Saturday, February 5, 2011

The Big Picture and the Pixels

Reading Gerald Weissmann, MD's 1987 book, They All Laughed at Christopher Columbus which lamentably appears to be sinking into rare, out-of-print oblivion.  I was lucky to pick one up at Dark Star Books, our local used book cavern.  I was looking for books on patient centering in medical care and liked the title.

I really like reading books that are about 10 or 20 years out-of-synch with the current best seller list.  It provides perspective on enduring problems -- medical care being a great example.  After urging our local congressman to help resolve the healthcare problem during the debates two years ago, his office responded...'We don't want to move too quickly.'  Let's see it had been 80 years since Republican President Herbert Hoover took office; he was the first president I know of to become concerned about healthcare in America.  Obviously something wasn't too swift in the congressman's office, but it wasn't legislation that would benefit Americans.

In Weissmann's second chapter, "Springtime for Pernkopf," he describes the situation in Austrian medical universities in 1938 when Hitler annexed Austria.  The new Dean of the University of Vienna medical facility, Professor Dr. Edward Pernkopf, summarized the role of medicine in the new state:  "To assume the medical care -- with all your professional skill -- of the Body of the People which has been entrusted to you, not only in the positive sense of furthering the propagation of the fit, but also in the negative sense of eliminating the unfit and defective."  Pernkopf lists the methods of racial hygiene as:  control of marriage, propagation of the genetically fit, discouragement of interracial breading, and sterilization of the genetically inferior."

What struck me was the reaction of the world.  When Pernkopf's Springtime came into bloom,  objecting, frightened, Austrian medical scientists understandably sought haven from the Nazi regime in other countries including Britain.  There was backlash from the UK medical professional who complained of increased competition and the heightened status the continental doctors had in the eyes of their new patients.  There followed many letters back and forth to The Lancet,  a UK medical journal akin to New England Journal of MedicineSamson Wright did the unthinkable and actually produced data to enlighten the subject.  He found that from 1933 to 1938 only 187 German doctors had been permitted to settle and follow their profession, less than 0.4% of the 50,000 names that were on the UK medical register.  Weissmann provides a few examples of other countries that had similar debates.

Fast forward to 2011, Raymond Hernandez provides an article for today's (Feb 5, 2011) New York Times/Region, "District Liked Its Earmarks, Then Elected Someone Who Didn't."  He uses New York's 19th congressional district to illustrate the benefits of earmarks that redistributed federal tax dollars to that district and how the new representative is a Tea Partier who aims to see that they go away.  Of course, this brings in the same sorts of parochial concerns that the UK doctors had about coming to the aid of German/Austrian  doctors.  Voters want to rein in federal spending, but they don't want to rein it in within their own paddock.  They only want to eliminate other people's, those that are abusive.

A Harvard Law School report on "Earmarks in the Federal Budget Process" published in 2006 showed that earmarks have lingered between a half a percent and around two percent of federal outlays between 1994 and 2005.  The number of earmarks dramatically in that time, but the value per earmark dropped.  Still that small percentage is on the order of tens of billions of dollars.

I'm all for keeping money local.  Rather than seeing money go to Washington to be reallocated back to the states, it makes sense to maintain local control and use the money for projects states and localities determine are important.  However, if you look at the 2011 Statistical Abstracts, you see that median incomes in the wealthiest states are almost two times that of the poorest states.

That causes me to rethink my position.  What that spread in incomes, maybe poor locals can't afford education and infrastructure improvements that keep them in the game.  Does it make sense for the feds to redistribute some of our nation's wealth to help out those folks?  Seems like it does.  Is it Socialism, Conservatism's bane?  Maybe.  Maybe especially when misused.  Then again, maybe it's prudence.

Susan Milligan's Us News and World Report article entitled, "Egypt protests Show that Poverty is a Threat to Global Security" provides perspective.  What Egypt seems as divorced from us as reality TV, in America there is a growing divide between the haves and the have nots.  There is also growing dissatisfaction with government solutions.  I certainly agree that when representatives siphon money back into their districts in order to gain re-election it is tantamount to bribery, but that doesn't mean the mechanism itself is corrupt.  It means the process by which it is applied is flawed.

It gets back to global versus parochial interests.  Instead of asking the narrow question, 'Can we eliminate earmarks?'  Maybe we should instead be asking the question, 'Do we want the representatives we send to Washington to represent the best interests of our society or of our community?'  They are not the same.  This is the question that was debated in the 1938 Lancets regarding the Austrian doctors.  We have to decide where the greatest pain might our local pocketbooks or in the stability of our country?  It takes the ability to look simultaneously at the big picture and at the pixels.  This is a skill Dr. Weissmann has in spades.  It is perhaps the rarest commodity in today's intellectual economy.

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