Today I cannot receive one of the most common and beneficial oral health activities, a six-month dental visit with my dental provider, Kaiser Permanente.
The reason why? I am refusing to have a panoramic X-ray.
This potentially profitable medical procedure for some dental practices is a recent development in the oral health field that has followed the proliferation of the panoramic technology in the past several decades. However, these are not universally recognized in developed nations as a best health practice for routine dental care compared to bitewing X-rays, which my past dentists used. Neither is without risk. … [More of my guest column in the Sept. 16, 2015, Lund Report health newsletter can be found here.]
UPDATE Sept. 20, 2015: One critic of my column printed on the Lund Report web site wrote this statement, apparently to correct the record about what the American Dental Association’s guidelines are:
The ADA’s guidelines from 2012 actually state that for new patients (such as Mr. Owen) a panoramic radiographic exam is recommended so it seems that Kaiser is following the ADA’s recommendation.
“Individualized radiographic exam consisting of Individualized evaluated for dental radiographic exam radiographic exam posterior bitewings with panoramic exam or radiographic exam, diseases and dental consisting of consisting of posterior bitewings and selected periapical based on clinical development selected periapical/ posterior bitewings images. A full mouth intraoral radiographic signs and occlusal views and/ with panoramic exam is preferred when the patient has symptoms. or posterior exam or posterior clinical evidence of generalized dental disease bitewings if bitewings and or a history of extensive dental treatment.”
I found this comment remarkable because the author of it, someone who identified him/herself as Peta Pita (likely an assumed name, and this person misspelled my name too), did not mention the statement that immediately precedes guidelines for all radiography recommendations for people of all ages. So this comment is factually inaccurate.
The ADA foremost states [I put in bold for emphasis]: “These recommendations are subject to clinical judgment and may not apply to every patient. They are to be used by dentists only after reviewing the patient’s health history and completing a clinical examination. Even though radiation exposure from dental radiographs is low, once a decision to obtain radiographs is made it is the dentist’s responsibility to follow the ALARA Principle (As Low as Reasonably Achievable) to minimize the patient’s exposure.”
What’s more, the ADA also states for adult patients the following (and this does not include panoramic radiography): “Adult dentate patients, who receive regularly scheduled professional care and are free of signs and symptoms of oral disease, are at a low risk for dental caries. Nevertheless, consideration should be given to the fact that caries risk can vary over time as risk factors change. Advancing age and changes in diet, medical history and periodontal status may increase the risk for dental caries. Therefore, a radiographic examination consisting of posterior bitewings is recommended at intervals of 24 to 36 months.”
I enclose a screen snapshot for those who may be unsure how to intepret a recommendation table. This section covers the issue mentioned above, just including recommendations for adults:
“All men dream: but not equally. Those who dream by night in the dusty recesses of their minds wake up in the day to find it was vanity, but the dreamers of the day are dangerous men, for they may act their dreams with open eyes, to make it possible.” T.E. Lawrence, Seven Pillars of Wisdom: A Triumph
I am finishing reading a fascinating biography on Thomas Edward (TE) Lawrence called Hero, by Michael Korda. It is a great study of how a 5’5’’ illegitimate son of an undistinguished, upper middle-class Englishman and Irish nanny became one of the most influential men in history.
Today Lawrence (1888-1935) remains one of the most celebrated and controversial figures of the 20th century. He was both a liberator of the Arabs against the crumbling Ottoman Empire and a sharp instrument in the militarism and diplomacy of the colonial powers—England and France—to carve up the Arab lands into pliable territories that became nation states. As time has shown, these countries had no religious and ethnic cohesion, and it now seems they may not stand the test of time.
For me, however, Lawrence was so many things. A certified hero and brilliant military tactician in guerilla war. A born leader of men. A charismatic fighter. A scholar and linguist. A consummate and tough-as-nails explorer. A great writer. A global celebrity, before there were celebrities, thanks mostly to a multimedia show after the war about his wartime exploits by the brilliant American publicist Lowell Thomas. An innovator in military strategy far ahead of his day.
Perhaps even as important as any other influence in his life, he was also a bastard—an illegitimate child at a time when such stigma had far greater stains than it does today. As a bastard myself (I was adopted), it is a link I have in common with Lawrence, as well as having visited places in the Middle East where he fought, including Aqaba, Wadi Rum, and the Sinai (all as a tourist in my case).
Winston Churchill, himself both a great World War II leader and controversial apologist for the colonial system he defended much of his life, called Lawrence “one of the greatest beings alive in this time.”
Aqaba a Feat of Imagination:
Of all his many exploits, Lawrence’s role in the Arab conquest of the port city of Aqaba, on the Red Sea, in July 1917, remains one of the singular most amazing feats of arms, logistics, and unrestrained imagination.
In 1917, when it appeared the Allies could lose the Great War, Lawrence and his band of Arab fighters travelled 600 miles on a weeks-long trek was through terrain so inhospitable that the Bedouin called it al-Houl (the Terror). The Arabs numbering 2,500 men entered Aqaba without a shot and lost just two men. Their opponents melted away. Lawrence then crossed the Sinai to Cairo to inform the new British commander-in-chief, Gen. Edmund Allenby, of this history-changing victory.
The event is the centerpiece of the 1962 epic film Lawrence of Arabia. For me, the scene that defines Lawrence and dreaming large is when he stays up all night and envisions how to change the tides of a war. In the morning, Lawrence convinces his ally, Sherif Ali, to join him with just 50 fighters, with the taunting line, “Aqaba is over there. It is only a matter of going.”
To this day, I keep a picture of that scene on my Facebook page as a reminder of acting boldly and dreaming impossible dreams.
What We Learn About Lawrence from Korda:
Korda’s depiction of Lawrence provides keen insight to the real man’s complicated life. As I read it with multiple lenses, I am impressed by many things that come through that have relevance to anyone today:
Lawrence followed a classic pattern of mastery: apprenticeship as an archaeologist with a master, multiple areas of intellectual interests, rigorous training and self-directed study, curiosity, open mind, willingness to take great risks.
