The Draw of Dermatology?

March 20, 2008

This piece in the New York Times focuses on a married couple, both Harvard Medical School students, who are in their fourth year and waiting to find out about their residency placements. Like many medical students around the nation, they’re competing for competitive placements in specialty fields instead of going into less lucrative (and possibly less intellectually stimulating?) fields such as family practice and internal medicine.

And the competition is expensive:

Already saddled with about $330,000 in education loans, they borrowed $20,000 more so they could fly around the country this winter for about two dozen residency interviews each. All told, each applied to 90 such training programs.

The article makes me a little sad in general. I had a conversation at CGI U with a med school student who warned me about the “vortex” of med school. Paraphrased: “Everyone’s the same. You get to med school all idealistic, wanting to help people and stuff. Then you spend years and years studying and working, and you see the people ahead of you getting money. You see the doctors with the nice cars and comfortable lives, and you start to wonder when you’re getting yours? And you get into so much debt that you realize you have to practice, and practice well if you want to get out of that hole.”

I’m certainly idealistic about why I want to go to medical school. In fact, the struggle for me is deciding between larger scale health policy work–doing research, designing disease control programs, advocacy, etc.–and traditional clinical work, or how to balance both. I’ve never seen myself as one to get into private practice, or really even treating patients full-time as a traditional clinician. But the vortex sucks many people in.

The problem is ultimately not with the medical students who are drawn to dermatology and plastic surgery for the better pay. Medical students will inevitably be drawn toward the specialties that combine interesting work with the highest pay. From the NYTimes again:

“It is an unfortunate circumstance that you can spend an hour with a patient treating them for diabetes and hypertension and make $100, or you can do Botox and make $2,000 in the same time,” said Dr. Eric C. Parlette, 35, a dermatologist in Chestnut Hill, Mass., who chose his field because he wanted to perform procedures, like skin-cancer surgery and cosmetic treatments, while keeping regular hours and earning a rewarding salary.

The market simply isn’t working here. We need more (many more!) primary care physicians. There’s a lot more demand for services there. But people who have the money to pay more for cosmetic treatments and surgery skew the demand away from those who don’t have the money to get adequate treatment for more life-threatening conditions like diabetes and high blood pressure.

I’m not sure what the solution is either. I know it would need to be a large-scale systemic change; merely getting pre-med students to read about Paul Farmer isn’t going to change everyone. Maybe having a single-payer system where doctors are compensated as much or more for basic services as they are for cosmetic services? Or maybe a loan-repayment situation where medical school is even more expensive, but all loans are automatically repaid by the government for those not going into specialties. Who knows. Suggestions?

Advertisements

Quoting King

July 8, 2007

I’m currently reading Shane Claiborne’s Irresistible Revolution. I’m sure I’ll blog on it more fully once I’ve completed my leisurely perusal, but for now I’d like to highlight some quotes Shane brought to my attention. These are from Martin Luther King, Jr.’s “A Time to Break Silence,” a speech given on the Vietnam war in 1967 at a meeting of “Clergy and Laity Concerned” at Riverside Church in New York City. MLK’s concerns went beyond his (incredible) devotion to civil rights in our country, to an even broader view of social justice. And it’s always good to reflect on values that should bring rich and poor, Christian and humanist, theist and athiest together.

mlkbeyondvietnam.jpg

[It became clear that the war in Vietnam] was sending their sons and their brothers and their husbands to fight and to die in extraordinarily high proportions relative to the rest of the population. We were taking the black young men who had been crippled by our society and sending them eight thousand miles away to guarantee liberties in Southeast Asia which they had not found in southwest Georgia and East Harlem. And so we have been repeatedly faced with the cruel irony of watching Negro and white boys on TV screens as they kill and die together for a nation that has been unable to seat them together in the same schools.

