Smoking soars among urban black youth

"Even as antismoking campaigns have sharply reduced tobacco use in society at large, smoking has remained far more common among the poor of all races."

October 20, 2007
Baltimore Journal (in the NY Times)
The Smoking Scourge Among Urban Blacks
By ERIK ECKHOLM (excerpts)

BALTIMORE, Oct. 15 — Outside subways stops and bars in parts of this blighted city, slouching hustlers mutter “loosies, loosies” to passers-by, offering quick transactions, 50 cents a stick or three for a dollar.

Their illegal, if rarely prosecuted vocation: selling loose Newport cigarettes to those who do not have $4.50 to buy a pack.

In small corner markets, customers sometimes use code words like “bubble gum” or “napkins” to receive individual cigarettes wrapped in a napkin. Or they buy a flavored Black and Mild, the latest smoking craze here, from an opened five-pack.

Out-of-package sales are common in the poor areas of many cities, an adaptation to meager, erratic incomes and rising cigarette taxes. But researchers say they are just one facet of a high smoking rate among low-income urban blacks.

Even as antismoking campaigns have sharply reduced tobacco use in society at large, smoking has remained far more common among the poor of all races.

Still, officials here said they were surprised when a recent study suggested that more than half of poor, black young adults smoke cigarettes — almost always menthol, almost always Newports.

In the latest twist, the study also found that nearly one in four of them also smoke candy-flavored cigarillos, often inhaling despite the danger posed by higher tar and nicotine levels.

Alarmed by the findings, the city’s health commissioner, Dr. Joshua Sharfstein, on Monday convened health experts, community leaders and high school students to discuss the spreading use of Black and Milds, plastic-tipped cigarillos that come in flavors like wine, cream and apple and are often seen in hip-hop videos and the HBO series “The Wire,” which is set in Baltimore.

Amid violence and drug problems, smoking may seem a comparatively harmless vice. “But if you take a step back,” Dr. Sharfstein said, “it’s the smoking that will end up killing a lot of these kids, maybe not next week but well ahead of their time.”

In a stepped-up antismoking campaign, Baltimore officials are offering free nicotine patches or gum and are considering stronger measures to control sales of loosies, which are easily available to youngsters.

“The whole issue here is that the social norms haven’t changed the way they have in most of society,” said Frances Stillman of the Johns Hopkins School of Public Health, co-author of the study of smoking habits among Baltimore’s poor, which was published in August in the American Journal of Public Health. “Everybody smokes, and everybody thinks it’s O.K.”

In this latest study, researchers interviewed 160 blacks ages 18 to 24 who were enrolled in job training. In the group, 60 percent smoked cigarettes and 24 percent had recently smoked cigarillos.

A survey of 1,021 low-income blacks in Detroit, published in 2005 in the American Journal of Preventive Medicine, found that 59 percent of men and 41 percent of women smoked, a finding that “shocked everybody,” said the chief author, Jorge Delva of the University of Michigan School of Social Work.

It has long been known that smoking rates are higher among the poor and least educated of all races, but Mr. Delva and other experts said the rates recently found among inner city blacks were surprisingly high, possibly indicating that they were undercounted in broad standard surveys.

For a mix of cultural reasons as well as targeted marketing, menthol cigarettes are particularly favored by blacks: 75 percent of blacks nationwide smoke them, compared with less than 30 percent of whites.

In recent years, the promotion budgets of major cigarette companies have been disproportionately devoted to menthols, said Gregory N. Connolly, director of tobacco control research at the Harvard School of Public Health. “It appears the industry is targeting the most vulnerable groups through advertising and manipulation of menthol levels,” Mr. Connolly said.

A resident of the Montebello alleys, Antonio Stokes, 39, who was vague about how he made money, agreed. Of the Newport he bummed off a friend the other evening, he said: “It’s worse than crack. They should have a detox center for these things, too.”

Comment - one of the effects of menthol is to anesthetize the throat and lungs so they don't report the pain from the damage the smoke is doing. In many case the impact of "low nicotine" cigarettes is that the users smoke more of them, trying to get the same impact, and draw the smoke deeper into their lungs and hold it in longer. Biomedically, they tend to have their lung cancers deeper in their lungs
than those who don't smoke "light" and "safer" cigarettes.

But, whatever else it is, there is a perception problem here. The benefits of the cigarette in terms of a short-lived spiked high are immediate, and the costs are distant and out of sight, out of mind.

Individual humans, who don't have some way to learn from each other in larger organized groups, are about equivalent to parakeets in their inability to relate the actions and the results, in another place and time.

And, individual humans who don't tap into such groups might as well not have them. They will simply repeat one more time the mistakes that millions of others have made and are making, and not learn anything from each other, and never improve.

Perception, social connections, and enough humility to realize there are truths that are not "obvious" in the short-run -- these are the keys to getting out of this mess.
"Inability to listen" is not limited to certain groups, such as "people in authority." In fact, demolishing all authority destroys the ability to learn.

This is tangled by having two meanings of the same word "authority" - one is having a solid basis for conclusions, and the other is "being the one who gives the orders." In trying to rebel against the second, people tend to also toss out the first.

That doesn't make sense. Somewhere, someone knows stuff way better than you. That's a fact of life. It should be the first lesson in school in every grade - not to make people feel bad, but to try to make people willing to get together and pool wisdom before they go off and make dumb decisions that everyone (or anyone) could have told them not to make.

In downtown Baltimore or Detroit, the problem is worse, in that "everyone" in the vicinity believes the same mistaken thing. Studies and billboard counts show that Tobacco and Alcohol advertising and billboards are concentrated in urban poor areas, and it's hard to believe those companies don't know where their own signs are located and why.

