Community For Better Health Care

Vol IX, No IX, August 9, 2011


In This Issue:

1.                  Featured Article: A Dearth of New Meds to treat neuropsychiatric disorders

2.                  In the News: What Happened to Obama? . .  In London? . . In Iowa? . .  In the Courts?

3.                  International Medicine: That intergenerational sleight of hand worked for a while

4.                  Medicare: Political Interference with Health Care increases Costs

5.                  Medical Gluttony: This time it started on a Rapid Transit Bus

6.                  Medical Myths: Losing consciousness in a ball room is always an emergency.

7.                  Overheard in the Medical Staff Lounge: A different crop of patients in the health care field.

8.                  Voices of Medicine: The Caterpillar Syndrome by SCOTT SATTLER, M.D.

9.                  The Bookshelf: The 9/11 Wars Is The West Any Wiser, Ten Years On?

10.              Hippocrates & His Kin: The Eyes of Texas are Upon Us

11.              Related Organizations: Restoring Accountability in HealthCare, Government and Society

Words of Wisdom, Recent Postings, In Memoriam, Today in History . . .

* * * * *Brazil

Announcing The 1st Annual World Health Care Congress Latin America, October, 2011 in
São Paulo, Brazil

The World Health Care Congress (WHCC) convenes the most prestigious forum of global health industry executives and public policy makers. Building on the 8th annual event in the United States, the 7th annual event in Europe and the inaugural Middle East event, we are pleased to announce the 1st Annual World Health Care Congress - Latin America to be held in October, 2011 in São Paulo, Brazil.

This prominent international forum is the only conference in which over 500 leaders from all regions of Latin America will convene to address access, quality and cost issues, including Latin American health ministers, government officials, hospital/health system executives, insurance executives, health technology innovators, pharmaceutical, medical device, and supplier executives.

World Health Care Congress Latin America will address escalating challenges such as improving access to quality care, financing and insurance models for health care, driving innovation in health IT, promoting evidence-based medicine and clinical best practices. World Health Care Congress Latin America will feature a series of plenary keynotes, invitational executive Summits, in-depth working group sessions on emerging issues, as well as substantial business development and networking opportunities.

For more information on the World Health Care Congress Latin America . . .

For information on the 9th Annual World Health Care Congress on April 16-18, 2012 . . .

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1.      Featured Article: A Dearth of New Meds to treat neuropsychiatric disorders

Drugs to treat neuropsychiatric disorders have become too risky for Big Pharma

Schizophrenia, depression, addiction and other mental disorders cause suffering and cost billions of dollars every year in lost productivity. Neurological and psychiatric conditions account for 13 percent of the global burden of disease, a measure of years of life lost because of premature mortality and living in a state of less than full health, according to the World Health Organization. Read more . . .

Despite the critical need for newer and better medications to treat a range of psychiatric and neurodegenerative diseases, including Alzheimer’s and Parkinson’s, drugs to treat these diseases are just too complex and costly for big pharmaceutical companies to develop. The risk of spending millions on new drugs only to have them fail in the pipeline is too great. That’s why many big drug companies are pulling the plug on R&D for neuropsychiatric and other central nervous system (CNS) medicines.

Our team at the Tufts Center for the Study of Drug Development has arrived at this conclusion after conducting surveys of pharmaceutical and biotechnology companies about the drug development process. These surveys allow us to generate reliable estimates of the time, cost and risk of designing new drugs. Our analyses show that central nervous system agents are far more difficult to develop than most other types.

One of the problems with neuropsychiatric drugs is that they take so long to develop. A CNS drug, we have found, will spend 8.1 years in human testing—more than two years longer than the average for all agents. It also takes more time to get regulatory approval—1.9 years, compared with an average of 1.2 years for all drugs. Counting the six to 10 years typically spent in preclinical research and testing, CNS drugs take about 18 years to go from laboratory bench to patient.

Few compounds survive this gauntlet. Only 8.2 percent of CNS drug candidates that begin human testing will reach the marketplace, compared with 15 percent for drugs overall. Failures also tend to occur later in the clinical development process, when resource demands and costs are at a peak. Only 46 percent of CNS candidates succeed in late-stage (phase III) trials, compared with 66 percent on average for all drugs. As a result, the cost of developing a CNS drug is among the highest of any therapeutic area.

What makes these drugs so risky? Assessing whether or not a candidate for, say, a new antibiotic works is relatively straightforward—either it kills the bacterium or it doesn’t—and a course of treatment typically lasts a few days, which obviates the need for long-term testing for safety and efficacy. CNS compounds, in contrast, have it a lot tougher. It is difficult to judge if a reduction of schizophrenic episodes or a cognitive improvement in Alzheimer’s patients is the result of a drug or a random fluctuation in the patient’s condition. Treatment periods can last as long as a patient’s lifetime. It is no wonder success rates are low. . .

Disclosure: The Tufts Center for the Study of Drug Development is funded in part by unrestricted grants from pharmaceutical and biotechnology firms.

Read the entire article on Scientific American – Subscription required . . .

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2.      In the News: What Happened to Obama? . .  In London? . . In Iowa? . .  In the Courts?  

We can no longer remain politically neutral if we want to salvage our healthcare from Government Control. We are going the way of Bismarck’s & Napoleon’s entitlements of two centuries ago.

What Happened to Obama? Absolutely Nothing. By NORMAN PODHORETZ

That is why my own answer to the question, "What Happened to Obama?" is that nothing happened to him. He is still the same anti-American leftist he was before becoming our president, and it is this rather than inexperience or incompetence or weakness or stupidity that accounts for the richly deserved failure both at home and abroad of the policies stemming from that reprehensible cast of mind.

He is still the same anti-American leftist he was before becoming our president.

Mr. Podhoretz was the editor of Commentary from 1960 to 1995. His most recent book is "Why Are Jews Liberals?"

Read the entire OpEd in the WSJ – Subscription required

Bachmann Wins Iowa Straw Poll  By JONATHAN WEISMAN And NEIL KING JR

AMES, Iowa—Rep. Michele Bachmann of Minnesota stormed to victory in the Iowa straw poll Saturday, flexing her organizational muscle and establishing herself as the front-runner in the state that holds the first nominating contest of the Republican presidential race next year. . . .

Read the entire report in the WSJ – Subscription required

Read more In The News . . .