Funny how these words still ring true today:

As I have walked among the desperate, rejected, and angry young men, I have told them that Molotov cocktails and rifles would not solve their problems. I have tried to offer them my deepest compassion while maintaining my conviction that social change comes most meaningfully through nonviolent action. But they ask — and rightly so — what about Vietnam? They ask if our own nation wasn’t using massive doses of violence to solve its problems, to bring about the changes it wanted. Their questions hit home, and I knew that I could never again raise my voice against the violence of the oppressed in the ghettos without having first spoken clearly to the greatest purveyor of violence in the world today — my own government.

And here a call for a brotherhood of man, rooted in King’s own Christianity, though it could as easily be read as a call for a global humanism (in fact, King might have been closer to that than most of the Christians we know):

This I believe to be the privilege and the burden of all of us who deem ourselves bound by allegiances and loyalties which are broader and deeper than nationalism and which go beyond our nation’s self-defined goals and positions. We are called to speak for the weak, for the voiceless, for the victims of our nation and for those it calls “enemy,” for no document from human hands can make these humans any less our brothers.

King also has this quote from a Buddhist leader on the war in Vietnam:

Each day the war goes on the hatred increases in the heart of the Vietnamese and in the hearts of those of humanitarian instinct. The Americans are forcing even their friends into becoming their enemies. It is curious that the Americans, who calculate so carefully on the possibilities of military victory, do not realize that in the process they are incurring deep psychological and political defeat. The image of America will never again be the image of revolution, freedom, and democracy, but the image of violence and militarism.

If you will, rephrase that quote for me with Iraq in mind instead of Vietnam (not the analogy is a perfect one, but analogies never are… this particular quote however makes a useful point):

Each day the war goes on the hatred increases in the heart of the Iraqis and in the hearts of those of humanitarian instinct. The Americans are forcing even their friends into becoming their enemies. It is curious that the Americans, who calculate so carefully on the possibilities of military victory, do not realize that in the process they are incurring deep psychological and political defeat. The image of America will never again be the image of revolution, freedom, and democracy, but the image of violence and militarism.

And here he waxes prophetic. One could make the same claim today about US militarism:

The war in Vietnam is but a symptom of a far deeper malady within the American spirit, and if we ignore this sobering reality…and if we ignore this sobering reality, we will find ourselves organizing “clergy and laymen concerned” committees for the next generation.

And another gem:

On the one hand, we are called to play the Good Samaritan on life’s roadside, but that will be only an initial act. One day we must come to see that the whole Jericho Road must be transformed so that men and women will not be constantly beaten and robbed as they make their journey on life’s highway. True compassion is more than flinging a coin to a beggar. It comes to see that an edifice which produces beggars needs restructuring.

And here’s another quote, though this time I’ve replaced “Communism” with “terrorism”:

This kind of positive revolution of values is our best defense against terrorism. War is not the answer. Terrorism will never be defeated by the use of atomic bombs or nuclear weapons. Let us not join those who shout war and, through their misguided passions, urge the United States to relinquish its participation in the United Nations. These are days which demand wise restraint and calm reasonableness. We must not engage in a negative antiterrorism, but rather in a positive thrust for democracy, realizing that our greatest defense against terrorism is to take offensive action in behalf of justice. We must with positive action seek to remove those conditions of poverty, insecurity, and injustice, which are the fertile soil in which the seed of terrorism grows and develops.


Freeganism

June 21, 2007

The NYT has an article on Freegans–people who reject consumerism and try to live off other’s trash.

Anthropologically speaking, it’s fascinating. Freeganism is certainly unsustainable (ironically) without the rampant consumerism of American society. The best metaphor is that of “scavengers of the developed world,” found on the front page of the NYT article.

While I may be too much of a cynic to find the lifestyle that appealing, all of it comes from a realization I can certainly sympathize with:

“Most people work 40-plus hours a week at jobs they don’t like to buy things they don’t need.”

May I always do work I love, and may I not buy crap I don’t need. Amen.


Obama’s Father’s Day

June 19, 2007

Eugene Robinson has a brief but excellent piece on TruthDig about Obama’s speech for Father’s Day. Fatherhood is, of course, a major theme for Obama, who’s own black father was absent. If you haven’t already read Dreams from My Father, I highly recommend it.