I took Dr. Stillman's course in Tobacco Control at Johns Hopkins last year and it was truly eye-opening. Example" One tobacco company tried to open the market in an Eastern European country by pointing out that cigarettes tended to kill people early, so the country could save money on not having to cover retirement benefits for all those people. They had to back off when this was published in the newspaper.

Smoking will kill 5 million people a year, every year. (source: Harvard).
The world-trade center attack killed 3 thousand people, once.
Guess which one we've spent more time and money trying to prevent.


See Should the FDA Regulate Tobacco,
Kennedy will ask FDA to regulate smoking,
Short YouTube hysterical videos on smoking - (don't be drinking a soda while viewing these!)

Jay Leno on Saddam Hussein and the tobacco industry

Zyban - bad day (office monitor)

And remember to wash your hands!

How I learned to stop smoking (on the porch)

When that guy across from you asks "Do you mind if I smoke?"

Oh, you don't always die from tobacco (song )

================
resource:

World Health Organization webpage on the toll of smoking worldwide.

Federal budget stalemate hurts the poor

While many organizations are inconvenienced, unable to plan or budget due to the failure of Congress to pass a budget by the start of this year (October 1), the limbo is literally killing individuals who depend on that funding. What isn't said is that federal budgets assume that the price of food is the same today as it was in 1989 when the guidelines were written.

It's part of the psychology that tells us "Inflation rose at a modest rate of 2% last month, excluding the volatile food and energy components." In other words, the rate of inflation experienced by corporations may have been 2%, and that experienced by individuals more like 20%, but you'd never know from those numbers.

The exclusion makes sense if food prices shoot up and down, averaging zero change. The exclusion sabotages the truth if food prices, gas prices, and heating oil prices just keep going up. With oil passing $88 a barrel yesterday, it's not clear how many hundreds of thousands or millions of people are not going to be able to afford heat this winter.

Maybe, Congress is unaware of the "hybrid" or fractal quality of this set of numbers as well, hiding the pain individuals feel from the comfort of on high. It seems that way from below. See Hybrid Images and Hybrid Reality. It would be a different kind of tragedy if the government is not responding because it actually appears to sincere people who would care if they knew that there is nothing important to care about. My "hybrid" posts discuss that possibility.

Certainly other guidelines to policy, such as the Gross Domestic Product, completely mask damaging actions and count spending our nations resources as "income" with no corresponding charge against "assets". (See Genuine Progress Indicator( Canada) :

GDP-based measures were never meant to be used as a measure of progress, as they are today. In fact, activities that degrade our quality of life, like crime, pollution, and addictive gambling, all make the economy grow. The more fish we sell and the more trees we cut down, the more the economy grows. Working longer hours makes the economy grow. And the economy can grow even if inequality and poverty increase.

The more rapidly we deplete our natural resources and the more fossil fuels we burn, the faster the economy grows. Because we assign no value to our natural capital, we actually count its depreciation as gain, like a factory owner selling off his machinery and counting it as profit.

and the US "Redefining progress", Wikipedia on the Genuine Progress Indicator with a link to the one article that is a must read if you can only read one. (But you need a subscription or to go to the library to get it.)

"If the GDP Is Up, Why Is America Down?" by Clifford Cobb, Ted Halstead, and Jonathan Rowe. Atlantic Monthly, October 1995, pp. 59-78.

Also see: Wake Up, the American Dream is over, Guardian, June 8, 2006:

Even America's richest think they're getting too many tax breaks from a government determined to keep the poor in their place. As poverty in the US grows, Paul Harris wonders what happened to the Land of Opportunity

This flawed accounting is like your child suddenly discovering that they can buy things on your credit card or their cell phone without having to "pay anything" and going on a spree. The result of that flawed perception, as we've demonstrated in our Systems Dynamics class, is that things just look just great, better than normal in fact, in a climbing curve until they abruptly hit the limit when it crashes to zero. This is what happened to the Georges Bank, once the best fishing in the world off Cape Cod, now an underground desert and junk yard.

People only respond to things they see, that seem real to them.

Supplies Dwindle at Food Pantries as Financing Bill Stalls in Washington New York Times Oct 18, 2007. by Winter Miller. emphasis added.

On a recent weekday at the BedStuy Campaign Against Hunger, one of Brooklyn’s largest food pantries, shelves that are usually piled high with staples like rice and canned meats were empty, a stark illustration of the crisis facing emergency food providers across the city.

The Brooklyn organization is among about 1,000 food pantries and soup kitchens supplied by the Food Bank for New York City, the largest distributor of free food in the city, whose mission has been crippled by what officials describe as its worst food shortage in years.

At its sprawling warehouse in Hunts Point, in the Bronx, the Food Bank is storing about half what it housed in recent years....

“It’s the first time in a few years that I could walk into the warehouse and see empty shelves,” said Lucy Cabrera, the president and chief executive of the Food Bank, which helps feed about 1.3 million people a year.

Officials at the Food Bank say the bare shelves stem from a steady decline in federal emergency food aid, though a farm bill stalled in the United States Senate could increase that aid.

According to a study to be released today by the Food Bank and Cornell University, New York City receives a little more than half the amount of emergency food annually from the federal government that it did three years ago. The shortfall is occurring as the number of families and individuals relying on soup kitchens and food pantries in New York City has risen to 1.3 million from 1 million since 2004.

