On Obscurity and the Human Spirit

A  View of Auvers--Vincent Van Gogh

 "Indian Summer is like a woman. Ripe hotly passionate, but fickle, she comes and goes as she pleases so that one is never sure whether she will come at all, nor for how long she will stay. In northern New England, Indian summer puts up a scarlet-tipped hand to hold winter back for a little while. She brings with her the time of the last warm spell, and uncharted season which lives until winter moves  in with its backbone of ice and accouterments of leafless trees and hard frozen ground. Those grown old, who have had the youth bled from them by the jagged edge winds of winter, know sorrowfully that Indian summer is a sham to be met with hard-eyed cynicism. But the young wait anxiously, scanning the chill autumn skies for the sign of her coming. And sometimes the old, against all the warnings of better judgment, wait with the young and hopeful, their tired, winter eyes turned heavenwards to seek the first traces of a false softening."

With that stunning opening, Grace Metalious began her book about a New Hampshire town based on the small towns of Gilmanton, Laconia and Alton Bay. 
There are many opening lines of great books: "Mother died today, or perhaps yesterday." (Camus, L'Etranger,) but there is none better, more evocative, more beautifully honed, more perfect in setting up the themes of the story (age vs youth, warmth vs cold, longing vs denial, desire stirring dry roots) than Metalious's opening of a book, which has been under appreciated and embraced for all the wrong reasons, while its true strengths were ignored. 

And it came from an obscure place--New Hampshire.

When the Phantom published his first book, he was invited down to New York City for a party with lots of literary lights and celebrities and young women from the publishing houses kept saying, "Oh, you are so obscure to have made such a big splash!"   And the Phantom thought, "But I've never heard of you, why does that make me obscure and you so central and famous?"  For these women, New York was the center of the world and everywhere else was just, "elsewhere."  They knew all about everyone who was anyone in New York and not much about people from elsewhere--so who was provincial?

New York may be, as the Phantom's older son once said, "The coolest city in the world," but there are cool places elsewhere. 

An Island in Maine

 When Van Gogh went to Auvers, he made it cool by painting it, by his perception of that rural French town. 

When Willa Cather goes to Nebraska and sees something magnificent in the prairie or when Henry David Thoreau spends a week on the Merrimack River or on Walden Pond, those places become cool, famous, important, because of the minds which have formed them into a perception for all of us. 

This, the Phantom supposes, answers that question, "if a tree falls in the forest and there is no ear to hear it, is there sound?"  The answer is: There is only sound if there is a brain to make sense of it--otherwise it's just waves in the air and means nothing. We are not talking about physical attributes, but meaning. 

And there is meaning everywhere--in Central Park, in Brooklyn, along Fifth Avenue and on islands few people could find on a map.  If Gauguin paints those islands and their women, they are no longer obscure, if we find for  them a place in our minds. 

Grace Metalious's High School

Walking on the Plaice Cove beach this morning in the purple time before the sun peaked up above the waves, the Phantom and his dog were alone.  He knew they were not really alone, because just yards off shore there were living creatures--seals, fish, birds--mostly unseen but still very real and present, and he thought, this place is as important as any on the planet.

Plastic Floating in the Ocean

A recent report on the state of Texas size flotilla of plastic bottles and bags floating the Pacific suggests it's even bigger than Texas and it's not just the Pacific.

Think of this when you toss out your bottle

 When we toss our plastic bottles and bags into the recycle been, most of us think it's being recycled into sweaters, new bottles and bags, but apparently not. Plastic does not biodegrade readily and rendering it back into yarn or usable material is costly, so ordinarily it does not go to a factory, but it finds its way to the ocean. How exactly, the Phantom is not clear. We need, of course, more images of what this stuff looks like in the ocean. It is out of sight, out of mind.  But the images of Wall-E, an earth which has become a junkheap well up and are not far from reality.  The ocean is vast, but it ends at the shore, as Maud once observed--she was quoting Dylan of course. It is now likely it ends at the plastic heap, or at least is defiled by it.

What is the back story here?

We have only one Earth and apparently it is not in any company's interest to make an effort to remove this trash from the seas. That is, there is no profit in cleaning up the mess. There is profit in making plastic bottles and bags.

Currents swirl the plastic into a vast junk heap

The Phantom is hoping someone smart might think of a way of profiting from saving the planet.  

