The nation has been captivated by the supreme court decision about PPACA. Surely, this is a huge decision that will frame our individual relationship with the government moving forward. But, there is so much more to PPACA that has failed to make the media’s headlines. Truly, there are any number of “800 pound gorillas” still in the room: 1) PPACA is not really about insurance 2) We have no idea what “cost” means in the context of healthcare delivery in the US 3) Even without the mandate and the supreme court decisions, the system is irreparably damaged.
The conversation has been focused on the issue of insurance and its affordability. PPACA was supposed to provide insurance for all. But, health insurance is not health care. Having an insurance policy doesn’t make magic happen. It does not bring a patient good doctors or the most appropriate care opportunities. Even if PPACA met that challenge, America’s health would not necessarily thrive nor would access improve.
Moreover, the mandate is not about insurance at all, it is about a benefit package that assumes to be about medical and healthcare products. For instance, the package includes fertility coverage for all Americans whether fertility is something of interest (or even possible) to the purchaser. I would argue that pregnancy is not a disease state, it is a privilege that requires enormous responsibility and expense. If a person cannot afford to get pregnant, how can that person afford to raise a child? On the other hand, the benefit package does not include a good mattress even for those with chronic back issues. In the end, PPACA will not be the safety net the government had hoped to provide not because of the Supreme Court decision but because it was not constructed to meet its objective.
As for cost, most Americans have no idea about the cost of care. Patients get an “explanation of benefits (EOB)” in the mail that describes hugely expensive services that they often don’t remember receiving. That EOB goes unchallenged because the patient bears no responsibility. At the same time, that EOB does a lot to scare the beneficiary to want to buy more insurance to protect him or herself from a $20,000 Emergency room bill. What is the real “charge?” the real cost? No one bothers to ask. If the patient knew that he could buy a chest-x-ray for $35, he or she might step up and get it done when his/her fever hit 103 degrees and his/her cough was unrelenting. Getting that antibiotic (cost for generic $4.00) on board could save his/her life. But, if that same person anticipates an ER visit, a 12 hour wait, and a bill for thousands of dollars it is less likely they will step up and get an early treatment. And yet, the government continues to promise that PPACA will shift the cost curve. Until we require medical and health related businesses to post their retail prices, we will never be able to legitimately talk about cost and our patients will not be able to make any reasonable decisions about “value.” PPACA fails to talk about real market forces and it doesn’t anticipate human nature.
And finally the ugliest gorilla in the room is an honest discussion of the tragedy we are standing by and watching, the deterioration of everything good we once knew about American medicine, starting with the patient/physician relationship. In anticipation of
PPACA, doctors have sold their practices to insurers and to hospitals to collect their dollars up front before things get too bad. Hospitals are eager as are insurers to be sure to create a network of providers at any cost lest they not be prepared for the administrative demands of PPACA. Not one person thinks that the Accountable Care Organizations mandated in PPACA are economically viable but we continue to march ahead so that we'll be ready “ when it happens.”
Today, patients are admitted to the hospital by a so called hospitalist who has never met the patient and who is too busy to call the patient’s treating physician. Patients call their doctors office at 4:00 thinking that someone will be there to answer their question, but everyone has gone home. They can call some 800 number if they wish. Continuity of care is as passé as a quarter per gallon of gasoline.
Pharmacists (both outpatient and inpatient) have assumed the authority to change a patient’s medication ad lib or demand they go through some step program to get a medication renewed that the patient has been taking for 20 years. They fail to mention that they (the pharmacists) get a bonus for convincing the patients to use generics or to change their medication to meet a contract formulary.
The government has been very successful in sucking the professionalism right out of the physician community. We (doctors) are accepting of things we would never have dreamed of. We condone the idea that someone without adequate training can do our job. We hand off care to others when the clock strikes the hour to go home regardless of the patient’s stability. We are conditioning our patients to accept less.
There are numerous accounts that suggest we had plenty of warning about the horrors of pre-world war II Germany. We ignored them. It is human nature to not believe the unbelievable. Our brain “tells us” if it doesn’t “register,” it can’t be happening. Wake up America. It is here and happening now. You are living through a huge transition to a societal state of Utopic Egalitarianism.
Hopefully, it is not too late for physicians to take back their profession and for Americans to reclaim their lives. Is American willing to deal with the 800 pound gorillas or will we just put them in a soundproof room and shut the door to reality.
We're meeting in San Diego on May5-6 and hope to collaborate with doctors from all over the country who desperately want to get back to the business of medicine and take care of our patients.
Read the 10 commandments and give us your feedback.
What do YOU think is most important when talking about reforming our health care delivery system ?
Post your comments … your ideas…
More specifics coming … It is a weekend you are not going to want to miss.
We're going to TAKE BACK THE PROFESSION … for our patients.. for the country … for the profession
The past several weeks of political debate have been painful for me as I'm sure they have for anyone who believes in liberty. It is time that someone grab the national microphone and put this political debate back on track. We could use Israeli Prime Minister Netanyahu as an example of focused inspired leadership. Tonight the Prime Minister made it clear that Israel has every right to defend itself, that the State of Israel is the ONLY democracy in the Middle East that protects the rights of every Israeli citizen regardless of race, religion or sex. He was speaking of the right of every Israeli to live under the umbrella of freedom that Israel built … for itself. Granted, the government of Israel is much different than that of the US … but the concept of liberty is ubiquitous. And he sets a wonderful example of a man defending liberty.
He held up a copy of a 1944 letter from the U.S. War Department rejecting world Jewish leaders' entreaties to bomb the Auschwitz death camp because it would be "ineffective" and "might provoke even more vindictive action by the Germans." Doesn't that sound like arguments we have heard about why we physicians should not stand up to the principles of the profession? Well, it is time we stand up and stop talking "amongst ourselves" and speak to the American public about why their freedom to choose their doctor, their care, and their ability to invest in their own lives and health is compromised every day by those who allow the government into our exam rooms. That threat has become increasingly imposing on our lives as professionals and it is time we say NO …
Do not allow the conversation to stoop to a discussion about a women's right to free contraception. This is about my liberty to do my professional best. It is about every American's right to keep their neighbor OUT OF THEIR POCKET BOOK. Since when is it okay to make any person "give it up" for anyone else. Entitlements as they are … are actually purchased (even though those receiving entitlements pay in much less than they pay out). Most of us do feel a moral obligation to help those who cannot help themselves. it is a privilege to have something to give. It is never okay for someone to take what is not theirs to take.
