a responsibility. But it leaves untouched the majority with secure insurance while getting the rest covered. As a result, it has had strong public approval. Experience with delivering the new plan is accumulating. And best of all, it offers a mechanism that can absorb change. The guaranteed health plan may cover 5 percent of the state at first, but as job-based health care disintegrates, the plan can take in however many necessary.

The reform has its hurdles, no question. Some residents are angry about being made to buy health coverage — 6 percent of income is not nothing. Next April, when the tax penalty kicks in (refusers will lose their personal tax exemption), you will hear about it. As enrollment and costs in the guaranteed plan rise, there will also be intense public pressure to increase the minimum employer contribution (currently just $295) and clamp down on the costs. But this is what a real system is for: gathering everyone in and enabling the hard choices.

The approach is not just a crazy Massachusetts idea (though Mitt Romney is running from parts of it). Reform plans recently put forward by everyone from the Republican Arnold Schwarzenegger to the Democrat John Edwards to a major new business coalition take the same tack. People don’t want the mess we have — not families, not employers and not health professionals. This offers a viable way forward.

If it’s still too much for people to accept, however, there is a second option, a fallback: we could guarantee coverage for today’s children — for their lifetime. It could be through private insurance or through a Medicare plan that families must enroll them in. Either way, the subsidies required are very much within our means.

We might even pass the fallback plan first. Then, while we are stymied fighting about how to fix the rest, there’d be at least one generation that could count on something more.

Atul Gawande, a surgeon at Brigham and Women’s Hospital and a New Yorker staff writer, is the author of the new book “Better.” He is a guest columnist this month.

And now here’s Mr. Kristof:

Finally, we’re beginning to understand what it would take to galvanize President Bush, other leaders and the American public to respond to the genocide in Sudan: a suffering puppy with big eyes and floppy ears.

That’s the implication of a series of studies by psychologists trying to understand why people — good, conscientious people — aren’t moved by genocide or famines. Time and again, we’ve seen that the human conscience just isn’t pricked by mass suffering, while an individual child (or puppy) in distress causes our hearts to flutter.

In one experiment, psychologists asked ordinary citizens to contribute $5 to alleviate hunger abroad. In one version, the money would go to a particular girl, Rokia, a 7-year-old in Mali; in another, to 21 million hungry Africans; in a third, to Rokia — but she was presented as a victim of a larger tapestry of global hunger.

Not surprisingly, people were less likely to give to anonymous millions than to Rokia. But they were also less willing to give in the third scenario, in which Rokia’s suffering was presented as part of a broader pattern.

Evidence is overwhelming that humans respond to the suffering of individuals rather than groups. Think of the toddler Jessica McClure falling down a well in 1987, or the Lindbergh baby kidnapping in 1932 (which Mencken described as the “the biggest story since the Resurrection”).

Even the right animal evokes a similar sympathy. A dog stranded on a ship aroused so much pity that $48,000 in private money was spent trying to rescue it — and that was before the Coast Guard stepped in. And after I began visiting Darfur in 2004, I was flummoxed by the public’s passion to save a red-tailed hawk, Pale Male, that had been evicted from his nest on Fifth Avenue in New York City. A single homeless hawk aroused more indignation than two million homeless Sudanese.

Advocates for the poor often note that 30,000 children die daily of the consequences of poverty — presuming that this number will shock people into action. But the opposite is true: the more victims, the less compassion.

In one experiment, people in one group could donate to a $300,000 fund for medical treatments that would save the life of one child — or, in another group, the lives of eight children. People donated more than twice as much money to help save one child as to help save eight.

Likewise, remember how people were asked to save Rokia from starvation? A follow-up allowed students to donate to Rokia or to a hungry boy named Moussa. Both Rokia and Moussa attracted donations in the same proportions. Then another group was asked to donate to Rokia and Moussa together. But donors felt less good about supporting two children, and contributions dropped off.

“Our capacity to feel is limited,” Paul Slovic of the University of Oregon writes in a new journal article, “Psychic Numbing and Genocide,” which discusses these experiments. Professor Slovic argues that we cannot depend on the innate morality even of good people. Instead, he believes, we need to develop legal or political mechanisms to force our hands to confront genocide.