There is some precedent.

Remember Jane Goodall?  She wasn't in business. She could not make a profit center out of chimpanzees.  But she somehow captured the imagination and good will of enough people with money to protect some chimps. 



Where is Jacques Cousteau when we need him?

Lessons from China for American Medicine

The August 25 New Yorker carries a confounding article by Christopher Beam about vioent attacks upon Chinese physicians by Chinese patients.  Among the many statistics is one from the Chinese hospital association which found that in 2012 there was one attack on a Chinese doctor in a Chinese hospital, every other week.  The attacks ranged from fatal stabbings to bludgeoning,  resulting in death or paralysis.

Another number: The record number of patients seen by a single physician, a pediatrician, was 314 patients in one 10 hour day, slightly less than 2 minutes a patient, assuming the doctor did not stop to eat or to go to the bathroom.

What is not clear from Mr. Beam's report is exactly how the Chinese system works:  He does mention the goal is to insure all Chinese by 2020, which suggests China does not now have universal coverage, and the article cites many cases of patients who opted to not consult a physician because they could not afford the fees.  It also notes other goals, including improving public health, improving service in rural and poor areas and improving immunization programs.  This does not sound like a government run health care system.  Checking on line, the health care system is variously described as "universal coverage" to virtually private, with "special care" clinics for the rich.

During the cultural revolution, "barefoot doctors," who had little or no medical training, and who worked part of their day in physical labor, were minted. Health care has not been a high priority for the Chinese. 

All this is interesting because of what is happening in America, which is nothing less than a sea change in medical care. Like many sea changes, it is happening beneath the surface, and has gone mostly unreported, but it is profound and will affect everyone, eventually. For now, doctors in the big metropolises (New York, Washington, Philadelphia, Los Angeles, San Francisco) are still shop keepers, running small businesses, covering their own overhead by what they earn in the office from fees and from laboratory or imaging studies they order on their own patients.

But in the smaller towns from Pennsylvania to North Carolina, from New Hampshire to New Mexico, doctors have added up the sums and decided, looking at their own individual debt packages from college and medical school, they are just too over extended to take out yet another loan to cover the computers, office equipment, phones, medical devices, office furniture, office rent, malpractice insurance premiums,  staff salaries, license fees, lawyers fees, accountant fees, payroll service fees.  It will take a lot of freshly minted doctors years to dig out from under their medical school debt--who would want to take on more?

And with insurance company payments constricting, the earn back time, when you finally cross over from paying off overhead to actually making a profit, for many doctors, that occurs around October of each year, if they are lucky. Up to that time, all the money in goes right out again, to cover expenses.  Obstetricians found, years ago, with malpractice premiums of over $100,000 a year, they were working six months just to pay off the premiums, before they could even begin to cover other expenses and, eventually, turn a profit. 

Given these cold numbers, the vast majority of new doctors and now, veteran doctors in the examining room specialties (internal medicine, family practice, pediatrics) are looking to hospital systems, corporations of various types, universities, government agencies to put them on a payroll.  Radiologists, pathologists, anesthesiologists have, for years, contracted with hospitals for their services.  But now internists and all the internal medicine specialists (hematology, oncology, rheumatology, endocrinology, neurology) are looking to be employed. The current number most often quoted is 89% of all physicians are employees now. 

Typically, the MBA corporate types offer a "bait and switch" option: Sign on for a relatively high salary, but know that is the highest salary you will ever see. After two years of that, the corporations starts squeezing the doctors to see more patients at a lower salary. Once you have moved your family to a new location, you are loathe to move again, but that's what is happening more and more as doctors see their salaries cut in half after the two year "honeymoon" period.  

Who will cry great tears for rich doctors who are making six figures?  

The fact is, they are barely reaching six figures, and many are not reaching more than five figures and as they make the difficult decision and pull up stakes and leave town, the patient is faced with high turnover in his doctors, as doctors simply follow the money elsewhere. 