When anyone runs for office, the question of motivation immediately and inevitably (as it should) rises to the surface. Is Obama talking about black men and responsibility because he cares, or to appeal to the white voter base that’s wondering just how black he is? Robinson wonders too:

Is Obama speaking to African-Americans, or is he really trying to reach those whites who believe that most of black America’s problems are self-inflicted? I’m paid to be skeptical, but I think something much deeper than political calculation is involved here. One revelation that comes with spending time with politicians is that they actually have core beliefs. To cite one example, John Edwards may be a multimillionaire but I can’t doubt his sincerity when he talks about poverty. I’ve seen him volunteer in a soup kitchen without first summoning the television cameras. He grew up poor, and the experience has never left him.

One can care about an issue and also use it for political advantage. This is what we as voters actually want–for candidates to spend time talking about issues that happen to be both important to us and meaningful to them. I like this man more and more.

Obama grew up without his black father. It doesn’t take a psychologist to discern the impact this absence had. He has explained it himself in his books, at considerable length. He talked about it Friday in the fatherhood speech, saying that his mother—struggling to raise two children as a single parent—at times needed to rely on food stamps to make it through the month. He also spoke with admiration of his wife Michelle’s father, who was diagnosed with multiple sclerosis yet supported his family by going to work every day at a water filtration plant, “even when he had to rely on a walker to get him there.”

And Obama also pointed out some economic undercurrents I hadn’t really though about:

There’s nothing startling about Obama’s analysis of the macroeconomic forces that contribute to the problem of absent black fathers. Blue-collar jobs that once paid well and offered security, such as his father-in-law’s job at the plant, have largely disappeared. “In the last six years, over 300,000 black males have lost jobs in the manufacturing sector,” Obama said. The forces of globalization are inexorable. Inner-city schools don’t prepare students to compete in today’s economy.

In general I like globalization because I see it bringing jobs to the poor in the developing world. I understand that there’s an effect on blue-collar workers in the United States, but I tend to see protectionism as a short-sighted and inefficient solution. We have to get those workers better jobs, not set up artificial barriers to their jobs going to more cost-effective, equally-needy overseas workers. But I’m certainly torn by the affect the current situation has. Notably, Obama recently had a minor political gaff that served to bring the outsourcing issue back onto the table for the Democratic candidates. And what does Obama–former overseas resident (Indonesia) that he is–say?

“While it’s not possible to stop globalization in its tracks, what we can do is make sure we have a government that’s looking out for our workers,” Obama said. “We can do more to create a government that’s creating quality jobs here in America, and we can do more to create a government that’s helping workers who lose their jobs.” In Newton, Obama spoke before about 300 people and promised to increase federal grants and job training programs to communities dealing with job losses.

I’m down with that.


If You Don’t Like to Think About AIDS, Don’t Read This.

June 10, 2007

Nicholas Kristof wrote a piece recently entitled “Save the Darfur Puppy.” I think he was going for getting a reaction with the title, and it worked, at least with me. You’ve probably notice that the media loves stories about endangered species–always cute, cuddly ones, never rodents–because people are moved by these stories. On the other hand, a crisis like the genocide in Darfur is unlikely to get airplay commensurate with its magnitude. And likewise with AIDS, which despite being of tragic scale–two or three flaming World Trade Centers full of people dying every day–rarely hits the news, in part because it’s the same old, depressing story, every day.

So, when I saw that Truthdig had an interview called “Stop Ignoring AIDS and Africa,” I gravitated light-wards. The piece is an interview of Stephanie Nolen, the author of a new book called “28: Stories of AIDS in Africa” which tells one narrative of a (real, actual, living and breathing) human being with HIV in Africa for every one million of the estimated 28 million living with the virus. I certainly plan on reading this book, but here’s what really caught my eye–this picture:

And its caption:

Bongos, an 8-year-old HIV-positive boy, waits in a hallway at the Sparrow Rainbow Village medical clinic in Johannesburg, South Africa, in November 2005.

