Archive for the ‘Medical’ Category
Mainly because the government doesn’t require certification. (Note the importance of government regulation.) Amy Tuteur writes in the NY Times:
IS home birth safe? That depends on where you ask the question.
In much of the developed world, home birth is a fringe practice, at about 2 percent of births or less, for obvious reasons: Childbirth is inherently dangerous, and if an emergency occurs, the baby or even the mother may die. Indeed, in the United States, the switch from home birth to hospital birth over the 20th century was accompanied by a more than 90 percent decrease in neonatal mortality and nearly 99 percent decrease in maternal mortality. Antibiotics, blood banking, safe C-sections and neonatology have combined to change death in childbirth from common to rare.
But there are places in the world where home birth is relatively safe, like the Netherlands, where it is popular at 16 percent of births. And in Canada, where it appears safest of all, several studies have demonstrated that in carefully selected populations, there is no difference between the number of babies who die at home or in the hospital.
In contrast, home birth in the United States is dangerous. The best data on the practice comes from Oregon, which in 2012 started requiring that birth and death certificates include information on where the birth occurred and who attended it. The state’s figures show that that year, the death rate for babies in planned home births with a midwife was about seven times that of births at a hospital.
Many studies of American home birth show that planned home birth with a midwife has a perinatal death rate at least triple that of a comparable hospital birth. (The perinatal death rate refers to the death rate of babies in their last weeks in the womb and first week outside it.)
Could racial or economic differences, or poor prenatal care, explain this deadly difference between home births here and in Canada? No. The relevant statistic is again perinatal mortality, and on that measure, the countries are roughly equal.
The problem is that there are two types of midwives in the United States. The first, certified nurse midwives, called C.N.M.s, are perhaps the best-educated, best-trained midwives in the world, exceeding standards set by the International Confederation of Midwives. Their qualifications, similar to those of midwives in Canada, include a university degree in midwifery and extensive training in a hospital diagnosing and managing complications.
The other, certified professional midwives, or C.P.M.s, fall far short of international standards. One 2010 study of midwives published in The Journal of Perinatology found that home births attended by nurse midwives had double the neonatal mortality rate of hospital births attended by nurse midwives, while home births attended by C.P.M.s and other midwives had nearly four times that rate.
This second class of poorly trained midwives attend the majority of American home births. And yet they are legal in only 28 states; in the rest of the country, many practice outside the law.
They used to be called “lay midwives” or “direct entry midwives,” in recognition of their lack of formal medical schooling. That didn’t sound very impressive. In a brilliant marketing ploy, they created a credential — the C.P.M. — and awarded it to themselves. Many receive their education through correspondence courses and their training through apprenticeships with another C.P.M., observing several dozen births and presiding at fewer. How woefully inadequate is this education? In 2012 the requirements were updated to require proof of a high school diploma.
They seem to believe they don’t need more training because they are “experts in normal birth.” As I often say, that makes as much sense as a meteorologist being an expert in sunny weather. Anyone from a taxi driver to a 12-year-old sibling can handle (and has handled) an uncomplicated birth. The only reason to have a trained attendant is to prevent, diagnose and manage complications, the very things that C.P.M.s never have to learn to do. . .
And do read the whole thing. The situation in the US is very bad, and the contrast with how Canada handles the issue is striking.
Ryan Devereaux and Cora Currier report in The Intercept:
Nearly seven months after the first shots were fired, the Pentagon has released its full report detailing the night of chaos and horror that left 42 patients and staffers dead at a Doctors Without Borders hospital in Kunduz, Afghanistan. In publishing the highly anticipated account, the military concluded that its attack did not amount to a war crime because its effects were not intentional, a view at odds with certain interpretations of international law.
In the wake of the attack, Doctors Without Borders, also known by its French name, Médecins Sans Frontières, or MSF, described the October 3 raid as “abhorrent and a grave violation of international humanitarian law,” adding, a “war crime has been committed.”
In announcing the report today, Gen. Joseph Votel, the head of U.S. Central Command, argued that was not the case.
“The label ‘war crimes’ is typically reserved for intentional acts — intentional targeting [of] civilians or intentionally targeting protected objects or locations,” the general said. The Americans “had no idea,” they were targeting the hospital, Votel said, and once they recognized what was happening, they called off the attack.