The MBA's who "manage" practices for corporations know nothing about "quality care" and they see anyone who has the piece of paper on the wall as the equal of any other--so a nurse practitioner or physician's assistant from the New England College of  Osteopathy or Quinnapiac University is the equal of a graduate of Harvard Medical School, who trained at Mass General. They  all can write prescriptions and charge insurance companies for the office visit. That's what counts to the MBA's. When asked about the way doctors would be assessed for "productivity" the MBA manager was faced with a description of a doctor seeing a complicated patient, who required a sonogram and a fine needle aspiration of a nodule and a history and physical and he was asked if the doctor doing all this was less productive than the pediatric nurse practitioner who saw five well babies during that same hour.  "It's the number of patients," the MBA replied. That became known as the infamous "body count" answer among the doctors at the biggest health care corporation in New Hampshire.  Since then, three of the four oncologists at that hospital, all three endocrinologists, two of three neurologists, four primary care internists have all quit and found work elsewhere. 

The MBA's still  have their jobs. In fact, from the corporate point of view, those MBA's have been "productive." They have reduced overhead, lowered the number of dollars spent on salaries for the unit.  If nurse practitioners are now managing diabetic patients and physician assistants are now de facto neurologists, not to worry--profits are up. 

It's all in the way you look at it.

It's a world in which the doctor has become disconnected from the patient. It's the road toward Chinese medicine.  

American Incompetence: Tyronne Hood and Criminal Law

No one who has ever seen "The Wire" would think the work of homicide police or public prosecutors is easy.  

But reading the New Yorker article about the case of Tyronne Hood, who was convicted on the testimony of three men who later recanted their sworn testimony, for a murder which in most of its important details matched three other murders by the victim's uncle, who had--get this--taken out a life insurance policy and collected $50,000 upon the death of the victim, one has to wonder about just how incompetent the judges, prosecutors in Chicago must be.

Even the judge who was charged with the responsibility of reviewing the case as one of possible wrongful conviction inexplicably refused to allow the evidence about the two other cases as being "irrelevant to the case of the third, connected murder.

Beyond all this, the story of one of the witnessing contained an astonishing inconsistency--he said he had been in a car with Hood who had the body of the victim in the back between the car, still two days after he had shot the man, and--get this--after the witness left, he had looked back at the car and saw two gun flashes toward the back seat, which matched the findings the murder victim had been shot in the gut and then in the back twice. Now why would you carry the body around in a car with you for two days, presumably parking it overnight, and then two days later shoot the body again?

The New Yorker, typically, allows for a story with enough length to explore the case in enough detail to be convincing.

Fortunately, for the detective in Chicago who appears to be a ruthless, thoroughly corrupt cop, for the judges, for the prosecutors and for the members of the police department who were assigned to reinvestigate the case, people in Chicago likely don't read The New Yorker. They are like those Southern sheriffs who sat grinning in court at their own trials for murdering Freedom Riders, eating popcorn, as if they were watching a comedy at the movie theater--they know they are safe as long as they can count on hometown justice.

One hopes someone at Justice, the feds, reads The New Yorker.

Maybe then the feds can go up to Chicago and clean out that rats' nest. 

Rahm Emmanuel may not be in a position to do it, but his old friend, Mr. Obama might be.

American Meritocracy, The New Class Paradigm and Regression to the Mean

Who needs Meritocracy? 

Of all the members of the Phantom's family, his eldest son clearly had the most verifiable academic talent: He scored a perfect score n the verbal part of his SAT and he read widely from the moment he learned to read.  When the time came to apply to colleges, he said, "I'm not going to some snob school," and he opted to go to college where he wanted to be, "the coolest city in the world"--at NYU.

His parents had been brought up to think the only way to enter the stratum of society to which they aspired was to go to the most elite colleges they could.  As the Yale provost told his entering class, "Welcome to Yale. Your future is assured."

His parents read the Sunday New York Times Society pages, the wedding announcements, which, next to the Social Register, defined who had made it in America,  and for many years it was a parade of Ivy League names. 

But over the years, something happened to dim the luster of those elite institutions.

For one thing, it is not clear the elite colleges can guarantee your future is assured, quite the opposite. Those colleges refuse to make public any sort of accounting and tracking about the success of failure of their graduates.  Yes, the society pages show graduates with multiple Ivy League merit badges, but those are a tiny percentage of all the graduates of the dozen or so most elite institutions.

Glamour, money, power. Shanty Irish. 

One of the driving forces which motivated the Phantom to want to go Ivy was worm's eye view he had from his own highly competitive high school: The really interesting, exciting, attractive kids he knew wound up at the elite schools; the Phantom felt if he wound up at a state school, he'd be mired with the losers, who were losers because they were uninteresting, lacked ambition, wanted only to drink beer and cheer on teams at the football stadium and would wind up selling insurance or real estate, a dismal fate--whereas the winners would be the senators, doctors, high power lawyers, who were so extolled in the Washington, D.C. area.