The problem besetting the citywide Food Bank is also affecting providers of emergency food nationwide who are supplied by America’s Second Harvest, the country’s largest hunger relief organization, which assists 50,000 providers. Federal food donations to food banks have been stagnant since 2002.

But organizations have been hit hardest by declines in a separate federal program that buys excess crops like peaches and potatoes from farmers and then donates them to food banks. Those donations have shrunk to 89 million pounds last year from 251 million pounds in 2003.

Senator Charles E. Schumer, Democrat of New York and a member of the Senate Finance Committee, says he is optimistic that the farm bill will pass within the next month. He said the delay involved sections of the bill unrelated to the nutrition portion.

Separately, the House of Representatives voted in July to increase the budget for food stamps and other nutrition programs by $4 billion, which would include an increase in emergency food assistance to $250 million from $140 million. It also would require an automatic increase in food assistance based on the rate of inflation, addressing one of the reasons food banks are now struggling.

“It’s devastating,” said the Rev. Melony Samuels, a minister at the Full Gospel Tabernacle of Faith who oversees the food pantry. “It has gotten so bad.”

In better times, the pantry might get 190 cases of assorted foods every week; now the shipments are much smaller. One recent week, all it got was six cases of peanut butter and pasta.

“In order to keep food on our shelves, we need to roll in $5,000 per month easily, and you’re looking at half or less of that coming in,” Ms. Samuels said, adding that she might not be able to stock her pantry with turkeys for Thanksgiving.

See also: Flash, US Solves World Hunger

By Elizabeth Williamson
Washington Post Staff Writer
Thursday, November 16, 2006; A01

The U.S. government has vowed that Americans will never be hungry again. But they may experience "very low food security."

What goes around comes around

It's not just "a small world" we live on -- it's a small "us" we are part of: there is, really just one of "us" here, with plants, animals, and people of all types including those with a "j" as the fourth letter of their middle name, or other irrelevant distinctions, such as "race" or "ethnicity" or administrative governmental unit of origin.

It turns out, viruses and bacteria don't really care about those distinctions that we take as so important. When bad things are let thrive, they come for all of us.

That would be true even if we had all come here from different planets, due to the intense "system effects" that mean anything affects everything, and vice-versa.

It's even more true since we were all born here on Earth, as were our parents, and our grandparents, etc. on backwards. (aside from my 2nd grade gym teacher, who I think was from Mars.)

So, we need to be very careful of the glee we take when someone "else" has managed to shoot a hole in the bottom of "their end" of our lifeboat -- and more so if we were involved in handing them the loaded gun.

This basic physical truth is one basis behind the various religions' description of the Golden Rule - some variant of "Do unto others as you would have them do unto you". Or we have the Christian Scriptures, where Jesus says (see other versions)

KJV: And the King shall answer and say unto them, Verily I say unto you, Inasmuch as ye have done it unto one of the least of these my brethren, ye have done it unto me. (Matthew 25:40).

Or, Islam's Book of Sincerity -'The believer will not truly believe until he wishes for his brother that which he wishes for himself.'

So, in today's papers we see some of that effect coming into play.

First, the home mortgage market. I wrote about the present disaster that is unfolding on us now back when there was still time to do something:

Honey, We're losing the house - Dec 7, 2006 (Pearl Harbor Day).
The Mortgage Trap Begins Closing - Dec 11, 2006
How does that help me? - Average American -- May 22, 2007
Rising Rates and the Soon to be Homeless - June 15, 2007
More on Foreclosures for the Baltimore Sun - June 15, 2007

So, what started as a large scale scam to dupe poor people into buying homes they couldn't afford and then close the trap on them has now turned into an international incident roiling stock markets around the globe. Now even rich people are being affected! Here's something from this morning:

In a Spiraling Credit Crisis, Large Mortgages Grow Costly.
New York Times
August 11, 2007

When an investment banker set out to buy a $1.5 million home on Long Island last month, his mortgage broker quoted an interest rate of 8 percent. Three days later, when the buyer said he would take the loan, the mortgage banker had bad news: the new rate was 13 percent.

“I have been in the business 20 years and I have never seen” such a big swing in interest rates, said the broker, Bob Moulton, president of the Americana Mortgage Group in Manhasset, N.Y.

“There is a lot of fear in the markets,” he added. “When there is fear, people have a tendency to overreact.” ...

For months after problems appeared in the subprime mortgage market — loans to customers with less-than-sterling credit — government officials and others voiced confidence that the problem could be contained to such loans. But now it has spread to other kinds of mortgages, and credit markets and stock markets around the world are showing the effects.

Those with poor credit, whether companies or individuals, are finding it much harder to borrow, if they can at all. It appears that many homeowners who want to refinance their mortgages — often because their old mortgages are about to require sharply higher monthly payments — will be unable to do so.

Some economists are trimming their growth outlook for the this year, fearing that businesses and consumers will curtail spending.

“You find surprising linkages that you never would have expected,” said Richard Bookstaber, a former hedge fund manager and author of a new book, “A Demon of Our Own Design: Markets, Hedge Funds and the Perils of Financial Innovation.”

... There were reports that a surprisingly large number of loans made in 2006 were defaulting only months after the loans were made.

There have been sudden changes in the mortgage market before, but this one may be both more severe and more damaging than those in the past.

I Investors made the mistake of assuming that housing prices would continue to rise, said Dwight M. Jaffee, a real estate finance professor at the University of California, Berkeley. “I can’t believe these sophisticated guys made this mistake,” he said. “But I would remind you that lots of investors bought dot-com stocks.”

