Yiddish Week 2007
Reflections, 1.

I'm back from the Yiddish Week. The strangest thing is how normal we all are, we fringe Yiddishists, all the flavors of (mostly American) Jewry represented: the usual Reconservadox spread plus a Charedi couple; secular folks; old and young; couples with jelly-smeared kids. And it feels like (maybe?) that there are slightly more people with kids and 2o-somethings among us. On the one hand, speaking Yiddish should be normal for those American Jews that do so. It should be a choice on the menu with the respect due it - by no means the only one, but definitely a possibility. On the other hand, ideologies that seem normal are tame. We don't want to be stamp collectors, do we?

You look so drawn

Satisfactory Comics has a blog!

Fuftsik Sent and Madona
Yiddish rap in the Jewish state.

Check out this article in Yediot Acharonot. I haven't heard the sound files yet. (Thanks to reader MJ for pointing this out.)

Update: As usual, I'm about three to four months behind the curve -- the disk came out in May. I just listened to some clips. Lipa it isn't, just saccharine frumification of perfectly good music. (Why would you need an ultra-O version [track 5] of La Isla Bonita?)

(Speaking of Yiddish and Madonna, the new issue of Afn Shvel has a great article by Marc Caplan on Ms. Ciccone Ritchie and her practice of Kabbalah.)

Incrementalism versus single-payer health care reform
Different routes to the same solution.

Cross-posted to Clinical Correlations (with some edits there)

Health insurance positions: The obvious imperfections of our current health care system have inspired a number of solutions. They can be organized into two broad categories, incremental or single-payer. Each of these solutions is advocated by a single-issue lobbying group. National medical organizations support these solutions in greater or lesser measure.

Advocacy groups: Physicians for a National Health Program provides information about the benefits and practical implications of a single-payer health care system. The list of members of its advisory board includes their organizational affiliations, but (as its name indicates) the group is composed of physicians, not medical organizations or professional societies.

Incrementalism is represented by the National Coalition for Covering the Uninsured, a broad-based coalition of a number of organizations, including the AMA, the American Hospital Association, the American Public Health Association, the American Academy of Family Physicians, pharmaceutical companies, insurance companies and other organizations. Given the divergent range of interests and philosophies represented by this list, it's no surprise that the NCCU's plan involves a number of less wide-reaching improvements in the current system, including transparent pricing; personal Medical Savings Accounts; and the expansion of public programs to cover the very poor.

Professional organizations: Many medical organizations act as both professional societies and as advocacy (i.e. lobbying) groups. Their "home" positions may in many cases differ from their compromise positions hammered out in coalitions with others. The American College of Physicians, on its Web site, advertises its support for the Health CARE Act, a proposal which would increase federal matching funds to those states expanding Medicaid coverage to all those beneath the federal poverty level, and which would also provide increase federal funding to those states which increase coverage for uninsured children.

For its part, the American Medical Association "will strongly advocate for incremental measures to expand coverage," and in keeping with this advocacy is a member of the HCCU. In the long term, says its Web site, it will continue to push for the adoption of a market-based plan to expand coverage, "relying upon incentives and voluntary approaches." Similarly, the American College of Surgeons endorses universal access to care "within our current pluralistic health care system," i.e. to be incremental in the pursuit of change, with some features being implemented on a state by state basis. The ACS further emphasizes that "reducing health care costs [through improving information technology] is much more desirable than containing costs by rationing care."

Compared to other professional organizations, the American Academy of Family Physicians is full-throated in its advocacy of a plan to ensure health care coverage for all. On its web site, it lists those services which should be covered for all who reside in the United States (a relevant distinction in these days of proposed immigration reform). Assured services with no co-payment include prenatal/maternity care; well baby/child care; evidence-based childhood and adult immunizations; and evidence-based periodic evaluation and screening services. Other assured services, including outpatient physician services and outpatient prescription medications, would require 20% co-payment. The AAFP is also the rare organization which specifies a funding mechanism: a national, broad-based tax. Under the AAFP plan, coverage would be rationed by a "resource-based relative value system."

Differences and similarities: The differences in advocacy positions - taken on their own and as participants in coalitions - of the American professional medical organizations remind practicing physicians, and especially physicians in training, that the current health-care system can justify various solutions. Advocacy can also be modified in coalition for the sake of practical lobbying.