But, as the years have passed, the Phantom's perceptions have changed. For one thing, the "losers" who went to the University of Maryland, often turned out to be very interesting people who did wonderful things in life. And the "winners" who went to Harvard, Yale and Princeton, turned out to be pretty unattractive, driven, unhappy people who actually never did much other than make money, buy expensive cars and homes, but who, if you went out to dinner with them, you found yourself looking at your watch, thinking about why it was taking the waiter so long to bring the check.

And being a partner at those high power Washington law firms no longer looks so glamorous.  What exactly do those guys do all day? Are they not kissing up, as they always did in high school, and then college? And working on the Hill? Oh, that. Just watch VEEP. Would you really want to live in that world?

In his thoughtful article in The American Conservative, Ron Unz mentions the fall off in math scores among Jewish students over the past decade or two, and he speculates about why this may have occurred. In the end, the most likely explanation is this new generation of Jewish students, who have been raised in relative comfort, are no longer as driven (some would say desperate) to learn what they will be tested on; they  do not have the same faith in the life changing power of scholastic success, and they do not have game because they simply do not care to get into the game. They have made the same choice the eldest son made, to opt out of "snob schools." The value of snob schools is no longer an article of faith.

What they value far more than being able to say they went to Harvard, Yale or Princeton, is to be able to  live in Brooklyn or the Upper West Side  or Chicago or San Francisco or Seattle and they are doing really interesting work, succeeding in areas which may be highly lucrative or simply highly rewarding--music, writing, business, engineering--areas in which the merit badge does not matter as much as the solution you've proposed to solve important problems. 

Part of the Phantom's family comes from the far West. When a very talented nephew considered  Princeton and Drexel for engineering, they were unimpressed with the Ivy League glitter; they wanted to look at the finances. Drexel offered a full five year ride with a Masters in Engineering. Princeton offered some financial aide, but seemed to say, "Hey, but we're Princeton." The boy went to Drexel, went to work solving interesting problems for the Philadelphia power company as an undergraduate and had a job with a very healthy salary, a promising career path the day he graduated. 

For an engineer like him, a  society name meant little--it was the problems that needed solving which attracted him. 

This engineer's  brother also came East to go to college, and, after four years,  got his  letter informing him he had been elected to Phi Beta Kappa, and that required $80 for the key. The parents thought it was a scam. They weren't sure what Phi Beta Kappa was. The Phantom frantically offered to pay for the key and tried to explain what an honor this is. "Yeah, well, if it's such an honor why don't they put their money where their mouth is?"  Culture gap there. 

In the real world, the Phantom has seen the whole scheme of work and reward upended, disrupted. As soon as he finished medical school, he framed all this diplomas from three different Ivy League institutions and put them on the wall of his new office, where they impressed almost no one. All his patients cared about was that he had his "MD" and his license, and did he participate with their insurance? If he did not, they'd go to the doctor who did, even if that doctor went to the American Medical School of the Caribbean. 

Life in North Hampton, far from the Ivy League

And, as it turned out, the Phantom got to know a graduate of that school and discovered he was one of the finest physicians he ever met, way better than the dozen or so Harvard Medical School grads he worked with, because he knew as much clinical medicine and he cared more about his patients, knew them better and never failed to take the time to remove the dressing and look at the wound, a necessary if not sufficient requirement for good medical care. The Harvard guys were too busy reading the Wall Street Journal to take the time to remove the dressing, to look at the wound. 

Now, the Phantom lives in New Hampshire, where people want to know if you hunt or fish or hike or ski or surf or boat.  The names of elite institutions mean very little to folks up here. They judge people by other criteria.  

Looking back at life in Washington, the Phantom remembers one dinner in particular, among many. The Phantom and his wife had been invited to dinner by the parents of students at the Sidwell Friends School, where their son had begun as a freshman in high school. Only a small number of students were admitted to SFS in the 9th grade, most starting in grade school or middle school, and this was an attempt to make the Phantom and his wife feel welcome. 

