The short, lumpy red couch in Stili Klikizos' second-grade classroom at Milwaukee's Fratney Elementary School was meant for quiet-time reading. Now it's "the sick couch," a place for ill students to lie down as they await the bus that takes everybody home at day's end. "The parents work and will lose pay if they come get them," she told me as I sat on the couch. Thanks to her union contract, Klikizos gets 12.5 paid sick days a year. Many of her students' parents aren't so fortunate. "It crosses socioeconomic lines. Sometimes kids tell me not to even call, since 'Mom will get fired if she leaves.'" Last year, several couch-sitters were belatedly diagnosed with swine flu.
The no-show parents are among the 40 percent of the private sector who don't receive sick pay. Among full-time workers, 73 percent are covered by paid medical days. (Ninety-one percent have paid vacation, 89 percent paid holidays). The percentage is far lower on every count for part-time workers, though it's not just the motel cleaning lady or immigrant dishwasher who is scared to call in sick, see a doctor, or pick up a kid from school. Retail sales supervisors and information technology managers deal with the same domestic crises.
They all have a stake in the little-noticed debate over paid sick days now unfolding in Washington, state capitals, and cities, with strong arguments for change confronting the economic and political realities of a recession that makes employers nervous about any extra costs. In Congress, the proposed Healthy Families Act—one of the last bills sponsored by Massachusetts Senator Ted Kennedy before he died—would guarantee as many as seven paid sick days a year for workers at companies with at least 15 employees. More than 30 million additional workers would be covered if it passes, including 6 million food-service and food-preparation workers who now have to either work when sick or lose pay. Consider that next time you're dining out.
Similar state and local proposals are launching debates in Connecticut, Massachusetts, and New York City. Laws are already in force in San Francisco and the District of Columbia, with the constitutionality of Milwaukee's soon to be argued in the Wisconsin Supreme Court. The face-offs echo those surrounding the Family & Medical Leave Act signed by Bill Clinton in 1993, with one side invoking morality and practicality and the other warning of dire economic consequences. The FMLA allows workers to take up to 12 weeks of unpaid leave to deal with a serious health problem, birth or adoption of a child, or care for a family member. Its impact has been decidedly benign.
Under a city ordinance that passed in 2008, Milwaukee workers would be eligible for up to five sick days a year if privately employed in a business of fewer than 10 workers, and up to nine days at larger firms. An employer that already provides paid leave, notably personal days or vacation, might get a pass. Still, the Metropolitan Milwaukee Association of Commerce insists the change would kill jobs "by making Milwaukee a high-cost island in which to do business." It doesn't acknowledge the possibility that new employer costs might be outweighed by reduced turnover and recruitment expenses.
In San Francisco, both the Chamber of Commerce and the Golden Gate Restaurant Assn. had similar qualms before its law took effect in 2007. Kevin Westlye, the association's executive director, says members assumed that, given the city's high minimum wage ($9.79) and mandated health insurance, paid sick leave was "strike three." The first two mandates still rankle, but paid sick days "is the best public policy for the least cost. Do you want your server coughing over your food?" The nightmare vision restaurateurs had of organized sickouts and staffers splitting "to go see the Giants play on a Friday," he says, hasn't panned out.
There's a pattern here. Washington declines to raise the federal minimum wage during hard times, and states tend to go ahead and do so. There's no question that the aftermath of the Great Recession is a tricky time to impose new costs, even if this is the right move for fairness and public health. It's a mistake for cities to "undertake a social justice agenda" and "ideologically impose" such mandates, says Kathryn S. Wylde, president of the Partnership for New York City, which represents major businesses. She's convinced of ill effects from the pending New York City proposal yet doesn't deny a popular allure. There's a certain inevitability to paid sick leave; as even Wylde concedes, "Who can argue that somebody should be cooking in a restaurant with a contagious flu?" Let the lumpy red couch in Milwaukee be used for reading, not recuperating.
This month, nearly 600 drug addicts broke out of a rehabilitation center in the northern Vietnamese city of Haiphong. The addicts overpowered guards at the state-run treatment facility and made a break for it. "We were completely overwhelmed," a security guard told the Associated Press. "Forty of us were not able to prevent them, many with canes and bricks, from escaping." Videos on the Internet show crowds of escapees marching through city streets.
Why were hundreds of patients fleeing treatment? Because in Vietnam, "treatment" looks a lot more like forced labor, complete with beatings and years of involuntary detention. Like neighboring Cambodia, China, Laos, Malaysia, and Thailand, the government of Vietnam has adopted a "get-tough" approach to drug treatment rather than evidence-based treatment. In Vietnam, more than 100 government-run facilities detain between 35,000 to 45,000 people for extrajudicial sentences of up to four years.
Vietnamese in these treatment centers are engaged in what the government calls "therapeutic labor": long hours at menial jobs for below-market wages -- whatever's left, that is, after the centers deduct for the cost of their meager food and Spartan lodging. Those who fail to meet work quotas are beaten. Patients who violate center rules can be locked in solitary confinement. "[T]hey beat people up, kicked the face, kicked the chest," a former resident of a rehab center near Hanoi told the BBC in 2008. "Later, people were made to work very hard. They said work to forget the addiction, work is therapeutic."
Opium cultivation and smoking are not new phenomena in Vietnam. But with economic liberalization and increased migration since the 1980s has come greater economic polarization and drug abuse. It is estimated that there are more than 100,000 injecting drug users in the country today, and nearly one in three is HIV infected.
Drug treatment hasn't kept pace with increasing abuse, and aside from some small-scale programs, allowed by the government but largely funded by other donors, effective treatment is virtually nonexistent. Instead, the government emphasizes compulsory, institutionalized treatment that isn't just inhumane, but also next to useless. Government reports have said that 70 to 80 percent of those who spend time in a center return to drug use. Other estimates put the rate closer to 90 percent -- and when drug users do relapse, they have no place to go, especially not to a compulsory "treatment" center. According to a study published this spring in the Journal of Urban Health, drug users in Vietnam who have been in rehab centers are more likely to be infected with hepatitis C than those who have not. Another study found that detention and fear of police led to greater risk of HIV infection among Vietnamese users.
