Sunday, January 17, 2010


One of my favorite quotes about power is from Frank Herbert's Chapterhouse: Dune:
"It is not that power corrupts but that it is magnetic to the corruptible."
This is part of longer passage about the failings of governments:
"All governments suffer a recurring problem: power attracts pathological personalities. It is not that power corrupts but that it is magnetic to the corruptible. Such people have a tendency to become drunk on violence, a condition to which they are quickly addicted."
The theme is repeated elsewhere throughout the book:
"Power attracts the corruptible. Suspect all who seek it."
"We should grant power over affairs only to those who are reluctant to hold it and then only under conditions that increase the reluctance."
I recently read Iain M. Banks new book, Transition, and discovered this particularly eloquent statement of the same basic idea:
"Only people already riddled with the internalized special pleading and self-importance that too much power brings could even start to imagine that this might be in any way sustainable."
It the conclusion of this longer reflection on the problem of life extension and/or immortality for the "wise" and the powerful:
"The old and powerful never want to let go. They always think they're both profoundly indispensable and uniquely right. They are always wrong. Part of the function of aging and dying is to let the next generation have its say, its time in the sun, to sweep away the mistakes of the previous age while, if they're lucky, retaining the advances made and the benefits accrued. It is an insane conceit. Power always drives to perpetuate itself, but this is a phenomenal extra distillation of idiocy. Only people already riddled with the internalized special pleading and self-importance that too much power brings could even start to imagine that this might be in any way sustainable."
These quotes bring to mind a number of current situations. There are myriad obvious examples of corruption among the powerful, but I'm especially struck by the applicability of these quotes to the appalling lack of term limits for elected officials AND the level of compensation enjoyed by such officials.
In my perfect world higher education would be freely available to all and would be a requirement for eligibility to vote. Those who chose to pursue higher education would also be required to repay their years of education in service work, for which they would receive a decent living wage. Those who serve well would be promoted to higher levels of authority—some of them to governing positions, as representatives of their peers—but not to never levels of pay (pay grade during service years would depend on number of dependents in the household). Once their terms of service were complete, they would be returned to the working population and would not be allowed to hold official positions again. If they were particularly passionate or motivated, they would be free to communicate their opinions to their representatives in government; they would have no official say (beyond their vote as an ordinary educated citizen, of course) in matters of state though.
OK. Now, dear readers, please start shooting holes in my utopian scheme so that I can begin work on plugging and repairing them.



Today at 10:00 in the morning I am sitting at my computer putting together this week's laboratory medicine quiz for the pathology residents. Which of the following fluids may be transfused simultaneously through an infusion line with red blood cells? I don't actually know the answer off the top of my head, but that doesn't really matter. I just pick questions from a question bank, copy them to the body of an email and send them out to the residents. They have a week in which to send me the answers. At the end of the year the person with highest percentage correct answers will get a cash prize. Usually about $150, but it depends on how generous the attending pathologists feel when I make the rounds, asking for contributions. It's a bit of a pain having to go from office to office, knocking on the doors, asking for contributions for this year's laboratory medicine quiz contest, but in the end all of the pathologists are great about it. They like to see us engaged in friendly intellectual competition and they understand that this is a fun way for us to get ourselves to study some rather dry topics. We're all intelligent, motivated, successful young doctors, after all. Of course they don't mind putting $10 or $20 dollars in the pot for our collective educational motivation.


I go to the front door, dreading the possibilities. A pair of young, bright-eyed Jehovah's Witness missionaries for me to deflate with my superior biblical knowledge? A real-estate agent asking permission to post signs in our yard, directing people to his open house? A 2o-year-old single mother of three selling the latest, greatest cleaning supplies that are both environmentally friendly and sure to remove grease, rust, blood, and fruit juice stains from even the stubbornest of surfaces?


It's Ronnie.

Ronnie is a young man who lives in the neighborhood with his diabetic father. Ronnie works two part-time minimum wage jobs and does yard work and other odd jobs when he can find them. Ronnie's father is severely disabled, cannot perform any sort of manual labor, and has never been trained for any other type of work. Between Ronnie's meager earnings and his father's social security benefits, the two of them are usually able to pay for rent and utilities, with just a little left for groceries. Ronnie's father is on Medicaid and most of his medications are covered, but there is a $34 copay each month for the insulin to control his blood sugar.