He added, “When you are an investor, and everybody else is doing the same thing and making money, you often forget to ask the hard question.”

And that is how a problem that began with Wall Street excesses that provided easy credit to borrowers — and made it possible for people to pay more for homes — has now turned around and severely damaged the very housing market that it helped for so long.

Not everyone had evil intentions, although predatory practices certainly worsened the problem. We have yet another case of what Jay Forrester called (50 years ago) "The law of unintended consequences", although at this point in our history I don't think these can be called "unexpected consequences" -- aside from the expectations of the structurally blind who have been deceived by their own myths.

In fact, this area of self-induced blindness is fascinating, and scary, and relevant to understanding why so many personal, management, and governmental level policy decisions look so stupid in the morning. Or, as the cartoon strip Calvin says: "How come dumb ideas seem so smart when you're doing them?" And in turn, that is akin to my favorite Snoopy cartoon:

Did you ever notice
that if you think about something at 2 AM
and then again at noon the next day
you get two different answers?

I was trained as an instrument pilot, and we were carefully taught how to read each instrument so we could navigate when you couldn't see out the window. One item in the tool kit was curious - a 3 inch disk covered with suction cups, suitable for holding soap in the bathroom. "What's this for?" I asked. Well, it turns out that is to save you from the alternative, which is smashing the face of an instrument on the cockpit panel so you stop paying attention to the blasted thing when it has decided to lie to you convincingly -- you can stick this over the instrument so you don't see it anymore.

Because, it turns out, all our instruments, and senses, lie to us. It's only by comparing notes that we can detect that one of them is "acting up". It's invisible by itself, in isolation, as are the tricks our own minds play on us. As Calvin says, - why do these things look so smart at the time? This is a serious question and worth reflecting on.

But cockpit instruments, computer readouts, or the minds of Calvin, Snoopy, or you or me, all can lie to us in the most convincing way. Most of the time they are right, some of the time we know the results look "funny", and some of the time they are very wrong but still look perfectly right. The altimeter tells us we're climbing when we're descending and about to crash.

That's what "consultation" is for. We need independent confirmation by others, preferably others who are not subordinate to us or trying to please us, or selected as friends because they always seem "agreeable" - ie, agree with us whether we're right or not. One of the strengths of "diversity" is that a diverse group doesn't share the same blind spots. So when that hand goes up, even though that person is "obviously wrong", we need to pay attention, because maybe our "obviously" unit is broken. It happens a lot, it turns out, to all of us.

I have an entire book titled " Why do smart people do dumb things?". It's a good thought. Getting caught up in the herd stampede is often one of the wrong things to do, even though we've been genetically selected from those who did listen when the herd detected a predator coming that we had missed. The impulse to go with the herd is "hard-wired" into our DNA now, and hard to even detect, let alone block.

This is well known in stage magic, which my dad taught me. Even if some guy in the third row sees what you're doing, if no one around him believes him, he will actually "un-see it", and by a few minutes later will have forgotten he ever thought he saw it, even though the videotape shows him seeing it, and asking people around him if they saw "it".

Well, I said at the front that there were two items where what went around came around - or where efforts to discriminate against and exploit poor people turned out to come back and bite us. My point is, those aren't unusual events, and don't require "God to see what we did." -- those are "system effects" in a small world.

Throwing out the concept "God" and being "scientific" does not remove our ultimate accountability for our own actions. We are still in our own prop-wash, and need to adjust to that fact of life. We are not finally free to exploit our neighbors or even distant lands with impunity, and no "terrorist" or "God" is required to bring the deeds of our hands back into our lives, often with amplification.

The bogus mortgage scam is one. The other is the concept that we can deny some people health care, and "get a way with it" or even "be further ahead because of it." Obviously, that is the unspoken assumption -- that the fate of "them" over "there" is completely distinct from the fate of "us" over "here."

The lessons of small-world systems thinking is "Not!". We're in the same lifeboat, and look identical to invading viruses and bacteria, that we have much more to fear from than "immigrants". In the US alone, it's now estimated that over 75 million people go without "health insurance" each year.

Actually "insurance" is a bogus concept and not necessary to the equation, and only muddies the water with middle-men concepts and fragmented thinking. So let's be clear. About a third of the US population has primary care health problems that could be taken care of, that should be, but aren't, each year. This number is rising, inexorably.

God may or may not "see", but viruses and bacteria and other bad things can detect "lunch" when they see it, as well as predatory corporations like Tobacco or Alcohol can. And, given air travel, our own "backyard" now includes most of the globe. Diseases that find a portal into our world through the poverty in India or China can result in deaths from disease here in the USA in under 48 hours. It's a very small world to viruses as well, who get to ride international flights, first-class for free.

But when they get here, where will they gain a foothold? Hmm. Maybe they can start in the sections of our towns where we let people get ill or die, more or less abandoned, because "there's nothing we can do?"

A while back I reported on the lady who died slowly, screaming in pain, on the floor of the King hospital in LA. , while everyone stepped over her and the janitor mopped up the blood she was vomiting. We do have a culture capable of doing that, of not seeing, on so many scales.
( A Patient Dies in Los Angeles - System Views. May 20 2007)

Well, the scale has just moved up one more level in LA, as that hospital failed inspection and was closed this week - removing the only hospital for miles around for poor people in that area, replacing poor care with none at all.

Los Angeles Hospital to Close after Failing Tests and Losing Financing.
New York Times
Aug 11, 2007
Jennifer Steinhauer and Regan Morris

Excerpts:

LOS ANGELES, Aug. 10 — Martin Luther King Jr.-Harbor Hospital, built in the aftermath of the Watts riots and one of the few hospitals serving the poorest residents of South Los Angeles, is headed for closing after federal regulators found Friday that it was unable to meet minimum standards for patient care.