Health Overhaul Is Dealt Setback By BRENT KENDALL

A U.S. appeals court in Atlanta handed the Obama administration its biggest defeat to date in the battle over the health-care overhaul passed last year, ruling the law's mandate on Americans to carry health insurance was unconstitutional. . . .

Read the entire report in the WSJ – Subscription required

Riots and flash mobs have root causes that government can't reach. By PEGGY NOONAN

The riots in Britain left some Americans shaken. In the affluence of the past 40 years, and with the rise of the jumbo jet, we became a nation of travelers. We have been to England, visited a lot of those neighborhoods. They were peaceful; now they're in flames. But something else raised our unease as we followed the story on TV and on the Net. I think there was a ping on the national radar. We saw something over there that in smaller ways we're starting to see over here.

The British press, left, right and center, was largely united in a refusal to make political excuses for the violence. Almost all agreed on the cause and nature of what happened. The cause was not injustice; this was not a revolt of the downtrodden masses, breaking into stores looking for food. The causes were greed, selfishness, a respect and even lust for violence, and a lack of moral grounding. Conscienceless predators preyed upon the weak. The weak were anyone who happened to be passing by . . .

Read the entire OpEd in the WSJ Subscription required

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3.      International Medicine: That intergenerational sleight of hand worked for a while

The welfare state was always an illusion

Author: Mark Milke

Appeared in the Calgary Herald

The latest deals to “save” American and Greek public finances—allowing those countries to put themselves into even deeper debt—should puncture the illusion the welfare state was ever a success. The fact is, it was always built on borrowed time and borrowed money. Read more . . .

That intergenerational sleight of hand worked for a while. Successive post-war generations went to the doctor, availed themselves of government services, built roads and enjoyed other partially debt-financed benefits. Problematically, they handed part of the bill for the same to future generations. It’s akin to buying an expensive home and handing the delayed mortgage payments to your kids when they turn eighteen.  

Greece is merely the most dramatic example of this intergenerational public finance “con job.” The recent European Union deal for Greece, where $109 billion Euros will be lent to tide that profligate country over yet again, is equivalent to $149 billion Cdn. Put another way, every Greek just borrowed another $13,847 Cdn. . . .

In 1995, Greece’s net liabilities already amounted to 81 per cent of GDP. (A country’s net liabilities are arrived at by subtracting assets from liabilities; GDP is the value of a country’s economy).  Back then, Canada’s net-debt-to-GDP figure was 71 per cent; Italy stood at 99 per cent; France, Germany and the United Kingdom had net liabilities of 38 per cent, 30 per cent and 26 per cent respectively. Portugal’s was 24 per cent and the U.S. debt figure was 54 per cent of GDP.

Fast forward to 2011 and all the countries on that list are deeper in debt as a percentage of GDP, save Canada: Greece: 125 per cent; Italy: 101 per cent; France 60 per cent; Germany: 50 per cent; Portugal: 76 per cent; the United Kingdom: 62 per cent; the United States: 75 per cent.

In Canada, our net liabilities are 34 per cent of GDP, substantially down from 1995, though up from the low-point in 2008 when the figure was just 22 per cent. (Between 1995 and 2008, our lowered ratio was helped both by a growing economy and some debt payback. Most other countries just kept borrowing.)

For the record, the fault for the ramped-up public debt cannot be placed on “too low” taxes. A variety of countries with widely differing tax levels all continued to borrow massively over that period.

For example, since 1995, and as a percentage of its economy, Greece’s total tax take has been about one-eighth to one-fifth higher than the United States (depending on the year). But high-tax Greece put itself into more debt as did the (relatively) low-tax U.S. Or consider the UK; its tax rates rose steadily since 1995 but so too its red ink problem.

In other words, the assumption that higher tax revenues will save a country from its spending and borrowing addiction is mistaken. That’s not any more likely than a modest raise for a consumer maxed out on her credit cards whose real problem is overspending.

Besides, higher tax rates do not necessarily equal higher revenues when compared with a moderately taxed nation.  A high-tax, inefficient tax regime can slow economic growth and encourage tax cheating and depress tax receipts—another one of Greece’s many problems, actually.  

In Canada, despite our relatively low net debt-to-GDP ratio at present, in most years, our governments played the same pass-the-social-welfare-bill-forward game. . .

Looking back over post-war years, there were always alternative policy options to the welfare state, ones that would still have provided security to citizens in Europe, the U.S. and Canada. For starters, options included mandated private savings accounts for health and pensions.  Had such accounts been started decades ago, each generation would have been forced to finance its own major social benefits through pre-funding. This would have been superior to the intergenerational transfer of wealth through the politicized tax-and-spend system.     

Instead, for decades, government borrowed massively to finance current social programs out of future tax revenues and handed the bill to future generations. It led to the illusion that the welfare state was sustainable.

Read the entire report . . .

Mark Milke is the Director of Alberta Policy Studies at the Fraser Institute. He also manages the Fraser Institute’s Centre for the Study of Property Rights

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Canadian Medicare does not give timely access to healthcare, it only gives access to a waiting list.

--Canadian Supreme Court Decision 2005 SCC 35, [2005] 1 S.C.R. 791

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4.      Medicare: Political Interference with Health Care increases Costs

ObamaCare threatens solvency of Colorado health plans
John R. Graham, Director, Health Care Studies, Pacific Research Institute
The Pueblo Chieftan

ObamaCare encourages state politicians to increase their interference with health-insurance premiums.

    In 2008 Colorado passed a law giving the Division of Insurance the power to deny premium hikes. To enhance this power, known as "prior approval," ObamaCare gave Colorado a $1 million grant last year to hire more insurance analysts to review rates.

   There is no evidence, however, that such power reduces the growth of premiums below those observed in states where insurance divisions wield no such power. And the future wave of political interference threatens the solvency of health plans in Colorado and other states. Read more . . .

    Health plans pay medical claims from providers whose charges have been rocketing skyward. ObamaCare doesn't give politicians control of fees that providers charge to private health plans — nor should it. But simply imposing political control over health plans' premiums does not keep a lid on health costs.

    In Massachusetts, the 2006 health reform ("Romneycare") led to draconian limits on premium hikes. Using the power that his Colorado counterpart received in 2008, the state's insurance commissioner refused 235 of 274 requested rate hikes for April 2010, and demanded that plans rebate premiums that had already been paid. But medical costs in Massachusetts increased faster after the new regulations than before.