It is winter here and it gets fairly cold at night. The bill for heating gas in the winter months can easily reach four or five times that of the summer months. When forced to choose between paying the gas bill and the copay for his insulin last week, Ronnie's father decided to keep himself and his son warm. He did not tell Ronnie that there had not been enough money for insulin. Ronnie only found out when he found his father on the floor, unconscious and barely breathing. Diabetic ketoacidosis. An ambulance trip. A day and a half of treatment and observation in the emergency room. A day of work lost for Ronnie. Ronnie and his father return home this morning to a house with heat and a little bit of food, but with no $34 for the insulin copay. They will not have $34 dollars again until Ronnie's next paycheck, five days from now.

Knock. knock. knock.

Ronnie hates doing this. He hates having to walk around the neighborhood asking for yard work. He hates knowing that all of us in our warm homes, happy and content with our own lives, will be made to feel uncomfortable by his neediness, by his very existence. He hates knowing that many of us will look through our peep-hole, see a slightly bedraggled young man, and automatically assume that he needs money for his next fix. Ronnie hates to ask for help. He also hates to see his father dying.

Knock. knock. knock.

Ronnie tells me about his last two days in the emergency room with his father. I already know why he is here at my door and I'm desperately trying to think of some odd jobs that I can have him do around the place. $34. On my resident's salary, that's about two hours worth of work. Can I find two hours worth of work for Ronnie to do? Two hours that he'll save me so that I can feel justified giving him the money to keep his father alive? Should I have him pick up the dog shit in our back yard? Should I have him pull weeds from the front yard that is going to be re-landscaped in a couple months anyway? Should I just give him the money and send him away so that I can get on with my day?

Ronnie and his father are a small but fairly representative sample of a huge and rapidly growing segment of our population: the underserved, underemployed, underpaid, and largely unheard poor. The poor. The poor without adequate access to healthcare. The poor without adequate government assistance for food and utilities. The poor who are reminded of how much it sucks to be poor in this country every time they have to ask for help. The poor who were born to the similarly poor. The poor who are marginalized when it comes to educational and employment opportunities. The poor who grow up undernourished because they're eating the shitty processed food that is less expensive per calorie than the healthy balanced diet that their developing bodies and minds really need. The poor who make the rest of us uncomfortable with their very existence. The poor who are desperate and sometimes steal to make ends meet. The poor who suffer at least as much mental illness as the rest of us, but who have virtually no access to treatment for such disease and must therefore self medicate with alcohol and illicit drugs. The poor who commit suicide far more frequently than the rest of us. The poor who are a nuisance to the rest of us, a problem about which we'd rather not have to think. The poor who turn to drugs to temporarily escape their poverty, only to find themselves enslaved to substances and dealers. The poor who cross an arbitrary line in the desert looking for employment, only to be arrested and deported... or to die of thirst under the hot sun when they've lost their way and are afraid to stay close to a road for fear of being arrested. The poor who have seen their mothers and older siblings beaten and raped and therefore figure that it's part of life and don't seek help or refuge when their turn comes. The poor who are far more likely to be murdered. The poor who join gangs and commit horrible acts of violence in an attempt to gain some sense of control and empowerment. The poor who rot in prisons for the rest of their productive lives while their families grow up, grow apart, grow old. The poor who bother us, interrupting our productive, healthy, happy lives by asking for help.

$34. A minuscule grain transferred across the fulcrum of economic disparity. A sick sad reminder of that day in the near future when the the situation will recur, when that $34 won't be available and the ambulance may or may not arrive in time. A reminder that the status quo just isn't enough when it comes to health care in this country.

Knock. knock.knock.

Monday, January 11, 2010

Frankl, Avatar, and most of all, Star Trek

Sorry folks, but I'm not literate, eloquent or creative enough to have drawn all of the above listed themes together. Fortunately someone else is. Areophany of Martian Utopia Cafe has written (yet another) truly excellent post. So good that I think I'll have to go back and read it again very soon. It is, in part, a reflection on finding meaning in an all too often cruel and ridiculous world, and in part an homage to the Star Trek novels, in the form of a series of well crafted mini-reviews. I've never read any of the Star Trek novels, but now that I know where to start, I think I might just have to.

Saturday, January 9, 2010


Selah is the transliteration of a Hebrew word that occurs frequently in the Psalms of David. There seems to be some debate about the correct interpretation, but the one that I was told most frequently as a child was, "stop and consider what you've just heard." Another translation is, "Let those who have eyes see and those who have ears hear." It is also used in some passages as a verb meaning to weigh or to measure against.