So, yes, we should develop early-warning systems for genocide, prepare an African Union, U.N. and NATO rapid-response capability, and polish the “responsibility to protect” as a legal basis to stop atrocities. (The Genocide Intervention Network and the Enough project are working on these things.)

But, frankly, after four years of watching the U.N. Security Council, the International Criminal Court and the Genocide Convention accomplish little in Darfur, I’m skeptical that either human rationality or international law can achieve much unless backed by a public outcry.

One experiment underscored the limits of rationality. People prepared to donate to the needy were first asked either to talk about babies (to prime the emotions) or to perform math calculations (to prime their rational side). Those who did math donated less.

So maybe what we need isn’t better laws but more troubled consciences — pricked, perhaps, by a Darfur puppy with big eyes and floppy ears. Once we find such a soulful dog in peril, we should call ABC News. ABC’s news judgment can be assessed by the 11 minutes of evening news coverage it gave to Darfur’s genocide during all of last year — compared with 23 minutes for the false confession in the JonBenet Ramsey case.

If President Bush and the global public alike are unmoved by the slaughter of hundreds of thousands of fellow humans, maybe our last, best hope is that we can be galvanized by a puppy in distress.

You are invited to comment on this column at Mr. Kristof’s blog, www.nytimes.com/ontheground.

Gawande

May 5, 2007

Today Dr. Atul Gawande is alone behind the firewall, telling us about how broken our healthcare system is.  And why we’re not doing anything about it.

As a surgeon, I’ve seen some pretty large tumors. I’ve excised fist-size thyroid cancers from people’s necks and abdominal masses bigger than your head. When I do, this is what almost invariably happens: the anesthesiologist puts the patient to sleep, the nurse unsnaps the gown, everyone takes a sharp breath, and someone blurts out, “How could someone let that thing get so huge?”

I try to describe how slowly and imperceptibly it grew. But staring at the beast it has become, no one buys the explanation. Even the patients are mystified. One day they looked in the mirror, they’ll say, and the mass seemed to have ballooned overnight. It hadn’t, of course. Usually, it’s been growing — and, worse, sometimes spreading — for years.

Too often, by the time a patient finally seeks help, I can’t help much.

We are adaptable creatures, and while that is generally good, sometimes it’s a problem. We have no difficulty taking prompt action when faced with a sudden calamity, like a bleeding head wound, say, or a terrorist attack. But we are not good at moving against the creeping, more insidious threats — whether a slow-growing tumor, waistline or debt.

It’s as true of societies as of individuals. We did not muster the will to reform our long-broken banking system, for example, until it actually collapsed in the Great Depression.

This is, in a nutshell, the trouble with our health care crisis. Our health care system has eroded badly, but it has not collapsed. So we do nothing.

For at least two decades, polls have shown that most consider our health system seriously flawed. With family insurance premiums now averaging $12,000 a year, the insured fear it will become unaffordable, and businesses regard health benefit costs as their single greatest obstacle to competing globally.

People without insurance are proven to be more likely to die, and 28 percent of working-age Americans are now uninsured for at least part of a year. Emergency rooms, required to care for the uninsured, have become so full they turned away 500,000 ambulances last year. As a result, large majorities support the idea of fundamental change.

Surveys also show, however, that 89 percent of Americans remain satisfied with their own health care and that 88 percent of the insured are satisfied with the coverage they have. So time and again, when confronted with the details and costs of any thoroughgoing reform, our enthusiasm evaporates.

I learned this lesson the hard way. I was in the Clinton administration when we lost health reform, partly because of special interests’ attacks, but mostly because the insured feared change more than the status quo. When voters in Oregon, one of our most liberal states, voted down a single-payer plan in a referendum in 2002, it was just the most recent sign of the pattern.

The only time the country has enacted a large-scale health system change was after a collapse. In 1965, when Medicare was created for the elderly and disabled, some 70 percent had no coverage for hospital costs. We’re not that badly off yet. Our health care system is like one of those tumors growing in my patients. The only questions are: When will it become bad enough to make us act? And will that be too late?

Reformers think we’re on the verge of waking up some morning, looking in the mirror and noticing the size of this tumor with enough alarm to do something radical about it. But isn’t it more likely we won’t?