I invite you all to a forum on May 4-5 in San Diego. We're going to take back the profession and have an open discussion about those principles that we believe should be the focus of the alternative to PPACA. I am hopeful that the Congressional doctor caucus will attend (all 14 doctors) and that Governor Romney and other other GOP candidate still in the race will put in an appearance. If we are going to gain public support we must have a strategy that I believe should be about a healthcare delivery system that protects choice and privacy; a system that drives cost down by virtue of a transparent free market: a system that allows physicians to practice their profession with professional autonomy without government interference.
Hold the date.. May 5-6 and join us in San Diego … where the weather is delightful and the opportunity to speak your mind is free !
thanks for listening … and if you don't mind .. one more reference to Prime Minister Netanyahu, Purim, and the story of Esther that he referred to tonight. The story is a simple one about Queen Esther, a Jew (unknown to her husband, the King). She was raised by her cousin Mordecai who earns the pleasure of the King because he is loyal and defends the King against a plot to overthrow him. Haman, appointed Prime Minister has issues with Mordecai because he will not succumb to his (Haman's) every wish and Haman decrees that all jews should be killed when he finds out that Mordecai is Jewish. In the end, Haman is found out and killed and Esther and Mordecai are given the privilege of writing a decree to counter the decree to kill the Jews. The decree that Esther and Mordecai wrote gave Jews the right to defend themselves. The holiday is celebrated with a great meal and charity. Whenever Haman's name is mentioned in the Megillah reading, everyone makes loud, awful noises.
The parable is a strong reminder… One woman can save the world and in so doing spread liberty and charity amongst her people. Stand with me and your colleagues to preserve the liberty of self determination that our patients deserve.
Marcy ..
No bird soars too high, if he soars with his own wings.
Nothing speaks to the truth like the acrid odor of reality. The bite can be surly leaving us with no where to go except to work with it. So it was today when I faced our new Medicare reality. Its ugly. Beware as you read on.
No, there are no death panels. It is worse.
Today, my patient was helicoptered to an ER from a cruise ship where she fell and was unable to ambulate. She came to the hospital where I practice specifically so I could care for her. I have known her for well over 20 years. But, upon admission to the ER, she was evaluated and sent home in an ambulance unable to walk with her 85 year old husband. No call to her doctor. No call to her children. Oh, and did I mention that she was given opiates for her pain. Had the ER doctor called and asked, I would have told him or her that opiates make most seniors crazy and put them at risk of falling but my patient can't take them at all.
Her daughter called me today having found her mother lying in her own urine. The ambulance company had delivered her to her bed and left her there where she couldn't move. I called the hospital and learned, this is the new Medicare. As a matter of fact, I learned that twice today. My patient's daughter was so concerned about her mother's condition she had her mother transported to an ER where her orthopedist was on call. Evaluation there demonstrated no fractures and again she was sent home having been told that this was a custodial issue and hospitalization was not covered by Medicare. Nothing was done to assure her safety. No call was made to her doctor. No follow up was expedited.
No tears … I will call a home health agency in the AM and make sure she has a foley catheter so she doesn't have to lie in her own urine. Her family has already paid for 24 hour care giver to stay with my patient until we can arrange for PT to help her bear weight. Then, we will get her into rehab and get her walking again, provided that her hip and knee are really okay. In seniors, we often find tiny chip fractures or other abnormalities on MRI when we thoroughly investigate why they can't bear weight or walk. Thank goodness, my patient has a wonderful family who will help. But, millions of seniors have no family and no committed doctor. They are left to lie in their own urine… the new Medicare. No its not a death panel. It really is worse. Sometimes, death comes as a matter of respect to our integrity as a human. Being left to lie in our own urine is disrespectful and not human and when executed by the medical community as a matter of course, it is unconscionable. Welcome to government run healthcare. Welcome to a morally if not fiscally bankrupt Medicare system.
I fear it will only get worse. As 2012 approaches, I have already received notification from Medicare Part D about my patients medication coverage. So sad, too bad… the meds your patient has been taking for 20 years to keep him or her alive is not covered. Doctor….. take care of it. Now it is in my hands and depending on my patient's bank account, I will or will not be able to provide the help they need. And I have 3 days to find a solution before the new year.
And we all understand that Medicare cannot cover custodial issues. But, when did we stop providing for the safety and welfare of our seniors? When did it become okay to leave them to lie in their own urine ? Congress is busily debating the SGR and what they are going or not going to pay me. Does that really matter if we have lost sight of human dignity? Isn't it about time we put our patient's life and safety as our focus rather than how many benefits Obamacare will cover? Medicare is not just fiscally bankrupt. It has been stripped of any decency. It is morally bankrupt.
This is the Medicare that Congress promised not to change. This is the Medicare that President Obama promised to preserve. Perhaps we would be better off if those in charge just showed our parents and grandparents some respect. That would be priceless.
Medicare Reform Requires that Americans take Personal Responsibility
I am thrilled that there is bipartisan discussion about Medicare reform. Paul Ryan and Ron Wyden should be commended for their efforts. But, as big as this reform may seem, it does not transform Medicare or our healthcare delivery system. It is not the solution to the question, "How do we create a healthcare delivery system that is both affordable and accessible to all Americans?"
Moving some of the risk from the public sector to the private sector will start to take the pressure off our national debt crisis. But, like alcohol, the idea of premium support only masks the problem and is inebriating in the short run. The cost of Medicare continues to climb at an accelerating pace and will continue to do so as long as the recipients of Medicare have no "skin in the game." Moreover, no insurer or public entity can continue to pay for a benefit package that persistently grows beyond things medically necessary like the infamous and well-advertised motorized scooter (at absolutely no cost to you).