In fact, Haiphong's escapees probably stand a better chance on the outside, if they can stay there: The city is one of three in Vietnam that is piloting the use of methadone to manage opiate addiction, the preferred approach in most developed countries. Indeed, trials of methadone maintenance therapy were already successfully conducted in Hanoi in the mid-1990s. So why not increase the number of slots in the Haiphong methadone clinic and offer the escapees voluntary enrollment? The U.S. government could help ensure that those who escaped can access services by redirecting its funding, which currently goes to HIV-treatment programs inside these abusive centers (though not the centers themselves), to programs based in the community.
Indeed, were Haiphong to expand access to the community-based drug treatment services it already offers and add counseling, employment prospects, and housing assistance, the city could become a model of humane and sustainable treatment. Those who were only occasional drug users -- and who don't need drug addiction treatment in the first place -- are more likely to find meaningful work and social support networks in the community to avoid becoming addicted. Serious addicts and casual users alike are likely to find better HIV prevention programs and services in the community.
Drug rehabilitation should provide drug users with a chance to regain control of their lives, repair broken relationships, and overcome destructive addictions. Rehab in Vietnam ruptures the lives of drug users, severs social support, and pretty much guarantees a return to drug use after years of abuse. No wonder drug users are escaping.
It is inevitable. The muscles weaken. Hearing and vision fade. We get wrinkled and stooped. We can’t run, or even walk, as fast as we used to. We have aches and pains in parts of our bodies we never even noticed before. We get old.
It sounds miserable, but apparently it is not. A large Gallup poll has found that by almost any measure, people get happier as they get older, and researchers are not sure why.
“It could be that there are environmental changes,” said Arthur A. Stone, the lead author of a new study based on the survey, “or it could be psychological changes about the way we view the world, or it could even be biological — for example brain chemistry or endocrine changes.”
The telephone survey, carried out in 2008, covered more than 340,000 people nationwide, ages 18 to 85, asking various questions about age and sex, current events, personal finances, health and other matters.
The survey also asked about “global well-being” by having each person rank overall life satisfaction on a 10-point scale, an assessment many people may make from time to time, if not in a strictly formalized way.
Finally, there were six yes-or-no questions: Did you experience the following feelings during a large part of the day yesterday: enjoyment, happiness, stress, worry, anger, sadness. The answers, the researchers say, reveal “hedonic well-being,” a person’s immediate experience of those psychological states, unencumbered by revised memories or subjective judgments that the query about general life satisfaction might have evoked.
The results, published online May 17 in the Proceedings of the National Academy of Sciences, were good news for old people, and for those who are getting old. On the global measure, people start out at age 18 feeling pretty good about themselves, and then, apparently, life begins to throw curve balls. They feel worse and worse until they hit 50. At that point, there is a sharp reversal, and people keep getting happier as they age. By the time they are 85, they are even more satisfied with themselves than they were at 18.
In measuring immediate well-being — yesterday’s emotional state — the researchers found that stress declines from age 22 onward, reaching its lowest point at 85. Worry stays fairly steady until 50, then sharply drops off. Anger decreases steadily from 18 on, and sadness rises to a peak at 50, declines to 73, then rises slightly again to 85. Enjoyment and happiness have similar curves: they both decrease gradually until we hit 50, rise steadily for the next 25 years, and then decline very slightly at the end, but they never again reach the low point of our early 50s.
Other experts were impressed with the work. Andrew J. Oswald, a professor of psychology at Warwick Business School in England, who has published several studies on human happiness, called the findings important and, in some ways, heartening. “It’s a very encouraging fact that we can expect to be happier in our early 80s than we were in our 20s,” he said. “And it’s not being driven predominantly by things that happen in life. It’s something very deep and quite human that seems to be driving this.”
Dr. Stone, who is a professor of psychology at the State University of New York at Stony Brook, said that the findings raised questions that needed more study. “These results say there are distinctive patterns here,” he said, “and it’s worth some research effort to try to figure out what’s going on. Why at age 50 does something seem to start to change?”
The study was not designed to figure out which factors make people happy, and the poll’s health questions were not specific enough to draw any conclusions about the effect of disease or disability on happiness in old age. But the researchers did look at four possibilities: the sex of the interviewee, whether the person had a partner, whether there were children at home and employment status. “These are four reasonable candidates,” Dr. Stone said, “but they don’t make much difference.”
For people under 50 who may sometimes feel gloomy, there may be consolation here. The view seems a bit bleak right now, but look at the bright side: you are getting old.
Dr. Jerry Jones uses two-way video at his home in Houston to consult with a patient across town. Dr. Jones is under contract to NuPhysicia, one of the new telemedicine companies.
ONE day last summer, Charlie Martin felt a sharp pain in his lower back. But he couldn’t jump into his car and rush to the doctor’s office or the emergency room: Mr. Martin, a crane operator, was working on an oil rig in the South China Sea off Malaysia.
He could, though, get in touch with a doctor thousands of miles away, via two-way video. Using an electronic stethoscope that a paramedic on the rig held in place, Dr. Oscar W. Boultinghouse, an emergency medicine physician in Houston, listened to Mr. Martin’s heart.
“The extreme pain strongly suggested a kidney stone,” Dr. Boultinghouse said later. A urinalysis on the rig confirmed the diagnosis, and Mr. Martin flew to his home in Mississippi for treatment.
Mr. Martin, 32, is now back at work on the same rig, the Courageous, leased by Shell Oil. He says he is grateful he could discuss his pain by video with the doctor. “It’s a lot better than trying to describe it on a phone,” Mr. Martin says.
Dr. Boultinghouse and two colleagues — Michael J. Davis and Glenn G. Hammack— run NuPhysicia, a start-up company they spun out from the University of Texas in 2007 that specializes in face-to-face telemedicine, connecting doctors and patients by two-way video.
Spurred by health care trends and technological advances, telemedicine is growing into a mainstream industry. A fifth of Americans live in places where primary care physicians are scarce, according to government statistics. That need is converging with advances that include lower costs for video-conferencing equipment, more high-speed communications links by satellite, and greater ability to work securely and dependably over the Internet.