Personally, I think a single-payer system is the only solution that would fix the gaping inequities in our system -- but I also realize that there are many ways of getting there. PNHP might better fit idealists, and NCCU, realists, but they have a goal in common: reducing the numbers of the uninsured. Perhaps the coalitions can themselves coalition to put the problem of the uninsured higher on the agenda of the 2008 elections.

Mr. Hales and his medical husbandry

"The first person to measure blood pressure was Stephen Hales, an English clergyman of creative genius, who in 1708 directly connected the left crural artery of a horse to a 9-foot-tall glass manometer using brass tubes and a trachea of [a] goose." (from McGee, Evidence Based Physical Diagnosis)

Our Son Leaves His Fifty-Inch Plasma-Screen TV
Behind Because There Will Be
No Room in the Dorm

The remote control is eight inches long
with a display that I never understand
no matter how many times
you explain it: "Dad,"
you said, looking not at me
but the flitting basketball
and the neon cheerleaders,
"it's universal." So it
is. Then why is it only your Mom and me
who have to stare
at this blank Buddha
in our living room?
Its four sides
four years
times forty
thousand
dollars.

The narrative voice is bliss

At times the Gemara gets so intoxicated with its own line of thought that it just goes right ahead and ignores the Mishnah.

(d)(5) hold on a minute!
In this week's New England Journal of Medicine, Wendy Parmet provides legal justification for my inchoate worries. (More about the author.)

Many important questions remain [regarding quarantine and detention for tuberculosis control]. First, courts have not decided how long someone may be held before a hearing is offered or what procedures are necessary in the event of a mass quarantine. Courts have also not yet decided what probability of risk justifies short-term or long-term detention. Nor have they clarified what evidence is needed to determine that a person is or may be infectious or how infectious a person must be to justify isolation. Most critical, courts have not explained what must be shown to conclude that a patient is noncompliant so that detention is the least restrictive alternative. In tuberculosis cases, courts have upheld detention when a patient has failed, like [Andrew] Speaker, to follow medical advice. But they have not considered how forcefully that advice must be given or what, if anything, the government has to do to facilitate compliance. [. . .]

Compulsory isolation and quarantine alone cannot stop the spread of XDR tuberculosis. Moreover, excessive reliance on compulsory measures can lull the public into a false sense of security and at the same time prompt people who are at risk to do exactly what Speaker did — run. Fortunately, most persons infected with tuberculosis want treatment and have no desire to infect others. When clinicians and health officials work with patients and have their trust, most will cooperate. By ensuring that coercion is used only when less restrictive alternatives will not work and with due regard for the rights of those detained, the law can foster public trust, minimizing the need for compulsion and laying the groundwork for the comprehensive and costly control programs needed to prevent the spread of XDR tuberculosis and other contagious pathogens.

Dr. Zauberberg
Or: How I learned to stop worrying and believe in the (d)(5) hold.

I'm now rotating. (Of course, we're all rotating together, being on the Earth and all.) I'm currently working on the Chest Service of Bellevue Hospital. "Chest" means "lung" which means (at least for most of our patients) tuberculosis. There are lots of lung diseases, but the most common ones (pneumonia, asthma, COPD [emphysema and bronchitis]) get thrown in the same big barrel as all the other medical conditions, spread out among all the other medicine teams on the regular wards. This particular ward I'm on now is limited to the tubercular.

It is a Manhattan version of the Magic Mountain. There are New Yorkers of unexotic ethnicity (Puerto Rican, say) who have AIDS; there are Asian immigrants who have had the misfortune to contract drug-resistant TB; there are the elderly and demented from Coler-Goldwater, who are exiled from their residence until their cultures come back negative, no acid-fast bacilli swimming redly past the eyepiece.

And then there are those who are under arrest, under Article 11.47(d)(5) of the New York City Health Code. In other words: they have TB, and they can't or won't either take their medications or modify their behavior so as not to pose a risk of contagion; they have been warned, and now they are shut in. They are under (d)(5) hold.

