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Mental Health Rather than Infectious Disease may be Haiti's Biggest Threat

Despite much concern about diseases spreading through Haiti's earthquake-shattered areas, one epidemiologist explains that mental health issues will be more widespread. By Katherine Harmon,
Scientific American, Jan 15, 2010.

As the aftershocks of the January 12 magnitude 7.0 earthquake outside of Port-au-Prince, Haiti, taper off and the dust settles, new needs are coming to light. The health of many of the three million residents said to have been shaken by the quake will be determined in the coming weeks as aid workers and others rush to treat the wounded, provide food and water, and try to prevent disease outbreaks.

Concern already has run high about the spread of cholera and typhus in a country whose everyday "water supply and basic sanitation services are still very deficient," according to the Pan American Health Organization. Many diseases, including malaria, HIV and typhoid, were already widespread issues in Haiti before the earthquake struck, and the intensely weakened health care system (established hospitals and clinics having collapsed or been damaged) and other infrastructure is expected to exacerbate these problems. . . .

But not all of the human harm from this disaster will be of the physical variety. For example, many experts have noted that the multitude of dead bodies—some 50,000 possibly having died in the disaster already, the Red Cross estimates—don't pose an infectious disease risk so much as a psychological threat to the survivors.

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There are 280 Million Americans without Legal Care Coverage!

LegalCare: It is Time to Lower Legal Costs and Ensure Affordable, Accessible Legal Coverage for All by Matthew S. Rice, M. D., Journal of American Physicians and Surgeons, AAPS

According to the American Bar Association, thousands of innocent working Americans are wrongfully convicted of crimes every year, in part due to negligent or poorly trained lawyers, careless judges, and prosecutorial misconduct. Samuel R. Gross, Professor of Law at University of Michigan, estimates that between 3.3 percent and 7 percent of convictions are erroneous, meaning that between 60,000 and 140,000 innocent Americans are incarcerated.

With attorney-legislators scrutinizing and planning the reform of medicine and the health insurance industry, it is only fitting that physicians apply the most current progressive healthcare reform principles to the legal profession. Attorney-legislators and other politicians and appointees are strongly encouraged to use the present healthcare reform momentum to simultaneously reform the legal profession. Doing so would greatly add to their credibility among constituents and other stakeholders, since they know essentially nothing about medicine and everything about law. Legal reform: it is time.

IllustrativeAnecdotes

·         Cameron Willingham was convicted of murdering his children by arson in 1992. Due in part to poverty, inadequate representation by legal counsel, and an inefficient, haphazard, paper-dependent Legalcare system based on medieval principles and practices, he was executed in 2004. The Texas Forensic Science Commission has been examining the flawed investigation that contributed to the execution of this man, thought by many arson experts to be innocent . . .

·         Eddie Lloyd was wrongfully convicted of rape and murder in 1985. Contributing factors to this tragic injustice included representation by a court-appointed attorney, poor hand-off between defense attorneys prior to trial, and the fact that another state-appointed attorney failed to meet with Lloyd or file a claim of ineffective assistance of counsel. Lloyd was exonerated after spending 17 years in prison, and died two years later.

Scope and Severity of the Problem

Legalcare costs in the U.S. are skyrocketing, with tort costs alone draining Americans of $865 billion dollars annually, a sum greater than the entire combined gross domestic products of New Zealand, Hong Kong, Ireland, Vietnam, Qatar, Ecuador, and Luxembourg. Billions more are wasted by fearful business owners complying with dubious regulations drafted by lawyers. Are we getting our money's worth? Is the United States anymore safe, just, or lawful than Japan or Great Britain, where the legal-cost burden is half of what we pay? According to The Times of London, our legal system is worse than that of either Russia or China.

The prohibitive costs of lawsuits and liability insurance are smothering small business owners and working Americans, who bear almost 70 percent of business tort liability costs. 

Class-action lawsuits result in multi-million dollar payouts to lawyers while consumers end up with nothing of value. David de Alba, a California Superior Court Judge, awarded attorneys who filed a class-action lawsuit against Ford Motor Company $25 million. What did the plaintiffs receive? Coupons they could apply toward the purchase of a new vehicle.