This really hits home, because I volunteered at Sparrow back in 2005. They do incredible work, and my few weeks there were extremely moving. Sparrow is an orphanage and adult hospice–a “village”–where those with HIV are cared for. The corridor in the background is the central part of Sparrow’s administrative center, which connects some of the hospital rooms (for the sickest patients), a kitchen, administrative offices, and even a makeshift morgue. Because most of the patients there receive some level of antiretroviral treatment Sparrow is really, sadly, one of the best places to be in Johannesburg if you’re a kid with HIV.

Here are some compelling quotes from Nolen’s interview on Truthdig:

You show people a picture of one sad-looking puppy and everyone runs for their wallet, and you tell them that 30,000 children die a day of diseases that can be prevented for less than a buck and nobody gives a rat’s ass. I don’t know what it is, what that says about us as a species, but I certainly know from a long time reporting about HIV in Africa that it’s true.

On narrating an issue where the statistics are numbing:

Their lives could not look more different in some ways than the lives of an American or a Canadian. But when you sit down in the little counselor’s booth in Malawi or Lusaka and they say to you, “You have AIDS, you’re going to die,” that doesn’t feel different than it would if you were in America. And it’s getting people to realize that those people had all—sure, they’re Africans—but they had all those same expectations around their lives. They want to graduate from high school, they want to start a little business, they want to, you know, persuade that really cute girl they’ve been eyeing for a long time to go out with them. It isn’t any different. You’ve really got to go, go really micro to make people understand that story, to get them past the numbers.

On finding stories of progress:

You know, I think we get very often this perception of it being a grim story where not very much changes…We also don’t hear that huge progress has been made in responding. There were, for example, when I started reporting on this full-time, there were fewer than 100,000 people on treatments and today there are 1.5 million in Africa. And everybody said, “You can’t do it, there’s no way you can treat in Africa.” Well, that’s a 13-fold increase in four years, and those people have better survival rates on treatment than most Americans on treatment do. So lots of victories.

On money and broken promises and the real roadblock to widespread treatment programs (trained health care professionals):

And there’s a lot more money available than there was….They need about $6.8 billion to meet those proposals, and they have, you know, like, $1.85 in change. Constantly, countries promise money and don’t deliver or don’t promise anything like what’s needed to respond. So we need money. I think, even more than money, these days we’re realizing that there are some more intractable problems that are going to need more creative solutions. So you can use that money to fly in boxes and boxes of pills. You can’t fly in nurses, doctors, pharmacists. I mean, you can fly in a few, but not enough to meet the needs of a whole, continent-wide healthcare program, right?

On the underlying economic inequalities that drive the epidemic:

You know, I meet lots of young women who’ve been given information about HIV but who are selling sex down at truck stops because their parents have died, they’re raising their siblings and that’s the only option that they have. So, you know, they say, “Fine, we’ve been told about HIV in the safe-sex textbooks, but HIV might kill me in five years or 10 years and we’re all going to starve to death next week if I don’t do this.” So, you can address some of the obvious things around prevention, but unless you change the factors that drive people into risky behavior, then you haven’t achieved very much.

And, a bit further afield, but still in Africa, on Darfur and the war in Uganda:

And, you know, it’s also interesting to talk about Darfur because, yeah, there are probably 300, 350,000 dead there and a lot of people displaced, but it is in fact a far smaller conflict than the war in northern Uganda which has been going on for 21 years. You have four times as many people displaced in northern Uganda. You have four times as many people dead. Well, when did we last hear about that one, right? I mean, Darfur is suddenly sexy because George Clooney goes there and, meanwhile, the war in northern Uganda that relies almost entirely on child soldiers … you don’t hear about that one.

On Bush’s PEPFAR program (providing treatment for AIDS in Africa):

Well, you know, I’ve done a lot of call-in radio lately where people call up and are yelling about the Bush administration letting people die, and here they are, spending all these billions of dollars in Iraq. Why don’t they do something in Africa? So I say to people, “Well, guess what? Actually the $15-billion, five-year program to intervene for AIDS in Africa, that the Bush administration dreamed up, has been the single greatest response to the pandemic ever.” And then there’s kind of silence on the end of the phone, you know?