At a news conference Friday, county officials said the hospital would probably close within two weeks, after patients were moved to other hospitals. All 911 calls will direct ambulances to one of the nine other hospitals in South Los Angeles. An urgent care center will operate on the site 16 hours a day.

he loss of the hospital for residents of the Watts/Willowbrook area of Los Angeles.

“They are going to be left without a safety net for health care,” said Janice Hahn, a Los Angeles city councilwoman whose district includes Watts. “There will be no trauma care, no emergency care and a lack of the basic services this community needs and deserves.”

Nearly since its opening 35 years ago in Willowbrook in South Los Angeles, the center has been a symbol of both the political neglect of South Los Angeles and its struggle to emerge from blight.

It pointed to many successes — it was once a teaching hospital for the nearby Charles R. Drew University of Medicine and Science and featured a respected neurosurgery unit — and in a neighborhood riddled with gang violence and myriad health problems common to poor urban areas, it was a safety net, though an increasingly imperfect one, for the poor and uninsured. The nearest public center is several miles away, which, in an area with many poor residents without cars, means nearly inaccessible.

Debates over the hospital’s future have always been tangled in racial politics. “It is actually quite tragic that this hospital that came into existence with such high expectations now dies because of the culture of incompetence,” said Joe R. Hicks, vice president of Community Advocates Inc., a Los Angeles research group. “It suffered what has often been called the soft bigotry of low expectations, because the Board of Supervisors were aware that the hospital was being nicknamed killer king by people who lived in the neighborhood and they continued to hide the ball.”

Others echoed the criticism. “The Board of Supervisors failed to put enough money and personnel into the hospital,” said Earl Ofari Hutchinson, a Los Angeles political commentator. “And now,” he said, “we are asking the question we always ask: Where are all these people going to go?”

What's the thought here - that "these people" should just die quietly and not bother "us"?
Regardless, I'm struck by the quote referring to the "soft bigotry of low expectations", that saw problems and just kept on doing nothing , or maybe never actually really "saw"the problems, but just kept on stepping over the writhing body on the floor.

That was true of the ER staff there that night, and of the management of the hospital, and the oversight Board, and of the State of California, and of the whole United States. We continue to just keep on "stepping over the body" as if it's not there or not our concern.

At that IS of concern, because the larger scale analog to the hospital closing is the whole health care system of the USA collapsing under its own weight, like some bridge in Minnesota.

Blindness is contagious, like the measles. We have to learn how to be blind to the pain of others, but then, once we master that, we can apply that blindness to being blind across the board.

Maybe, that's not the best strategy for keeping the plane in the air. We made this mess, and we can clean it up, but first we have to come to grips with national-scale denial that there is a very serious problem.

Heading upstream

There's a very basic concept in Public Health known as "going upstream". The cartoon above illustrates the concept. (if you "click" on the picture it should zoom up to a bigger size.)

Imagine our hero, Tim, sees smoke coming up over the mountain, but he cannot see the source because the mountain is in the way. Say the smoke is killing the crops and Tim wants to "fix" the problem. Where should he go to start looking for the solution?

He could head towards the largest amount of smoke, to the right.
He could head towards the "center" of the problem, directly above.
He could head towards the "worst problem area" or densest smoke, to the upper left.
or
He could follow the smoke "upstream", going around the mountain or possibly over it, until he finds the "source" of the smoke.

I relate to this problem. I was in Edmonton once, visiting, and went to the top of a high rise building to catch the view. We saw all this distant smoke and asked where it was coming from. They said, "Oh, that's from a forest fire in the Rocky Mountains, about 45 miles west from here." So, we got in the car and headed west and went to fight the fire, 50 miles up a dirt logging road from Revelstoke. I'll describe our narrow midnight escape someday.

But, the point is, it is not really true that "Where there's smoke, there's fire." Many people seem to take that much too literally, and head for the densest smoke to look for the fire. Others head for the "center" of the visible problem, and others head for the largest amount of smoke.

In Public Health, we're taught to forget all that, sigh, pack a bag, and head "upstream" to locate the actual source of the problem. Often the source is not visible from where we are.

So, whether it's cancer along the Mississippi river, or developmental problems from lead paint poisoning, or gunshot wounds in the Emergency Room, we follow the Toyota Way and ask "Why?" at least five times - the same way you always got in trouble with your parents when they told you to do something.

For example - Why are so many children getting poisoned by old lead-based paint? Because the paint is peeling off and hasn't been replaced.
Why?
Because they live in terrible housing that's falling apart and neglected.
why?
Because they're poor and the poor are exploited and no one seems to care. Because despite tremendous technology, we can't make decent housing for $1000. Because despite amazing science we can't make companies and jobs that seem able to stay alive and in business. Because the people who could help don't realize there is a need, or are overwhelmed with how large the need is. Because the people who live there don't realize they could get subsidized housing in a much better place and don't know how to "sign onto our website and register for housing now!"

Why?

Now, you're getting into culture and how we distribute resources and education, and how we help or don't help each other, and how we respond to need by hiding the problem and pushing it out of our backyard into someone else's, instead of fixing what's wrong.

The Toyota Way really emphasizes that problems need to be brought to the surface, and made visible, so they don't fester and result in bad results later. Here's a view out of the window of where I'm currently writing this. Can you spot a "hiding" place and see what's happening here?


A huge pile of trash has built up just around the corner and out of sight of the main road.