No insurer or public entity will be able to afford to take the risk of a medical insurance policy until that policy resembles insurance, an actuarial bet to protect the purchaser from financial catastrophe. Congressmen Ryan and Wyden make it clear that their legislation would insist that all competing plans be at least as comprehensive as Medicare. The cost of these competing benefit plans will be boundless and not affordable to most Americans, much like commercial insurance is today.
Americans love and deserve choice but choosing a favorite requires that there are distinguishing features. As it is, most Americans don't choose their insurance, their employers do. And when offered the choice, the plans are so confusing and incomprehensible, no ordinary American can decipher them. My patients generally ask me what to choose. I love the idea of choice but with the mandates placed on the private insurers, I'm not sure where the choice would come.
Reforming Medicare demands that Americans take back the responsibility of their own health. Freedom is NOT free. The right to self-determination with regard to medical decisions requires a transparent, market-driven system where doctors and hospitals post their prices and patients pay directly for those services that are not insurable. Preventive care, for instance is not insurable.
Preventive care includes everything from wearing a seat belt (not paid for by the government or any insurer), eating healthy food (also a personal responsibility except in the case of the very poor), to having your cholesterol checked routinely A mammogram at this time is $75.00 cash. A Chest-x-ray is $35.00 cash. A routine doctor's visit is usually less than $100. A lab test to check your cholesterol is less than $15. This is affordable healthcare that when paid for by the patient does not require a special form or an authorization making it much more available than it is even now when paid for by insurance.
I believe that most Americans do feel the moral obligation to pool our resources and take care of those who need our help. Cancer is an unforeseeable medical catastrophe that should be covered by insurance, whether public or private. But most Americans do not want to pay for their neighbor's blood pressure medication particularly when their neighbor is overweight and spends Sundays eating potato chips in front of their television. That neighbor should buy his own medication and that medication should be affordable in a transparent marketplace.
It is reasonable and wise to ask Medicare to compete with private insurers but only if we truly reform the system into a legitimate medical insurance system. At the same time, things not insurable should be able to be purchased in a transparent marketplace. If personal responsibility and the opportunity for patients to buy non-urgent medical care directly is not central to Medicare reform, we can only expect that the problems of accelerating costs and lack of access will intensify and hasten the death of what was once the best healthcare delivery system in the world.
Marcy L Zwelling-Aamot, MD FACEP
Chair of the Board, American Academy of Private Practice
Regulators and doctors must work together to ensure safety of biologic medicines
By Dr. Marcy Zwelling-Aamot, chairperson of the Board of the American Academy of Private Physicians (AAPP) - 12/15/11 04:41 PM ET
The U.S. Food and Drug Administration (FDA) is holding an important public meeting today on its proposed biosimilar user fee program recommendations. This meeting is a major step in making biosimilars available for the first time in the United States. Biosimilars will benefit the patient community-at-large – but only if important safety measures are adopted.
Biosimilars are the lower cost imitative versions of biological medicines, which are advanced therapies made in living systems. These cutting-edge medicines treat non-Hodgkin’s lymphoma and several other cancers, Hepatitis C, and even Multiple Sclerosis. Over 350 million patients worldwide have benefited from approved biologic medicines, and over 650 new biologic medicines and vaccines are being developed to treat more than 100 diseases, yet there are no “biosimilar” versions of these products available in the United States.
In 1984, when Congress enacted legislation ushering in generic versions of chemical drugs, biologics were not included as they were considered “too complex”. Yet a provision in the 2010 healthcare reform package authorized the FDA to figure out how to approve biosimilars for cost saving purposes. The FDA is expected to issue its guidance, known as the “biosimilars pathway” by end-of-year. Industry, physicians and patients are waiting intently to see what measures will be included.
It appears the FDA recognizes the unique challenges of biologic and biosimilar medicines. In its proposed recommendations for a biosimilar use fee program, it refers to the “nascent state of the biosimilars industry in the United States” and notes the “complexity and level of effort required for FDA oversight of manufacturing and post-marketing safety issues.”
Accordingly, to ensure patient safety and efficacy of all biologic and biosimilar medicines, the FDA will have to implement robust clinical and nonclinical measures. This includes clinical trials, unique proprietary names to reduce medication errors and a track and trace system in case a patient accidentally gets sick from a medicine. Above all else, we must ensure that the patient-physician relationship is maintained. Only patients, in consultation with their physicians, are in a position to make critical medical decisions.
It is worrisome that upholding the patient-physician relationship has not been endorsed by the U.S. American Medical Association (AMA), the professional body of doctors that has large influence over national and state healthcare laws and regulations. In a recent meeting in New Orleans, the AMA amended its position on biosimilar medicines, enabling a pharmacist to switch a patient from a biologic to its biosimilar version without expressed consent or even knowledge from the patient or the physician. This policy is misguided because it could hurt patient choice and access to all biologic products and complicate patient safety.
As a physician residing in the state of California, I want what’s best for my patients. We must ensure that all drugs are safe and work, no matter the cost. As biologic medicines are much larger and multifaceted compared to traditional medicines like Tylenol or cholesterol drugs, we cannot apply the same thinking to their approval process and policy guidelines. So far it appears the FDA recognizes the importance of patient safety but it’s critical that physicians and regulators work together to ensure these measures are ultimately adopted.
Dr. Marcy Zwelling-Aamot, whose practice is in Los Alamitos, is the former president and current chairperson of the Board of the American Academy of Private Physicians (AAPP).
Don’t expect any solution to the Medicare financing crisis any time soon.In order to find a solution, we must start asking the right questions and we have to face a bit of economic reality. I have not heard any politician come close to an honest discourse about the economic actuality of our healthcare delivery system failure.