Lawrence achieved military greatness by not being a soldier, but by being atypical and an anti-soldier, which was the right strategy for the right place at the right time. He did know how to shoot and use explosives too.
Throughout his life, Lawrence built and used powerful networks. This included the British intelligence-gathering for the Middle Eastern theatre, top cabinet officials in London, the Foreign Office, the Secretary of War, Arab tribal leaders, and military officers. Lawrence built his networks by leveraging the importance of what he could do for them and say to them. And vice versa.
Lawrence was supremely confident in his views, which were grounded in rigorous personal experience with first-hand encounters in the field, in dangerous situations, and with an expert understanding of multiple disciplines (cartography, language, military history, religion, and culture).
Lawrence never wasted time doing thing that were not of interest to his curiosity and imagination.
Lawrence was never afraid of pain and embraced it as a means of understanding limits he always tried to break. Great leaders have always been able to respond to and even master their pain and suffering and not be bent or broken by it.
Lawrence was a good judge of character, and understood who to align himself with in his career path–always choosing the right master, such as Gen. Allenby.
Lawrence always made his work stand out, and the quality of his work caught the eye of wise superiors, from his work analyzing the Arab revolt for his military peers in Egypt that was keenly followed to his Oxford thesis on Crusader architecture in the Middle East that opened doors to field work in the desert.
Lawrence relished the outdoors, adventure, drama, the myth of a hero’s quest, and creating links where others failed to see what he understood.
Lawrence fully understood the importance of symbols, such as the knife he bought in Arabia, the Arab dress he wore, and his physical place in a march among leaders of the revolt.
Lawrence mastered theater and stagecraft in his actions to influence opinions and motivate and inspire people in a guerilla war.
Lawrence inspired others by taking great personal sacrifices and showing he was willing to sacrifice himself for the good of the larger mission.
Lawrence never disowned his upper middle-class upbringing, and he used it to navigate his way out of some early young mistakes to positions of power afforded only to the privileged.
Lawrence realized that ideas with deep historic and religious roots are what motivate movements, not weapons and tactics alone.
Lawrence recognized the importance of storytelling and myth making, and he used all of his talents to control his story and brand.
Lawrence was a shape shifter, who could be different things to different people, but always himself.
Becoming Great on Your Own Terms:
I think one of the most telling periods of his life came after he graduated from Oxford and spent four years in the Syrian/Turkish desert at Carchemish on a dig, where he learned his craft (1911-‘14) under the auspices of Sir Leonard Woolley. (That relationship would be revived when Woolley became part of the Arab Bureau in Egypt that Lawrence was assigned to.) Lawrence used his time well on this project. This experience meant organizing projects, motivating workers, settling cultural disputes, finding friends in all ethnic groups, studying the larger political world around him, and seeing the chances this knowledge could bring.
Every one of these skills he employed later in his more active setting at war. Lawrence took what appeared to be useless skills and made them his strongest attributes that no other person in the British army had. He had made himself indispensable by following his own path.
For anyone looking for a bit of a reboot in their life, in terms of making more of a mark with their job, their relations, their purpose and meaning, I say, give Korda’s book a look on a long trip or holiday. You may find some lessons to be learned from someone who truly dreamed his life in daylight, and then died young.
(Ed. Note: Dozens of links are provided below, after the introduction.)
Detroit’s unwanted celebrity status nationally and internationally continues to fascinate me. Detroit is now known as a failed American urban experiment. For the more cynical or the painful realists, it represents the dark end to America’s middle-class dream, and the embodiment of the decline of American power and even its civilization.
Detroit rose like a phoenix at the beginning of the 20th century and then experienced the near death of the American automobile industry at the start of the next one, culminating in the taxpayer-funded bailouts of General Motors and Chrysler during the Great Recession. Once the nation’s fourth largest city, the population has fallen from 1.8 million to less than 800,000 in 50 painful years.
Since the violent Detroit riots of 1967 that killed 43 and burned more than 1,000 buildings, the community has transformed into a nearly all-African-American city. Sadly, it now ranks as the country’s murder and arson capital. Multiple factors, well beyond Detroit’s control, spurred these changes. These include white flight and suburbanization, along with national racial politics and globalization.
From a public health perspective, there are not many major cities doing worse. Entire neighborhoods have been vacated. Burnt out shells of homes and businesses dot the urban landscape that now is turning to seed. Nearly half of the city’s children live in poverty. Once glorious buildings that were testament to the confidence in industrial capitalism, notably the ghostly Michigan Central Station, stand vacant as monuments to a past glory. They are our America’s modern-day Roman Colosseum, symbol of a dying or dead empire.
Detroit is also my home town, where some of my family have long roots as Michiganders. It is the place where my life story began, at the intersection of two stories of my adoptive and biological families, who all eventually fled or simply moved away.
To help others understand Detroit Motor City and why it matters, now more than ever, I have compiled some of my favorite links to resources, films, books, and online content that I have uncovered recently. Take a moment to learn more about this famous place that once was the world’s greatest industrial city.
Detroit, Enduring Icon of Decline and “Ruin Porn” Celebrity
Beautiful Terrible Ruins, art historian Dora Apel examines ways Detroit has become the paradigmatic city of ruins, via images, disaster films and more and notes that the images fail to show actual drivers in the downward spiral, such as globalization, neoliberalism, and urban disinvestment
Diehard Detroit, a time lapse video of many of Detroit’s famed architectural ruins, abandoned factories and homes, monuments, buildings, and freeways, with absolutely no perspective on the meaning behind the mayheim, just titilating entertainment with great technique and a cool drone toy (it is stunning visually, and thus classic “ruin porn”)
Detroit’s Stunning Architectural Ruins, and Why Documenting Its Faded Glory Matters (an article by the Huffington Post, a liberal blog which exploits unpaid “contributors” more than Henry Ford ever did his factory workers)
How Detroit Went Broke, an in-depth investigation by the Detroit Free Press of Detroit’s 50-year history prior to its historic bankruptcy declaration, including unsustainable borrowing, population decline, pension mismanagement, tax shortfalls, state failures, and leadership failures particularly of former indicted Mayor Kwame Kilpatrick
Five years of foreclosures as shown by an investigation of the Detroit Free Press–a vast sea of distressed properties and ruined dreams
Burn, a documentary film by Tom Putman and Brenna Sanchez, tells a year-long story of the year in the life of Detroit firefighters, who battle uncontrolled arson against all odds (amazing filmmaking!!! … from the firefighters interviewed: “That is how you burn a city down. One at a time.”)