In any Toyota plant, or anywhere near it, you would not find such a thing. They find they get better results if they deal with problems as they arise, instead of letting them stack up until the total pile becomes so overwhelming that no one wants to even think about it anymore.

Well, I hear a reply, that's because everyone is overwhelmed and stressed-out these days and no one has TIME to deal with "other people's problems."

Why?

This is actually a puzzling problem, related to multi-level depression or something. The "poor" in this country are poor at $10,000 a year, versus $200/year in India or China, if that. I think the figure is that something like a billion people earn less than $1 per day on this planet.

Why?

What's the most intriguing to me is that people in the US seem so fragmented and often unwilling to help each other out, or be helped, even when there are many really good-hearted people who are trying to help.

Or, even when the problem becomes desperate. A family about to lose their home because the mortgage payment just doubled on their fancy new loan would rather lose the home than try to have a second family move in and share the space and share the mortgage payment.

Why?

Because people just don't know how to get along with each other and things always turn bad.

Why?

After easily 5,000 years of written history, why is it that people haven't yet figured out how to get along with each other? If this is a big deal, here, in poverty, in Iraq, why isn't THAT what we study in school, from kindergarten through PhD level work, instead of algebra and physics?

"Because we need all this science and technology to save us from the mess we've made of things here."

Umm... Isn't the dependence or science and technology and the rejection of "learning how to get along" precisely the reason WHY we just spent $1,000,000,000,000 on the post-9/11 "homeland security" and war? That would have bought a lot of houses. Isn't the failure of management and labor to talk one of the big reasons GM lost its lead in the auto business and had to layoff hundreds of thousands of workers?

Well, for "cultural reasons" learning to get along is not a high priority.

Why?

In my book, it keeps coming back to this. We have what appear to be "technical" or "production" or "cost effectiveness" or "safety" problems, and they appear to be intractable, unsolvable by anything we can do. Then we find that "anything we can do" excludes the one thing that seems like it WOULD help, namely, putting a lot of resources into understanding how people should work together, relate, overcome conflict, and fix each other's roofs.

Why?

And that is precisely the point of the "Health, Behavior, and Society" focus on the role that "culture" and "distal factors" play on the visible immediate problems in front of us.

Don't look at the smoke. Go find the fire. Put the fire out, and the smoke will stop.

One last thought - some people argue that this kind of reasoning is no good because it doesn't involve mathematics. They've somehow deified the idea that there is such a thing as rigorous qualitative reasoning. I'm against sloppy thinking, sure.

But I've had more math than most people in this discussion. I've had 6 years of calculus, quantum mechanics, general relativity, statistical thermodynamics, etc. I taught financial modeling to MBA's.

Too often, the request for more math is an effort to avoid doing something that you already know you should be doing. We know enough now, with no more math at all, to know that a root cause of most of the mess we're in is that we don't know how to live with each other and work together. If we could solve that single problem, most of the rest would just dissolve, like a pearl necklace with the thread pulled out.

But, for those who insist on math, and are so deeply rooted in the culture of worship of "hard sciences", be of good cheer. I'll give you the math and you can be happy. You just may need to "come to the mountain" a little and learn about feedback control loops and all the rest of the non-linear, loop-based mathematics that YOU, dear you know who I mean, have been avoiding hoping that everything would fall neatly into linear causality, open paths with clear starts and finishes, and the General Linear Model and its grip on research.

And, in fact, with a little Laplace Transform wizardry, even those dreaded loops will flatten out and you can use your existing math and solve the problems with STATA -- even though the basic assumptions about unbiased estimators won't be met. Who ever checks those anyway?

So, enough. I'm off to breakfast.

A Patient dies in Los Angeles - Systems Views

The LA Times reconstructed the scene today from the videotape and interviews.

Parked in the emergency room lobby in a wheelchair after police left, she fell to the floor. She lay on the linoleum, writhing in pain, for 45 minutes, as staffers worked at their desks and numerous patients looked on.

Aside from one patient who briefly checked on her condition, no one helped her. A janitor cleaned the floor around her as if she were a piece of furniture. A closed-circuit camera captured everyone's apparent indifference....

Alerted to the "disturbance" in the lobby, police stepped in — by running Rodriguez's record. They found an outstanding warrant and prepared to take her to jail. She died before she could be put into a squad car.

How Rodriguez came to die at a public hospital, without help from the many people around her, is now the subject of much public hand-wringing.

Questions are being asked of "How could this happen?"

Rodriguez's son, Edmundo, 25, said he still couldn't understand why his mother died. "It's more than negligence. I can't even think of the word."

And blame is being focused on the last person in what always proves to be a very long chain of contributing events:

David Janssen, the county's chief administrative officer,... said that the preliminary investigation suggests that the fault primarily rests with the nurse who resigned. "I think it's a tragic, tragic incident, but it's not a systemic one."

But, while legal issues of blame proceed, from the bleachers we can start an analysis of the "system factors" that all came together in this tragic result. And, as with many previous studies in errors, odds are very high that there are many more distant factors that were are work here. It is important to delve into the always-surpising world of "How could this happen?"

You can read the Times article, and start with as much information as I have, but I'll try to put it into a "systems thinking framework."

First, though, let's abandon the idea that the nurse is "to blame." Yes, she may have made an error in judgement - but that's a type of problem humans have that is fully predictable, and the collection of other people around her should have caught that and reversed that error before harm occurred. So, remove the nurse entirely from your mental picture of the scene, and just look at what else was going on, as we change the "zoom" setting on the lens and back out to larger and larger contexts.