And its problems:

…They’re saying a group that’s going to get U.S. funds to distribute condoms or put AIDS programs in schools or care for sick people, has to sign a piece of paper condemning sex work. And that’s like crazy moral language that just has no place in a place where people are selling sex to eat.

I like Stephanie Nolen. And I like Truthdig.

(If you’d like to learn more about or donate to Sparrow, please do so!)


Shooting the Messenger

January 20, 2007

200px-hrant_dink.jpg

Turkish journalist Hrant Dink was shot and killed in broad daylight on a street in Istanbul. Dink had been outspoken about the Ottoman genocide of Armenians at the start of the 20th century. While this may seem like ancient history to present-minded Americans, it plays heavily into regional politics in Turkey and Armenia. Many Turks think the killings were a justifiable part of a civil war, while Armenians see it as genocide (most non-Turkish sources I’ve read agree with the latter).

Being a prominent journalist about an unpopular issue is never an easy task. But in some places the messenger is more likely to get shot than in others. For example, I don’t think Anderson Cooper has gotten many death threats lately. (However, this may be a symptom of how any prominent journalist–especially American ones–pander to the system. If you’re not getting death threats or hate mail, your work might not be that important…)

So how big of a deal is calling the killing of Armenians genocide in Turkey? Evidently it’s illegal to insult the Turkish state (in America it’s mostly legal, just unpopular). From CNN:

Described as a “well-known commentator on Armenian affairs,” Dink had been called into court a number of times on allegations of “insulting” the Turkish state in his writing.

And apparently Dink isn’t the first Turkish journalist to be targeted for unpopular beliefs:

Joel Campagna, Mideast program coordinator for the Committee to Protect Journalists, said, “Like dozens of other Turkish journalists, Hrant Dink has faced political persecution because of his work. Now it appears he’s paid the ultimate price for it.”

Campagna said that Turkey “must ensure that this crime does not go unpunished like other cases in the past and that those responsible for his murder are brought to justice.”

He said that over the last 15 years, 18 Turkish journalists have been killed — making the country the eighth deadliest in the world for journalists in that period. He said many of the deaths took place in the early 1990s, at the peak of the Kurdish separatist insurgency.

Unlike Anna Politkovskaya, who was likely assassinated by the Russian government itself (for criticism of atrocities in Russia’s war on Chechnya), Dink’s death is more likely that of an Islamist or Turkish ultra-nationalist extremist (the assassin reportedly shouted “I shot the infidel”), categories which can often become blurred, but the Turkish government is anything but blameless for the overall situation:

Aram Hamparian, executive director of the Armenian National Committee of America, told CNN that the case is the “product of the environment that the Turkish government has created” — its persistent denial that the killings of the Armenians last century did not amount to genocide.

How Turkey handles this event, along with its relations with the Kurds, will also inevitably tie into Turkey’s desire to join the European Union. But while this killing raises political questions, it also brings me to a more philosophical inquiry.

Is there really a right to free speech? Do people inherently have an inalienable right to life, liberty, and the pursuit of happiness? Where do any of these rights come from? In the idealistic sense the answer may be yes, we have these rights, but many authors on human rights (Farmer ‘s Pathologies of Power comes to mind) would be the first to admit that they can’t “prove” rights. Nobody truly possessed a right to freedom of speech or freedom of religion until people decided that they had those rights, declared them, and made them a reality.

A right can exist as an ideal that has no real correspondence to actual conditions, but over time the ideal may come closer to realization. Our freedom of speech is still imperfect, but there are arguably more people in the world today who can speak freely than ever before. There will always be people and governments who will shoot the messenger, but if we shed light on and punish those who violate the right to speech, we may move closer to the ideal, if only incrementally. In the same sense, I hold that people have a right to health care–a right that is inseparable from our right to life–but recognize that this right is less realized in America than any other wealthy nation. The act of smoothing over the edges between the ideal and the reality is the whole pursuit of social justice.

Update: A suspect has been arrested in the case.