Interview with filmmakers Putnam and Sanchez on their documentary Burn (great read on scrappy filmmaking with a purpose)
The Making of Burn—so, you want to make a great film no one in power gives a crap about, but you have to do it anyway
Martin Daly and Margo Wilson’s research into the clearly identified risks that stepparents pose to their stepchildren has led to some of the most influential and path-breaking insights to emerge in the past three decades in the field of human psychology and evolutionary psychology.
The two Canadian-born researchers found overwhelmingly powerful evidence globally that stepparenthood has “turned out to be the most powerful epidemiological risk factor for child abuse and child homicide yet known.”
What’s more, they conclude in their influential 2002 paper, The Cinderella Effect: Parental Discrimination Against Stepchildren (1), that “non-violent discrimination against stepchildren is substantial and ubiquitous.”
Daly and Wilson turn to the research done widely in non-human species on Darwinian selection. Under this model of “the selfish gene,” the care of dependent young will ordinarily be directed selectively toward close relatives of the caretaker.
Daly and Wilson write that “psychological adaptations that produce discriminative parental solicitude vary between species, in ways that reflect regularities in each species’ ancestral environment of evolutionary adaptiveness (EEA).”
According to Daly and Wilson, “there is nothing magical about parental discrimination: preferential treatment of one’s own young exists only where a species’ ecology demands it.” The two see no reason why the evolution of the human psyche would be excluded from this logic.
Daly and Wilson’s wealth of evidence
Daly and Wilson’s research provides clear epidemiological evidence, including the use of an archive of 87,789 validated reports of child maltreatment in the United States. They support their findings with dozens of peer-reviewed studies of stepparenting abuse across cultures that also find similar patterns of abuse and stress.
These findings have yet to be refuted in any serious peer-reviewed paper. They are constantly cited by critics, who fail to show any new evidence refuting their findings.
Daly and Wilson’s research also went well beyond lethal and abusive treatment of children by their non-genetic parents. The outcomes they list include show how medical care is restricted, education funding is withheld, and other forms of non-physical abuse and favoritism prevail. Some of the main findings include:
In several countries, including Canada and the United States, stepparents beat very young children to death at per capita rates that are more than 100 times higher than the corresponding rates for genetic parents.
Children under three years of age who lived with one genetic parent and one stepparent were estimated to be seven times as likely to be the victims of validated physical abuse as those living with both their genetic parents.
In a Korean study of schoolchildren in the 3rd and 4th grades, 40 percent of those living with a stepparent and a genetic parent were reported to be “seriously battered” once a month or more, compared to 7 percent of those living with both their genetic parents.
In Finland, 3.7 percent of 15-year-old girls living with a stepfather claimed that he had abused them sexually, compared to 0.2 percent of those living with their genetic fathers.
Consistent findings of research show that stepparents and stepchildren alike rate their relationship as less close and less dependable emotionally and materially, and that all parties in stepfamilies are less satisfied, on average, than persons living in intact first families.
Stepchildren suffer elevated rates of accidental injury, both lethal and nonlethal, from infancy onwards, likely because they are not monitored and protected as closely, and they experienced elevated mortality in general, not just from assaults.
Research in the island of Dominica has shown that stepchildren have chronically elevated levels of the stress hormone cortisol, which is strongly associated with worse health outcomes in nearly all categories.
Numerous American studies, controlled for parental means, have demonstrated that children living with stepmothers do not receive the same regular medical and dental care than children living with their genetic parents.
Less money is spent on food in stepmother households.
Fiscal support from families for higher education is substantially reduced for stepchildren, even when both parental wealth and the child’s scholastic record are statistically controlled.
Weighing the evidence, Daly and Wilson also note that most stepparents also find pleasure helping to raise the children of their partners, and that many stepchildren are better off in stepfamily situations than those where the parent did not remarry. However, they write stepparents do not feel the same “selfless commitment” common in genetic parents.
In response to their critics, Daly and Wilson cite that literally “hundreds of self-help manuals for stepfamily members” all focus on the difficult issue of how to cope with the characteristic conflicts of stepfamily life.
Research continues to verify findings of Daly and Wilson
Other researchers besides Daly and Wilson continue to verify their findings. For example:
Schnitzer and Ewigman (2008) in the Journal of Nursing Scholarship found that children residing within households with adults unrelated to them had nearly six times the risk of dying of maltreatment-related unintentional injury. But risk was not higher for children in households with a single biologic parent and no other adults in residence.
Stiffman, Schnitzer, et al. (2002) in the journal Pediatrics reported that children residing in households with adults unrelated to them were eight times more likely to die of maltreatment than children in households with two biological parents.
Harris, Hilton, et al. (2006), in a study of 378 cases of filicide (killing one’s son or daughter), found that at least five times as many of the child victims lived with genetic fathers, while the raw frequencies of filicide were roughly equal between stepfathers and biological fathers.
Tooley, Karakis, et al. (2005) reported that step-children under 5 years of age were at a significantly increased risk of unintentional fatal injury of any type, and of drowning in particular. They also reported that children from single-parent families were generally not found to be at significantly increased risk of intentional or unintentional fatal injury, while children who lived with neither of their biological parents were at greatest risk overall for fatal injury of any type.
A 2008 Scottish Government study found that living in a “reconstituted” family with step-children or stepparents increased the risk of developing behavioral problems.
The danger of ignoring the myth (that is backed by evidence)
The research by social scientists and epidemiologists undermines the Brady Bunch myth of a balanced family involving parents and children with no genetic relations—the guys in this family having no genetic relations to the girls. The more appropriate model to discuss the validty of research is the older and still maligned trope of an evil stepparent, notably the stepmother, as clearly acknowledged by Daly and Wilson in referencing Cinderella in their research title.