In a statement, MSF said it had not had an opportunity to review the military report before it was posted online, though the organization did receive a two-hour verbal briefing from Votel on Thursday. The humanitarian group fired off a set of unanswered questions, and repeated its call for an independent inquiry into the attack by the International Humanitarian Fact Finding Commission.
“MSF and other medical care providers on the front lines of armed conflicts continually experience attacks on health facilities that go uninvestigated by parties to the conflict,” the statement read. “However, MSF has said consistently that it cannot be satisfied solely with a military investigation into the Kunduz attack.”
While Votel stressed that the conclusions of the report were subjected to legal review by military lawyers, the general’s argument that the absence of intentionality meant the attack on the MSF could not be a war crime wades into complex legal territory. According to the International Red Cross definition, “war crimes are violations that are committed willfully, i.e., either intentionally…or recklessly…The exact mental element varies depending on the crime concerned.” Following the release of the report, Patricia Gossman, Human Rights Watch’s senior researcher in Afghanistan, tweeted, “It is established principle of customary international law that war crimes can be committed through recklessness.”
What’s more, Votel’s claim appeared inconsistent with the military’s own law of war manual, which states, “In some cases, the term ‘war crime’ has been used as a technical expression for a violation of the law of war by any person; i.e., under this usage, any violation of the law of war is a war crime. This has been longstanding U.S. military doctrine.” According to the findings of their report, the investigators looking into the Kunduz attack noted violations of the rules of engagement, and also breaches of the laws of war.
MSF president Meinie Nicolai said that “a grave breach of international humanitarian law” is not determined solely by whether or not the act was intentional.
“With multinational coalitions fighting with different rules of engagement across a wide spectrum of wars today, whether in Afghanistan, Syria, or Yemen, armed groups cannot escape their responsibilities on the battlefield simply by ruling out the intent to attack a protected structure such as a hospital,” Nicolai added.
The Kunduz report comes in the context of a disturbing trend of attacks on medical facilities. This week, an MSF-supported hospital was bombed in Syria, killing three doctors. MSF says seven medical facilities that it works with in Syria have been hit this year, while four have been bombed in Yemen.
Votel, who was the head of U.S. Special Operations Command at the time of the Kunduz raid, confirmed that more than a dozen U.S. service members were disciplined for their roles in the airstrike — they would not, however, face criminal charges in connection with the ordeal. Repeating much of what the military has already claimed with respect to the attack — an account that has changed multiple times — Votel framed the tragedy as the result of overlapping human and technological errors. . .
Later in the report (but read the whole thing):
. . . Donna McKay, executive director for Physicians for Human Rights, slammed the military’s punishments as insufficient. “The decision to dole out only administrative punishments and forego a thorough criminal investigation of October’s deadly strike in Kunduz is an affront to the families of the more than 40 men, women, and children who died that night, punished merely for being in a hospital, a supposed safe haven in a time of war,” McKay said in a statement.
The military’s response does not assure the future of MSF’s work in one of Afghanistan’s most volatile regions.
“We can’t put our teams – including our colleagues who survived the traumatic attack – back to work in Kunduz without first having strong and unambiguous assurances from all parties to the conflict in Afghanistan that this will not happen again,” Nicolai, the MSF president, said.
The Pentagon has approved a $5.7 million effort to rebuild the facility it destroyed, and as “a gesture of sympathy,” more than 170 individuals have received condolences for loved ones injured or killed, Votel said. “$3,000 for wounded and $6,000 for killed,” he said.
On Thursday, The Intercept published a months-long investigation into the attack on the hospital, based on dozens of interviews with American and Afghan officials, witnesses, regional experts and survivors of the air raid. The picture that emerged was one of remarkable confusion about who was in charge, and of a divergence between how American and Afghan forces viewed the situation.
Afghan authorities claimed that the Taliban were using the hospital to launch attacks — despite fervent denials from MSF that there were armed fighters in the compound, and a lack of evidence to back up the Afghan officials’ claims. A senior Western official told The Intercept that the Afghans’ “biggest fear after the strike was that this would put a chill on their being able to request U.S. air support when shit hits the fan.” . . .