The nation is finally coming to understand that Medicare is “not sustainable.” It is just a fairy tale to pretend that the government can continue to pay for all things for all seniors.And it is not honest to call Medicare just an insurance policy. Truly, the Medicare program has become a medical bank that pays for all health related “things” for all seniors including scooters and persons to clean your home if you are not able.
Any politician promising that this can continue is only pandering to assure his or her own election. “Not sustainable” does not just mean that young Americans won’t have Medicare as we have come to know it.“Not sustainable” means that Medicare and the entire healthcare delivery system must change NOW: for Seniors NOW, for everyone NOW.The system is broken and we have to deliver medical care better and less expensively for everyone.
It is foolish and naïve to think that any mandate (whether constitutional or not) will fund medical care for all.Universal insurance coverage does not change the healthcare delivery system. It does not improve access and it does not make things less expensive. Further, in every insurance market including the Medicaid market, there are about 15% who choose not to participate regardless of the cost.In fact, the Medicaid market has been very difficult to penetrate even though the insurance is free to those who qualify.A mandate only allows us to create another expensive, burdensome bureaucracy to chase down “violators.”
If we more fully examine why medical care is SO expensive, we can only conclude that it is government regulations that add dollars to the expense column but nothing to the quality of care.“Pay for Performance” programs have been an abject failure.Programs that punish those who don’t comply don’t change habits.More government interference does not make for better healthcare, enhance outcomes, increase the number of insured, or decrease the cost of anything.
When Congress authored the Medicare bill back in 1965, people lived on average, to about 64 years of age.It was never intended that the Medicare tax would actually pay for any senior’s medical care.If there were some dollars paid out, it would only be for a very short period of time.Now, we live longer and retire earlier.It is nonsense to expect the government to pay for a senior’s medical needs for 30+ years when they paid into the system at a marginal rate for only 40 years.
If America were willing to concede that Medicare should work like a real insurance system (an actuarial bet to protect the purchaser from financial catastrophe), we might be able to make things work.The government would only be responsible for covering a medical catastrophe.That would require that seniors purchase re-insurance from commercial insurers and we would need to turn the outpatient marketplace into a transparent competitive market.
The good news is that this would definitely make healthcare at every level more affordable and more accessible.Moreover, it would allow the government to fund either directly or through voucher systems a real insurance program and not go bankrupt.It would also allow for more personal choice and demand that physicians be directly accountable to their patients.
The vision of affordable accessible high quality care can only be met without government interference.This bite of economic reality could mean a sweet transformation into an accountable medical care delivery system but only if our legislations come to the table looking for real answers.
a video message on youtube… just click below
here is a video about the radioactivity in japan .. pretty powerful …
I hope this hopes to curb your fears.. have a great week…
Marcy
Fear the Media Meltdown, Not the Nuclear One (UPDATED) Relax: this is not another Chernobyl or Three Mile Island, and I'll tell you exactly why. The only thing to fear is the sensationalist reporting that has the world panicked. (UPDATE: Fuel rod fire?) March 15, 2011 – by Charlie Martin
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The March 11 earthquake off the coast of Japan has been an unprecedented disaster. Now estimated to have been a magnitude 9 earthquake — one of the top five earthquakes measured since reporting started in 1900 — it was the result of a “megathrust” in which an area of sea floor bigger than the state of Connecticut broke free and moved under the force of colliding tectonic plates. It was so strong that it literally moved the entire island of Honshu eight feet to the east. The earthquake was then followed by a tsunami comparable to the Boxing Day tsunami of 2004 — but since the epicenter of the quake was only a few miles off the coast of Japan, the tsunami struck the heavily populated coast of Honshu with almost no warning, basically washing many coastal villages off the face of the earth.
The earthquake and tsunami seriously damaged reactors at the Fukushima Daiichi (“number one”) and Daini (“number two”) in Okuma, in Fukushima Prefecture, and also damaged the Onagawa plant in Miyagi Prefecture. In total, of the 55 nuclear power generation plants in Japan, 11 have been forced to shut down, cutting power generation capacity in Japan dramatically and forcing the country to adopt a series of rolling blackouts. It would seem impossible to overstate the severity of the crisis.
The media, however, has risen to the challenge, with a combination of poor information, ignorance, and alarmism, along with antinuclear activists passing themselves off as unbiased experts.
Let’s try to make some sense of it all.
Basics of How Reactors Work
The Fukushima plants have several reactors built on the same basic design, either by GE or by Japanese companies licensed by GE. These are all “boiling water” reactors, which means just what it sounds like: the heat of the nuclear reaction boils water; the steam generated is used to drive turbines and thereby generate power. The water in direct contact with the reactor core known as “coolant” is nothing particularly special, just demineralized; water itself isn’t very susceptible to becoming radioactive, but minerals and contaminants in the water can be. If the water is purified, there’s less radioactive waste to deal with.
The cooling water is pumped past the reactor core in normal operation to get the energy with which power is generated, and of course to cool the core. If there’s an accident, the reactor is shut down by inserting the “control rods,” made of some material that absorbs neutrons and so slows the nuclear fission from which the reactor gets its power. Even a shut down reactor continues to need cooling, however; there’s an immense amount of residual heat still left in the reactor core. This means continuing to run the pumps, and of course with the reactor shut down they can’t be run from the reactor’s power, so there are diesel generators as a backup, and batteries as a further backup to the generator.
If all the cooling fails for some reason, the accumulated heat can’t escape; the water boils away, and once it’s gone, the materials that make up the reactor core break down. This is a Bad Thing, because the controls on the reactor fuel also break down; it starts to heat up again. This is what’s called ameltdown. When this happened at Chernobyl, the reactor core quickly became hot enough to vaporize the reactor’s fuel and a good part of the other material around it, leading to an explosion that destroyed the building that housed the reactor.