Conversation around the table bounced around the years the various parents had spent at Harvard, mostly in the sixties.  At one point, one of the parents was teased because his daughter had opted to go to Stanford, rather than Harvard, and everyone pretended this was a great calamity, while the disgraced parent played along and everyone enjoyed themselves immensely.  The Phantom looked across the table at his wife and she back at him and they knew what each other was thinking.  He could see the alarm in her eyes, because she knew the Phantom was on the verge of dropping a bomb on these smug elitists, and she fingered her fork in a way which suggested she could quickly throw it across the table and find the Phantom's throat with it.

It was a scene from Downton Abbey, cum Washington, D.C., but the chatter was less urbane and with fewer classical allusions. 

And the Phantom and his wife held their tongues, more or less, until they got back to their car, where she said, "Well, if this is the upper class, you can have it." 

"You know," the Phantom said. "We knew some Vanderbilts in New York. We have rubbed shoulders with real lace.  We took care of Roosevelts, Onassis, Whitneys, Paysons,  at the New York Hospital. They were the elect because of the families they came from, or because of the sheer wealth, and none of them seemed as insecure as the bunch we just saw. Their status is all tied up in those schools and they have to trot it out for full display. It's a little pathetic."

"Ah, but they are the winners. They work for Covington and Burling, the Washington Post, Brookings, all the glittering prizes. But, they are just so unappetizing."

"Well, but they all went to Harvard.  That's what matters."

The Drawn Out Medical Degree: The New York Times

Viewing a Nuclear Explosion: American Science at It's Peak

The August 1 New York Times carried an article "Drawn Out Medical Degree," in which it reported about the move toward reducing the traditional four years of medical school to three. 

The Phantom has often said the American medical profession has been ineluctably moving toward where the British medical system was in 1970, and this is another instance.

Any physician talking about medical education tends to see the system from a worm's eye view. Ask an American doctor what we ought to be looking for in a future doctor and he will describe his own attributes. So, for years, doctors have endorsed the absurd "qualification" of being good at calculus, because they were selected for being good at calculus and those who weren't were eliminated, so there is nobody left in the professional corridors of power to raise the manifestly true point that being good at calculus is in no way predictive of being good at medicine, or surgery, or that calculus is even helpful in a medical career. Ditto for organic chemistry, physics,  physical chemistry and comparative anatomy.

The fact is, the American system of educating doctors went from the pre Flexner commercial diploma factory to the university based diploma mill which created a very high bar, and attracted "high achievers" but likely did not find the best doctors.

If it were up to the Phantom, he would start identifying  students out of high school, as they arrive at college--and they should go to college--and provide a pre medical school curriculum through college which allowed the students to judge whether or not they really want to be doctors and would provide a tracking system to identify who might really become good doctors in a meaningful way. This system would separate the students seeking to do "clinical medicine" from those doing research while allowing for overlap and what is called "translational medicine."

Currently, every student is prepared to be all things, a researcher in microbiology, anatomy, pathology, biochemistry, etc and the process is discouraging and counter productive. 

A better system would allow for some acceleration of the training process, for those who could learn all the biochemistry they needed to know in 6 weeks rather than a full year. This is called "competence based" training, by which they mean, if you can learn anatomy enough to pass the exam in one semester, you can hurry through medical school in a few years. This should work well for the "preclinical" sciences, which are mostly forgotten by fourth year anyway, but it would not work for clinical training, which simply requires exposure to patients, the widest variety of diseases with enough repetition to make sure physicians actually graduate knowing what they are doing. Clinical competence cannot be acquired quickly, and no test devised by man has ever been able to test for it. You cannot know whether an airplane pilot is competent to fly by giving him a number two pencil and having him do a multiple choice test. There is no substitute for flying hours. There are flight simulators in aviation and there are simulator dummies in medicine, but there is no way to assess the complexity of decisions necessary in either which is easy. 

Surgeons who complete their residencies nowadays cannot go to the operating room without an older surgeon assisting them, because Libby Zion laws restricted the number of hours they could work, the number of cases they could do and so they "finish" not being adequately trained, because surgery, like flying simply requires a certain number of hours of practice. 


The new Phantom system would eliminate the high price institutions (Harvard, Columbia, Penn, Cornell) as "elite" institutions which can price their "product" exorbitantly, and replace them with government sponsored students. Medical education ought to be free and tied to "pay back" in service from the students.  Harvard could still educate tomorrow's doctors, but it would be paid no more than U. Mass for that privilege. 