“The technology has improved to the point where the experience of both the doctor and patient are close to the same as in-person visits, and in some cases better,” says Dr. Kaveh Safavi, head of global health care for Cisco Systems, which is supporting trials of its own high-definition video version of telemedicine in California, Colorado and New Mexico.
The interactive telemedicine business has been growing by almost 10 percent annually, to more than $500 million in revenue in North America this year, according to Datamonitor, the market research firm. It is part of the $3.9 billion telemedicine category that includes monitoring devices in homes and hundreds of health care applications for smartphones.
Christine Chang, a health care technology analyst at Datamonitor’s Ovum unit, says telemedicine will allow doctors to take better care of larger numbers of patients. “Some patients will be seen by teleconferencing, some will send questions by e-mail, others will be monitored” using digitized data on symptoms or indicators like glucose levels, she says.
Eventually, she predicts, “one patient a day might come into a doctor’s office, in person.”
Although telemedicine has been around for years, it is gaining traction as never before. Medicare, Medicaid and other government health programs have been reimbursing doctors and hospitals that provide care remotely to rural and underserved areas. Now a growing number of big insurance companies, like the UnitedHealth Group and several Blue Cross plans, are starting to market interactive video to large employers. The new federal health care law provides $1 billion a year to study telemedicine and other innovations.
Michael Stravato for The New York Times
From thousands of miles away, Dr. Oscar Boultinghouse checks the eye of a patient.
With the expansion of reimbursement, Americans are on the brink of “a gold rush of new investment in telemedicine,” says Dr. Bernard A. Harris Jr., managing partner at Vesalius Ventures, a venture capital firm based in Houston. He has worked on telemedicine projects since he helped build medical systems for NASA during his days as an astronaut in the 1990s.
Face-to-face telemedicine technology can be as elaborate as a high-definition video system, like Cisco’s, that can cost up to hundreds of thousands of dollars. Or it can be as simple as the Webcams available on many laptops.
NuPhysicia uses equipment in the middle of that range — standard videoconferencing hookups made by Polycom, a video conferencing company based in Pleasanton, Calif. Analysts say the setup may cost $30,000 to $45,000 at the patient’s end — with a suitcase or cart containing scopes and other special equipment — plus a setup for the doctor that costs far less.
Telemedicine has its skeptics. State regulators at the Texas Medical Board have raised concerns that doctors might miss an opportunity to pick up subtle medical indicators when they cannot touch a patient. And while it does not oppose telemedicine, the American Academy of Family Physicians says patients should keep in contact with a primary physician who can keep tabs on their health needs, whether in the virtual or the real world.
“Telemedicine can improve access to care in remote sites and rural areas,” says Dr. Lori J. Heim, the academy’s president. “But not all visits will take place between a patient and their primary-care doctor.”
Dr. Boultinghouse dismisses such concerns. “In today’s world, the physical exam plays less and less of a role,” he says. “We live in the age of imaging.”
ON the rig Courageous, Mr. Martin is part of a crew of 100. Travis G. Fitts Jr., vice president for human resources, health, safety and environment at Scorpion Offshore, which owns the rig, says that examining a worker via two-way video can be far cheaper in a remote location than flying him to a hospital by helicopter at $10,000 a trip.
Some rigs have saved $500,000 or more a year, according to NuPhysicia, which has contracts with 19 oil rigs around the world, including one off Iraq. Dr. Boultinghouse says the Deepwater Horizon drilling disaster in the Gulf of Mexico may slow or block new drilling in United States waters, driving the rigs to more remote locations and adding to demand for telemedicine.
NuPhysicia also offers video medical services to land-based employers with 500 or more workers at a site. The camera connection is an alternative to an employer’s on-site clinics, typically staffed by a nurse or a physician assistant.
Mustang Cat, a Houston-based distributor that sells and services Caterpillar tractors and other earth-moving equipment, signed on with NuPhysicia last year. “We’ve seen the benefit, ” says Kurt Hanson, general counsel at Mustang, a family-owned company. Instead of taking a half-day or more off to consult a doctor, workers can get medical advice on the company’s premises.
NuPhysicia’s business grew out of work that its founders did for the state of Texas. Mr. Hammack, NuPhysicia’s president, is a former assistant vice president of the University of Texas Medical Branch at Galveston, where he led development of the state’s pioneering telemedicine program in state prisons from the mid-1990s to 2007. Dr. Davis is a cardiologist.
Working with Dr. Boultinghouse, Dr. Davis and other university doctors conducted more than 600,000 video visits with inmates. Significant improvement was seen in inmates’ health, including measures of blood pressure and cholesterol, according to a 2004 report on the system in the Journal of the American Medical Association.
In March, California officials released a report they had ordered from NuPhysicia with a plan for making over their state’s prison health care. The makeover would build on the Texas example by expanding existing telemedicine and electronic medical record systems and putting the University of California in charge.
California spends more than $40 a day per inmate for health care, including expenses for guards who accompany them on visits to outside doctors. NuPhysicia says that this cost is more than four times the rate in Texas and Georgia, and almost triple that of New Jersey, where telemedicine is used for mental health care and some medical specialties.
“Telemedicine makes total sense in prisons,” says Christopher Kosseff, a senior vice president and head of correctional health care at the University of Medicine and Dentistry of New Jersey. “It’s a wonderful way of providing ready access to specialty health care while maintaining public safety.”
Georgia state prisons save an average of $500 in transportation costs and officers’ pay each time a prisoner can be treated by telemedicine, says Dr. Edward Bailey, medical director of Georgia correctional health care.
With data supplied by the California Department of Corrections and Rehabilitation, which commissioned the report, NuPhysicia says the recommendations could save the state $1.2 billion a year in prisoners’ health care costs.
Gov. Arnold Schwarzenegger wants the university regents and the State Legislature to approve the prison health makeover. After lawsuits on behalf of inmates, federal courts appointed a receiver in 2006 to run prison medical services. (The state now runs dental and mental health services, with court monitoring.) Officials hope that by putting university doctors in charge of prison health, they can persuade the courts to return control to the state.
“We’re going to use the best technology in the world to solve one of our worst problems — the key is telemedicine,” the governor said.