The wicked stepmother is a frequent character in folklore. This myth is older than feudalism, and found globally. The darker Brothers Grimm version of Cinderella (Aschenputtel) has her stepmother’s cruelty on full display, compared to simply wickedness in the Disney rendering. A recent cinematic evil stepparent was captured in the classic Cold War film thriller The Manchurian Candidate, which included an evil stepfather in partnership with his Soviet spy wife to manipulate her son to kill a presidential candidate and advance a dark Soviet conspiracy.
Joseph Campbell, author of Hero with a Thousand Faces, notes that myths incorporated the tools that people used, and those tools are associated with power systems that are involved in the culture of their time. In the case of the trope of the evil stepparent, the myth has not been supplanted. Evidence shows otherwise. It is still alive for good reasons.
Why this matters for policy makers
There continues to be great stepparents and foster parents, by the thousands. I know many great people in both camps. They deserve praise for doing a job that may have few rewards and tremendous stress. I am in awe of those who I personally know (colleagues in Alaska).
However, policy makers, educators, law-enforcement agencies and social service agencies need to be reminded of very real risks of some family situations. The New Zealand-based nonprofit called Child Matters notes that having a stepparent is a known risk that should be considered for the well being of all children.
Efforts by “soft” social science publications, like Pscyhology Today, to downplay the valid research into the hazards stepfamilies can pose to innocent children do not help the group that needs the help most of all.
Our larger understanding of stepparenting should not, as Daly and Wilson write, “suffer from the misconception that a ‘biological’ explanation for stepparental violence is a claim of its inevitability and imperviousness to social controls, which, if accepted, will excuse the violence.”
They rightly claim that these misunderstandings block progress in understanding and helping kids. Acknowledging the evolutionary process and its relevance to human affairs can only help. I believe Daly and Wilson are spot in their claim that the most harm is done by “those who adhere to the implausible notion that stepparenthood is psychologically equivalent to genetic parenthood and that ‘bonding’ experience is sufficient to evoke the full depth of parental feeling.”
(1) Daly M & Wilson M (2002). The Cinderella effect: parental discrimination against stepchildren. Samfundsøkonomen 2002 (4): 39-46.
As a native of Detroit, I present this first of several essays, with a profound sense of sadness. (See my photo blog for my first photo essay.)
It is hard to accept that my birthplace, this once great global city, has become a symbol for American industrial decay and capitalism’s larger ills. At one point, Detroit boasted nearly 2 million residents in the 1950s. Today is barely counts 700,000 residents. [Updated census figures, 5/5/2015.]
In its heyday of bustling industrial production, Detroit served as a global icon for American ingenuity, industrial might, and economic power. During World War II, when the larger metro area produced the country’s war weaponry to defeat the Axis powers, Detroiters proudly called their city the Arsenal of Democracy. In the 1920s and 1930, about 40 percent of all automobiles were manufactured in the Motor City and the Ford River Rouge plant was the world’s largest.
Today, Detroit is known more as the murder capital of the United States, and the arson capital. All told, 90,000 fires were reported in 2008, double New York’s number—for a city 11 times larger—according to Mark Binelli, author of Detroit City is the Place to Be. It is the epitome of racial politics. Binelli notes, 90,000 buildings are abandoned, and huge swaths of the 140-square mile urban area are now returning to nature. Beavers, coyotes, deer, packs of wild dogs, and foxes are now reported in the city.
I just visited Detroit, and the trip had a more profound impact on me than I was prepared for. How is it that our country could undertake two overseas wars to conquer and rebuild nations—Iraq and Afghanistan—and yet abandon a city that helped to make the country the global power it once was.
National partisan politics have played a role, with Detroit becoming a symbol of the Democratic Party’s failure, as a black city and union city, in the eyes of white and conservative detractors. Then there are NAFTA (pushed by Bill Clinton) and industry fleeing the country for cheaper manufacturing from global suppliers and gross mismanagement of the Big 3 automobile companies, two of whom were bailed out by U.S. taxpayers in 2009.
White flight eventually followed long-simmering racial tensions. There have been Detroit race riots in 1863, 1943, 1967, and 1987. Those riots were stoked by historic racism, redlining, job discrimination, and the building of freeways that helped to destroy America’s inner cities. Today, some criminal fringe actors among Detroit’s mostly black residents are burning what’s left of their own city, for at times just the hell of it.
Charlie LeDuff, author of Detroit, An American Autopsy, painted a heart-breaking tale of the city’s self-destructive conflagrations through the tales of firemen trying to combat the arsonists. “In this town, arson is off the hook,” said a firefighter to LeDuff. “Thousands of them a year bro. In Detroit, it’s so fucking poor that a fire is cheaper than a movie. A can of gas is three-fifty, and a movie is eight bucks, and there aren’t any movie theaters left in Detroit so fuck it.” (I will do a photo essay of fire-ravaged homes shortly.)
That latest malaise, on top of repeated political scandals and corruption by the city’s bureaucrats and criminal politicians, was a crushing bankruptcy filing in the face of an $18 billion debt. In December 2014, after a year an a half in limbo, a grand bargain was struck with creditors, the city, the state, and private industry that prevented the city from selling its city-owned artwork (Rembrandts, Van Goghs, and more) in the world famous Detroit Institute of Arts.
As I wandered the glittering white palace that is the DIA, I wondered, what’s more important, this art or the blocks and blocks of emptied neighborhoods that most of this country has forgotten.
Coming back to Portland was hard. I posted a comment on Twitter as soon as I arrived back home how bizarre it was to be back in the whitest city in North America, Portland, after spending time in the city that America defines as African-American.
This week, I attempted to do what consumers world over try to do: figure out the cost of a transaction to make an informed decision before I acted. Everyone from market shoppers in Malawi to mega-billionaires choosing to invest their capital does this. They all are promoting their self-interest and also trying to save or even make money.
I wanted to know what a doctor’s visit would cost and how much truly might be or might not be covered. If needed, I wanted to know if I had to find a better bargain, if the first option would not be an affordable activity with my plan. It might have been easier to walk across the Sahara barefoot, without water.