    Now Massachusetts' health plans are hemorrhaging cash, and a senior regulator has described the mess as a "train wreck." [Romney was the Governor who engineered this train wreck. We must keep him out of Washington, DC or the whole country will be in a train wreck.]

    Suppose the increased resources and power flowing from ObamaCare cause the Colorado Division of Insurance to "go rogue," as in the Bay State.

     In a new study, “Bust or Bailout? The Future of Private Health Plans Under ObamaCare,” I model Colorado health plans' future solvency under these conditions — where government control causes health costs to increase, while premiums are kept artificially low.

     Although Colorado health plans are currently actuarially sound, the simulation shows that five of the top 10 health plans (none involved in the study) would be threatened with insolvency by 2017. The Kaiser Foundation Health Plan of Colorado, largest in the state, would experience an underwriting loss as soon as 2013, and face insolvency as soon as 2015. Of course, national carriers might easily choose to exit Colorado. Aetna has already announced such a move.

    Nor is there evidence that prior approval of premium increases has protected consumers from unreasonable rate hikes. My study examines data on premiums and premium-review laws for small-group premiums in 43 states in 2006 and 2008. Nineteen states were "file-and-use," which means that health plans must submit premium increases to the insurance commissioner, but he has no power to reject them.

    Twenty states required prior approvals of rate changes by the insurance department, and four were unregulated. No connection is evident between prior approval and a lower change in rates from 2006 to 2008, nor the absolute value of rates in 2008. . .

    The notion that politicians can control health costs is a conceit of the ruling class. Health costs will only decline when patients, not politicians, directly control more of our health spending. This cannot happen until President Obama's health law is repealed. In the meantime, Colorado should reject politicized control of insurance premiums.


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 Government is not the solution to our problems, government is the problem.

- Ronald Reagan

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5.      Medical Gluttony: This time it started on a Rapid Transit Bus

Mrs. Pinkerton, an 85-years-old lady had a full day of shopping. She got on the rapid transit bus to go home. She leaned against the window and dozed off. The lady behind her felt she had passed out (don’t we all when we doze off?) and told the driver there was a lady slumped over in a coma. He stopped the bus and called Emergency 911. Mrs. Pinkerton awoke, noted all the commotion, and observed the activities. She was surprised when the EMT came on board and carried her off the bus and into an ambulance.  She states she was fully awake in the ambulance, but why shouldn’t she enjoy the ride? It was probably free, at least to her, since she didn’t order the ambulance. Read more . . .

She was wheeled into the Emergency Room and was greeted by the nurse who took her vital signs.  Her BP, pulse, respiratory rate, and body temperature were all normal. She asked the nurse why she was here. The nurse looked a little surprised and told her she had passed out and they would be checking her out to make sure she was fine. In her fine British accent, noting that her hat and veil were removed as well as her long gloves, hose and heels, “I beg to differ with you.” The nurse, not wanting to challenge an elderly lady, proceeded to establish an intravenous line, get saline running, and waited for the doctor.

The doctor was there within minutes, checked her over briefly by reading the nurse’s vital signs, noting that the patient had a history of hypertension, gastro-esophageal-reflux disease (GERD), irritable bowel syndrome (IBS) and asthma. He advised the RN to proceed with the standard coma protocol, signed the standing orders, and she was whisked off to the x-ray room and a brain CT was done. By this time, the ECG tech had finished an electrocardiogram which was normal and the lab tech had drawn half dozen tubes of blood. The brain CT scan was completed and sent to the home of the radiologist on call while the Chest X-ray was being done. This was also transferred by Tele-Med. Mrs. Pinkerton was then taken to the cardiac lab and an ECHO-Cardiogram was done. It showed good cardiac function with a LVEF of 60% (Left ventricular ejection fraction reflecting that the force of the left ventricle contraction was normal pumping 60% of the cardiac volume in each contraction.)

She was then returned to the ER gurney to await the results of all the test. Over the next two hours all the reports drifted in and were normal.

When she was advised that she could go home, she reminded them that she was out shopping, didn’t have a car, and was riding the bus back to her house. So, since she was now stranded with no bus to board, would they be so kind as to call that nice limousine with a nurse in the back to take her home? They offered to call a cab but she declined stating the hospital was so far out from her home that she couldn’t afford it. Although it was near midnight, she asked them to call her daughter and awaken her and see if she could come and take her home.

She was given the discharge papers with a note to call her personal physician and be seen the next day.

When she came in, we obtained the entire ER records by fax and went over them with the patient.

The history was as noted by the nurse. The ER report was correct and corresponded to ours. The vital signs were again normal. Our physical examination of the head, heart, lungs, abdomen, and neurological exam of the cranial nerves, motor, sensory, reflexes and coordination were all normal.

Reviewing the hospital record indicated that their physical examination was also entirely normal.

The laboratory exam revealed a normal complete blood count, normal electrolytes, normal prothrombin time, normal kidney function, normal liver function, essentially normal urinalysis except for 10-20 white and epithelial cells which would be normal for a lady this age. (She probably was of the vintage that when she washed her vulva and urethra in the shower or tub, she would close her eyes in a sense of propriety.)

Of the expensive studies we noted a normal chest x-ray, normal electrocardiogram, normal Computerized Tomography scan of her brain, a normal ECHO cardiogram with a normal LVEF eliminating the heart as a cause of syncope.

The only recommendation was to have her personal physician order a gastro-esophageal-duodenoscopy to evaluate her GERD vs Peptic ulcer.

Of course, we wouldn’t think of subjecting an 85-year-old female in excellent health to this procedure that was so well and easily controlled with acid reducers and acid neutralizers.

We were unable to get the cost of this ER visit, but it was certainly on the order of the $6,000 to $9,000 bills we’ve seen for the past two or three years. The cost should have been zero if the hysterical lady on the bus would just have let her doze for another 15 minutes until she was home.

 In this case not one of the tests was necessary. And the final recommendation out of the ER door for a $5,000 endoscopy procedure was totally illogical and unnecessary.

Medical Gluttony, par excellante.

Editor’s Comment: We don’t wish to be critical of our ER physician colleagues who are always in a difficult position with what walks through the door. They can’t make a clinical decision based on a hysterical spouse, daughter or friend who takes them to the emergency because of their hysteria. But this is a system failure. May I indulge you in another similar case with a different outcome? See Myths below . . .