Malcolm Gladwell has argued that when health care costs drive General Motors into bankruptcy, and 300,000 workers lose coverage overnight, that will be the next big crisis to prompt wholesale change. I thought so, too. But it now looks as if G.M. will instead wither slowly, shedding a plant here, a division there. And faced with a slow withering, we all just muddle on.

The case for sweeping reform — for severing health insurance from the workplace and creating a new system — is undeniable. But it’s going to be a long time before the large majority of Americans with decent coverage are persuaded to risk changing what they have. How then to cure a malignant health care system? Can we act before the patient collapses?

The answer is yes, but only if we make changes that alter most people’s coverage gradually, while still providing a path out of this mess. My next column will describe just that.

Atul Gawande, a general surgeon at Brigham and Women’s Hospital and a New Yorker staff writer, is the author of the new book “Better” and a guest columnist this month. … Maureen Dowd’s column will appear tomorrow.

Gawande and Kristof

May 1, 2007

Guest columnist Atul Gawande writes on “The Power of Negative Thinking,” and Nicholas Kristof re-asks Bush’s question “Is our children learning?” Here’s Dr. Gawande:

We Americans believe instinctively in the power of positive thinking. Whether one is fighting a cancer, an insurgency or just an unyielding problem at work, the prevailing wisdom is that thinking positive is the key — The Secret, even — to success. But the key, it seems to me, is actually negative thinking: looking for, and sometimes expecting, failure.

We were given a revealing and, for a surgeon like me, disheartening example recently with the scandal at the Walter Reed Army Medical Center. The real puzzle was how one institution could be responsible for helping to save the highest percentage of battle-wounded soldiers in history and for providing such disturbingly neglectful care afterward.

Soldiers told of extraordinary care at Walter Reed that had saved them despite multiple limbs blown away, burns over 90 percent of their bodies, brain injuries previously considered unsurvivable. And then they told of outpatient facilities, at the same hospital, where wheelchair-bound soldiers were stranded without food, the brain-injured denied aid because they couldn’t fill out forms.

What explains this? The final report recently released by the military’s independent review group did not find good people in one department and bad people in another. The soldiers testified over and over about how “caring” and “dedicated” they found Walter Reed’s personnel to be. “The staff here is great,” a wounded officer insisted.

But in one part of the hospital good people succeeded, and in the other good people failed.

The review revealed severe strains — from plans to close Walter Reed in four years and orders to privatize certain services — but these pressures applied everywhere at the hospital. The primary difference was whether leaders accepted the value of negative thinking or not.

Consider how Walter Reed helped lower the death rate for wounded soldiers. It was 25 percent in the first Persian Gulf war; today it is less than 10 percent. Trauma care did not change. Medical personnel are actually stretched thinner than before. But they have tracked weekly data on injuries and survival rates, and actively looked for failures and how to overcome them.

Nothing was too trivial. During a visit with colleagues at Walter Reed early in the Iraq war, I was struck, for example, by their attention to eye-injury statistics. Instead of being proud of saving some soldiers from blindness, the doctors asked a harder, more unnerving question: why had so many injuries occurred? They discovered that the young soldiers weren’t wearing their protective goggles. Too ugly, the soldiers said. So the military switched to cooler-looking Wiley X ballistic eyewear. The soldiers wore their eyegear more consistently, and the eye-injury rate dropped immediately.

Encouraged by leaders to think negative, medical staff members also reported on transport problems for the injured, soldiers’ not wearing their Kevlar, communication glitches, unexpected infections — and instituted changes to address them. The result: they are saving soldiers who’d never have been saved before.

Contrast this with the same leaders’ approach to care afterward. The independent review group found zero effort to track how soldiers were doing in rehabilitation. No one pushed to discover failures. As a result, failures were unrecognized, yet everywhere to be seen. The review group found the same problems The Washington Post had: disorganized, bureaucratic care with glaring gaps; dismal living conditions; dangerous staff shortages.

“It was a one-sided representation,” said the Army medical chief and former Walter Reed commander Lt. Gen. Kevin Kiley when the atrocious conditions were first exposed. “While we have some issues here, this is not a horrific, catastrophic failure.” He was just trying to think positive.