Expenses related to defensive medicine practices add $124 billion annually to healthcare costs, more than enough to give a $10,000 health insurance premium to each chronically uninsured American. 

The burden of lawsuits in America is an unseen "tax" of $9,827 on each working family of four. Unless you're Warren Buffett or Bill Gates, your family or small business is just one serious legal bill away from bankruptcy, and all bankruptcies in America involve at least one expensive legal bill. . .

While half of all Americans will require Legalcare services in any given year, almost 280 million Americans lack legal insurance. For those few Americans who do have legal insurance coverage, most plans only cover a limited number of attorney visits and fail to provide coverage for preexisting situations such as divorce proceedings, custody cases, bankruptcy, or cases involving alcohol or drugs, thus exposing hardworking families to unlimited financial liabilities. Even those Americans with coverage are struggling to cope with soaring legal expenses. As a nation we can no longer afford to accept the status quo. The cost of inaction is simply too much to bear. . .

Racial minorities, the poor, non-citizens, and men receive longer prison sentences than whites, the wealthy, citizens, and women, respectively. Recent studies by the American Bar Association estimate that half of all poor Americans suffer from at least one serious legal problem each year, but 75 percent of them have no access to Legalcare services. While the average profit per partner of the most successful law firms soared to $755,000 annually over the past 10 years, these same attorneys only provided eight minutes per day of pro-bono Legalcare services to the needy and helpless who suffer from serious legal conditions. Clearly, perverse profit motives have hindered the ability of many attorneys to reach their potential in providing low-cost or free Legalcare services to the poor.  Imagine an America in which disenfranchised socioeconomic groups and disparity ethnic groups had access to the same quality Legalcare afforded to the wealthiest Americans!

Too many Americans go without high-value preventive Legalcare services such as professional income tax preparation and reviews; estate, will, and trust planning; legal risk reviews; precrime legal mitigation assessments; and other critical legal services available only to the wealthiest Americans. Routine use of preventive legal services could help Americans avoid future liabilities, but owing to prohibitive costs, many working American families forgo such counsel only to suffer the far greater consequences of future legal or regulatory noncompliance. Our legal system has become a criminal and civil system, and the time for reform is well overdue.

Lower Costs to Make Our Legalcare System Work for People and Businesses— Not Just for Lawyers.

Inefficient and poor-quality Legalcare costs the nation hundreds of billions of dollars every year. Billions more are wasted on administration and overhead, and this problem will only worsen as legal spending increases over the next decade. We must redesign our Legalcare system to reduce inefficiency and waste, and improve Legalcare quality, driving down costs for families and businesses. We can do this by: (1) adopting state-of-the-art legal information technology systems; (2) ensuring that clients receive, and attorneys deliver, the best possible counsel, including preventive legal services and chronic-offender management services; and (3) liberating attorneys from perverse profit incentives by implementing a national single-payer Legalcare system.

Legal costs and quality can vary tremendously among firms and attorneys; however clients have limited access to this information.  We must require firms and attorneys to collect and publicly report measures of legal costs and quality, including data on hourly fees, legal errors, miscarriages of justice, attorney-to-client staffing ratios, overruled motions, reversed verdicts, and conviction rates.

We must align incentives with excellence. Sadly, many attorneys collect fees based on the volume of services provided rather than on the quality of those services. For example, a working parent might take her obese child to an attorney to sue a school for damages arising from chronic illnesses caused by the federally funded school lunch program. The attorney might think to himself, "I could make a lot more money by taking this case and billing these people $400 per hour, rather than telling them that the case is futile."

Enter Legalcare, a national single payer legal system that would set reimbursement rates for attorneys and link quality legal counsel with incentives. Legalcare would cover all Americans and drive down legal costs across the board. Legalcare would be administered by a Department of Legal Services (DLS). Reimbursement rates would be modeled on the highly successful Medicare program, and would range from $12.56 to $170.65 per attorney-client session, based on coded documentation of the complexity and quality of Legalcare services provided.

Tackling the Disparities in Legalcare

Although all Americans are affected by this crisis in our Legalcare delivery system, an overwhelming body of evidence indicates that certain populations are significantly more likely to receive lower quality Legalcare than others.