What I tried to do is impossible for American consumers trying to figure out the price of just about every medical procedure, doctor’s or dentist’s visit, and hospital activity.
Today, except the for very rich who do not need insurance, there is no such thing as a functioning U.S. health care market, where consumers can freely choose to pick their providers and choose lower-cost options. Insurance companies and providers do everything possible to hide prices and bully and even threaten insured consumers who are trying to make choices that occur in rational and functioning markets.
The Commonwealth Fund notes, “… the U.S. health care market is unlike any other market: patients rarely know what they’ll pay for services until they’ve received them; health care providers bill different payers different prices for the same services; and privately insured patients pay more to subsidize the shortfalls left by uninsured patients. What’s more, prices for health services vary significantly among providers, even for common procedures such as laboratory tests or mammograms, although there’s no consistent evidence showing that higher prices are linked to higher quality.”
The Commonwealth Fund argues that even some modest reforms in pricing transparency, with our broken system, could lead consumers to “receive high-quality services from lower-cost providers … This, in turn, could encourage competition among providers based on the value of care—not just on reputation and market share.”
So what does this have to do with me and my experience? Everything, actually.
Gauging consumers one by one: the thousand cuts approach:
For years, I have consistently tried to get dentists and doctors to give me a price quote before a visit. To date, I have never had any medical provider provide me prices or codes without fighting tooth and nail, and often it is with caveats that claim they are exempt from any responsibility if their pricing information is wrong, even with the diagnosis code for a routine checkup.
Here is how the health provider and health insurance fraud and rip-offs work, patient by patient, and this is how it recently happened with me.
Step one: Call the provider and have them evade sharing information.
“We can’t provide you a diagnosis code until you see the physician.” To which I reply, “I am trying to understand if the charge will be covered by my insurance company.” They answer, “We can’t do that because the doctor may do [fill the BS line that you prefer].”
Step two:Call the insurance companyand have them not tell you if a possible charge by a provider is within their “usual and customary charges”—a term that is behind a wall of secrecy and never shared with consumers, ever.
“Hello, I’m trying to determine if my visit to my physician is covered and if the charges are within your accepted ranges.” They reply, “Sir, we can’t do that. We’d need to know the diagnosis codes and procedure codes before we can possibly investigate that.”
To which I reply, “Sir/mam, I don’t have that. Doctors’ offices never tell you that. I don’t have the codes.” Or, if I was able to get a code for a check up, “Here is the diagnosis code [fill in code], what is your accepted charge.”
The reply could be, “Sir, I told you we would need the diagnosis code to investigate…” Me interrupting, “Sir/mam, I just told you they won’t give me that code, and no doctor…” Them interrupting, “Sir, you are becoming agitated, stop interrupting me. I was saying we need the diagnosis….” Me interrupting, “I am not becoming agitated. I am behaving perfectly rationally. I just want to know what this will cost and how it will be covered.”
They reply, “Sir, I have already told you, without a diagnosis code and procedure code, we are not able to provide you…” Me interrupting again, “Sir/mom, did you just hear me when I said the office will not provide me with a diagnosis code.”
Usually such a song and dance can go on for about five or 10 minutes. In the end, the insurance reps will likely have bullied the consumer and employed their standard and tested propaganda that justifies preventing nearly all consumers from knowing if any medical procedure will truly be covered and at what level. The same works for hospitals, clinics, and other practices, who will not share their prices.
In short, they have created a system that perpetuates waste, fraud, and abuse, one patient at a time, systemwide—and it is a system that remains protected by powerful special and political interests who profit from this.
Who the hell created this mess and what it means:
We can thank our political process that encourages special interests to buy influence and bankroll candidates with campaign donations for a good chunk of this mess. We can also thank the so-called health insurance companies from protecting their market share that makes the United States the most inefficient and most expensive health care system among all developed nations.
The Commonwealth Fund also has found that the U.S. system underperforms and has worse outcomes than 10 other industrial nations, mirroring past findings. No surprises there—this fact has been reported by health and public health researchers now for years. The U.S. economy devotes an absurd 17.7 percent of GPD to health care spending, almost double that of its peers.
The Center for American Progress has described the consolidation of power by the bloated middlemen of our dysfunctional health care system as a crisis, due to consolidation and market control. The center reports the “lack of competition has led to growing insurer profits, increased costs and reduced coverage for enrollees, an epidemic of deceptive and fraudulent conduct, and rapidly escalating costs.”
From the early 1900s to the present, major efforts to reform the U.S. health care system to create a national health system have failed. Some of the principal profiteers that have safeguarded the status quo are the monolithic health insurance companies, like Premera Blue Cross, my provider.
Other bloated health benefits providers include Aetna, Wellpoint, UnitedHealth Group, Cigna MetLife, and Humana. All of these companies are major political players who donate generously to members of Congress and state officials.
The health insurance model is a system vigorously defended by the GOP-controlled Congress, whose members theoretically support open markets, when in fact GOP members have attempted to derail the Affordable Care Act more than 50 times as of January 2015. And that reform was ultimately about reforming the existing health insurance market, not changing the system to promote openness in pricing or improving population health that is linked to universal health care systems.
The ACA only offered modest efforts to promote transparency. The law requires hospitals to publish and annually update a list of standard charges for their services. Other provisions about requiring exchanges to show prices are at best failed and complicated efforts that do nothing to break the wall of secrecy that has fed the beast that is our health insurance market.
The most pathetic part of this is, when I as a consumer try to do something, I am labeled a problem and seen as the bad guy. But I am OK with that, because doing the right thing always will meet with resistance. I have never kissed a doctor’s feet or behind, or those of companies that profit through monopolistic practices. I do not intend to start now. It just rubs me that today when I see the doctor, and tell him to make his pricing transparent, he will roll his eyes and give that “whatever look.”
The resurgence and outbreak of the most contagious virus on the planet, measles, has led to a swarm of media stories that have tried to report responsibly about the pockets of perpetrators of bogus science.