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Medical Gluttony thrives in irresponsible Government and Health Insurance Programs.

It Disappears with Appropriate Deductibles and Co-payments on Every Service.

If this lady had been told there was a 20% co-payment when she arrived and been asked for a check or credit card for $120 co-payment, she was alert and oriented enough that she would have demanded to be taken home immediately. This Gluttony would have been stopped at the ER registration desk. This would be such a simple and easy solution to the health care over-utilization problem. But it’s too simple for lawyers in Congress who prefer 100 page laws over a one paragraph registration protocol.

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6.      Medical Myths: Losing consciousness in a ball room is always an emergency.

I was a guest at a Ball at the Sutter Club in Sacramento. In the foyer, a lady sitting in a straight back chair, was slumping forward and sideways. The screaming ladies got my attention and when I saw what was happening, I helped her to the floor.

“Don’t you want to get her back up in the chair?” someone shouted. I said no. That would put her in a coma for sure. Her pulse was strong and her breathing was steady on the floor. Read more . . . The crowd gasped as the elderly lady was starting to move and raise her head slightly. I told her to lie there for a few more minutes to let her circulation stabilize. The circulation to her brain had probably been somewhat diminished because of heat from the crowd, plus some alcohol, and sitting bolt upright in a straight back chair which allowed the blood to her brain to descend to the lower portions of her body much like edema of the legs. By this time she started talking to some of her lady friends who were standing and sitting next to her.

I started to move back to my family, when I heard a lady say, “I still think we should call an ambulance.”

So I quickly moved back and sat down on the floor next to the lady who was now very alert and somewhat jovial. She thanked me and I sat there a few more minutes speaking with her to make sure I didn’t miss some important medical history until much of the crowd vanished.  I then helped the lady to her chair. She made it easily. She maintained a good pulse and strong breathing and I assured the ladies near by that she would be just fine.

So I took this opportunity to discuss what I did to those in attendance. The room was stuffy and the lady had a few drinks and her blood pressure probably dropping causing her to slump out of the chair. By putting her on the floor, her head was level with her heart and the heart could basically loaf and still get fresh blood to her brain even with a blood pressure that my have dropped to 90 or 80 or even less. It didn’t matter in the supine position since a blood pressure of “even less” would still pump the blood loaded with oxygen to her brain. After lying there for a few moments, she regained her cardiac output and pressure very likely returned to normal despite not having any medical equipment there to measure it. She did just fine.

It was after the patient in the afore mention section came to the office (after her dozing on the bus) that I realized that this lady could have had the same ER experience. If a doctor happened to ride the rapid transit bus, then my Mrs. Pinkerton could also have avoided the unnecessary hospitalization. The ultimate health care cost savers depend on an intelligent, composed laity with a large number of Allied Health specialists from EMT to respiratory therapist and other health care workers throughout most communities. Together physicians, nurses and allied health specialists should be able to trim at least 25 percent of Gluttonous health care costs and destroy the MYTH that all emergencies have to be evaluated in the hospital emergency rooms. At least 25 percent of alleged emergencies are only crises in the minds of the people around those who have a dozing session on the way home from a strenuous shopping center at age 85.

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Medical Myths originate when someone else pays the medical bills and allow a trip to the ER.

Myths disappear when Patients pay Appropriate Deductibles and Co-payments on Every Service and stop at the registration desk when asked for the payment beforehand.

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7.      Overheard in the Medical Staff Lounge: A different crop of patients in the health care field.

Dr. Rosen: Has the nature of your patients changed recently?

Dr. Sam: Those that are assigned to us by the Independent Practice Associations change every month.

Dr. Dave: Isn’t that the truth. Just after we got 300 welfare Medicaid patients dumped into our practice, we are finding it difficult to find consulting physicians. Read more . . .

Dr. Rosen: Are you having difficulty in finding just a few specialties uncovered?

Dr. Edwards: We’ve found a number of specialties with hardly anyone taking referrals. This week we couldn’t find a dermatologist for a patient with a difficult rash which was not responding to the usual steroid creams.

Dr. Milton: The HMOs are telling our patients they need a colonoscopy at age 50. We’re having difficulty finding enough Gastroenterologists to see these patients. Some of our loyal consultants who have seen our colon patients for decades are no longer taking new GI patients with a combination HMO/Medicaid insurance profile.

Dr. Edwards: Just wait until the ObamaCare dumps another 35 million patients into the Medicaid trenches which are fast becoming cesspools as they succumb to ruptured appendices and gall bladders and bowel obstructions with no one to care for them.

Dr. Milton: That’s how the socialists got ObamaCare approved. When PEW did their stats on people with no health insurance, the welfare/Medicaid people generally answered the poll as not having health insurance. They did not see Medicaid as insurance. Ultimately logical if you can’t find a doctor that is willing to see twice as many patients per hour to break even, despite giving inferior care at seven minutes a patient and increasing your risk for malpractice.

Dr. Rosen: Well, it’s beginning to look like many of the new crop of patients in the field are no longer worth harvesting. A farmer will plough his rice under if the cost of harvesting exceeds the rewards of the crop. It looks like medicine has reached this equinox. The financial rewards of seeing patients is beginning to exceed the cost of seeing, evaluating, and spending hours on the phone to try to get someone to do a procedure that the HMO demands being done. And if the procedure doesn’t get done, the HMOs review your charts and do not return in their quarterly distribution what they withheld from your reimbursement because of what they perceive as poor clinical care when it was their unreasonable demands that caused it.

Dr. Edwards: We are in the Business-Professional world of commerce where lean marketing and lean health care reigns supreme. We can’t spend so much time on the MUDDA of health care that doesn’t facilitate quality.

Dr. Milton: We need more business men in Congress and fewer attorneys as the first step in turning health care around. Otherwise medicine will be place into increasing restrictive legal straight jackets.

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The Staff Lounge Is Where Unfiltered Opinions Are Heard.

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8.      Voices of Medicine: A Review of Local and Regional Medical Journals

IN MY OPINION From the Humboldt-Del Norte Medical Society

The Caterpillar Syndrome by SCOTT SATTLER, M.D.

As a family practice doc for the past thirty-odd years, I’ve had the opportunity to follow the births, lives and deaths of many Humboldt County residents. One of the most humbling and rewarding aspects of my practice has been its involvement with the intricacies of the dying process and the medical and family dynamics involved. As a profession, we don’t talk about this very much; not that it’s secret per se, but perhaps it’s that we hold it as sacred. Most of us are shy when it comes to sharing these things. Yet we can gain a great deal from looking in this direction, as it is such an integral part of our practices and of our personal lives. Read more . . .