First, an entire room of other people, patients and staff, was apparently paralyzed. We need to ask how that sort of thing happens. This brings to mind the Kitty Genovese stabbing and slow death in New York City, where hundreds of people watched from their apartments and did nothing, not even call 911. It brings to mind Stanley Milgram's famous experiments, where subjects, told by a person in a white coat to deliver electric shocks to another person, continued to do so far past the point where the other person screamed and finally went silent. It brings to mind not only "It's not my job" but also "... and the last time I intervened I was punished and told if I did it again, I'd be fired."

It seems that everyone in the room, staff and patients, had been conditioned to observe an unfolding tragedy, and sit passively by and do nothing. Hmm. Sounds like the sort of operant conditioning and behavior modification that 20 years of watching television might create.

Actually, it also sounds like a lot of people were in a burned out, depressed, helpless, hopeless state and maybe had given up trying to change the world around them, and this was just one of a hundred things around them daily that was going wrong.

It appears that the patient was Latina, overweight, and had no health insurance or regular family doctor. We might investigate bias, bias, and an entire nation that seems to stand by indifferently while 50 million residents of the US with no "coverage" try to get adequate primary medical care by swamping emergency departments. This problem is very well publicized, but the American public is too busy with other problems right now to focus on that.

On a mid-range scale, it seems that California or Los Angeles is standing by, not helping, while another hospital that attempts to help the poor sinks into debt and finally drowns.
The LA Times article points out:

The incident has brought renewed attention to King-Harbor, a long-troubled hospital formerly known as King/Drew....Over the last 3 1/2 years, King-Harbor has reeled from crisis to crisis.

Based on serious patient-care lapses, it has lost its national accreditation and federal funding. Hundreds of staff members have been disciplined and services cut.

Janssen said he was concerned that the incident would divert attention from preparing the hospital for a crucial review in six weeks that is to determine whether it can regain federal funding.

If the hospital fails, it could be forced to close.

Then what? Then what will the people in this neighborhood do for primary and emergency medical care? Drive 45 minutes to Beverly Hills? The same problem of inner city hospitals closing is visible across the US. They want to move out to the rich suburbs and focus on care for rich people with great health "coverage." Or, they have no choice, because of the perverse "unintended side effects" of demanding that they must provide emergency services to anyone who shows up, whether they can pay or not - and a national health care system that means 50 million people can't pay. The public hospitals and all the caring staff in them are being burned out, gutted, and deleted.

One of the roles of the field of "Public Health" is to hold up such uncomfortable mirrors, stop focusing entirely on how to repair gunshot wounds in the Emergency Room, or how to get faster ambulance dispatch, and start asking why so many people are getting shot in the first place.

Yes, in this case a nurse resigned. But, in many ways, it appears that she was a victim too, and likely a person who went into nursing because she really wanted to help, and tried to help, and just finally ran out of the ability to cope with the job that society had created for her. Day after day, night after night, social tragedies that could at best be patched and sent back out into the world to be damaged again and return again. I doubt that she started as a mean or uncaring person. How many hours had she been on duty? How was she coping with the fact that even this job looked like it would evaporate soon? What else was going on that she needed to attend to?

No, I don't think that removing this single person will "fix" this problem and stop such things from ever happening again in this hospital or in Los Angeles or in the USA.

How can people just look the other way? It's baffling.

But, now that we've all seen this larger issue squirming in pain on the floor, and feel helpless to do anything about it, it must be time to shake our heads in disbelief at "those people", and go see what else is on TV.

I'm not trying to be mean - only to illustrate that this problem of being overwhelmed with other people's problems is not some local thing that only happens in this hospital ER in LA. That doesn't make it less of a problem - it makes it more of a problem.

When a whole nation says "there's nothing we can do..." it's right, but it's wrong.


Article: Tale of last 90 minutes of Woman's Life,
By Charles Ornstein
Los Angeles Times
May 20, 2007

The Future of Emergency Care in the US Health System
Institute of Medicine, June 2006

Crisis Seen in Nation's ER Care
The Washington Post (registration required)
June 15, 2006

Emergency medical care in the United States is on the verge of collapse, with the nation's declining number of emergency rooms dangerously overcrowded and often unable to provide the expertise needed to treat seriously ill people in a safe and efficient manner

Emergency Medical System in Crisis, USA
Medical News Today

Emergency Care - A system in crisis
Journal Watch

Kellerman AL. Crisis in the emergency department. N Engl J Med 2006 Sep 28; 355:1300-3.

Photo credit: In the Emergency Room by ebilflindas

Patient team empowered diabetes care in LA

Much of the model I suggest in my Capstone presentation is in use in Los Angeles - including teams of caregivers amplified by teams of local residents in a cascading help-your-neighbor approach.

Here's excerpts from an article Diabetics Need Much More Than a Shot from today's LA Times.

Managing the disease requires constant support and substantial investment, but would pay off in the end for thousands of people.

By Susan Brink
[Los Angleles] Times Staff Writer

May 7, 2007

Diabetes is afflicting more people, at younger and younger ages, sending doctors, insurers and public health officials into a tizzy as the epidemic threatens to overwhelm the healthcare delivery system. The annual cost of healthcare for an adult with diabetes is more than $13,000, and rates of Type 2 have risen sharply in the wake of the upsurge in obesity in this country.

A bold experiment is unfolding in Los Angeles County that may serve as a lesson for the nation as it battles the epidemic.