WITHOUT the blessing of insurers, telemedicine could never gain traction in the broader population. But many of the nation’s biggest insurers are showing growing interest in reimbursing doctors for face-to-face video consulting.
Starting in June, the UnitedHealth Group plans to reimburse doctors at Centura Health, a Colorado hospital system, for using Cisco advanced video to serve UnitedHealth’s members at several clinics. And the insurer plans a national rollout of telemedicine programs, including video-equipped booths in retail clinics in pharmacies and big-box stores, as well as in clinics at large companies.
“The tide is turning on reimbursement,” says Dr. James Woodburn, vice president and medical director for telehealth at UnitedHealth.
Both UnitedHealth and WellPoint, which owns 14 Blue Cross plans, are trying lower-cost Internet Webcam technology, available on many off-the-shelf laptops, as well as advanced video.
UnitedHealth and Blue Cross plans in Hawaii, Minnesota and western New York are using a Webcam service provided by American Well, a company based in Boston. And large self-insured employers like Delta Air Lines and Medtronic, a Blue Cross Blue Shield customer in Minneapolis, are beginning to sign up.
Delta will offer Webcam consultations with UnitedHealth’s doctor network to more than 10,000 Minnesota plan members on July 1, says Lynn Zonakis, Delta’s managing director of health strategy and resources. Within 18 months, Webcam access will be offered nationally to more than 100,000 Delta plan members.
Dr. Roy Schoenberg, C.E.O. of American Well, says his Webcam service is “in a completely different domain” than Cisco’s or Polycom’s. “Over the last two years, we are beginning to see a side branch of telemedicine that some call online care,” he says. “It connects doctors with patients at home or in their workplace.”
Doctors “are not going to pay hundreds of thousands of dollars for equipment, so we have to rely on lower tech,” he adds. The medical records are stored on secure Web servers behind multiple firewalls, and the servers are audited twice a year by I.B.M. and other outside computer security companies, Dr. Schoenberg says.
In Hawaii, more than 2,000 Blue Cross plan members used Webcams to consult doctors last year, says Laura Lott, a spokeswoman for the Hawaii Medical Service Association. Minnesota Blue Cross and Blue Shield started a similar Webcam service across the state last November.
Doctors who use the higher-tech video conferencing technology say that Webcam images are less clear, and that Webcams cannot accommodate electronic scopes or provide the zoom-in features available in video conferencing. “If they are not using commercial-grade video conferencing gear, the quality will be much lower,” says Vanessa L. McLaughlin, a telemedicine consultant in Vancouver, Wash.
Last month, Charlie Martin, the crane operator, was back in the infirmary of the Courageous for an eye checkup. In Houston, his face filled the big screen in NuPhysicia’s office.
After an exchange of greetings, Chris Derrick, the paramedic on the oil rig, attached an ophthalmological scanner to a scope, pointed it at Mr. Martin’s eye, and zoomed in.
“Freeze that,” Dr. Boultinghouse ordered, as a close-up of the eye loomed on the screen. “His eyes have been bothering him. It may be from the wind up there on the crane.”
PatientsLikeMe provides forums where more than 65,000 members with epilepsy, multiple sclerosis and more than a dozen other disorders are encouraged to share details about their conditions and the success or pitfalls of specific drug treatments.
“When patients share real-world data, collaboration on a global scale becomes possible,” the site says. “New treatments become possible.”
Moreover, in a world where serious side effects often emerge only years after a new medication enters the market, such real-time information from real-world patients may also provide an early warning signal for drug safety problems.
PatientsLikeMe has an innovative for-profit business model, too. It sells health data, gathered from member profiles but with certain identifying information removed, to drug makers and others for scientific and marketing research.
Jamie Heywood, the company’s chairman, says both patients and drug makers delve into that data to meet their own needs.
Members can seek out patients of the same age, sex, and disease progression, whose profiles are displayed on the site, to see which drugs or doses worked for them. Drug makers can pinpoint subgroups — say, severely depressed middle-aged men — who reported the greatest improvement on a particular medication.
“What we have done is made a system that allows you to think about personalized medicine,” says Mr. Heywood. He co-founded the site in 2004 with his brother Ben and a friend after another brother, Stephen Heywood, developed amyotrophic lateral sclerosis, or A.L.S., commonly known as Lou Gehrig’s disease. (Stephen died in 2006.)
But pharmaceutical crowd-sourcing also raises important questions about the trade-off between the benefits of information sharing and the risk of patient exploitation.
Some people share their health information for the sake of the greater good. Yet they typically have no way of knowing whether their health profiles contribute directly to the development of more effective treatments — or are simply mined to create more effective drug marketing.
“Do we need to protect people who have illnesses from being exploited?” says Cathy Dwyer, an associate professor at Pace University who has studied how advertisers market to consumers based on their online behavior. “It’s a very tricky line because people absolutely need emotional support when they are dealing with illness.”
PatientsLikeMe is one of many sites that promote the idea of the “e-patient,” a health consumer empowered by online information gathering. Along with offering health resources, many of these sites are also engineered to foster an environment where patients effectively promote treatments to other patients, without a doctor as intermediary.
The lines become blurry in these new arenas. There are unbranded “disease awareness” communities — for example, on Facebook or YouTube — where a drug maker may pay people to moderate patient forums or give testimonials but might not prominently display that fact to participants. Other sites collect consumer health data to help drug makers aim at specific kinds of consumers, using psychological cues.
Unlike television viewers, who can immediately spot direct-to-consumer drug ads, consumers on some health sites may not fully understand that they could be subject to marketing or marketing research, even if they have read the site’s privacy policy.
“We are talking about a digital pharma stealth economy that is emerging,” says Jeff Chester, the director of the Center for Digital Democracy, a nonprofit group that works to safeguard user privacy. “You don’t know who is being paid to moderate. You don’t know who’s listening in to your conversation. You don’t know what exactly they are focused on and what they are doing with the information.”
In many ways, PatientsLikeMe is open and clear about its data collection and how it makes its money.
The site’s privacy policy explains that it shares members’ data, shorn of certain personal identifiers, with drug makers and others. Even as the policy encourages people to share their health information so others can learn from their experiences, it advises members that the more personal details they disclose, the more they risk being publicly identified.