There is an aspect of the dying process that I have observed on many occasions that begs for discussion and contemplation.  I wonder whether others who are working with the dying have observed this phenomenon, and I wonder whether, as you read this article, you might nod your head in recognition.  Then again you might consider these musings merely the dodderings of a chronologically gifted, eccentric airhead. I look forward to your impressions and invite you to share them with me.

There is a Sufi saying that there is but one major sacred book—the sacred manuscript of nature. The perception in this editorial comes from observing one of nature’s wonders—caterpillars. After hatching from its egg and devouring its eggshell, the caterpillar spends its life exploring its favorite vegetation, eating, and growing. Then, at a given point, it is as if it knows that it is time for its caterpillar life to end, and there emerges an irresistible desire to prepare for its caterpillar demise. “Been there. Done that. Got the fuzzy t-shirt. Time to move on…” might be its driving motive. An internal switch is thrown; the desire to eat wanes and then disappears, supplanted by a desire to find a secluded protected environment where it will conclude its caterpillar life in relative safety. It finds the underside of a twig on its favorite bush, wraps itself in its security-blanket cocoon and surrenders to the overwhelming urge to release all aspects of its caterpillar life, simply trusting that all is well and as it should be. And then it dies to being a caterpillar.

I can almost imagine younger, more energetic caterpillar friends urging it to eat, eat just a little, and perhaps wanting it to stay involved with caterpillar community life.  And in completion of this fantasy, I hear the cocoon-spinner’s final plea to its more active companions: “If you really want to help me, just keep the birds away.”

I think many humans do this, too. Over the years I’ve noticed a similar pattern, especially in elders who have recently survived the death of their lifelong mate. Quite often the surviving spouse would unexpectedly die within six to eighteen months after their loved one passed. When I talked with their families, I often heard a similar story, namely that the surviving spouse had proceeded to wrap up the family business after the funeral of their mate, had often mended any personal issues that needed tending, and then simply withdrawn from societal obligations, reduced their food and fluid intake, gotten the dwindles and simply died. It was as if a switch in the core of their being had been triggered, and they knew that their life as a human was drawing to its natural end.  They were fully ready to move on, and all family entreaties to “eat just a little more” were kindly ignored. They did not meet the formal medical criteria for depression. They were not, on the whole, nearly as unhappy as their families. I have seen this pattern of end-of-life behavior time and time again.  Sometimes the triggering scenario is different. I often saw a similar pattern of behavior in those diagnosed with end stage malignancies. When confronted with the reality that long-term quality survival was no longer a realistic option, this pattern often emerged. The gift of cancer, it seems, is that of Time. Unlike sudden cardiovascular death, the incurable cancer patient is given a window of time within which to do the necessary homework on the physical, mental and spiritual planes if they so desire and if they are given the freedom and the opportunity to do so. Read: “Keep the birds away.” Frequently this end-of-life-pattern mimics the pattern described above, namely, that of the Caterpillar Syndrome.

I do not feel that this condition is pathologic. There is little, if any disease on the part of the patient, unless those caring for them induce this condition out of their own frustration, anger, fear or greed.  I have felt no sense at all of suicidal ideation in these patients. Is the caterpillar being suicidal when it attaches its silk purchase to the twig and starts to spin its cocoon?  To the contrary, my sense is that this syndrome is a part of the ‘Death with dignity’ that we espouse so repeatedly at the theoretic and institutional levels. As physicians we have a hard time dealing with this.  We have a hard time remembering that our obligation of caring for patients begins and ends with actual caring for our patients. This includes inquiring as to their most heartfelt desires at this stage of life, and honoring them, supporting them, and indeed protecting them from ‘the birds,’ namely those who would impose a different scenario upon them for their own personal needs and desires.  We owe this to our patients, for who can provide this service to them if not us?

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VOM Is an Insider's View of What Doctors are Thinking, Saying and Writing about

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9.      Book Review: The 9/11 Wars  Is The West Any Wiser, Ten Years On?

Learning the hard way

A mixed bag of books on the wars that followed al-Qaeda’s attack on America,
 all of them worth reading
From the Economist | print edition | Books and arts | Sep 3rd 2011 |

The Rise and Fall of Al-Qaeda. By Fawaz Gerges. Oxford University Press USA; 272 pages; $24.95. To be published in Britain in November; £12.99. Buy from,

Rock the Casbah: Rage and Rebellion Across the Islamic World. By Robin Wright. Simon & Schuster; 307 pages; $26.99 and £17.99. Buy from,

Cables from Kabul: The Inside Story of the West’s Afghanistan Campaign. By Sherard Cowper-Coles. Harper Press; 312 pages; £25. Buy from

The 9/11 Wars. By Jason Burke. Penguin Global; 709 pages; $16. Allen Lane; £30. Buy from,

IS THE West any wiser, ten years on? Policymakers certainly know more than they did on September 11th 2001—about the nature of al-Qaeda, for example, and what drives young Muslims to emulate it—and have shed at least some of their illusions about the West’s ability to shape the Muslim world to its liking. But as these four very different books show, salutary lessons have yet to be learned.

Anniversaries of the attacks on the twin towers prompt the question: who’s winning? In the first and shortest of these books Fawaz Gerges, a professor at the London School of Economics and author of several studies of jihadism, argues that the West has won, but doesn’t realise it. Al-Qaeda, he suggests, was never the monster many imagined it to be, and is now a virtually spent force. The only thing that keeps it alive is fear stoked by self-serving politicians and ignorant media. “A decade after September 11”, he writes, “over-reaction is still the hallmark of the US War on Terror.” He has a point, but is a little too quick to brush aside those experts who think al-Qaeda still has some kick in it.

In “Rock the Casbah” Robin Wright goes further, arguing that Islamist extremism has been thoroughly discredited and that a vibrant counter-jihad is sweeping the Muslim world, exemplified most recently in the Arab spring. Her book serves as a corrective. Commentators have spent a decade bewailing the absence of tolerant, peace-loving Muslims ready to stand up and be counted. But they were there all along, struggling to be heard. Now Islam’s assorted bloggers, rappers, feminists and reformers have found in Ms Wright, a former Washington Post journalist, a worthy chronicler. They are so lively and likeable it seems churlish to suggest that she overrates their importance.