Paul Kiel reports in ProPublica:
Two years ago, the president of Credit Management Services, a collection agency in Grand Island, Nebraska, presented a struggling local family with the keys to a used 2007 Mercury Grand Marquis. To commemorate the donation, the company held a ceremony that concluded outside its offices, where the couple and their two young girls could try out their new car.
The family’s story was dire: their eight-year-old daughter’s failing kidney had led to multiple surgeries and a deluge of medical bills, according to an article in the local newspaper.
But CMS played another role in the family’s life, one the article didn’t mention. The company had previously sued the couple eight times over unpaid medical bills and garnished both of their wages. As recently as two weeks earlier, CMS had seized $156, a quarter of the girl’s father’s paycheck.
Shortly after the ceremony, CMS released the family from further garnishment, court records show. But just four months later, the company filed a motion to start up again. The couple, who did not respond to attempts by ProPublica to contact them, has since declared bankruptcy.
In almost any other state, such a barrage of lawsuits against a family in desperate financial straits would be remarkable. Not in Nebraska. There, debt collectors frequently sue over medical debts as small as $60 and a simple missed doctor’s bill can quickly land you in court.
Filing suit is one of the most aggressive ways to collect debt, but no one tracks how frequently it happens or to whom. An examination of Nebraska’s courts, however, shows that where debtors live can have an enormous, and unexpected, impact on the quantity and types of lawsuits.
Nebraska’s flood of suits isn’t merely a reflection of residents’ inability to pay their bills. About 79,000 debt collection lawsuits were filed in Nebraska courts in 2013 alone, according to a ProPublica analysis. In New Mexico, a state with a population, like Nebraska’s, of around two million, about 30,000 suits were filed. Yet by virtually any measure, households in Nebraska are significantly better off than those in New Mexico: Income is higher. Poverty is lower. And fewer families fall behind on their bills.
The reason for the difference is simple. Suing someone in Nebraska is cheaper and easier.
The cost to file a lawsuit in Nebraska is $45. In New Mexico, where suits are filed at about one-third the rate as in Nebraska, the fee for smaller debts starts at $77.
Nebraska lawmakers, of course, didn’t set out to turn the Cornhusker State into the Lawsuit State. Instead, it appears no one understood the consequences of having cheap court fees: Suing became an irresistible bargain for debt collectors. It’s a deal collectors have fought to keep, opposing even the slightest increase.
For debtors, unaffordable debts turn into unaffordable garnishments, destroying already tight budgets and sending them into a loop. “It’s just been a vicious cycle,” said Tanya Glasgow, a single mother in Lincoln, Nebraska who’s been sued several times. “It’s been horrible.”
“I resent the stereotype that these are not hard-working people” said Katherine Owen, managing attorney in Legal Aid of Nebraska’s Omaha office. “Truly the majority of them simply cannot afford it. That’s it.”
Lawsuits over medical debts are, of course, filed in other states, usually by hospitals. What makes Nebraska unusual is that almost all the suits are brought by locally owned collection agencies that pursue debts on behalf of medical providers. Although ProPublica found collection agencies filing suits in large numbers in other states, particularly Indiana and Washington, none could match the sheer volume in Nebraska.
It’s a difference that came as a surprise to researchers, consumer advocates, and collection professionals both in and outside of Nebraska. . .
There’s lots more. It’s a long article.
Some good news, reported in Mother Jones by Kevin Drum:
The decision last week by United Healthcare to drop out of Obamacare got a lot of attention, but the truth is that UH was a pretty small player in the exchanges. What’s more important—but hasn’t gotten much attention—is the fact that more and more Obamacare insurers are getting close to profitability. Richard Mayhew comments:
2014 was a year where there were only guesses about both the Exchange population, the market structure, and federal policy structure (specifically the risk corridor revenue neutrality restrictions. 2015 had a bit more clarity on who was coming into the market, what was working and what was not working, and what federal policy on risk corridors would actually be. 2016 is the first year where the policies are priced on functionally decent real information and some of the amazingly dumb strategic decisions have been unwound through either course changes or through exiting the market.
As a simple reminder, competitive markets should see some companies make money and some companies that offer more expensive and less attractive products lose money. I would be extremely worried if everyone was making money after three years, just like I would be extremely worried that everyone was losing money after three years of increasingly better data.
Obamacare critics have spent a lot of energy trying to pretend that premiums on the exchanges have skyrocketed, but that’s never been true. What is true is . . .