For corporate clients, the site also functions as a sophisticated data-mining tool that allows them to better pinpoint consumers and to develop new or improved drugs. PatientsLikeMe adopts a more bottom-line approach to companies than it does when advocating its greater-good policy to consumers.
“Yesterday, you couldn’t engage with patients because of regulatory conflicts and lack of patient access,” one corporate pitch says on the site. “Today, all that has changed. It’s time to interact directly with your new customers: patients.”
Among the services the site provides to its corporate clients is analysis of members’ conversations, broken down by age, sex, disease progression and treatments, to “learn not only what’s being said about your brand, but by whom.” Another service allows drug makers to conduct market research on 25 to 50 of the most active users on the site — typically those who post messages often and have emerged as opinion leaders — who consent to participate. Afterward, drug makers can refine their marketing efforts based on the effect of the program “on patient dialogues across the entire community,” the site says.
Ms. Dwyer of Pace says she has been “really, really shocked at the blatant manipulative language” that some sites use to describe their corporate services to industry versus how they describe themselves to consumers.
Ben Heywood, president of PatientsLikeMe, says the program for drug makers that focuses on the site’s most active users is not meant to promote specific messages. After participating in the program, he says, members do not disseminate industry ideas on the site. Some members, he says, simply want to share their opinions with drug makers, but they aren’t paid to do so.
Jamie Heywood says that such data analyses provide insight for drug makers on how best to reach patients, but the site itself does not market drugs to its members. Moreover, the Heywood brothers say, the site openly describes its industry services.
“Our objective is to teach the company,” he says, “not teach the patient about the company’s products.”
Still, some of PatientsLikeMe’s competitors have taken a less aggressive approach to how they market patient data.
CureTogether.com, for example, has occasionally earned money by e-mailing advertisements aimed at its members who have certain health conditions on behalf of drug makers seeking participants for clinical trials, says Daniel Reda, who co-founded the site with his wife, Alexandra Carmichael.
But CureTogether does not post a person’s profile for other members on the site to see or give drug makers access to members’ health data in any form, he says. “The best way to protect people,” Mr. Reda says, “is to collect as little information as possible.”
SAN FRANCISCO — It is an image both shocking and strangely serene: 10 beauty queens, each with a broad smile, sparkling earrings and a beautiful gown. And written across the bottom of the photograph is a simple, stark question.
“Which one,” it reads, “deserves to die?”
The image is part of a provocative advertising campaign by San Francisco Hep B Free, which aims to eradicate the disease with citywide vaccinations against hepatitis B. The campaign debuts here in print and on television this week and is aimed at jarring the city’s large Asian population into confronting the stubborn public health hazard of hepatitis B.
San Francisco health officials estimate that as many as 1 in 10 residents of Asian descent are infected with the virus here, a percentage that contributes to the nation’s highest rate of liver cancer, an unhappy distinction for a city that prides itself on its innovative universal health plan as well as its response to past epidemics like AIDS. In the general population, about 1 in 1,000 people are infected with hepatitis B, which attacks the liver.
A large part of the problem, according to leaders in the Chinese-American community, which is the largest Asian ethnicity here, is the stigma attached to the disease, which is endemic in much of Asia. The advertisements encourage people to get a “simple blood test” because “hepatitis B can be treated, even prevented.”
“We are not a confrontational group,” said Fiona Ma, a state assemblywoman from San Francisco, who is Chinese-American. “No one wants to talk about it. But we know that people care about their families and their friends. And maybe if they know it can affect them, then maybe they’ll talk about it.”
Ms. Ma knows of what she speaks; several years ago, she learned she had hepatitis B, which she apparently contracted from her mother. The virus that causes the disease can be spread through blood or other bodily fluids, said Dr. Edward A. Chow, vice president of the San Francisco Health Commission, who said that the disease often displays few symptoms in its carriers.
“It doesn’t manifest itself until it’s really too late,” said Dr. Chow, who said about 25 percent of patients, if untreated, develop serious ailments like liver failure.
The campaign’s confrontational approach has ruffled some feathers. Vicky M. Wong, the president and chief executive of DAE, the San Francisco firm that developed the ads, said that several of the beauty queen models walked out of the photo sessions because they were worried about its approach.
“There were so many debates as to whether ‘Are we going too far, is this right or not?’ ” said Ms. Wong, whose company specializes in campaigns geared to Asian audiences. “We got a lot of pushback. But there’s a lot of people who loved it.”
Ted Fang, a committee member for Hep B Free, said the high rate of infection among Asians here has been especially frustrating considering that a vaccine for the disease has existed for nearly 30 years.
“We have the medical tools, so long as doctors will test their patients and monitor them,” Mr. Fang said. “We can knock out this disease.”
Mr. Fang and others liken the city’s efforts to the battle against AIDS, which ravaged San Francisco and its gay community in the 1980s and 1990s and also inspired in-your-face tactics. The Hep B Free program began several years ago with a more gentle campaign — the tagline was “B A Hero” — but organizers said it had gone only so far.
“Saying ‘Life is beautiful; get tested,’ doesn’t work,” Ms. Wong said.
For the “Which one deserves to die?” campaign Ms. Wong enlisted volunteers from the Asian community to pose for photographs, depicting families, a basketball team, a group of doctors and office workers.
While the campaign is being published in several languages — including Chinese, Korean and Vietnamese — a target group is English-speaking doctors, outside the Asian community, who might not be aware of the prevalence of the disease.
“Within our ethnic groups, we are all aware of this, because we all have friends and families who have it,” Dr. Chow said. “But if you are a very busy practitioner who has a lot of different types of patients, you may not know to check at first.”
For Ms. Ma, the assemblywoman, who said she discovered she was positive for hepatitis B when she tried to donate blood, her goal was to bring the disease “above ground,” she said. And it is personal: while she is in good health, her mother, who is in her 70s, had part of her liver removed as a result of the disease.
She recovered, Ms. Ma said, but others she knew have not.
First-year resident Dr. Rachel Seay, third from left, circumcises a newborn in George Washington University Hospital's delivery wing on March 12.