This is justified by public health necessity, which is defined by the New York City Department of Health. On a case by case basis, the DOH balances the danger of contagion, the necessity of treatment, and the contingency of private circumstances.

I wish I had something wise to say here, something which would precisely trace this intersection so we could see it as clearly as pathologists see the offending acid-stained bacilli. All I can do - as usual - is ask myself questions while I immerse myself in the work the system requires of me in the name of the patients.

I've been thinking all day of the word "misprision," but I'm sure it's not as foreboding or relevant here as it seems.

The GH-2
A validated two-question happiness screening instrument.

1. In the past two weeks, have you felt hopeful, exuberant, happy, joyful, or energized?

2. In the past two weeks, have you felt pleasure from things which ordinarily give you pleasure?

If the answer to either 1. or 2. is "Yes," proceed with the full nine-question happiness screening questionnaire.

Queasiness of summer

Pressed in our book of estimations
a crumbled leaf.

The minimum gain through loss -

The first word my bell learns
is were-I.

A Louisvillian's dubious claim to fame

Crystal Meredith? Went to school with her.

Not that I agree with her suit.

What it's like to be an intern
A week before I unbecome one.

Resident: Says "Let's get a quick [arterial blood] gas."

Intern:
1. Sighs inwardly.

2. Goes and finds
a. a little syringe with some heparin in it so that the blood doesn't clot
b. some alcohol swabs
c. a Ziploc bag
d. another little syringe for a second try
e. needles to stick with

3. Goes into the patient room, lays supplies at bedside. Says: "I'm sorry, I need to get some blood from you."

4. Realizes that he has forgotten
a. Gauze
b. Some ice in the bag

5. Raises up the bed so he doesn't break his back.

6. Finds the pulse.

7. Gives the patient a considerate and well-meaning count-of-three.

8. Sticks the patient.

9. Doesn't get it on the first try [return to step 5], or the second, or the . . . ha! Gets it on the third try.

10. Holds gauze on the sticking point till the bleeding stops.

11. Takes the bag up to the lab.

12. Knocks on the door. Shouts "Hello?" Hears an echo.

13. Pages the person he's looking for.

14. Hands in the blood.

15. Waits by the computer, refershing the lab results page about twenty times till the results come back.

16. Hustles back to the resident with slip of paper in hand. "The gas [huff, puff] is seven point [whew] two three . . ."

Resident [absentmindedly]: "Hey, thanks! Yeah, I thought that's what it would be. Listen, can you just get some quick cultures off this guy -- and then guaiac him?"

What about stupid versus dumb?

Sage advice heard in the ER today:
"It's much better to be smart than intelligent."

I am distraught!

Gertel's closes tomorrow.

I will eat for comfort.

Justice, justice, shalt thou eat

A blog about the "social justice hechsher." (Hat tip to S.B. of Louisville.)

Avraham Burg: chauffeured hypocrite
And partial prophet.

Yes, Burg is a paragon of self-righteousness ("so attached to Zionism," wrote a commentator in Haaretz, "that he drove around with a chauffeur paid for by the Sochnut years after he left its employ"), but he makes many thought-provoking points about problems afflicting Zionism. (English here.)

NB: I don't at all agree with his misguided political analogies, and I don't think Israeli society is basically violent. But I do think Zionism suffers from weaknesses, and few other Zionists (or ex-Zionists) besides Burg are pointing these out with such uncompromising clarity.

Difficulty naming objects
. . . in English, maybe.

Neurology consult's note (about a Spanish-speaking patient of mine): "The patient has some difficulty naming objects. He calls eyeglass lenses 'crystal.'"
In other words, he calls eyeglass lenses cristal.

Random booksightings

I saw some interesting books at BEA. I also learned that asking politely "Do you have any samples?" will work only if (like my wife) your badge bears the name of a major book publisher, or if you are leadng a three-year-old by the hand and you are looking at children's books.