Even in the face of rock-solid research, done at the population level, proving without question that there is no link between autism and autism spectrum disorder and the measles, mumps, and rubella vaccine, the naysayers continue to promote ideas that have the same validity as racial eugenics of scientific quacks and Nazi racists. There are many parties who are helping to fan the flames of ignorance that threaten innocent children who have no ability to tell parent deniers that they put infants at serious health risks when they do not have their kids immunized from extremely infectious and very preventable illnesses.
Former Playmate Jenny McCarthy and clusters of deniers on both sides of the political spectrum are partially responsible for the resurgence of measles we are seeing around the country today.
What is particularly irresponsible is when formerly balanced media outlets choose to fan the debate flames to promote their products when there is no scientific or medical basis for claiming the issue is “a debate” as opposed to a public health crisis that requires layers of interventions to ensure the best health outcomes for all of us.
Tonight, I read the Oregonian newspaper’s story seeking to solicit input from science deniers with this astounding headline: “In the debate over vaccines, where do you stand?” At the bottom of the story were numerous blog comments that were not moderated. No surprise the journalistic adventure gave Portland’s now world-famous anti-fluoride, vaccination-denier, and anti-public-health community another platform to spout nonsense. Such sloppy journalism keeps bogus science alive and well, even when quackery like eugenics is now considered bad and un-modern. (In the end, quack science is still quack science.)
Reporter Kjerstin Gabrielson wrote, “What influenced your decision to immunize or not immunize your children? Has the recent measles outbreak in the United States swayed your opinion? What concerns do you have about immunizations? What concerns do you have about the diseases vaccines are designed to prevent?”
In response to the Jenny McCarthy style journalism I found, I chose to write this note directly to the reporter. Here it is. I hope she can make amends later for her journalistic transgressions and learn a little bit more the history of communicable diseases in the Oregon, where diseases like smallpox literally helped to wipe out many Native American communities before most white settlers arrived.
Letter Sent Feb. 4, 2015, by email:
Ms. Gabrielson: What exactly were you and your editors possibly thinking framing the public heath issue of a scientifically proven health intervention (MMR vaccination) that is used globally to save lives by giving precedence to perpetrators of junk science whose ideas have now been thoroughly disproven by peer-reviewed, country-wide, and massive population-based studies showing absolutely no proven link to autism and the MMR vaccine?
Do you even understand what a population-based study is? Do you understand statistical significance or P-values? Do you understand the perpetrator of this bogus original article has been thoroughly debunked? Do you even know the history of this state where infectious diseases literally wiped out entire Native American villages on a scale that makes Ebola look like a mild chest cold?
If I were to start claiming, say that European Jewry was responsible for causing World War I and helped to defeat Germany, would you print an article with a headline talking about, tell us your thoughts on the debate about Jews’ role causing WWI. Would you open up your comment blog to Nazis and skinheads who will speak with utter sincerity using widely disproven racial eugenics theory that have the exact same scientific validity as those perpetrated by former Playmate Jenny McCarthy?
Maybe you should learn about what happened to Native Americans in Oregon barely 160 years ago, due to smallpox and malaria. Maybe that might inspire you and your paper to use your brains. Promoting profits for junk reporting at the expense of public health is rather disgraceful if you ask me.
Few books stay with me for long. I read them and give them away. One has stayed on my bookshelf, now for 26 years. That book is Dr. Stephen Bezruchka’s The Pocket Doctor. First published in 1982 by the Mountaineers, this pocket-size reference, now being published at a bit more than 100 pages, is exactly what its title implies. It is a guide to help a traveler cope with illnesses many people in the developing world face daily. You can buy it online from many vendors, like Powell’s Books.
I credit this book for saving my bacon and mental health on several best-forgotten nights. It helped me cope with medical problems that are normal for hundreds of millions of residents globally, and for me something I did not experience back in the comfort of the United States. But I am not the only writer and traveler who praises Bezruchka and his book.
Why many trust Bezruchka’s work
Bezruchka is a Canadian-born former emergency-room doctor trained at some of the nation’s best universities (Standford, Harvard, Johns Hopkins). He has both an MD and MPH. He has worked with medical specialists in the developing world, notably Nepal for 10 years. He also has written a great guide called Trekking in Nepal, which I used back in 1989. Today he is a lecturer on global health at the University of Washington School of Public Health (UW SPH) and a nationally recognized advocate for health care reform to improve public health outcomes and to eliminate health and income inequality.
I have taken this book with me now to three continents: Asia, Africa, and South America. I just cannot say goodbye to it, even when my developing-nation jaunts seem fewer and fewer.
The advice it provides has helped me to self-diagnose all manners of common gastrointestinal disturbances, such as food poisoning (nasty and scary in a crappy place), dysentery, and common diarrhea. I also used it to help me obtain the necessary medicine for what I still believe was malaria, which I had in Kigali, Rwanda in 1997.
With this book in my hand, I felt I could handle the predicaments that afflict visitors from developed countries to less-developed areas. In my 1988 published version, 13 pages are devoted to common drugs and medicines that address typical maladies, such as the antibiotic ciprofloxacin, to tackle infections, with information laid out in a table on a drug’s use, likely place of need (city, remote, “third world”), form, and dosage.
Basic health care advice can be fun with good writing
Bezruchka’s writing is straightforward and direct. In his chapter on drugs, he begins his recommendation with a simple message: “Remember that drugs, though valuable, are not a cure all.” He provides advice on assembling a medical kit, working with doctors at home and abroad, and dealing with major sources of health problems—namely, food and water.
Bezruchka also highlights a major global health issue that is more severe than microbial agents, trauma from vehicle accidents. “Trauma, especially that caused by motor vehicle accidents results in the majority of disability acquired in developed countries,” writes Bezruchka. “This is even more true in third world countries. Trauma causes more disabilities to travelers in foreign countries than all the exotic diseases put together.” That observation remains true to this day, as shown in global health data.
But there is much more. Rabies? Check. Animal attacks? Covered. Ticks and leeches, fever, rashes? All addressed. The two-page section, in my old and battered version, on dealing with stress in less-developed nations is a classic summary of what many first-world travellers experience.
“If the culture shock of a third-world setting with its attendant poverty and hopelessness have you in despair, take steps to improve your psyche,” writes Bezruchka. “Seek out help, another traveler, or a religious organization or individuals.”