The new federal health-care law has raised the stakes for hospitals and schools already scrambling to train more doctors.
Experts warn there won't be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges.
That shortfall is predicted despite a push by teaching hospitals and medical schools to boost the number of U.S. doctors, which now totals about 954,000.
The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient.
The U.S. has 352,908 primary-care doctors now, and the college association estimates that 45,000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007.
A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients.
Proponents of the new health-care law say it does attempt to address the physician shortage. The law offers sweeteners to encourage more people to enter medical professions, and a 10% Medicare pay boost for primary-care doctors.
Meanwhile, a number of new medical schools have opened around the country recently. As of last October, four new medical schools enrolled a total of about 190 students, and 12 medical schools raised the enrollment of first-year students by a total of 150 slots, according to the AAMC. Some 18,000 students entered U.S. medical schools in the fall of 2009, the AAMC says.
But medical colleges and hospitals warn that these efforts will hit a big bottleneck: There is a shortage of medical resident positions. The residency is the minimum three-year period when medical-school graduates train in hospitals and clinics.
There are about 110,000 resident positions in the U.S., according to the AAMC. Teaching hospitals rely heavily on Medicare funding to pay for these slots. In 1997, Congress imposed a cap on funding for medical residencies, which hospitals say has increasingly hurt their ability to expand the number of positions.
Medicare pays $9.1 billion a year to teaching hospitals, which goes toward resident salaries and direct teaching costs, as well as the higher operating costs associated with teaching hospitals, which tend to see the sickest and most costly patients.
Doctors' groups and medical schools had hoped that the new health-care law, passed in March, would increase the number of funded residency slots, but such a provision didn't make it into the final bill.
"It will probably take 10 years to even make a dent into the number of doctors that we need out there," said Atul Grover, the AAMC's chief advocacy officer.
While doctors trained in other countries could theoretically help the primary-care shortage, they hit the same bottleneck with resident slots, because they must still complete a U.S. residency in order to get a license to practice medicine independently in the U.S. In the 2010 class of residents, some 13% of slots are filled by non-U.S. citizens who completed medical school outside the U.S.
One provision in the law attempts to address residencies. Since some residency slots go unfilled each year, the law will pool the funding for unused slots and redistribute it to other institutions, with the majority of these slots going to primary-care or general-surgery residencies. The slot redistribution, in effect, will create additional residencies, because previously unfilled positions will now be used, according to the Centers for Medicare and Medicaid Services.
Some efforts by educators are focused on boosting the number of primary-care doctors. The University of Arkansas for Medical Sciences anticipates the state will need 350 more primary-care doctors in the next five years. So it raised its class size by 24 students last year, beyond the 150 previous annual admissions.
In addition, the university opened a satellite medical campus in Fayetteville to give six third-year students additional clinical-training opportunities, said Richard Wheeler, executive associate dean for academic affairs. The school asks students to commit to entering rural medicine, and the school has 73 people in the program.
"We've tried to make sure the attitude of students going into primary care has changed," said Dr. Wheeler. "To make sure primary care is a respected specialty to go into."
Montefiore Medical Center, the university hospital for Albert Einstein College of Medicine in New York, has 1,220 residency slots. Since the 1970s, Montefiore has encouraged residents to work a few days a week in community clinics in New York's Bronx borough, where about 64 Montefiore residents a year care for pregnant women, deliver children and provide vaccines. There has been a slight increase in the number of residents who ask to join the program, said Peter Selwyn, chairman of Montefiore's department of family and social medicine.
One is Justin Sanders, a 2007 graduate of the University of Vermont College of Medicine who is a second-year resident at Montefiore. In recent weeks, he has been caring for children he helped deliver. He said more doctors are needed in his area, but acknowledged that "primary-care residencies are not in the sexier end. A lot of these [specialty] fields are a lot sexier to students with high debt burdens."
By Philip P. Pan Washington Post Foreign Service Thursday, February 25, 2010; A12
TAIKONUR, KAZAKHSTAN -- The dry steppe stretches to the horizon in all directions from this remote outpost in southern Kazakhstan. But peeking out of the sandy soil, amid the sagebrush and desert shrub, are thousands of wells arranged in geometric patterns, each extracting radioactive treasure.
These desolate fields sit above one of the world's largest deposits of uranium, and with nuclear energy in a renaissance, a rough-and-tumble battle is underway for access to them.
The race echoes the geopolitical jockeying to control Central Asia's rich reserves of oil and natural gas -- a variation on Rudyard Kipling's Great Game, complete with corporate intrigue, a disgraced spy chief and an alleged plot by the Kremlin to keep this former Soviet republic under its thumb.
Leading energy and mining firms from Russia, China, Japan, France and Canada have already invested billions here. Kazakhstan, meanwhile, is seeking to leverage its ore into a larger role in the global nuclear industry and has taken a stake in the U.S.-based nuclear giant Westinghouse.
Long obscured by the country's opaque political system, the maneuvering for uranium burst into the open last year with the arrest of Mukhtar Dzhakishev, the highflying chief executive of the state nuclear firm Kazatomprom. The KNB, local successor to the KGB, accused him of transferring the rights to 60 percent of the nation's uranium deposits -- worth billions of dollars -- to offshore companies under his control.
Dzhakishev, 45, denied the charge and remains in prison. But in a remarkable breach of security, somebody leaked a 64-minute video of him speaking to KNB investigators. In footage posted on YouTube, he offered a rare look at the shifting global alliances behind Kazakhstan's efforts to transform itself from a mere producer of raw uranium to a nuclear powerhouse involved in every aspect of the industry.
He also dropped a bombshell: Russia, he alleged, had engineered his arrest to scuttle a series of pending deals and prevent Kazakhstan from becoming a more independent and formidable competitor.
"I've had plenty of time to think over the situation, and I've been trying to figure out who benefits from it," he said, addressing an unseen interrogator. "I came to the conclusion that it plays into the hands of the Russians."