The Epitomal Transhumanist

January 19, 2007

This video of Ray Kurzweil (about 23 minutes long) is an excerpt from an annual seminar called TED Talks (for Technology, Entertainment and Design) that features leaders from a variety of fields. While most of the talks seem to focus on society or technology, the perspectives are quite broad: Al Gore, Rick Warren, Daniel Dennett, Bono, and Richard Dawkins have all graced its stage in recent years.

Ray Kurzweil is a prominent transhumanist, and has one of the most optimistic views of technology possible. One of his more recent books is The Singularity is Near, which describes his view that not only is the eventual surpassing of humanity by artificial intelligence inevitable, it is also nearer than we think. In Kurzweil’s view this process will include the merging of our own personal consciousness with the advanced capabilities of computers to eventually be able to process more quickly, analyze more astutely, retrieve data more accurately, and so on. In Kurzweil’s view, what truly distinguishes homo sapiens is not our current biological status, history, or accomplishments, but our impetus to transcend our limitations. Technology merely offers us a new vehicle for our transcendence.

Regardless of whether you embrace his views wholeheartedly (they seem a bit optimistic even for me) or you feel a shiver of terror or silent mockery slipping down your Luddite spine, Kurzweil’s thought should be examined because of his influence. He’s a successful inventor and author, and a prominent figure among futurists and transhumanists. Here’s a summary of sorts of Kurzweil’s TED talk:

Can we predict the future? While certain specifics of technological progress are very hard to predict, overall trends are predictable, and they’re also exponential. Growth in one technology enables and promotes growth in another technology. 50 years to adopt telephones, 8 years to adopt cell phones. TV took decades, but new technologies- like the internet- have taken off much faster.

Kurzweil then makes an analogy to biological evolution. The evolution of genetic material (DNA/RNA) took billions of years, but once certain genes were in place (or the common “tool-kit,” as evo-devo would put it) more rapid (~10 million years) change, like the Cambrian “explosion” (a term that is disliked in many circles) can occur. But as the first technology-creating species, our culture has allowed us to “evolve” on a level that is exponential in comparison to biological evolution (which is one reason we have a hard time understanding evolutionary time scales).

It took tens of thousands of years to develop agriculture, then thousands to move to more centralized forms of government (those two are arguably related, but the direction of causality is disputed), civilization led to quicker technological development, etc. The last 500 years of technological growth were incredible, but the last century has been even more impressive- bringing us widely available automobiles, radios, TVs, airplanes, medical technology, computers, Internet, not to mention space flight and an incredible plethora of new weapons systems with which to butcher each other.

This emphasis on technological development as an exponential process is a major theme of Kurzweil’s work. But, he points out, people always begin doubting when exponential growth for future technology is predicted. This growth is a result of

“worldwide chaotic behavior.. You would think it would be a very erratic process, yet you have a very smooth outcome… Just as we can’t predict what one molecule in a gas will do- it’s hopeless to predict a single molecule- yet we can predict the properties of the whole gas using thermodynamics very accurately. It’s the same thing here- we can’t predict any particular product, but the result of this whole worldwide chaotic, unpredictable activity of competition in the evolutionary process of technology is very predictable, and we can predict these trends very far into the future.”

Kurzweil also talks about the suboptimal nature of much human biology (so much for perfect design). For example, our metabolism, which leads us to hold onto every calorie, is a throwback to our hunter-gatherer days and is something that we might like to modify to prevent obesity in developed nations. And another problem, which seems to be Kurzweil’s main fascination: “Long life spans (as in more than 30) weren’t selected for.”

While some of his examples are sketchier than others, the idea of an engineered erythrocyte (red blood cell) that could increase oxygen capacity greatly is particular interesting. In my view, Kurzweil has a tendency to exaggerate about some possibilities, but then again, exponential growth will always appear as an exaggeration to those in a linear-growth mindset.

I think more important than any individual predictions about technological progress that Kurzweil makes (like reverse-engineering the brain by 2020), his main point stands: the progress of technology throughout history has been accelerating. The main question tends to be whether we’ll be able to harness these technologies to make life more certain, more pleasurable, more equitable, more eco-friendly, and more connected (and therefore more meaningful on some level) or to just wipe each other off the planet.