Bezruchka even has sections on death and how to cope with returning from travels with an illness. I definitely experienced lingering issues when I came back and took this advice to heart.
Meeting Bezruchka later in life
When I first met Bezruchka in person during my studies at the UW SPH, I mentioned how much I enjoyed his book and used it frequently in Nepal. I even mentioned how enterprising Nepalis had published black-market copies of his book they were peddling on the streets in Kathmandu. As I recall, he considered that a compliment to the value of his work.
Sometimes small and perfectly executed creations are ones that have the most impact. In Bezruchka’s case, there is far too much to choose from to say what is best—from published papers to advocacy to mentorship of future health leaders. I will submit this still fine tome as work that stands the test of time and proves that small is often better.
I began this blog in March 2012 to share my perspectives on public health issues and to integrate multiple disciplines and perspectives that the traditional public health field either is not doing or does not want to do–such as speaking with moral clarity on the public health threat posed by firearms in the United States.
My blog has had nearly 38,000 page views as of late November 2014. This means this web site is getting more visibility and traffic than many published papers by academic researchers. Many of their peer-reviewed articles will never be seen because they are behind a firewall run by for-profit companies that prevents publicly-financed research from reaching policy-makers, the popular media, and the public who pays for the research.
To celebrate the eventual “fall of the wall,” meaning the for-profit firewall that is stifling innovation and blocking research from having greater value to the public, I am going to highlight a few of my more popular public-health articles based on visitors and page views.
I think it is time to start dismantling the firewall and to start telling public health’s story with more traditional storytelling techniques, with more creativity that bridges disciplines, and with an eye on upstream advocacy.
The articles I shared above do not follow the traditional model of public health writing or practice, and some challenge the current U.S. models as broken and even morally bankrupt, particularly regarding the historic deathly silence by public health leaders at the local and national level and at universities in the face of firearms-related violence in the United States.
So if you landed on this page and find yourself within the claustrophobic walls of academia as a student, grad student, or faculty member, and you have not been exposed by your peers or the faculty to the value of blogging, here 38 reasons why you need to get off your freaking butt right now and get to work. If you work in a public health office and your office is not actively using social media because of out touch managers and your office is not advocating with lawmakers, you need to show leadership and become the change you want to see and not wait for others to do it for you.
Yes, it is time to think creatively and innovate and challenge the old guard whose ways are failing to make a greater impact.
My list of blogs/articles may be updated as I continue to publish more of them. I am now using this blog to discuss organizational behavior, multi-disciplinary research, and stories based on personal and professional experiences as the starting point for discussing larger issues. I hope you come back from time to time to check out my articles. Thanks.
(Note, I am publishing this blog post as both a page and post on my blog.)
Renowned psychiatrist, philosopher, and writer Viktor Frankl stands as a giant among 20th century thinkers. The Austrian-born Frankl (b. 1905, d. 1997) was a psychiatrist whose life was transformed by his experiences as a Jewish prisoner who survived the Holocaust and internment at the Auschwitz death camp and three other German concentration camps.
With the exception of a sister, all of his immediate and extended family and his beloved wife were murdered by the Nazis. From the aftermath of this horrific experience, he embarked on a life’s work that provided deceptively simple but remarkably clear ideas that literally provide a framework on how all people can live meaningful lives.
Frankl survived his brutal internment, which should have killed him, by seeing a purpose in his ugly reality and by taking control of his responses to that experience with positive actions and a mental attitude that ensured his survival and also his outlook on life and his fellow man and woman. His simple ideas offer no shortcuts, and they uncomfortably place each person in control of how they choose to respond to life’s challenges, even ones as unforgiving as genocide and mass murder.
Frankl proposes all of us are motivated to seek a higher purpose, even when our circumstances are as cruel as a death camp surrounded by barbed wire and vicious men armed with machine guns. Frankl writes: “Man’s search for meaning is the primary motivation in his life not a ‘secondary rationalization’ of instinctual drives. This meaning is unique and specific in that it must and can be fulfilled by him alone… .” More than pleasure, more than material things, meaning motivates us all. It is our purpose for being.
Man’s Search for Meaning, a book that changed modern thinking
Frankl published those principles in his highly acclaimed and influential 1946 memoir, Man’s Search from Meaning, which today has been translated in more than 20 languages and has sold more than 10 million copies. It is considered among the most influential books in the United States, according to a Library of Congress survey.
He originally developed the framework for his sparse set of powerful ideas when he was practicing psychiatry in Vienna before the Nazi occupation and saw how he could help patients overcome their suffering by making them aware of their life’s calling. His treatise, stashed in his coat, was literally lost when he was imprisoned.
Later in his life, when he had achieved global recognition because of the widespread popularity of his bestseller, he was asked by a university student: “…so this is your meaning in life… to help others find meaning in theirs.” His reply was as clear and direct as the theory behind his therapy, “That was it, exactly. Those are the very words I had written.”
As one writer influenced by Frankl, Genrich Krasko, points out, Frankl’s ideas are more prescient today, given millions have no meaning in their lives, particularly in affluent societies: “Viktor Frankl did not consider himself a prophet. But how else but prophetic would one call Frankl’s greatest accomplishment: over 50 years ago he identified the societal sickness that already then was haunting the world, and now has become pandemic? This ‘sickness’ is the loss of meaning in people’s lives.”
Logotherapy, Frankl’s foundational theory
Frankl called his system logotherapy, derived from the Greek word “logos,” or “meaning.” It has been called existential analysis, which may over-simplify its scope. The philosophy and medical practice boils down to providing treatment through the search for meaning in one’s life. Its utterly basic but ultimately powerful foundational ideas are easily summarized:
Life has meaning in all circumstances, even terrible ones.
Our primary motivation in living is finding our meaning in life.
We find our meaning in what we do, what we experience, and in our actions we choose to take when faced with a situation of unchangeable suffering.
Frankl notes, “Most important is the third avenue to meaning in life: even the helpless victim of a hopeless situation facing a fate he cannot change, may rise above himself, may grow beyond himself, and by so doing change himself. He may turn a personal tragedy into triumph.” This latter point is particularly poignant, as it calls out the role that adversity can have in shaping us and our destinies and improving our character and our life’s narrative.