Eyal Press has a follow-up to his story (blogged earlier) on how Florida Department of Corrections abuses mentally ill prisoners:
On January 24, 2013, the Florida Department of Corrections received a grievance letter from an inmate named Harold Hempstead, who was imprisoned at the Dade Correctional Institution. The letter was brief and its tone was matter-of-fact, but the allegations it contained were shocking, raising troubling questions about the death of a mentally ill inmate named Darren Rainey, who had collapsed in a shower seven months earlier, on June 23, 2012—a case that I wrote about in the magazine this week. According to Hempstead’s letter, the death had been misrepresented to disguise the abuse that preceded it. The reason Rainey collapsed in the shower, Hempstead alleged, was that he had been locked in the stall by guards, who directed scalding water at him. Hempstead’s cell was directly below the shower. That night, he had heard Rainey yelling, “I can’t take it no more,” he recalled. Then he heard a loud thud—which he believed was the sound of Rainey falling to the ground—and the yelling stopped. Hempstead concluded his letter by calling for an investigation.
A week after receiving this information, the Florida D.O.C. sent Hempstead a terse response. “Your grievance appeal is being returned without action,” it stated. In the months that followed, Hempstead continued to file grievances with the D.O.C. He also wrote to the Miami-Dade County Medical Examiner Department and to the Miami-Dade police. At first, nothing appears to have been done in response to the letters, which is perhaps not surprising: prisoners routinely level false accusations at guards. Hempstead’s allegations might have carried more weight if an employee at Dade had backed them up. However, as I noted in my article, the psychiatrists in the mental-health ward at Dade feared (reasonably) that reporting even minor misconduct could trigger harsh retaliation from the guards, putting their own safety at risk. When Hempstead turned to some counsellors for support and guidance, they urged him to keep his accusations vague and to stop “obsessing” about Rainey. But Hempstead, who has been diagnosed with obsessive-compulsive disorder, was determined to get the word out. With the help of his sister, Windy, he eventually contacted the Miami Herald, which on May 17, 2014, published a front-page story on Darren Rainey, called “Behind bars, a brutal and unexplained death.”
The literature on whistle-blowers is full of stories about moral crusaders who risk everything to expose misconduct and succeed only in upending their own lives. (This is one of the themes of my own book on the subject, “Beautiful Souls.”) At first glance, Hempstead’s story appears to veer dramatically from this script. Prompted in part by the revelations he made, the Justice Department has launched an investigation to determine whether Rainey’s death was part of a broader pattern of abuse. Some of the guards in the mental-health ward at Dade have been reassigned. The Florida D.O.C. has adopted a series of reforms, including crisis-intervention training for corrections officers and other steps that may deter future violence.
But it is also possible that Hempstead’s story will end less happily, particularly when it comes to the question of whether justice will be done. Although investigations are ongoing, none of the guards who allegedly took Rainey to the scalding shower have been charged with any crimes. (They have since resigned, and their files included no indication of wrongdoing.) Earlier this year, an autopsy of Rainey that was forwarded to state prosecutors ruled the death “accidental,” and did not recommend criminal prosecution.
Meanwhile, Hempstead has paid a steep price for exposing the circumstances under which Rainey died. After the reporter Julie Brown, of the Miami Herald, interviewed him, several corrections officers threatened him with solitary confinement. Hempstead has since been transferred to another prison and placed in “protective management” status by the D.O.C., but his reputation as a whistle-blower (“Miami Harold,” as some now put it) has not been forgotten, and will follow him as long as he remains behind bars.
That will be a long time: specifically, until 2161, the year Hempstead will be released, if he somehow lives long enough to serve the hundred-and-sixty-five-year sentence that Judge Brandt Downey handed him, in 2000, for his involvement in dozens of house burglaries. Hempstead, who is now forty, was twenty-two at the time. . .
I don’t wish to appear apocalyptic, but things in general seem to be breaking down badly, and few are being honest about it. (For example, Cleveland pays $6 million as a settlement with Tamir Rice’s family but admits no wrongdoing, which seems inane: was the $6 million nothing more than a gift in a spirit of generosity? Quite clearly Cleveland believes that there was wrong-doing, else they would not write a $6 million check.)