Do not all Americans deserve access to the best available Legalcare? Could a poor working member accused of drug possession simply walk into the office of a politically connected trial lawyer, and receive the Legalcare he needed and deserved at an affordable price? Of course not! Lawyers demand cash retainers, ranging in the thousands to tens of thousands of dollars for criminal defense. He would likely end up with a poorly trained, non-connected public defender, and spend years languishing in prison. According to a damning 2002 report, many public defenders are "unqualified, irresponsible, or overburdened and do little if any meaningful work for [their] clients." It is our nation's moral duty to ensure that attorneys and law firms provide affordable counsel to all Americans, especially our most vulnerable and disenfranchised; and to end the practice of "cherry-picking" easy clients or lucrative cases. . .

Attorneys must be required to keep electronic legal records (ELR) for their clients, the benefits of which are substantial: improved administrative efficiencies, improved quality of Legalcare, elimination of legal errors, reduction of redundancies and paperwork, and lower Legalcare costs, among others. The ELR should be modeled after the functional and efficient Department of Defense electronic medical record, AHLTA, which is arguably the "Porsche" of electronic medical records. The National Coordinator of Legal Information Technology would ensure that attorneys who fail to be meaningful users of the approved ELR  (Attorney Hypermetric Longitudinal Technology Application) by 2015 face reduced payments and other financial penalties from the DLS. In a general sense, meaningful users of the ELR are defined as attorneys who demonstrate to the government that they are using electronic documentation, that their technology is connected in a manner that provides for electronic exchange of legal data to improve quality of legal services, and those attorneys who submit information to the government on legal outcome measures.

The National Institute of Comparative Legal Effectiveness would monitor attorney-client decisions via the ELR to make sure that lawyers do what the DLS deems appropriate, fair, and cost-effective.  The goal is to reduce costs and guide attorneys' decisions, with the aim of standardizing and improving legal outcomes for all Americans. . .

Affordable, Accessible Coverage for All

We must guarantee affordable and accessible legal counsel for all Americans. Currently, with nearly 280 million Americans lacking legal insurance, rising costs are a burden on working families and small businesses. It is simply too expensive for individuals and families to buy the Legalcare they need and deserve on the open market, and is impossible for many with ongoing or preexisting legal problems.

We must require law firms and attorneys to accept clients with pre-existing legal problems (to include recalcitrant criminal behavior, drug and alcohol addictions, and civil problems such as complicated divorce and custody battles), at fair reimbursement rates set by the DLS. We can no longer allow attorneys and firms to accept easy or lucrative cases while dismissing those who cannot pay, or who suffer from challenging legal conditions.

Legalcare would be budget-neutral if it were funded with a small addition to the existing Federal Insurance Contributions Act tax (FICA), and a federal tax of 75 percent on all tort awards and on all court filing fees. Legalcare will enable all deserving Americans to get the comprehensive and quality legal benefits they need and deserve at a fair and stable price. It will eliminate the two-tiered Legalcare system currently in place, keeping courthouse doors open for all, regardless of economic status or race.

Read the entire Legalcare proposal at www.jpands.org/vol14no4/rice.pdf.

Matthew S. Rice, M.D. is a family physician in Tacoma, Wash. Contact:

matthew_s_rice@yahoo.com. Also see www.SinglePayerLegal.org.

© The Association of the American Physicians and Surgeons, Jane M Orient, MD, Executive Director, Managing Editor; Winter issue of JAPS, Lawrence R Huntoon, MD, PhD, Editor-in-Chief, editor@Jpands.org 

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New Predictors of Disease
  

NOVEL CRYSTAL BALL: One day Y-shaped molecules called autoantibodies in a patient's blood may tell doctors whether a patient is "brewing" certain diseases and may even indicate roughly how soon the individual will begin to feel symptoms.
By Abner Louis Notkins Scientific American

Overview/Predictive Antibodies
In autoimmune diseases, such as type 1 diabetes, the immune system mistakenly manufactures antibodies that target the body's tissues.

Certain of these "autoantibodies" appear many years before overt symptoms of disease, suggesting that screening for these molecules could be used to predict who is at risk of falling ill.