All of these are appropriate responses to a recent post by Areophany at Martian Utopia Cafe about the atrocious Isreali policies toward Palestinians.

So read his post; read the references; weigh his words; stop and consider. Selah!

Friday, January 8, 2010

What is food to one man is twitter poison to others

Today the U.S. State department, as part of its increasing interest in social networking, will launch a contest to "tweet what you think democracy is in 140 characters or less." The winner is the person whose 140 (or less)-character tweet is re-tweeted the greatest number of times in the next two weeks receives an HD digital video camera.

In his
recent article in Foreign Policy about the State Department's interest social networking, Indiana Senator Richard Lugar writes:

"The adroit use of social networking sites, such as Twitter, Facebook, and others, coupled with text messages and increasingly widespread mobile-phone technology, can help lend support to existing grassroots movements for freedom and civil rights, connect people to information, and help those in closed societies communicate with the outside world. It also promises to give a strong economic boost to small entrepreneurs and the rural poor. The World Bank estimates that for every 10 percent increase in the number of mobile-phone users in a developing country, there is nearly a 1 percent increase in its economic output."

This emphasizes the positive applications of social networking for international (and domestic) development. Just over a week ago, however, Will Heaven of the
Telegraph painted a rather darker picture:

"In Iran, for instance, the government controls the internet with a nationalised communications company. Using a state-of-the-art method called "Deep Packet Inspection", data packages sent between protesters are now automatically broken down, checked for keywords, and reconstructed within milliseconds. Every Tweet and Facebook message, in other words, is firmly on the regime's radar." did Scott Peterson in
his article in the Christian Science Monitor:

"Iran already has powerful Internet eavesdropping and hacking capabilities, thanks to systems sold to by Nokia and Siemens. 'We didn’t know they could do this much,' a network engineer in Tehran told the Wall Street Journal last June. 'Now we know they have powerful things that allow them to do very complex tracking on the network.'

Iran was 'drilling into what the population is trying to say,' a California Internet security specialist was quoted as saying in the Journal. 'This looks like a step beyond what any other country is doing, including China.'"

I wonder why Senator Lugar didn't mention this... or why there isn't any sort of disclaimer on the State Department's
contest announcement site.

I use Facebook frequently and Twitter occasionally. I use my cell phone pretty much non-stop, especially for texting and email. Generally I'm a big fan of social networking systems and a proponent of the exploding accessibility to and use of mobile technology worldwide. I'm especially intrigued by some of the
disease surveillance and other public health efforts. But I don't fool myself for one minute into believing that just because such systems have been used for good, they aren't also being exploited for more sinister purposes, both abroad and at home.

Sunday, January 3, 2010

Follow-Up: Part 1

OK, this is where I tackle the first half of the items on that list in my previous post.


Hematopathology is the subfield of pathology that deals with diseases of the blood, bone marrow, lymph nodes, and spleen. About 27 months ago I decided to pursue a career in hematopathology. It's a fairly lucrative field, always in high demand, and offers just the right amount of variety without so much that one becomes entirely overwhelmed. It's also at the cutting edge of medicine. It employs wonderful technologies like flow cytometry, FISH analysis, and various molecular assays, as well as plenty of time behind the scope and even the option of some patient contact (should a pathologist ever actually desire such a thing). Until just over a year ago I thought I had everything settled. I knew I'd have great recommendations from the hematopathologists in my residency program and had little doubt about my ability to get a spot in one of the better fellowship training programs in the country. A little less than a year ago, after having gone through an exhausting application process and interviewed at several top-notch programs, I decided not to pursue subspecialty fellowship training in hematopathology.

Yet another amazing book by one of my favorite authors, living or dead, Ken MacLeod. It's an all too timely tale of an all too possible future (several aspects of which I'd love to see realized!). It includes plenty of enticing themes (super-intelligent robots, space elevators, etc.), but what I particularly enjoyed was the setting: a world in which religion held little sway.


My wife, Kate, is an anesthesiology resident. In march of 2009 she was offered (and accepted) a subspecialty training fellowship in pediatric anesthesiology at Seattle Childrens, giving us a specific reason and date for our long anticipated return to our beloved Emerald City. Also, after not having ever observed an anesthesiologist's role in the OR from the beginning to the end of a case, I recently accompanied Kate to work for a day and watched her perform local nerve blocks and run cases. Very interesting and very technical. In a spirit of reciprocity she accompanied me to work and watched her first-ever autopsy.