I saw:

Fotografiando las matematicas (a gorgeous album with depictions of "integral," "solid," and other concepts)

a volume of addresses by Sir William Osler, put out by Duke UP, of interest only because it demonstrated a tendency to hyperannotate a work which is actually not all that worthy of interest (e.g. the reader is informed helpfully that "Nicotine, Bacchus, and Aphrodite" refer to the vices of smoking, alcohol, and sex, respectively)

a book of problems in number theory from the training manuals of the Math Olympiad team from the U.S.

some fascinating Spanish-language poetry

Lineas Urbanas, a slim collection of essays in Spanish about New York City

a facsimile hardcover edition, pocket-size in all but width, of Les Fleurs du Mal with illustrations by Matisse

. . . but no Judaica, because I didn't get over to where it was

TB, Airborne
Traveling XDR class.

Now the truth can be told: if I were the other night intern, I would have been taking care of the phthisic traveler a few days ago. Even though I didn't have the pleasure of putting on a mask and going into his room in Bellevue (sorry, "a New York hospital," as the first Times article coyly put it), I feel compelled to provide some information about a question we're all wondering about: how easy is it to get tuberculosis on an airplane?

You can't do that experiment. (Though it would be fun!) What does the literature say? Google Scholar gave me links to two articles. One of them talks about TB transmission from an infected crew member to his colleagues. The other, by Kenyon et al., is titled "Transmission of Multidrug-Resistant Mycobacterium tuberculosis during a Long Airplane Flight." We read in the abstract: "In April 1994, a passenger with infectious multidrug-resistant tuberculosis traveled on commercial-airline flights from Honolulu to Chicago and from Chicago to Baltimore and returned one month later. We sought to determine whether she had infected any of her contacts on this extensive trip."

In brief, their findings were as follows:

1. The researchers managed to get in touch with 802 fellow passengers, or about ninety percent of the people on the airplanes the woman traveled on -- a commendable effort.

2. Of these passengers, twenty-nine tested positive on the "TB skin test." Twenty-two of these had previous risk factors for tuberculosis, which means it's impossible to tell in this case (since the passengers weren't followed beforehand) whether their skin tests were positive before they ever took that flight.

3. Of the seven without previous risk factors for TB, six were on the longest flight the passenger took (a nine-hour jaunt from Chicago to Honolulu). They all sat in the same section, and four of them sat within two rows of the passenger.

The authors conclude, "The transmission of [the TB organism] that we describe aboard a commercial aircraft involved a highly infectious passenger, a long flight, and close proximity of contacts to the index patient."

How does this article relate to the now-famous globe-trotting lawyer? The kicker here is that the woman in the article was "highly infectious". To wit:

The index patient was a 32-year-old Korean woman, who according to relatives was taking no antituberculous medication but had previously been treated for tuberculosis — twice as an adolescent in Korea and once within the past two years in Japan — with unknown medication. She arrived in Honolulu in April on a tourist visa and was reportedly coughing and lethargic while staying with friends (Household 1) for five days. She then flew from Honolulu to Chicago and from Chicago to Baltimore, where she remained with friends (Household 2) for one month. Members of Household 2 reported a worsening of her symptoms, including progressive cough, lethargy, shortness of breath, fever, night sweats, and the eventual onset of scant hemoptysis. In May she returned to Honolulu, flying from Baltimore to Chicago and from Chicago to Honolulu. Eight days after returning to Household 1, she had an acute episode of hemoptysis, described as consisting of approximately 1 liter of bright red blood. Hospital evaluation revealed extensive pulmonary disease (Figure 1), and her sputum was highly positive (3+) for acid-fast bacilli and was culture-positive for M. tuberculosis. The patient died of pulmonary hemorrhage and respiratory failure five days after being hospitalized.

She died of TB shortly after the flights in question, and was highly infectious when she flew. Contrast this with the patient in this week's story, who has so-called "active" tuberculosis (the organism is in his blood) but does not appear to be either symptomatically ill or highly infectious (the amount of TB-causing organism in his sputum is low).

Was quarantining the passenger in this most recent case (or, rather, attempting to quarantine him) the right thing to do? Probably, since he is infected with so-called XDR (extremely drug resistant) TB, which is associated with a higher mortality rate. It's best to be on the same side, even though it's probably unlikely that anyone he traveled with got infected.

(However, I'll take the opportunity to mention that many organizations (schools and the like) use the TB skin test indiscriminately, without assessing their members' risk factors for TB, their infectiousness if they do test positive, and the resultant small likelihood of transmission even if they are infectious.)