Negative thinking is unquestionably painful. It involves finding and exposing your inadequacies, which can be overwhelming. And not every problem discovered can be solved. You live in a state of perpetual dissatisfaction.

That’s an unhealthy way to be in large parts of life: you don’t want to constantly seek out the inadequacies of your children, your looks, your abilities as you age. But in running schools or businesses, in planning war, in caring for the sick and injured? Negative thinking may be exactly what we need.

Atul Gawande, a general surgeon at Harvard Medical School and a New Yorker staff writer, is the author of “Better: A Surgeon’s Notes on Performance.” He is a guest columnist this month.

And now here’s Mr. Kristof:

In this presidential campaign, we need somebody who wants to address the question President Bush once raised: “Is our children learning?”

International testing shows that U.S. schools do a lousy job teaching math and science, in particular. And far too many American students aren’t going to college or even completing high school, undermining our competitiveness for decades to come.

Moreover, the U.S. education system reinforces the gulfs of poverty and race. Well-off white kids tend to go to good schools that propel them ahead, while many poor black and Hispanic kids attend bad schools that hold them back.

For inspiration, presidential candidates might look at this bold three-part plan for improving American schools:

End requirements for teacher certification.

Make tenure more difficult to get so weak teachers can be weeded out after two or three years on the job.

Award $15,000 annual bonuses to good teachers for as long as they teach at schools in low-income areas.

Those ideas are cribbed from a provocative report on education from the Hamilton Project, which is affiliated with the Brookings Institution. The report was prepared by Robert Gordon of the Center for American Progress, Thomas Kane of Harvard and Douglas Staiger of Dartmouth, and it fits in with a burst of other research pointing in similar directions.

In the past, we tried to ensure the quality of teachers through certification procedures. But that has failed. Growing evidence indicates that certification requirements limit the pool of potential teachers — and discourage midcareer switches into teaching — without accomplishing much else.

“Teachers vary considerably in the extent to which they promote student learning, but whether a teacher is certified or not is largely irrelevant to predicting their effectiveness,” concluded a report last year for the National Bureau of Economic Research.

The reality is that paper credentials can’t predict who will be an effective teacher. A half-dozen studies have found that teachers with graduate degrees aren’t any better than teachers without them. Other studies show that teachers who did well on their own SATs, or went to selective colleges or had high G.P.A.’s, don’t make significantly better teachers, either.

Yet teachers still vary tremendously in their effectiveness, as the Hamilton Project study found when it examined results in Los Angeles schools. It looked at the 25 percent of teachers who raised their students’ test scores the most, and the 25 percent who raised students’ scores the least. A student assigned to a class with a teacher in the top 25 percent could expect — after just one year — to be 10 percentile points higher than a similar student with a bottom-tier teacher.

“Moving up (or down) 10 percentile points in one year is a massive impact,” the authors wrote. “For some perspective, the black-white achievement gap nationally is roughly 34 percentile points. Therefore, if the effects were to accumulate, having a top-quartile teacher rather than a bottom-quartile teacher four years in a row would be enough to close the black-white test score gap.”

The Hamilton Project study recommends that the weakest 25 percent of new teachers should be denied tenure and eliminated after two or three years on the job (teachers improve a lot in the first two years, but not much after that). That approach, it estimates, would raise students’ average test scores by 14 percentile points by the time they graduated.

“There’s no decision that school districts make that’s more important than the decision regarding who is going to stand in front of the classroom,” Professor Kane said. “Yet most districts spend more time choosing textbooks than they do reviewing the performance of teachers on their first few years on the job.”

School reform could also play a major role in fighting poverty and spreading opportunity. One sound proposal is to pay substantial bonuses to get the most effective teachers into schools with low-income students. It’s simply unfair for America’s neediest students to be continually assigned to the weakest teachers, perhaps consigning them to another generation of poverty. Higher pay will help recruit and retain excellent teachers.

Neither Democrats nor Republicans have offered much leadership on education. Democrats have been too close to teachers’ unions to rock the boat, and Republicans don’t invest in education — so Mr. Bush’s No Child Left Behind effort has ended up as an underfinanced mess.

What we need now is for a presidential candidate to seize these ideas and run with them. Any takers?

You are invited to comment on this column at Mr. Kristof’s blog, www.nytimes.com/ontheground.