And it would eliminate the burgeoning ranks of "medical schools" now in full flower and pare back to the number the nation really needs, not the number entrepreneurs can sell.

But most of all, it would focus on selection, finding the right people for the right jobs. It would do this scientifically, relentlessly and we'd all be better off for it.

It would mean, among other things, part time physicians would likely be phased out. Why train a physician at government expense, who, predictably, would serve only 10 or 15 years, when you could train one who would, on an actuarial basis, serve 20 or 30 years?  It's not cost effective to train doctors who will not serve. Currently, high  edebt drives doctors to keep practicing, at least enough to pay off their debts. But for those women, who are married to high earners, that incentive is often not enough, as increasing numbers of women doctors are saying, "My kids come first. We can afford for me to work only 2 days a week."

So, in the case of public health, the Phantom is all for abandoning the unplanned, "free market" system we say we have, for a government run system of training. 

Better bang for the buck.

The Curious Phenomenon of American Incompetence

No Incompetent Paddler Survives This 

Appollo 11 landing Neil Armstrong on the moon.  American Navy Seals swooping down on a compound in Pakistan and killing Osama Bin Laden and escaping with his body.  Any day at the Cleveland Clinic cardiac surgery suite.  Drones which kill a terrorist suspect half a planet away while the operator doing the killing sits safely in a dark suite in Langley, Virginia.  Sully Sullivan's airplane hits a flock of geese and he sets his airplane down in the Hudson River with not a single (human) life lost.

These are what we like to think about when we tell ourselves America is number one, competent to an astonishing degree.

But those are the exceptional cases. Those are what we are capable of, on a good day. But day in and day out, across America, the American way is not that.  The American way is the police department in Memphis which sits on rape kit tests, never bothering to process them, while serial rapists continue to prey on local girls and women for years. And multiply that incompetence by a thousand police departments from Baltimore to Los Angeles to Chicago.  There are the drugs which are approved for sale with warning bells going off, only to poison patients for years and esteemed professors like Milton Friedman shrugging it off, decrying the very existence of any institution to prevent bad drugs from reaching the population (i.e. decrying the FDA), asserting that drug companies can be regulated by the market, by fear of lawsuits.  In a sense, Mr. Friedman argued for institutionalized incompetence, because he was horrified by the idea of "regulations."

But what are regulations, if not a codified system for insuring competence?

During World War II, the American military suffered astonishing losses through sheer incompetence of generalship. Prior to D Day,  a training exercise off the coast of England was intercepted by German U boats and several hundred soldiers and sailors were slaughtered, during a training exercise.  The D Day invasion itself was a disaster, succeeding only because overwhelming numbers were thrown at a numerically inferior force. 

German commanders, after the war told of how astonished they were the allies never targeted the dams, which if bombed would have flooded their ball bearing factories and ended the war early--the German tanks would have been stopped in their tracks, literally.  American bright boys, like Robert Macnamara, who selected targets, simply were incompetent. American Sherman tanks, built by Henry Ford, were vastly inferior to the German built Panzer tanks. The American tanks were death traps, incompetently conceived and constructed, rolling powder kegs,  in which American soldiers were immolated, while the German tanks withstood face to face combat admirably.

Americans built Microsoft and Apple and Silicon Valley, and MIT, but that accounts for a small slice of the American workforce. In every state, in every health care organization incompetent "coders" and auditors dog doctors, transforming every effort at good quality care into a mindless race to the bottom.

Competence usually begins with a master, who actually knows something other people need to know and would benefit from knowing--and he imparts that wisdom and discipline to people who disseminates this down a line of command, usually through a hierarchy, which insures discipline, quality control and exacting execution.

But that sort of leadership, that willingness to be unloved if you are the leader, that insistence on performance, ahead of personal relationships, ahead of comfort, ahead of loyalty, that is a stern and ruthless discipline, which Americans somehow lack.

Our political system, our financial system somehow, in ways beyond the comprehension and experience of the Phantom, institutionalize incompetence. 

Maybe this happens here because we are a polyglot nation--and we are reluctant to say, "This is how it must be done" because we realize in a diverse world, there are many ways of doing things, and many measures of success.