To prevent that from happening in commercial reactors in the capitalist bloc, the reactor is inside three concentric safety vessels: first, the “boiler” itself; second, a massive steel bottle; and third, an even larger and more massive reinforced steel, concrete, and graphite outer containment vessel. In case of a meltdown, the whole reactor should be contained within the steel secondary containment vessel, but if it’s not, the molten reactor core drops to the graphite floor of the third vessel, where it spreads out across the floor. This causes the reactor to stop, and it can cool naturally. Eventually the pieces can be cleaned up.
This whole structure is then inside a big conventional steel building that is the outside wall of the reactor complex.
What happened at Fukushima Daiichi
The original earthquake hit. Three of the six reactors were in operation, the other three were shut down for scheduled maintenance. The reactors were designed to sustain an earthquake of magnitude 8.2; at magnitude 9, the Honshu quake was 16 times more powerful. This caused the plant to automatically shut down; this was apparently successful, but …
About an hour later, the tsunami hit. The tsunami did two significant things: it destroyed the backup generators that kept the pumps running, and it apparently so contaminated the reserve coolant that it was not only no longer pure, but was so mucked up with the scourings of the tsunami that it couldn’t be safely pumped. At this point, the reactor was in some trouble.
As the reactor heated up, water began to react with the zirconium fuel-rod containers, liberating hydrogen, which started to build up in the boiler. The operators began to vent gases from the reactor to reduce the pressure, liberating the hydrogen into the outer façade building. These gases are mildly radioactive, mainly with nitrogen-16 and several isotopes of xenon, all products of the fission reaction that powers the reactor; apparently they were vented into the outer building in order to slow their dispersion and give them a chance to lose radioactivity.
Hydrogen in combination with the oxygen in the air can be explosive, and at some time after the venting started in reactor 3, the hydrogen in the outer façade exploded, blowing off the walls of upper half of the building and leaving the steel structure exposed. This explosion put six workers in hospital, with various injuries and one apparent heart attack. This was the first spectacular explosion that raised great clouds of white smoke.
This was reported in the New York Times as “radiation poisoning.” No other source has reported this, including the IAEA. Apparently, according to the Times, radiation poisoning breaks arms.
The second explosion was another hydrogen explosion; as before, apparently what was destroyed was the outer building that surrounds the containment, not the containment itself.
Confusion
This is the point at which the media confusion starts. Many stories concentrating on the reactor accidents were illustrated with blazing pictures of a natural gas plant explosion and a burning oil refinery, much more visually impressive than a building with the façade stripped off, but giving the false impression of a blazing inferno at the reactors.
Several headlines said “nuclear explosion,” which is something very different from “an explosion in a nuclear power plant.”
Anti-nuclear politicians like Congressman Ed Markey and anti-nuclear activists from groups like the Institute for Policy Studies warned ominously of “another Chernobyl” — which this isn’t and never will be; the reactors are wildly, radically, different in design. (More on this below.)
Television talking heads talked about the “containment building.” Which is strictly true, since the building in which the containment is housed would be the “containment building” — but misleading and confusing, because the containment for all three reactors remained intact.
So there’s the first bottom-line point: at least so far, the inner, steel, containment vessel on all three Fukushima reactors remains intact.
Radiation
When the gases started to be released from the containment vessels, that meant there was some release of radiation. With their usual nuance, the media reported only that there was radiation released; since there was detectable radioactivity on the clothes and bodies of the men injured in the explosion, this apparently turned into “radiation poisoning,” even for the poor guy who had the heart attack.
But how much radiation was really released? There are several ways to measure radiation, but what we’re usually concerned with is the dose received — that is, how much radiation has hit the body of someone who gets exposed. It can be thought of like sunburn — if you’re out in strong sunlight for fifteen minutes, you are getting a “small dose” of sun; four hours, and you get a “big dose” and may get a sunburn.
In the U.S., this is usually measured as Roentgen, named for the discoverer of X-rays. (Strictly, it’s measured as “Roentgen absorbed dose” or rad, and the dose in humans is “Roentgen equivalent in man” or rem, but for our purposes it’s close enough to say 1 Roentgen = 1 rad, = 1 rem.) In the rest of the world, dose is measured in Sievert, with 100 Roentgen to 1 Sievert. A whole-body dose of 6 Sievert or 600 Roentgen is called the “LD 50/30 dose,” meaning that 50 percent of the people who get that dose will die within 30 days.
The highest dose rate — that is, the dose received in a period of time — that was observed around the Fukushima reactors was about 1015 microSeiverts per hour, but rapidly dropped to about 70 microSeiverts per hour. In other words, 0.001015 Sieverts per hour, or about 0.1 Roentgen per hour. The highest total body dose reported so far has been 106 milliSieverts, 0.106 Sieverts, or about 10 Roentgen.
What does this mean? Well, in the U.S., the average background radiation is around 7 milliSieverts (700 milli-Roentgen) a year; we here in Colorado nearly double that (more in some places, like Leadville) and some places have a background radiation of 50 times that or more.
So 1015 microSieverts is pretty significantly above normal background radiation, but that’s not the whole story either. By comparison, a CT scan exposes you to about 5 milliSieverts, 0.5 Roentgen; the total dose of the highest exposure reported has been about 20 CT scans. High altitude commercial flights have more radiation than normal background; 10 Roentgen is about twice what a intercontinental flight attendant gets in a year.
Effects of radiation
There’s no question that the effects of big doses of radiation are pretty awful; various systems break down, you can’t absorb food — in fact, vomiting and diarrhea are some of the first symptoms, along with hair loss — and eventually, your immune system fails and you die as a result of massive infections, or hemorrhaging, or dehydration. These effects are known as acute radiation syndrome, ARS.
Low levels of radiation are another thing. Obviously, we all are exposed to some radiation because of the normal background. The usual model, based on the people affected in Hiroshima and Nagasaki, and later Chernobyl, is called a “linear dose response model,” and assumes that if a dose of 100 rem causes there to be 10 percent more deaths in a population, then a dose of 10 rem will mean 1 percent more, 1 rem about 1/10th of one percent more, and so on.
This is a conservative model, but it has a problem — it predicts that places with high background radiation, like Colorado, will have higher cancer rates than places with low background radiation.