Eyal Press has a shocking story in the New Yorker:
Shortly after Harriet Krzykowski began working at the Dade Correctional Institution, in Florida, an inmate whispered to her, “You know they starve us, right?” It was the fall of 2010, and Krzykowski, a psychiatric technician, had been hired by Dade, which is forty miles south of Miami, to help prisoners with clinical behavioral problems follow their treatment plans. The inmate was housed in Dade’s mental-health ward, the Transitional Care Unit, a cluster of buildings connected by breezeways and equipped with one-way mirrors and surveillance cameras. “I thought, Oh, this guy must be paranoid or schizophrenic,” she said recently. Moreover, she’d been warned during her training that prisoners routinely made false accusations against guards. Then she heard an inmate in another wing of the T.C.U. complain that meal trays often arrived at his cell without food. After noticing that several prisoners were alarmingly thin, she decided to discuss the matter with Dr. Cristina Perez, who oversaw the inpatient unit.
Krzykowski, an unassuming woman with pale skin and blue eyes, was thirty at the time. The field of correctional psychology can attract idealists who tend to see all prisoners as society’s victims and who distrust anyone wearing a security badge—corrections officers call such people “hug-a-thugs.” But Krzykowski, who had not worked at a prison before, believed that corrections officers performed a difficult job that merited respect. And she assumed that the prison management did not tolerate any form of abusive behavior.
Perez was a slender, attractive woman in her forties, with an aloof manner. When Krzykowski told her that she’d heard “guys aren’t getting fed,” Perez did not seem especially concerned. “You can’t trust what inmates say,” she responded. Krzykowski noted that complaints were coming from disparate wings of the T.C.U. This was not unusual, Perez said, since inmates often devised innovative methods to “kite” messages across the facility.
Krzykowski mentioned that she had overheard security guards heckling prisoners. One officer had told an inmate, “Go ahead and kill yourself—no one will miss you.” Again, Perez seemed unfazed. “It’s just words,” she said. Then, as Krzykowski recalls it, Perez leaned forward and gave her some advice: “You have to remember that we have to have a good working relationship with security.”
Not long after this conversation, Krzykowski was working a Sunday shift, and a guard told her that, because of a staff shortage, T.C.U. inmates would not be allowed in the prison’s recreation yard. The yard, a cement quadrangle with weeds sprouting through the cracks, had few amenities, but for many people in the T.C.U. it was the only place to get fresh air and exercise. Overseeing this activity was among Krzykowski’s weekend responsibilities.
The following Sunday, access was denied again. The closures continued for weeks, and the explanations increasingly sounded like pretexts. When Krzykowski pressed a corrections officer about the matter, he told her, “It’s God’s day, and we’re resting.” In an e-mail to Perez, Krzykowski expressed her concern.
A few days later, Krzykowski was running a “psycho-educational group”—an hour-long session in which inmates gathered to talk while she observed their mood and affect. After a dozen inmates had filed into the room, she noticed that the guard who had been standing by the door had walked away. She was on her own. Krzykowski completed the session without incident, and decided that the guard must have been summoned to deal with an emergency. But later, when she was in the rec yard, the guard there disappeared, too, once more leaving her unprotected amid a group of inmates.
Around the same time, the metal doors that security officers controlled to regulate the traffic flow between prison units started opening more slowly for Krzykowski. Not infrequently, several minutes passed before a security officer buzzed her through, even when she was the only staff member in a hallway full of prisoners. Krzykowski tried not to appear flustered when this happened, but, she recalls, “it scared the hell out of me.”
In theory, the T.C.U. was designed to provide mentally ill inmates with a safe environment in which they would receive treatment that might allow them to return to the main compound. Krzykowski discovered, however, that many inmates were locked up in single-person cells. Solitary confinement was supposed to be reserved for prisoners who had committed serious disciplinary infractions. In forced isolation, inmates often deteriorated rapidly. As Krzykowski put it, “So many guys would be mobile and interactive when they first came to the T.C.U., and then a few months later they would be sleeping in their cells in their own waste.”
Not only did Krzykowski suspect that few inmates in the T.C.U. were getting better; she was certain that the guards were punishing her for the e-mail she had sent to Perez. But she was afraid to complain about her situation. She didn’t even tell her husband, Steven, fearing he would insist that she give notice. He was an unemployed computer-systems engineer, and they could not afford to forgo her modest paycheck. . .