Professor Gerges and Ms Wright both argue that the West has done a poor job of understanding the Muslim countries where they have intervened. Their case is powerfully reinforced by Sherard Cowper-Coles in “Cables from Kabul”, published earlier this year. Sir Sherard, a former British ambassador to Afghanistan, exposes the group-think—the belief that sufficient military effort would bring success—that has blighted Western efforts there over the past decade. Witty, urbane and shrewdly observed, his book is a withering critique of Anglo-American delusions—and of official Afghan shortcomings. It is also a vivid picture of the life of a British diplomat in a uniquely challenging post.

In “The 9/11 Wars”, the biggest and most ambitious of these books, Jason Burke says his aim is to provide “a grubby view from below”: to focus on the ordinary people affected by conflict rather than on decision-makers in far-off capitals. But his book does much more. Its 700-odd pages attempt to knit together into a coherent whole the vast sprawling fabric of the global “war on terror”.

This is a daunting task, yet Mr Burke largely accomplishes it. His book is the best overview of the 9/11 decade so far in print. It is also the summation of the career of a fine journalist (he works for the Guardian and the Observer), a writer who, crucially for his subject, knows South Asia as well as he knows the Middle East.

More than most authors (and for that matter most politicians) Mr Burke is alert to the complex, multi-dimensional nature of what he dubs the “9/11 wars”. He sees them as a messy, protracted conflict or series of conflicts, spread over a wide geographical canvas, and possessing no clear beginning or end. He has no time for ideological narratives, whether from George Bush or Osama bin Laden, that reduce these wars to a neat slogan. Equally nuanced is his characterisation of al-Qaeda and its ilk. He does not see the group as some unified “axis of evil”, but as an “amorphous, dynamic and fragmented movement based more on personal relations and a shared world view than on formal membership of an organisation.”

Mr Burke agrees that al-Qaeda is weaker than it was a decade ago and that its ideology has lost much of its appeal. But he is unwilling to write its obituary just yet. Having spent much time in the wilder parts of Afghanistan and Pakistan—today the centre of the global struggle—he takes seriously the threat al-Qaeda and its allies still pose to the governments of both countries. And, like Sir Sherard, he is sceptical that the West is pursuing the right policies. . .

If there is a seed of optimism in “The 9/11 Wars”, however, it is in its diagnosis of the weakening, though markedly not the demise, of al-Qaeda. The movement and its allies have not merely discredited themselves through resorting to indiscriminate violence. With their Utopian global agenda, far removed from everyday needs and grievances, they have in the end alienated the very populations (in Iraq, Saudi Arabia, Jordan and elsewhere) whose support they counted on. All politics is local: a banal lesson, perhaps, but one that could have a significant bearing on the outcome of this long twilight struggle.

Read the entire book review at The Economist  . . .
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The Book Review Section Is an Insider’s View of What Doctors are Reading about.

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10.  Hippocrates & His Kin: The Eyes of Texas are Upon Us

With a Texan possibly becoming our next president, we need to look what Law & Order looks like.

Sign on a Texas Ranch:




Now That Sounds Like a Very Effective NO TRESPASSING SIGN, Don’t you think?

Read more . . .

Sign in a Texas Restaurant:




Now That Should Give Every Mother a Grave Concern for Behavior, Don’t you think?

Sign in a Ford Truck Dealership:




Now that’s a welcome you won’t soon forget!


To read more HHK . . . 
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Hippocrates and His Kin / Hippocrates Modern Colleagues
The Challenges of Yesteryear, Yesterday, Today & Tomorrow

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11.  Organizations Restoring Accountability in HealthCare, Government and Society:

                      The National Center for Policy Analysis, John C Goodman, PhD, President, who along with Gerald L. Musgrave, and Devon M. Herrick wrote Lives at Risk, issues a weekly Health Policy Digest, a health summary of the full NCPA daily report. You may log on at and register to receive one or more of these reports. This month, read about consumer directed health care . . .

                      Pacific Research Institute, ( Sally C Pipes, President and CEO, John R Graham, Director of Health Care Studies, publish a monthly Health Policy Prescription newsletter, which is very timely to our current health care situation. You may signup to receive their newsletters via email by clicking on the email tab or directly access their health care blog. This month read about: Big Government and Health-Care Stocks . . .

                      The Mercatus Center at George Mason University ( is a strong advocate for accountability in government. Maurice McTigue, QSO, a Distinguished Visiting Scholar, a former member of Parliament and cabinet minister in New Zealand, is now director of the Mercatus Center's Government Accountability Project. Join the Mercatus Center for Excellence in Government. This month, read their research: No Correlation Between State Unemployment and Stimulus Funds Received . . .

                      To read the rest of this column, please go to

                      The National Association of Health Underwriters, The NAHU's Vision Statement: Every American will have access to private sector solutions for health, financial and retirement security and the services of insurance professionals. There are numerous important issues listed on the opening page. Be sure to scan their professional journal, Health Insurance Underwriters (HIU), for articles of importance in the Health Insurance MarketPlace. The HIU magazine, with Jim Hostetler as the executive editor, covers technology, legislation and product news - everything that affects how health insurance professionals do business.

                      The Galen Institute, Grace-Marie Turner President and Founder, has a weekly Health Policy Newsletter sent every Friday to which you may subscribe by logging on at A study of purchasers of Health Savings Accounts shows that the new health care financing arrangements are appealing to those who previously were shut out of the insurance market, to families, to older Americans, and to workers of all income levels. This month, you might focus on the Rough Week that ObamaCare had . . .

                      Greg Scandlen, an expert in Health Savings Accounts (HSAs), has embarked on a new mission: Consumers for Health Care Choices (CHCC). Read the initial series of his newsletter, Consumers Power Reports. Become a member of CHCC, The voice of the health care consumer. Be sure to read Prescription for change: Employers, insurers, providers, and the government have all taken their turn at trying to fix American Health Care. Now it's the Consumers turn. Greg has joined the Heartland Institute, where current newsletters can be found.

                      The Heartland Institute,, Joseph Bast, President, publishes the Health Care News and the Heartlander. You may sign up for their health care email newsletter. Read the late Conrad F Meier on What is Free-Market Health Care?. This month take an overview of recent months of Health Care News . . .