What really happens is exactly the opposite — we in Colorado have a lower cancer rate than people at sea level.
Why this would happen is currently unknown, and in any case the rates of cancer are small enough it’s hard to be sure how much of it is due to normal radiation exposure anyway, but there’s certainly some reason to think that the linear dose-response model is too conservative, that some amount of radiation has no particular harmful effect.
What happens, though, is that the model affects how we think about radiation. Very small amounts of radiation are detectable — it’s literally “shining a light” at us, begging to be detected. Following the linear dose response model, there are assumed to be health effects of very small radiation exposures, and that means the regulations require even very very small releases to be reported.
Unfortunately, they tend to be reported as “a very small release of RADIATION.”
Another Chernobyl?
Still, what some people are saying is this is “another Chernobyl.” So let’s talk about Chernobyl for a minute. The accident at Chernobyl was the biggest reactor accident that’s well-known, although probably not the worst reactor accident of any kind. In the Chernobyl accident, a reactor of a radically different design, with a containment building but no containment vessel, overheated and exploded; most sources say the graphite that made up the bulk of the reactor core caught fire, although some sources say the graphite didn’t actually catch fire, combust, it just was very hot. According to the UN report, about 50 people died as a result of the accident, some of them dying from acute radiation syndrome. The highest exposure reported was about 16 Gray — which is another damn unit. There are more physicists than there are things to measure, I guess they have to pack them in somehow. But a Gray is a Sievert, approximately.
That 16 Gray dose is about 1600 Roentgen, 1600-1700 rem, or nearly three times the “lethal” dose. That’s 160 times as great as the worst dose reported from Fukushima.
What’s more, the Chernobyl fire distributed large amounts of radioactive material around — including about 10 tons of the actual reactor core. Unlike the Fukushima reactors, Chernobyl had no containment vessel, so once it was burning it was open to the outside, and diffused easily through the atmosphere, eventually spreading across much of northern Europe and a good bit of western Asia.
At the time of the accident, there were many terrifying predictions of the long-term health effects of the radiation.
The UN investigated these effects, and reported on them, in 2005, 2008, and 2011. The report concludes that there may be as many as 4000 additional deaths total that can be attributed to the effects of Chernobyl, but that’s among all the deaths in one of the most densely populated parts of the world. In other words, the linear dose-response model predicts that perhaps one person in a million might die somewhat earlier than they would have otherwise. Statistically. But we can never know if the prediction is correct.
In fact, the 2005 report says that a much, much bigger effect on public health comes from the rumors and uncertainty:
Alongside radiation-induced deaths and diseases, the report labels the mental health impact of Chernobyl as “the largest public health problem created by the accident” and partially attributes this damaging psychological impact to a lack of accurate information. These problems manifest as negative self-assessments of health, belief in a shortened life expectancy, lack of initiative, and dependency on assistance from the state.
The fatalistic feeling of being doomed leads to passivity, as well as other more significant mental health issues; this is entirely due to poor information and uninformed alarmism.
“Experts” in the media
Now, let’s look at some of the media reports.
One of the first ones I saw (pointed out to me by my PJ colleague Richard Pollock) was this story inChannel News Asia:
Several experts, in a conference call with reporters, also predicted that regardless of the outcome at the Fukushima No. 1 atomic plant crisis, the accident will seriously damage the nuclear power renaissance.
And who are these experts?
“The situation has become desperate enough that they apparently don’t have the capability to deliver fresh water or plain water to cool the reactor and stabilize it, and now, in an act of desperation, are having to resort to diverting and using sea water,” said Robert Alvarez, who works on nuclear disarmament at the Institute for Policy Studies.
Hmm. Robert Alvarez. At the Institute for Policy Studies. Which, according to its web site:
IPS became involved in environmental issues through the anti-nuclear movement, a natural extension of its long history of work on the “national security state.” In 1979, IPS Fellow Saul Landau won an Emmy for his documentary “Paul Jacobs and the Nuclear Gang,” which tells the story of the cover-up by the U.S. nuclear program and of the hazards of radiation to American citizens. In 1985, Fellow William Arkin published Nuclear Battlefields: Global Links in the Arms Race, which helped galvanize anti-nuclear activism through its revelations of the impact of nuclear infrastructure on communities across America.
Anti-nuclear movement? Next?
“It is considered to be extremely unlikely but the station blackout has been one of the great concerns for decades,” said Ken Bergeron, a physicist who has worked on nuclear reactor accident simulation.
Kenneth Bergeron, author of Tritium on Ice: The Dangerous New Alliance of Nuclear Weapons and Nuclear Power.
I wonder, who else was on this call?
“Joseph Cirincione, the head of the Ploughshares Fund.” This would be the same Ploughshares Fundthat:
… supports a global network of experts and advocates who are now poised to realize the vision of a nuclear weapon-free world. We leverage the impact of those funds with our own advocacy, with our ability to raise the profile and visibility of key issues, and by convening and engaging with organizations and leaders in the field.
“Paul Gunter is [sic] the U.S. organization Beyond Nuclear,” which:
… aims to educate and activate the public about the connections between nuclear power and nuclear weapons and the need to abandon both to safeguard our future. Beyond Nuclear advocates for an energy future that is sustainable, benign and democratic. The Beyond Nuclear team works with diverse partners and allies to provide the public, government officials, and the media with the critical information necessary to move humanity toward a world beyond nuclear.
Gunter also, according to ecologia.org:
… is a co-founder of the Clamshell Alliance. A resident of Warner, New Hampshire, he has been arrested at Seabrook for nonviolent civil disobedience on several occasions.
I begin to see a pattern. Google those several names; you’ll find that over and over again, these same four names are being quoted as “nuclear power experts.” All of them closely associated with anti-nuclear organizations.
I wonder if they might have an agenda?
What to make of all this
No one can tell you that there will absolutely not be a catastrophic failure — really catastrophic, like Chernobyl or worse — at one or more of the Fukushima reactors. At the absolutely worst case, some combination of accidents and failures could break through all three major containments and release a large amount of radiation through the “China Syndrome” or something like it.