Continue reading. And read it all.
Later in the article:
. . . Even at the height of the economic crisis, jobs in corrections were plentiful in Florida—the state has the third-largest prison population in the country, behind Texas and California. Insuring that inmates with mental illnesses receive psychiatric care is a constitutional obligation, according to Estelle v. Gamble, a 1976 case in which the Supreme Court held that “deliberate indifference to serious medical needs of prisoners” amounted to cruel and unusual punishment.
Around the same time, the Court ruled, in O’Connor v. Donaldson, that a Florida man named Kenneth Donaldson had been kept against his will in a state psychiatric hospital for nearly fifteen years. The ruling added momentum to a nationwide campaign to “deinstitutionalize” the mentally ill. Activists decried the existence of mental hospitals that were filled, as one account put it, with “naked humans herded like cattle.” During the next two decades, states across the country shut down such facilities, both to save money and to appease advocates pushing for reform. But instead of funding more humane modes of treatment—such as community mental-health centers that could help patients live independently—many states left the mentally ill to their own devices. Often, highly unstable people ended up on the streets, abusing drugs and committing crimes, which led them into the prison system.
By the nineties, prisons had become America’s dominant mental-health institutions. The situation is particularly extreme in Florida, which spends less money per capita on mental health than any state except Idaho. Meanwhile, between 1996 and 2014, the number of Florida prisoners with mental disabilities grew by a hundred and fifty-three per cent.
The Supreme Court failed to clarify how psychiatric care could be provided in an environment where the paramount concern is security. According to medical ethicists, prison counsellors and psychologists often feel a “dual loyalty”—a tension between the impulse to defer to corrections officers and the duty to care for inmates. Because guards provide crucial protection to staff, it can be risky to disagree with them. But, if mental-health professionals coöperate too closely with security officials, they can become complicit in practices that harm patients.
After Krzykowski met with Perez, she told herself, “Maybe I’m being too sensitive—boys will be boys.” Aware that she was a newcomer to the world of prisons, she decided that the corrections officers at Dade were far more qualified than she was to determine how to maintain order.
At a morning staff meeting in June, 2011, a psychotherapist at Dade named George Mallinckrodt aired a different view. The previous day, Mallinckrodt announced, an inmate had shown him a series of bruises on his chest and back. The injuries had been sustained, the inmate claimed, when a group of guards had dragged him, handcuffed, into a hallway and stomped on him. Several other inmates confirmed the account, Mallinckrodt told his colleagues. He accused Dade security officials of “sabotaging our caseload,” and said that action needed to be taken.
In the days after the meeting, Krzykowski recalls thinking that “sabotaging” was “a pretty strong word—a loaded word.” Mallinckrodt was known to be on friendly terms with some of the patients in the T.C.U., and Krzykowski felt that he had become too aligned with the inmates—“too much on their side.” She told me, “I thought he’d become an advocate—you know, a hug-a-thug.”
Krzykowski tried to focus on providing good care, but she discovered that she had limited power to make decisions. State law mandated that prisons offer inmates twenty hours of activities a week, and when she was hired she was told that she would be responsible for insuring that this happened in the T.C.U. But every time she proposed an activity—yoga, music therapy—her superiors rejected it. Invariably, the reason cited was that it posed a “security risk,” even though the activities were meant to alleviate aggression.
One day, Krzykowski brought in a box of chalk, in the hope that inmates could draw on the pavement in the rec yard. On another occasion, she gave a rubber ball to an inmate who had schizophrenia; she thought that he would benefit from tactile play. An officer returned both items to her, ostensibly because they posed safety hazards. Krzykowski felt that she was being taught a lesson about knowing her place. “I kept getting the message that whatever security says goes,” she said.
Krzykowski had heard enough stories about inmates assaulting prison staff to know how dangerous it was to work without protection. One day in the rec yard, after a guard left her alone, an inmate sidled up to her and put his hands on her backside. The inmate was tall and imposing, and had been diagnosed as psychotic. Krzykowski thought of screaming for help, but she sensed that the guard who had vanished would not come rushing back if she did. Instead, she froze. After a moment, she hurried away without looking back. The inmate didn’t follow her. For days afterward, she was shaken. “He definitely could have overpowered me,” she said. “I could have been assaulted, raped—anything.” . . .