Experts know that the cost of care could be much lower if patients could take simple measures to control their disease and avoid complications: nerve damage, amputations, heart disease, blindness, even death. But surveys show that many, even those with adequate health insurance, do not get that care, which is costly and labor intensive, demanding daily attention from patients and timely responsiveness from doctors.

Poverty creates additional obstacles, such as finding fresh vegetables or a safe place to exercise. Study after study shows that low-income people have less access to healthcare and a greater risk of getting sick and dying prematurely.

But in an odd twist to the usual healthcare disparity story, more than 1,000 L.A. residents in low-income areas, most of them uninsured or on MediCal, are getting the gold standard of aggressive diabetes management — better, even, than many with insurance who live in ritzy ZIP codes.

The care is taking place at clinics in East L.A. and South L.A., two communities with the highest rates of diabetes in the county, as well as three other outlying clinics. A team of L.A. doctors is participating in the experiment, training nurse practitioners, pharmacists, social workers and community educators to intervene in a way that doctors cannot do.

They're offering frequent patient checkups to monitor the disease, and teaching patients to track blood sugar, get out and take a walk, cut out the doughnuts, all the things they need to do to keep complications at bay.

They are reaching people with uncontrolled disease in some of the county's poorest pockets.

"The county patients [in the program] receive care that is as good, and probably better, as anywhere in the country," says Dr. Mayer B. Davidson, endocrinology professor at Charles Drew Medical Center and UCLA.

There are signs that it's working. Studies so far show that patients in the program have improved blood sugar and have had fewer emergency room visits and hospitalizations.

Local pioneers

The intensive program is a response from local academic and public health experts to the crisis ahead. One of those experts, Dr. Anne Peters, professor at USC's Keck School of Medicine and an endocrinologist who specializes in diabetes, works both sides of the disease's socioeconomic divide.

Peters has a Beverly Hills practice ... But she also has a second job: supervising teams of workers on the same intensive model at five clinics including the Edward Roybal Health Center in East L.A., and the Hubert Humphrey Health Center in South L.A.

Reducing complications is key to protecting patients and controlling costs. It's not rocket science: lose weight, watch your diet, exercise, monitor blood sugar, blood pressure and cholesterol, take your medications, have regular eye and foot exams.

But often, these simple things aren't done.

Doctors needed

Peters' practice is an exception. She's a private practice doctor who spends as much time with her patients as they need. Her practice follows a team model, with a staff of nutritionists, educators, nurses and nurse practitioners to advise and prod patients via face-to-face discussions, phone calls and e-mails.

"I personally believe that anyone can take good care of their diabetes, no matter who they are or what their level of education," she says. "But they need a team, or at least a guide."

So successful has Peters' method been, that six years ago, she launched a pilot program for the county, supervising a team of professionals trained to educate, monitor and, when necessary, nag. The program took off in four other county centers in 2005.

The treatment team members make phone calls, hold classes, help patients change their diets, prescriptions or medication doses. They will even visit patients' homes to keep treatment on track.

Community members who speak the same language and share the same culture and who have successfully controlled their diabetes are recruited to teach classes and help coordinate care for newcomers to diabetes management. The idea is to allow specialist physicians to become consultants to community-savvy teams who offer up a steady drumbeat of medical attention and lifestyle education.

"It makes more sense to reach out to people where they live 24/7, and not think that a visit every three months to a provider is where all the care happens," says Dr. Jeffrey Guterman, medical director of the L.A. County Department of Health Services.

Before being accepted, patients in the county program sign an agreement that they will keep appointments and follow medical instructions. If they fail to comply, they're out. [editor note - it's hard to evaluate the success rate if failures are excluded. The point of my Capstone is to try to figure out what determines the drop-out rate and address that.]

Because funding is limited, patients can stay with the program only 6 to 9 months, but the expectation is that they can learn to control their disease in that time, then go back to a primary care physician. Those county doctors are ready, having been trained in how to manage diabetes patients.

Early studies suggest that the program works. A report in the April 2006 American Journal of Managed Care looked at how a key blood sugar test, called A1c, was controlled in 367 patients in the L.A. County program the year before and the year after they entered the program.

The A1c guideline was met by only 28% of participants when they were under traditional medical care. After a year in the program, 60% of patients met the blood sugar level goal.

[Effective Diabetes Care by a Registered Nurse Following Treatment Algorithms in a Minority Population -

Conclusion: A nurse making clinical decisions based on detailed treatment algorithms did a better job of achieving ADA-recommended process and outcome measures than physicians providing usual care.

(Am J Manag Care. 2006;12:226-232)

A second study published in February in the journal Diabetes Care found that diabetic patients in the program reduced their use of emergency rooms by half and cut down on hospitalizations. Total hospital charges dropped that year for the 331 patients studied to $24,630, from $129,176 the year before.

[ Effect of a Nurse-Directed Diabetes Disease Management Program on Urgent Care/Emergency Room Visits and Hospitalizations in a Minority Population

Mayer B. Davidson, MD¹, Adeela Ansari, MD¹ and Vicki J. Karlan, MPH

Diabetes Care 30:224-227, 2007]



Peters, ... keeps her private practice going only through donations from grateful, wealthy diabetic patients to a foundation she has started.

The health insurance benefits that her Westside patients have cover visits — generally about every three months. They don't cover extra visits to change medications or search out the reason blood sugar has fallen out of control. They don't cover time spent analyzing complex blood glucose printouts, insulin pump data or teaching patients to adjust insulin and drug doses.

Nor do they cover time for long discussions, phone calls, e-mails or the nutritionist, educators and nurses she employs to advise and prod patients....

---

susan.brink@latimes.com