Autoantibodies might also serve as guides to disease severity and progression and might even warn of risk for some nonimmune disorders.

Screening for predictive autoantibodies could one day become routine, although a dearth of preventive treatments currently stands in the way.


A middle-aged woman—call her Anne—was taken aback when one day her right hand refused to hold a pen. A few weeks later her right foot began to drag reluctantly behind her left. Af­ter her symptoms worsened over months, she con­sulted a neurologist. Anne, it turned out, was suf­fering from multiple sclerosis, a potentially dis­abling type of autoimmune disease. The immune system normally jumps into action in response to bacteria and viruses, deploying antibodies, other molecules and various white blood cells to recog­nize and destroy trespassers. But in autoimmune disorders, components of the body's immune sys­tem target one or more of the person's own tis­sues. In Anne's case, her defensive system had be­gun to turn against her nerves, eroding her abil­ity to move.

Every story of autoimmune disease is sad—but collectively the impact of these illnesses is staggering. More than 40 autoimmune condi­tions have been identified, including such com­mon examples as type 1 (insulin-dependent) dia­betes, rheumatoid arthritis and celiac disease. Together they constitute the third leading cause of sickness and death after heart disease and can­cer. And they afflict between 5 and 8 percent of the U.S. population, racking up an annual medical bill in the tens of billions of dollars.

Recent findings offer a way to brighten this gloomy picture. In the past 10 years a growing number of studies have revealed that the body makes certain antibodies directed against itself—otherwise known as autoantibodies—years, and sometimes a decade, before autoimmunity causes clinical disease, damaging tissues so much that people begin showing symptoms. This profound insight is changing the way that doctors and re­searchers think about autoimmune conditions and how long they take to arise. It suggests that physicians might one day screen a healthy per­son's blood for certain autoantibodies and fore­tell whether a specific disease is likely to develop years down the line. Armed with such predic­tions, patients could start fighting the ailment with drugs or other available interventions, there­by preventing or delaying symptoms. . . .

Early Insight from Diabetes

People familiar with advances in genetics might wonder why researchers would want to develop tests for predictive autoantibodies when doctors might soon be able to scan a person's genes for those that put the individual at risk of various disorders. The answer is that most chron­ic diseases arise from a complex interplay between environ­mental influences and multiple genes (each of which makes but a small contribution to a disease). So detection of susceptibil­ity genes would not necessarily reveal with any certainty whether or when an individual will come down with a particu­lar autoimmune condition. In contrast, detection of specific autoantibodies would signal that a disease-causing process was already under way. Eventually, genetic screening for those with an inherited predisposition to a disease may help reveal those who need early au­toantibody screening.

Studies of patients with type 1 dia­betes provided the first clues that auto­antibodies could be valuable for predict­ing later illness. In this condition, which typically arises in children or teenagers, the immune system ambushes the beta cells in the pancreas. These cells are the manufacturers of insulin, a hormone that enables cells to take up vital glucose from the blood for energy. When the body lacks insulin, cells starve and blood glucose levels soar, potentially leading to blindness, kidney failure, and a host of other complications. . .

More important, these studies also raised the prospect that doctors might forecast whether a child is at risk for type 1 dia­betes by testing blood for the presence of these autoantibodies. Clinical researchers found that an individual with one auto­antibody has a 10 percent risk of showing symptoms within five years. With two autoantibodies, the chance of disease jumps to 50 percent; with three autoantibodies, the threat rockets to between 60 and 80 percent. . .

The discovery that autoantibodies frequently herald the onset of type 1 diabetes prompted scien­tists to examine whether the same might be true in other au­toimmune diseases. One that has been the focus of especially intense research is rheumatoid arthritis, a debilitating condi­tion that is highly prevalent, afflicting about 1 percent of the world's population. In those affected, the immune system at­tacks and destroys the lining of the joints, causing swelling, chronic pain and eventual loss of movement.

Predicting Other Diseases

Immunologists have recently unearthed an auto­antibody that is present in 30 to 70 percent of patients diag­nosed with rheumatoid arthritis . . .

To read the rest of this remarkable research. . .

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