It’s very likely that there has been at least a partial meltdown in one or more of the reactors — but “meltdown” doesn’t mean “catastrophic release.” The reactor would not just have to melt down, but also penetrate both the still containment vessel and the concrete outer layer, and both were designed explicitly to keep that from happening.
What we can say is that it’s not very likely to be a catastrophic accident, and gets less likely with every minute. The Japanese are cooling the reactors down, and adding boron, which “poisons” the nuclear reaction by absorbing neutrons, the “sparks” that make the reaction go.
The amount of radiation that has been released is, so far, actually very minor. Instead of being “another Chernobyl,” which the IAEA put at INES level 7, this is INES level 4 — and Three Mile Island was level 5. So far, Fukushima is not just not another Chernobyl, it’s not even another Three Mile Island.
And finally, when you hear someone in the media giving one of these catastrophic predictions, check who it is. So far, the catastrophic predictions are consistently coming from people who have been professionally and personally committed to shutting down nuclear weapons and nuclear power for decades.
(UPDATE: Fuel rod fire?)
Charlie Martin writes on science and technology for Pajamas Media.
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Please take a good look at this article from February … this is SO dangerous… indeed, the President thought that he would shut up the AMA and the doctors by giving us "SGR" … but as I have shouted over and over and over .. this is NOT a good plan… The SGR is just a government formula and as you can see, there will be other compromises we will have to make to keep this government developed and manipulated formula including compromising the medications we prescribe for our patients.
My Friends and Colleagues … we MUST develop a plan that makes sense.. a plan that is PRO-ACTIVE that empowers our patients to make choices that are good for them (personally) and empowers doctors to do the right thing for the people who trust them … our patients.
I will repeat my plan .. simple as it is again ..
1) Transparency … all prices must be posted in doctors' offices, hospitals and insurers AND THE GOVERNMENT must post what they will pay for each and every procedure or visit.
2) Private contracting… on a VOLUNTARY basis, all patients should be allowed to contract with their physician (even within the Medicare system).
3) We must get back to REAL insurance … an actuarial bet that protects us from the financial catastrophe of a medical illness and those plans MUST BE AVAILABLE to anyone who wants to buy them….. they should be affordable. IF there is anything that the government does … it must be to underwrite this indirectly…. People who buy insurance more often when they can afford it.
4) Tort reform …. I personally like the California system but I am open to other opportunities and better ideas.
Please advise why this is not a good and productive means to a reasonable end … more affordable, more accessible care ….
I won't reiterate the problems with Obamacare. It does NO good to bitch and moan … we are smarter than that. DOCTORS do have the answers…. Let's get the message out there !
Our anniversary gift to America (the first anniversary of Obamacare) should be a viable, reasonable, affordable solution …. LET'S DO IT … NOW !
Join me … write to your patients, write op-ed pieces, produce you-tubes. You know my history … one person CAN change the world … but if you want to do that you can't just sit back and watch time go by…
I am going to Washington this month … join me ! Meet with the PRCC … Let's make it happen ..
Marcy
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February 12, 2011
Obama’s Budget Seeks Deep Cuts in Domestic Spending
By JACKIE CALMES
WASHINGTON — President Obama, who is proposing his third annual budget on Monday, will say that it can reduce projected deficits by $1.1 trillion over the next decade, enough to stabilize the nation’s fiscal health and buy time to address its longer-term problems, according to a senior administration official.
Two-thirds of the reductions that Mr. Obama will claim are from cuts in spending, including in many domestic programs that he supports. Among the reductions for just the next fiscal year, 2012, which starts Oct. 1, are more than $1 billion from airport grants and nearly $1 billion from grants to states for water treatment plants and similar projects. Public health and forestry programs would also be cut.
Home energy assistance to low-income families and community service block grants would be cut in half, and an initiative to restore the Great Lakes’ environmental health would be reduced by one-quarter.
The administration readily concedes, even boasts, that the president will not win any race to outcut Republicans. In the House, Republicans are trying to slash up to $100 billion in the current fiscal year alone before they begin writing their own proposed budget for 2012 and beyond.
But the administration contends that its plan would leave the country in better overall fiscal health than the path Republicans envision. Even as they seek to downsize domestic programs, they would exempt the Pentagon from budget reductions, make permanent all the Bush-era tax cuts that are to expire at the end of 2012 and repeal cost-saving provisions of the health care law.
Mr. Obama would also extend the Bush tax cuts, but not for people whose taxable income is more than $250,000 a year. His budget does not count that proposed change as a savings; in fact, the huge revenue loss from extending the tax cuts for all income below that amount is included in his deficit projections for the remainder of the decade.
By 2015, the senior administration official said, Mr. Obama’s budget would show a deficit of just over 3 percent of the gross domestic product, down from three times that level, and at roughly the point that economists consider stable; it would hover around that point through 2021. But beyond 2021, an aging population and rising health care costs are forecast to drive annual deficits higher again.
With Republicans in charge of the House, Mr. Obama’s budget is more a statement of his priorities and philosophy than an actual template for federal spending and tax policy. Long-term budget projections — and especially deficit forecasts — are frequently unreliable because they are subject to so many political and economic variables. The point of Mr. Obama’s forecast is less to promise a specific result than to signal to voters and financial markets that he is serious about reducing annual deficits.
Mr. Obama’s budget will also serve as his frame for the debate with Republicans over the highly political act of writing next year’s budget — even as he tests Republicans’ willingness to compromise on the more divisive solutions to the nation’s long-range imbalances. “This is the opening bid in a long process,” said Senator Richard J. Durbin, Democrat of Illinois and the second-ranking Senate leader.
Previewing his budget message, Mr. Obama has argued for weeks that cuts deeper than he is seeking could threaten the fragile economic recovery and that America’s future growth and competitiveness demand increases in programs for education, infrastructure, innovation and research.