                      The Foundation for Economic Education,, has been publishing The Freeman - Ideas On Liberty, Freedom's Magazine, for over 50 years, with Lawrence W Reed, President,  and Sheldon Richman as editor. Having bound copies of this running treatise on free-market economics for over 40 years, I still take pleasure in the relevant articles by Leonard Read and others who have devoted their lives to the cause of liberty. I have a patient who has read this journal since it was a mimeographed newsletter fifty years ago. Be sure to read about Freedom University offers an introductory, interdisciplinary, comprehensive overview of the workings of a free society

                      The Council for Affordable Health Insurance,, founded by Greg Scandlen in 1991, where he served as CEO for five years, is an association of insurance companies, actuarial firms, legislative consultants, physicians and insurance agents. Their mission is to develop and promote free-market solutions to America's health-care challenges by enabling a robust and competitive health insurance market that will achieve and maintain access to affordable, high-quality health care for all Americans. "The belief that more medical care means better medical care is deeply entrenched . . . Our study suggests that perhaps a third of medical spending is now devoted to services that don't appear to improve health or the quality of care–and may even make things worse."

                      The Independence Institute,, is a free-market think-tank in Golden, Colorado, that has a Health Care Policy Center, with Linda Gorman as Director. Be sure to sign up for the monthly Health Care Policy Center Newsletter. This month read about the crises we’re in: America is in crisis: The constitutional system of checks and balances is failing to keep government within its proper bounds. Read more . . .

                      Martin Masse, Director of Publications at the Montreal Economic Institute, is the publisher of the webzine: Le Quebecois Libre. Please log on at to review his free-market based articles, some of which will allow you to brush up on your French. You may also register to receive copies of their webzine on a regular basis. This month, read Mr Masse’s Review: Statism and the Decline of the Roman Empire . . . or the Soviet Union . . . Or Quebec.  

                      The Fraser Institute, an independent public policy organization, focuses on the role competitive markets play in providing for the economic and social well being of all Canadians. Canadians celebrated Tax Freedom Day on June 28, the date they stopped paying taxes and started working for themselves. Log on at for an overview of the extensive research articles that are available. You may want to go directly to their health research section.

                      The Heritage Foundation,, founded in 1973, is a research and educational institute whose mission was to formulate and promote public policies based on the principles of free enterprise, limited government, individual freedom, traditional American values and a strong national defense. -- However, since they supported the socialistic health plan instituted by Mitt Romney in Massachusetts, which is replaying the Medicare excessive increases in its first two years, and was used by some as a justification for the Obama plan, they have lost sight of their mission and we will no longer feature them as a freedom loving institution and have canceled our contributions. We would also caution that should Mitt Romney ever run for National office again, he would be dangerous in the cause of freedom in health care. The WSJ paints him as being to the left of Barrack Hussein Obama. We would also advise Steve Forbes to disassociate himself from this institution.

                      The Ludwig von Mises Institute, Lew Rockwell, President, is a rich source of free-market materials, probably the best daily course in economics we've seen. If you read these essays on a daily basis, it would probably be equivalent to taking Economics 11 and 51 in college. Please log on at to obtain the foundation's daily reports. You may also log on to Lew's premier free-market site to read some of his lectures to medical groups. Learn how state medicine subsidizes illness or to find out why anyone would want to be an MD today.

                      CATO. The Cato Institute ( was founded in 1977, by Edward H. Crane, with Charles Koch of Koch Industries. It is a nonprofit public policy research foundation headquartered in Washington, D.C. The Institute is named for Cato's Letters, a series of pamphlets that helped lay the philosophical foundation for the American Revolution. The Mission: The Cato Institute seeks to broaden the parameters of public policy debate to allow consideration of the traditional American principles of limited government, individual liberty, free markets and peace. Ed Crane reminds us that the framers of the Constitution designed to protect our liberty through a system of federalism and divided powers so that most of the governance would be at the state level where abuse of power would be limited by the citizens' ability to choose among 13 (and now 50) different systems of state government. Thus, we could all seek our favorite moral turpitude and live in our comfort zone recognizing our differences and still be proud of our unity as Americans. Michael F. Cannon is the Cato Institute's Director of Health Policy Studies. Read his bio, articles and books at

                      The Ethan Allen Institute,, is one of some 41 similar but independent state organizations associated with the State Policy Network (SPN). The mission is to put into practice the fundamentals of a free society: individual liberty, private property, competitive free enterprise, limited and frugal government, strong local communities, personal responsibility, and expanded opportunity for human endeavor.

                      The Free State Project, with a goal of Liberty in Our Lifetime,, is an agreement among 20,000 pro-liberty activists to move to New Hampshire, where they will exert the fullest practical effort toward the creation of a society in which the maximum role of government is the protection of life, liberty, and property. The success of the Project would likely entail reductions in taxation and regulation, reforms at all levels of government to expand individual rights and free markets, and a restoration of constitutional federalism, demonstrating the benefits of liberty to the rest of the nation and the world. [It is indeed a tragedy that the burden of government in the U.S., a freedom society for its first 150 years, is so great that people want to escape to a state solely for the purpose of reducing that oppression. We hope this gives each of us an impetus to restore freedom from government intrusion in our own state.]

                      The St. Croix Review, a bimonthly journal of ideas, recognizes that the world is very dangerous. Conservatives are staunch defenders of the homeland. But as Russell Kirk believed, wartime allows the federal government to grow at a frightful pace. We expect government to win the wars we engage, and we expect that our borders be guarded. But St. Croix feels the impulses of the Administration and Congress are often misguided. The politicians of both parties in Washington overreach so that we see with disgust the explosion of earmarks and perpetually increasing spending on programs that have nothing to do with winning the war. There is too much power given to Washington. Even in wartime, we have to push for limited government - while giving the government the necessary tools to win the war. To read a variety of articles in this arena, please go to

                      Hillsdale College, the premier small liberal arts college in southern Michigan with about 1,200 students, was founded in 1844 with the mission of "educating for liberty." It is proud of its principled refusal to accept any federal funds, even in the form of student grants and loans, and of its historic policy of non-discrimination and equal opportunity. The price of freedom is never cheap. While schools throughout the nation are bowing to an unconstitutional federal mandate that schools must adopt a Constitution Day curriculum each September 17th or lose federal funds, Hillsdale students take a semester-long course on the Constitution restoring civics education and developing a civics textbook, a Constitution Reader. You may log on at to register for the annual weeklong von Mises Seminars, held every February, or their famous Shavano Institute. Congratulations to Hillsdale for its national rankings in the USNews College rankings. Changes in the Carnegie classifications, along with Hillsdale's continuing rise to national prominence, prompted the Foundation to move the College from the regional to the national liberal arts college classification. Please log on and register to receive Imprimis, their national speech digest that reaches more than one million readers each month. This month Choose recent issues. The last ten years of Imprimis are archived.