In short, no matter what circumstances we find ourselves, so long as we have a purpose, we can find fulfillment. What’s more, we are fulfilled by right action and by “doing,” not through short-term pleasure or narcissistic pursuits.
Frankl argues that meaning can be found in meaningful, loving relationships, in addition to finding it through purposeful work or deeds. In fact, it was the strong love of his first wife that kept him alive amid the unspeakable horrors of Auschwitz. He felt her presence in his heart and it literally let him live when others around him perished.
Frankl’s core ideas at odds with more ‘accepted’ health and mental health paradigms
Frankl’s ideas collide with behaviorist models, which show that conditioning will determine one’s responses—the proverbial Pavlovian dog or Skinnerian lab rat. By contrast, through his own experiences and those he observed treating depressed and suicidal patients before and after the war in Vienna, Frankl claims that “everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances.”
When faced with a situation, we all chose. But our power is defined by our actions. “Between stimulus and response, there is a space,” he claims. “In that space is our power to choose our response. In our response lies our growth and our freedom.”
The concept of personal choice conflicts with extensive research that clearly documents how one’s environment, race, socioeconomic status, and more—the so-called social determinants of health (SDOHs)—shape one’s life more than one’s individualistic decisions.
For two years, while earning my MPH at the University of Washington School of Public Health from 2010 to 2012, I found myself frequently and painfully at odds with current research and literally thousands of studies that proved to me that SDOHs will impact our lives in the most profound ways.
Yet I found the field and its most ardent practitioners lacking an explanation that showed the real power people have in controlling their personal outcomes. This is something that the public health field and my faculty sharply criticized by showing the medical model, which tells persons to control their health, has largely failed to promote wider population health metrics.
While I do embrace a “policy and systems” approach, I even more strongly believe that every person has the ability to make life-changing choices, every minute of every day—from the food they put in their mouth, to devices they watch daily, to the people they associate with, to the jobs they take or do not take (however awful often), to the way they manage their personal emotions. They have choices, and often they are cruel and brutally unfair choices, which often favor the privileged.
Frankl was famous for meeting with some patients, asking them to reflect on finding meaning in their lives over their entire life span, and providing the mental treatment they needed to take control of their lives without future interventions or drugs, which predominates the American model of mental health treatment. Some of his patients only required one session, and they could resolve to deal with life’s circumstances without any further intervention.
This is a radically and in fact dangerous model that challenges how the United States is grappling with mental illness nationally, though many practitioners use Frankl in their work. One psychiatrist I tweeted with wrote me back saying, “I’m far from the only one [using Frankl]! There’s a large humanistic community in the counselling/psychotherapy world.”
Frankl’s ideas continue to be studied, refuted, debated, and argued by learned and well-intentioned academics, which I think would amuse Frankl. He was more interested in the practical work of day-to-day living and less with becoming the subject of a cult following.
As one commentator I saw in a documentary who knew Frankl noted, Frankl was not interested in fame, otherwise he would be more famous today.
Here is just one example showing how theorists explain logotheraphy; see the table by Paul Wong on life fulfillment and having an ideal life.
Why Frankl’s thinking profoundly inspired me and thousands of others
For more than three decades, I have been wrestling with the concept of personal responsibility and the influence of our environment and systems that impact our destinies. Such factors include one’s family, country, religion, income, the ecosystem, our diet, and political and economic forces, among others.
I also have been fascinated by examples of people choosing hard paths in dire circumstances as the metaphor that defines successful individuals’ life narratives. In Frankl’s death camp reality, this ultimately boiled down to choosing to be good, and helping fellow prisoners, or choosing to partake in evil, which many prisoners did as brutal prisoner guards called kapos.
No one gets a free pass in this model, and all people in all groups can be one or the other, Frankl says. “In the concentration camps, for example, in this living laboratory and on this testing ground, we watched and witnessed some of our comrades behave like swine while others behaved like saints,” writes Frankl. “Man has both potentialities within himself; which one is actualized depends on decisions but not on conditions.”
I had not been able to order these two lines of thinking into a coherent set of principles, as Frankl so perfectly did. When I stumbled on him quite by accident or maybe design this summer, while reading books by Robert Greene and even management guru Stephen Covey, I had that most rewarding and delicious feeling of “aha.” It was more like, “Wow, what the hell was that!”
It felt like a thunderclap. I almost reeled from the sensation. I then began to tell every single person I know about Frankl, and I learned many of my colleagues had already read him. I felt robbed not one teacher or academic, at three respected universities I attended, had covered or even mentioned Frankl, when his ideas are foundational to our understanding of the fields of psychology, public health, business, organizational behavior, religion, and the humanities in the 21st century.
Frankl’s ideas matter to each of us, in everyday life
One my most satisfying feelings is discovering that one’s personal life experiences and ideas on issues as big as the meaning of life also resonate profoundly with millions of others—those who have read his work. Even more gratifying is discovering that the core principles to living life amid hard choices can be grounded in principles that can help everyone, even in the most dire of personal experiences.
My own travels in the developing world stand out for me. I met countless people facing vastly more painful, difficult, challenging lives than I have faced. Yet, the wonderful people I met had nothing but smiles and treated me with genuine sincerity. I had to ask myself, why is it that so many people are clearly content when their surroundings indicate they should be experiencing utter despair and even violent rage. Why is there kindness in their hearts and peace with their reality.
I understood at all levels what I was experiencing. But Frankl’s framework ties this rich set of personal experiences to all of us, and to larger existential ideas of what we are meant to do with our time.
For Frankl, the answer is just doing what life needs us to do. As Frankl wrote nearly 70 years ago, “Life ultimately means taking responsibility to find the right answer to its problems and to fulfill the task which it constantly sets for each individual.”
With that point, I now must ask you, the reader, What are you doing with your life, and are you doing what you are being asked to do? You cannot escape this question, and if you avoid it, you will always have the pain and emptiness of not listening to your own calling. The choice of course is your own.