Russian officials dismissed the allegation as nonsense. But Dzhakishev's words carry weight because he was one of Kazakhstan's most respected and dynamic businessmen, part of a younger generation recruited into government by the country's autocratic president, Nursultan Nazarbayev, to modernize a flagging post-Soviet economy. For more than a decade, he stood at the center of the Kazakh uranium rush, turning a near-bankrupt state firm paying employees with food rations into the world's top uranium producer, with annual profit of more than $300 million.
His success positioned Kazakhstan to take advantage of surging international interest in atomic energy as an alternative to fossil fuels linked to global warming. With 53 nuclear plants under construction worldwide and nearly 500 others planned or proposed to be operating by 2030, demand for uranium to fuel reactors has soared. Available stockpiles from dismantled weapons are dwindling, analysts say, and nobody can ramp up production as quickly as Kazakhstan.
Nazarbayev calls uranium a strategic asset as important to Kazakhstan as its $35 billion oil industry. Only the nation's fledgling environmental movement has dared object, pointing out that Kazakhstan has yet to recover from its days as the Soviet Union's main atomic test site.
The Soviets conducted 456 nuclear blasts in northeastern Kazakhstan, more than anyone else anywhere in the world. Much of the region remains contaminated, residents suffer elevated rates of cancer and other radiation-related illnesses, and babies continue to be born with deformities.
"Nothing good can come of the world's push for nuclear energy, and we should understand this better because of our past," said Mels Eleusizov, a veteran environmentalist who complains that the uranium industry is shrouded in secrecy, with no independent monitoring.
Kazatomprom and its foreign partners mine uranium primarily by injecting sulfuric acid into the ground, where it reacts with the ore. The solution is then pumped into a plant that distills it into a powder known as yellowcake. The process is cheaper than traditional pit mining, and officials say it is safer and cleaner.
Before his arrest, Dzhakishev struck a series of deals giving foreign firms access to uranium mines in exchange for help moving Kazakhstan into higher-end segments of the nuclear fuel cycle. Each made Kazakhstan less dependent on Russia, its traditional partner in the industry.
The Canadian mining giant Cameco agreed to establish a joint plant to prepare yellowcake for enrichment, the process that makes uranium capable of sustaining a nuclear chain reaction. A French and Japanese conglomerate signed on to help build the facilities that turn enriched uranium into fuel rods. Kazatomprom also landed agreements to become China's main supplier of nuclear fuel, and its Westinghouse stake gave it a piece of the reactor-construction business.
"The inducement for all of us to cooperate is access to the uranium resources and building that relationship with Kazatomprom," said Jerry Grandey, Cameco's president and chief executive.
Kazakhstan continued to rely on Russia for uranium enrichment, the most sensitive fuel stage because of proliferation risks, and the two nations began work on a joint enrichment facility in Siberia. They also opened talks to create a market goliath uniting Kazakh uranium and access to markets with Russian technology and facilities. The talks stalled, though, apparently over whether Kazakhstan would be an equal partner or a junior one.
In the leaked video, Dzhakishev said Russia began to pursue deals to edge Kazakhstan out of the Japanese market and guarantee a uranium supply through a Canadian producer, Uranium One. But he said he outmaneuvered Russia by persuading Japanese partners to take a blocking position in Uranium One and insist on a Kazakh role in the Japanese market.
In a sign of Moscow's frustration, Russian officials approached one of Dzhakishev's vice presidents and offered to help him oust his boss, according to a former Kazatomprom executive, who spoke on the condition of anonymity for fear of reprisals. But the vice president rejected the plan.
When the KNB began investigating Kazatomprom, Dzhakishev blamed officials who he said were upset at him for refusing to give them contracts or mining rights, friends said. Among those he had rebuffed was the powerful KNB chief himself, Amangeldy Shabdarbayev, according to Dzhakishev's brother, Yermek.
As the probe dragged on, Dzhakishev worried he had fallen out with Nazarbayev. Dzhakishev's wife, Zhamilya, said he declared his loyalty to the president in a May meeting and distanced himself from two old friends and Nazarbayev foes -- the president's exiled son-in-law, Rakhat Aliyev, and the tycoon Mukhtar Ablyazov, who had fled the country and accused Nazarbayev of stealing his business, Kazakhstan's largest bank.
Nazarbayev assured Dzhakishev that "everything would be fine," Zhamilya said. But two weeks later, on May 21, the KNB detained him and seven of his top executives. In a documentary on national television, the agency cast him as mastermind of a scheme to sell the nation's uranium to foreigners for personal profit.
The arrest unnerved Kazatomprom's partners and prompted a rare protest from the country's leading businessmen, who issued a letter defending Dzhakishev as a smart, honest entrepreneur. He had friends inside government, too; newspapers soon obtained documents showing that senior officials had approved his deals.
The KNB video was the most astonishing leak. Dzhakishev came across as worried about losing business in Japan and China more than losing his freedom, warning that Kazakhstan would be Russia's "raw materials appendage."
In a sensational news conference last month, Dzhakishev's wife asserted that the KNB chief personally passed her a copy of the video before it appeared on the Web and urged her to show it to the president. Shabdarbayev denied the claim but was removed from his job five days later.
Many of Dzhakishev's defenders said Russian agents manipulated Nazarbayev into approving his arrest. Others say he fell victim to a fight within the elite over uranium riches, and Russia just happened to benefit. He is languishing in a secret KNB prison, where his health has deteriorated sharply, his attorneys said.
Nazarbayev, meanwhile, has appointed a veteran bureaucrat to replace him; the official's son-in-law is chief of Russia's state uranium supplier.
Kazakh regulators recently approved the Uranium One deal that Dzhakishev opposed. "Everything that Mukhtar worked out, we can forget about now," said Galym Nazarov, Kazatomprom's former treasurer. "Gradually, Russia is replacing us in the market."
By Dan Balz and Jon Cohen Washington Post Staff Writers Wednesday, December 16, 2009; 12:30 AM
As the Senate struggles to meet a self-imposed, year-end deadline to complete work on legislation to overhaul the nation's health-care system, a new Washington Post-ABC News poll finds the public generally fearful that a revamped system would bring higher costs while worsening the quality of their care.