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Words of Wisdom, Recent Postings, In Memoriam, Today in History . . .

Words of Wisdom

"Be fully aware. Be engaged. Remind yourself to live in the present moment, The Zone."— Jim Fannin: Nightingale-Conant author

"What's dangerous is not to evolve." — Jeff Bezos: the founder, president, and CEO of

"I've failed over and over and over again in my life and that is why I succeed." — Michael Jordan: a former professional basketball player

"Innovation distinguishes between a leader and a follower." — Steve Jobs: co-founder, chairman, and former CEO of Apple Inc.

Some Recent Postings

In This Issue:

1.        Featured Article: Tourette’s syndrome

2.        In the News: Our world is a much wilder place than it looks

3.        International Medicine: Government’s Health Spending Crises

4.        Medicare: Who Has Power to Stop a Rogue President?

5.        Medical Gluttony: Government Gluttony: Insurmountable Debts

6.        Medical Myths: It’s Safe to be a WhistleBlower? Not unless we make it safe.

7.        Overheard: If it weren’t for Republicans in the House, I’d spend another $800 Billion

8.        Voices of Medicine: Deal With the Patient, NOT the Computer

9.        The Bookshelf: Life After Death By Jeff Sugarman, MD

10.      Hippocrates & His Kin: Can you really go without Health Insurance?

11.      Related Organizations: Restoring Accountability in Medical Practice and Society

In Memoriam

Lucian Freud

Flesh and dust

The ECONOMIST | Jul 22nd 2011 | by E.B. | LONDON

THROUGHOUT the history of art, nudes were idealised templates for humanity, with rippling muscles, tidy breasts and smooth skin. Not for Lucian Freud, who died at home in London on Wednesday, aged 88. For him, the nude was something more naked, more real. His portraits were often confrontational and unsettling, whether the subject was a local thief or the Queen of England (who kept her clothes on). In his “dingy studio”, writes William Grimes in his fine obituary for the New York Times, Freud’s “contorted subjects, stripped bare and therefore unidentifiable by class, submitted to the artist’s unblinking, merciless inspection.”
This apparent mercilessness is what makes Freud’s work difficult, but also mesmerising. Rarely is the human form captured in all its vulnerability, with all ofits flaws. Freud’s gift to painting was to demystify the nude—to find the beauty in the grotesque—and to do it without seeming unaffectionate. “For me the paint is the person,” Freud explained to Lawrence Gowing, a biographer.
A survey of tributes to the man reveals a delicious glut of adjectives. His nudes had a “fleshiness and mass,” observes Mr Grimes, with faces that “showed fatigue, distress, torpor.” His female subjects “seemed not just nude but obtrusively naked.” Michael Glover in the Independent marvels at the “gorgeous, swollen, egregious fleshiness” of his figures. Florence Waters in the Telegraph considers Freud's legacy of “gracelessly posed, grossly sagging” women. His work evokes thoughts of “a face sculpted in paint that appears to fold and puff like a cauliflower ear.”
But perhaps the finest recollection comes from Sue Tilley, the somewhat unwieldy subject of Freud’s painting “Benefits Supervisor Sleeping”, which sold at auction in 2008 for £17.2m ($33.6m). A 280-pound (20-stone) civil servant, Ms Tilley posed for Freud for several paintings—a physically arduous experience—and the results are often described as remarkably unflattering. But her description of their time, as printed in the Guardian, is enlightening for the way it captures the artist’s humanity and unhurried discipline. . .

He wasn't cruel—he painted what he saw. What strikes me most is, I look at my fat ankles and my fat feet every morning and I think they look just like that painting. Even the skinny girls don't look good, do they? He painted out of love. . .

 Read the entire obituary in The Economist:

On This Date in History - August 9

On this date in 1974, Gerald R. Ford succeeded Richard M Nixon, who resigned, as President.

This was the first time in our history; a man not chosen even indirectly by the people became the President of the United States. Gerald R. Ford had been named by Richard Nixon anad confirmed by the Congress to succeed Spiro Agnew as Vice President when Agnew resigned; when Nixon residned in the Watergate scandal, Ford became President. If ever the United States government could have been brought to a paralyzed halt that, we feared, could have been the time. But it held firm. The people held firm. The strength of any government, in this country, lies not in those who govern but in the electorate.

On this date in 1936, Jesse Owens dominated the Olympics. Today, we want to remind you oof just how much an individual can do. An American names Jesse Owens, a Black American competing in the Olympic Games hosted by Adolf Hitler in 1936—a Black American competing under the eyes of the world’s leading, most virulent advocate of white Aryan superiority. On this day, Jesse Owens, already a great trac star, became the first man to win four medals in the Olympic Games. He stood in the winner’s platform at the Olympic Stadium, a living proof of the wrongness of Mr. Hitler.

After Leonard and Thelma Spinrad

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Please note that sections 1-4, 6, 8-9 are entirely attributable quotes and editorial comments are in brackets. Permission to reprint portions has been requested and may be pending with the understanding that the reader is referred back to the author's original site. We respect copyright as exemplified by George Helprin who is the author, most recently, of “Digital Barbarism,” just published by HarperCollins. We hope our highlighting articles leads to greater exposure of their work and brings more viewers to their page. Please also note: Articles that appear in MedicalTuesday may not reflect the opinion of the editorial staff.

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Always remember that Chancellor Otto von Bismarck, the father of socialized medicine in Germany, recognized in 1861 that a government gained loyalty by making its citizens dependent on the state by social insurance. Thus socialized medicine, or any single payer initiative, was born for the benefit of the state and of a contemptuous disregard for people’s welfare.

Thus we must also remember that ObamaCare has nothing to do with appropriate healthcare; it was similarly projected to gain loyalty by making American citizens dependent on the government and eliminating their choice and chance in improving their welfare or quality of healthcare. Socialists know that once people are enslaved, freedom seems too risky to pursue.