But in the end, either the rape kit is tested and the rapist caught, or he is not. Either the patient anesthetized upon the table makes it to the recovery room alive, or he does not. Either the plane lands safely or it crashes and burns. Either the war is won and the new government is in place and remains functioning, or we have ISIS in Iraq making a mockery of every American life lost there. Either the Congress passes legislation to resolve the child immigrant tidal wave, or it does not. Either the Congress decides government is a good thing, or it decides not to govern.  Either the bankers and Wall Street types who gave us incompetent credit back securities are tolerated or they are not.  Either schools teach children what they need to know, or they do not. 

All this flows from the nature of our citizenry. If we are uneducated, undisciplined, tolerant of failure and incompetence, we get what is coming to us. 

What Soldiers Know

Angry. Rush, Boehner, McConnell, Cruz, Republicans.

Anyone who spends time on the Historyporn website sees enough images of bodies stacked up at concentration camps, laughing soldiers posing in front of a woman or a man hanging behind them and one might wonder: How do people get to be so thoroughly depraved?

Where did all that anger come from, which resulted in the stacks of bodies, the hanging bodies?

The fact is, you can be trained, not just to hate, but to function dispassionately.  In fact, you have to learn to be able to do this do do surgery, to be a medical intern.  We learned, step by step, how to resuscitate a patient, how to slip an endotracheal tube into his open mouth and into the trachea, how to find a vein and to  cannulate and catheterize the vein, how to apply the "paddles" and shock the patient. All things, which, to the untrained eye, might look like a gross violation of the patient's body. But, in the end, it was, we were trained to believe, in the patient's best interest. We did these things to save a life.

 And if  the "code" ended unsuccessfully, you stepped back and watched the nurses wrap the body and while they were doing it, you might be checking your watch to see if the cafeteria had closed. 

At Memorial Sloan Kettering Hospital for Cancer and Allied Diseases, so many patients died so frequently, you hardly noticed, after a while. Just move on,  and keep doing rounds. 

But beyond desensitization, training could allow you to function, step by step despite great distraction.  One dark night on call,  a nurse who still had freckles and could have passed for a sixth grader dragged me down the hall to see a man who was literally frothing at the mouth. Great yellow brown bubbles were gurgling out of his mouth; his eyes bulged and he struggled to gasp for each breath. At a glance, I knew, from training, he was in pulmonary edema. I told the nurse what I had been taught to do: Get the rotating tourniquets and the syringes of morphine and  Lasix. When those did not work, I asked for the vacuum bottles. I had never actually used these bottles, but I had been instructed. Plunging the business end of the connecting tube into the femoral artery, I watched the bottles suck off 500 cc of blood in less than twenty seconds. And the man took a deep breath and said, "Oh, better." 

There was nobody there to help us--it was 2 AM and no cardiac team could have reached us in time. It was just me and the sixth grader, who in fact, behaved very well, because she had  been trained. The whole thing took five minutes, max.  It was the first time either of us had treated acute pulmonary edema, but we had been taught, and we did what we were taught and it worked.  We did not have time for feelings, for shrinking back, for anything but action. 

The next time, we'd be more removed, and less terrified, and the time after that it would be just another day  at the office. 

Listening to members of the 101st airborne on "Band of Brothers" you hear the same thing. People are getting body parts blown off around you and you just do what you have been trained to do, and do it and don't think about what most human beings would think about. Shut out all other thoughts and do what you have been told to do.

And that, likely, is what happened to those concentration camp soldiers, to those grinning troops who had just hanged someone. It had all become routine. They were told how to act, and they acted, and when nothing bad happened to them, in fact when they were congratulated, after a while they did not even think about the woman whose body hung behind them. Just a day at the office.

That's why it's so important who guides behavior and why, from the top. Once the course is set, that's the direction the ship sails. 

"I was just following orders," became the infamous excuse at the Nuremberg trials and that was dismissed outright.  Now privates are taught, there is a line you cannot cross, even if ordered. But, there is a conflict here, and I'm not sure it's really been resolved. Certainly, those grinning American soldiers who had stripped their prisoners naked at Abu Gharib prison and made them form a human pyramid, crossed that line when they dehumanized their prisoners. But once you buy into the mentality of group think, be a team player, where does that end?

When you have a bunch of angry men in Congress, they will send along instructions and the sergeants and privates down the line will just do what they've been trained to do and follow orders and get validated,  no matter what. It will take the exceptional private to say, "Hey, wait a minute, this is a kid you're telling me to throw overboard."