A bare majority of Americans still believe government action is needed to control runaway health-care costs and expand coverage to the roughly 46 million people without insurance. But after a year of exhortation by President Obama and Democratic leaders and a high-octane national debate, there is minimal public enthusiasm for the kind of comprehensive changes in health care now under consideration. There are also signs the political fight has hurt the president's general standing with the public.
One bright spot for the president in the poll is Afghanistan. His announcement Dec. 1 that he was ordering an additional 30,000 U.S. troops to that country, to bolster the 68,000 already there, wins majority support. More than half of all Americans, 52 percent, approve of how he is handling the situation there, up from 45 percent before the speech.
But Obama and the Democrats have had decidedly less success convincing the public that their health proposals will bring positive change. More than half of those polled, 53 percent, see higher costs for themselves if the proposed changes go into effect than if the current system remains intact. About as many (55 percent) say the overall cost of the national health-care system would go up more sharply. Moreover, just 37 percent say the quality of their care would be better under a new system; 50 percent see it as better under the current set-up.
Even among those who presumably stand to benefit most from a major restructuring of the insurance market -- the nearly one in 5 adults without coverage -- there are doubts about the changes under consideration. Those without insurance are evenly divided on the question of whether their care would be better if the system were overhauled.
The findings underscore the political risks for Obama and the Democrats as they push to enact health-care legislation. Democrats believe passage of the bill will give them a political boost, despite the fractious debate that has surrounded the legislative struggle. But they are moving ahead in the face of a sharply divided country, with no certain guarantees that their efforts will be rewarded politically.
* * *
Obama's domestic battles have taken their toll, as his approval ratings on key issues have sunk to the lowest points of his presidency. On health care, 53 percent disapprove of his performance, a new high. On the economy, 52 percent disapprove, also a new high mark in Post-ABC polling. Same on the deficit, on which 56 percent now disapprove of his stewardship. On the politically volatile issue of unemployment, 47 percent approve of the way Obama is dealing with the issue; 48 percent disapprove.
Under the weight of these more negative reviews, the president's overall approval rating has dipped to 50 percent, down from 56 percent a month ago. Other national surveys have recorded his ratings at or below 50 percent in recent weeks, but this is his lowest level yet in a Post-ABC News survey.
The erosion in the president's standing has been driven by continued slippage among political independents, particularly among independent men. For the first time, a majority of independents disapprove of his overall job performance, and independents' disapproval of his handling of health care and the economy tops six in 10.
Americans still trust the president more than Republicans in Congress to handle the economy, health care and energy policy, although they do so by smaller margins than in recent months. Obama's advantage on the economy has been sliced in half since June, and he now holds just a narrow seven-point edge on health care.
At the same time, nearly a quarter of those who disapprove of Obama's handling of health care say they trust neither party on the issue, a sign that Republicans still have work to do to win the confidence of many Americans.
Some of the changes away from the president and the Democrats in this poll stem from a more GOP-leaning sample than in previous surveys. In this poll, the Democratic advantage in partisan identification has been shaved to six points, the first time in more than a year that the gap has been lower than double digits. There is also near-parity between the parties, when nonpartisans who "lean" toward one party or the other are counted, also a first for 2009.
The numbers of Democrats, Republicans and independents varies by poll, with each random sampling of adults producing slightly different population estimates. Samples are statistically adjusted to known census demographics, but not to predetermined levels of partisanship, which themselves change over time. A single poll is not enough to draw conclusions about a lasting GOP resurgence, or a short-term shift.
* * *
Following the twists and turns of the health-care debate has proved dizzying for insiders and the public alike, with provisions appearing and disappearing as Democratic leaders in the House and Senate try to assemble enough votes to pass legislation. The survey suggests the advocates of comprehensive reform have not been able to produce broad national support for change.
In the poll conducted this month, 51 percent say they oppose the proposed changes to the system; 44 percent approve of them. Two-thirds say the health-care reforms would add to the federal deficit, with two-thirds of those people calling such an increase "not worth it."
More than six in 10 favor expanding Medicare to people ages 55 to 64 who lack insurance--a proposal included in one Senate compromise effort that appears unlikely to survive final negotiations. By a 2 to 1 margin, more Americans say a new system will weaken rather than strengthen the Medicare system.
On the issue of whether and how to expand coverage to those who do not have it, 36 percent favor a government plan to compete with private insurers, 30 percent prefer private plans coordinated by the government and 30 percent want the system to remain intact.
On Afghanistan, the president's improved standing stems from a popular policy position -- about six in 10 back his decision to send the new forces -- and is bolstered by other big movements in public views on the war.
A narrow majority, 52 percent, see the war in Afghanistan as worth its costs, a six-point increase from last month. Most, 56 percent, now see success in Afghanistan as critical to making progress in the broader war on terrorism, the most to say so in polls back to July 2008.
For the first time, Democrats tilt toward seeing winning the Afghanistan war as essential to the overall campaign against terrorism (48 percent say so to 41 percent who say it is not). Independents -- 56 percent say essential, 38 percent say not -- are also more in this camp than ever.
One of the motivating forces here is that nearly three-quarters of Americans are "extremely" or "very" angry at the Taliban for having supported Osama bin Laden and al-Qaeda before Sept. 11, 2001. Across party lines, those who are intensely angry at the Taliban are more apt to see success in Afghanistan as critical to winning the U.S. campaign against terrorism.
At the same time, barely half of those polled are confident the president's new strategy for Afghanistan will succeed, with about one in 10 highly confident.
About four in 10 say the July 2011 timeline Obama set for the beginning of a troop drawdown is "about right," about three in 10 want the pullback to start sooner and about two in 10 want it later. Regardless of their assessment of the timing, most, 55 percent, oppose Obama's having set a specific deadline for this to occur, with Republicans and independents broadly opposed and Democrats largely supportive.
More than seven in 10 expect large numbers of U.S. troops to remain in Afghanistan for many years to come, with a near-even split among those who anticipate a long-term deployment on whether that is allowable. Republicans and Democrats are about equally likely to foresee a lengthy U.S. military role there, but Republicans tilt toward supporting this, with Democrats against it.
The poll was conducted Thursday through Sunday by conventional and cellular telephone among a random national sample of 1,003 adults. The margin of sampling error for the full survey is plus or minus three percentage points.
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