Mr. Obama would reduce military spending and some health program costs, but neither party is tackling the unsustainable long-term growth of entitlement programs like Medicare or proposing to raise revenues significantly to close the budget gap.
“This is a budget that’s at that pivot point where we’re saying we now have to move from making sure the recovery takes hold, while being careful not to undermine it, to start to move in the direction of putting policies in place that deal with the deficit,” said the administration official, who spoke on the condition of anonymity in order to preview budget details, “because if we don’t deal with the deficit, it becomes the potential next substantial economic challenge.”
The $1.1 trillion in total deficit reduction that the administration will claim through the 2021 fiscal year is measured from spending levels enacted by Congress and the president for the 2010 fiscal year. Comparisons of the impact of Mr. Obama’s new budget and House Republicans’ proposals on deficits and the size of government are difficult to make until both budgets are available.
House Republicans will begin work on a 2012 budget after they finish trying to shrink current spending. But their proposed $100 billion cut for this fiscal year, already four months old, would translate over a decade into more than $1 trillion in deficit reductions, budget analysts say.
Yet even if House Republicans can resolve internal fights over the cuts and pass them, such reductions will not survive opposition from Mr. Obama and the Democratic-controlled Senate. The Republicans’ zeal for spending cuts, however, suggests that Mr. Obama ultimately could be forced to accept bigger reductions in overall nonsecurity spending than he now supports.
The president has proposed a five-year freeze of such spending, through 2015, which the administration estimates would save $400 billion in the next 10 years.
Decades of budget history would suggest, however, that neither party can sustain the levels of cuts they are proposing for nonsecurity discretionary spending, which while just over a tenth of the federal budget covers most government programs, like air traffic control, national parks and cancer research.
Typically, such spending has grown faster than inflation, but not nearly as fast as that for much bigger items whose costs are driving projections of a dangerously mounting debt — the military, the entitlement programs Medicare, Medicaid and Social Security, and interest on that debt.
While the Pentagon would not be subject to his freeze, Mr. Obama proposes reducing its previous spending plans by $78 billion over five years and cutting several weapons programs, including a Joint Strike Fighter engine and Marine expeditionary vehicle.
Together with “a pretty big reduction” in war costs from troop withdrawals in Iraq, the overall military budget would be smaller in real terms than it currently is, the administration official said. “We’re going from an environment where, if something was for defense, it was outside of normal budgetary discipline,” the official said, “and we’re saying that can’t be anymore.”
Mr. Obama’s budget assumes new revenues, mostly from tax changes he has already proposed that would affect multinational corporations and upper-income individuals, and savings from reduced interest payments on what he calculates as a lower federal debt.
The president will also challenge Congress to offset the high costs of two actions repeatedly approved by lawmakers and presidents — one prevents the alternative minimum tax from annually hitting many middle-class households rather than only the affluent taxpayers it was intended for, and the other blocks a law that would slash payments to doctors who treat Medicare patients. In past years, the costs of those remedies have often simply been added to deficits.
To pay for adjusting the alternative minimum tax for three years, through 2014, Mr. Obama again will propose a limit on the tax deductions that people in the top brackets can claim. Congress has rejected that idea, which would raise roughly $300 billion over 10 years.
To offset the cost of protecting physicians’ reimbursements for two years, he will propose $62 billion in savings through changes that squeeze Medicare and Medicaid payments to hospitals and doctors and expand the use of generic drugs in federal health programs.
The budget confirms that Mr. Obama is not taking the lead in embracing the kind of far-reaching deficit-reduction plan recommended in December by a bipartisan majority of his fiscal commission. It proposed saving $4 trillion over a decade through specific cuts in spending for domestic, military and entitlement programs and new revenues from overhauling the tax code.
Instead, he has called on Republicans to negotiate with him to reach that goal.
While that disappoints deficit hawks in both parties, many say they are sympathetic or even supportive of his caution because neither party seems ready to compromise.
Senator Kent Conrad of North Dakota, chairman of the Senate Budget Committee and a Democratic member of the fiscal commission, said: “In this highly partisan environment, if the president proposes something, there is automatically some group that is opposed. It may be better for him to play the role of referee.”
Mr. Conrad added: “To get a result, the president has got to be part of a larger process that involves Republicans and Democrats, the House and Senate. How one gets to the table is not just one move, it’s a series of moves. And it’s very, very difficult.”
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Health information technology is here to stay. But, is it really a good thing for the medical industry? Does it really improve patient care? The government would have us believe so. The government has put its foot forward with a huge investment in the electronic health record. The stimulus package included billions of dollars to induce doctors to purchase an EMR by offering $40-50,000 if the doctor participates in a program that they call meaningful use. Meaningful use requires that a doctor send data to the doctor and that he participate in E-prescribing. The electronic health record would be a HUGE opportunity if it collected good clinical data but to date, it still remains mostly a billing opportunity. The data extracted is financial data and actually gives us bad information. The government will be collecting that information but depending on what they do with it, it could be a step backward rather than forward. Bad data is worse than no data. The electronic health record would be a HUGE opportunity if it created a sequential look at our patients’ health relative to the rest of their life. But, it remains event based and fails to deliver the right clinical data. If we could track our patient’s health using input from their daily activities, we could learn a lot about why things happen. Health is not an event; it is about a life. We need to build a better EMR in order to capture useful clinical data. Finally, the electronic health record along with E-prescribing could be a wonderful opportunity to save time, improve accuracy, and save paper (and money). But, insurers and pharmacy benefit managers have already undermined vendors by obstructing our ability to put in our drug of choice. Some programs do not allow doctors to prescribe what the patient needs. The keyboard actually will not enter the drug into the appropriate space. The electronic health record and E-prescribing has (in these instances) become obstructive. It is time the HIT industry hear doctors “better.” They need to address our patients’ needs. A tool is only good if it helps us perform better. When it is obstructive, decreases productivity, doesn’t answer the questions we are asking, and when it gets in the way of good patient care, we need to go back to the drawing board and get it right.