After reading one of Ken MacLeod's other books, The Star Fraction I was convinced that my nearly complete state of computer illiteracy would be a tremendous handicap in any possible version of the future, so I finagled my way into an undergraduate introductory course on Unix. It was great fun, and though I don't use Unix or Linux on a daily basis, much of what I learned about computer systems/structures has served me since. I enjoyed the course so much, in fact, that for most of the past year I was thinking I'd pursue a career in biomedical informatics. I spent a month at the Mecca of pathology informatics, University of Pittsburgh, attended three national meetings on biomedical informatics (presented a poster at one of them), and dove head first into every informatics-related project that came my way. Ultimately, however, I decided that even though I do believe that innovations in informatics and the technology to support them are the future of medicine, I was more concerned about the future of a habitable planet, so I chose a different path.


As mentioned above, reading one of Ken MacLeod's books inspired me to take a Unix class. That's not the only manner in which it inspired me though. I read The Star Fraction while I was still planning on a career in hematopathology. It had been several years, however, since I'd discovered that I derived no great joy or satisfaction from medicine, and even as I was making plans for the next stage in my training and career, I was hoping to find something else -- and yet afraid to really look for it. Ken's book introduced me to a vast array of social, scientific, political and (as far as I can tell) completely original ideas that served to shake me into a realization that if I wasn't pursuing a career in which I truly believed and about which I could work up a decent passion, then I might just be wasting the most important (the only truly important?) opportunity of my life. Reading Ken's book also lit a fire under my lazy ass in regard to politics and world events. I've always been vaguely aware of the goings on in the world, but have tended to depend on one (relatively decent) source of information (NPR) and then done little with said information. I still don't pursue the truth as rabidly as I'd like, but I'm far more aware and far more skeptical of any one source... and I'm rapidly shedding my fear of using my voice on behalf of people and causes that are ignored or misrepresented. Thank you, Ken.

health care

What blogger worth his salt hasn't touched on health care in the past year? As 1) an MD working in a university hospital that serves most of the uninsured of the community, 2) an observant individual who has now lived in two of the three poorest states in the USA, and 3) someone with many friends in other countries throughout the world, I have no doubt that the US health care system is a disaster. The worst and foremost failing is that it is a health care system instead of a health system. Until the emphasis is correctly placed on promotion of health through education, healthy living environments, healthy workplaces (and work practices), and real, meaningful reduction of the economic disparity that is running rampant, any health care system is going to be nothing more than an expensive band-aid that rapidly becomes entirely unaffordable. Enough ranting though... especially as I'll return to health care related topics later in this post. Suffice it to say that none of the US health care proposals of the past year have gone nearly far enough, and they've all been "shaved, sterilized, and destroyed" to the point that the end result will only be slightly better than the current state of affairs. It will be better... but there'll still be a LONG way to go before health in the USA is even close to being adequately reformed.


Until seeing trailers for the movie of Watchmen I was entirely unaware of the story. Fortunately I have three cousins who more than made up for my childhood lack of comic books. While conversing with one of them about the film trailer, he told me, "if you only ever read one comic book or graphic novel, it should be Watchmen." So I picked up a copy and read it. It was truly great. The movie was excellent too... and I like it better and better each time I see it. If you haven't seen it, read the book first. If you have seen it, be sure to watch the Director's Cut. If you've seen the Director's Cut, watch the Ultimate Cut, which includes all of the Black Freighter sequences that were left out of the theatrical version. Oh... and Watchmen is not the only comic book or graphic novel I'll ever read. I've already read V for Vendetta and I'm looking forward to starting the Sandman series.


Scotch whisky at it's finest. I do love Laphroaig, Caol Ila, and even Ardbeg, but when push comes to shove, if I had to settle on just one, it would be the Signatory 18-year-old Bruichladdich. Enough said. Slainte Mhath! Slainte Mhor!


For this I'll refer to my previous post on the topic. In summary, I'll paraphrase and respond to a line from the movie Gladiator:
There was once a dream that was Obama. You could only whisper it. Anything more than a whisper and it would vanish... it was so fragile. And I fear that it will not survive the winter.
The man has survived a winter, but the dream has not.

On that rather somber note, I will close this post. I will be back to cover the other half of the topics though, so stay tuned.