Bringing Ebola to the United States By Special Delivery

Talk about difficult choices:  you've got two American health care workers, trying to save lives in Africa, working with patients, who've got Ebola. They acquire the disease from their patients and are likely to die in Africa because the hospitals there cannot provide the same level of care as American hospitals. If you can keep them hydrated with intravenous fluids, support their blood pressures, dispose of their diarrhea and vomitus, keep their wounds clean, they may stand half a chance of pulling through.

So, you arrange for a private jet to bring them back to Atlanta, to Emory University Medical Center, just down the road from the Center for Disease Control and you put the Director of the Center on TV, saying we've got everything under control, and nobody in the United States can possibly get Ebola by importing these two bodies which are teeming with the virus, for which we have no vaccine and no anti viral.

We know how to do this sort of isolation here in our university hospitals, with our space suits and our sterile rooms and all that.  Nobody is going to get infected here. We've got this under control.

On the other hand, the same chief of the CDC was just on the same News Hour program a few days earlier, explaining how the CDC had discovered a freezer full of vials containing small pox, which, somehow our ultra high tech CDC failed to kill and just kept in storage for a few decades. A regrettable oversight. But no harm, no  foul.

I'm just saying: Even at our best centers, things go wrong.

When we deal with Ebola, say at that Level 4 Army Fort Detrick in Frederick Maryland--where they had the Crisis in the Hot Zone, the rooms where they handle those viruses, in their petrie dishes have special ventilation which suck air inside rather than venting it out to the world around the fort. Do they have that at the Emory University Hospital?

Remember Crisis in the Hot Zone?  The message there was, despite all your efforts, things will eventually foul up. There was a lot of talk in Crisis in the Hot Zone about diseases "going global."  It's inevitable, the doctors interviewed there said. The surprise is, it hasn't happened sooner.  

And when health care workers at Emory get out of their space suits, will they not go down to the cafeteria and eat lunch with other hospital employees?

And what will happen to the diarrhea and vomit teeming with virus, as the linens are disposed of at the hospital? Who will handle these items and what if a cloth soaked in blood falls out of a bag and is picked up by a housekeeping aide who goes home on the bus that night?

In an operating room, you have a circulating nurse who watches everyone and screams bloody murder when anyone breaks sterile field. Will they have some watchdogs looking over the patients' rooms at Emory, 24/7?  Surgeries may go on for a few hours--it's easier to be vigilant for lapses in sterile technique in those controlled rooms, but what about a ward room for days on end? 

Now, it's entirely possible some day some African will hop a jet when he's still incubating Ebola virus during its 21 day incubation and he will not spread the virus on that airplane, but when he arrives in Detroit or Los Angeles, he'll get sick and go to an unsuspecting emergency room. So we cannot "control our borders" as Scott Brown would say. 

Once, when a young man showed up in the George Washington University hospital emergency room with bubonic plague (acquired in South America) he was admitted and cared for by Martin Wolfe, MD, a renown tropical disease specialist,  who could only practice in Washington, DC, where the State Department and the cosmopolitan nature of that city could keep a man like him busy and up to date. And the patient was cured.  And nobody in the hospital acquired plague. But there were effective antibiotics for plague.

One might argue, better to get experience with Ebola under these "controlled"conditions than being surprised in some random ER someday in Washington, DC, New York or L.A. 

But the fact is these workers, who were wearing space suits and who knew what they were doing--they got Ebola. 

Which just goes to show, no human endeavor is without error. Mistakes are made all the time in hospitals, and usually you can correct them.  But here, somebody wipes a nose reflexively, or gets a needle stick or gets sprayed through or around his goggles and now you've got the beginning of a little epidemic.  Nothing that will wipe out Atlanta. Sherman did more damage, but still, no system devised by man is perfect, especially systems devised by Americans. Germans might pull it off for longer, but we Americans, we tend to be a little sloppy. 

We did get a man to the moon and back, but in some ways that was easier. Nobody was going to cause a catastrophe on Apollo 11 by sneezing.  

But every once in a while, we miss frozen "O" rings and all hell breaks loose.

I'm just amazed Ted Cruz and Scott Brown and Rush Limbaugh have not got hold of this one. Secure our borders! Once and for all!