Thursday, December 31, 2009

On Reflection at the Turn of the Year: 1

The end of the year is a time for remembering and reflecting.  Several things are on my mind these days.

This year I will be hitting several “30’s:” aspects of my professional life that in 2010 I’ll have been about for thirty years.  There are a number of ways in which I know that, but one of them is literally in my hands.

I don’t mean that this theme in my work is simply in my control.  I mean that I can see the evidence in the skin on my fingers.  My skin is always dry, and frequently cracked.

The issue is hand washing, but the point is not hand washing itself.  I don’t want to suggest that thirty years ago we weren’t concerned about washing our hands, or about a safe, sanitary environment.  Still, some things have changed.  We have always had gloves around, and we’ve always used them for sterile environment.  We’ve always washed our hands, but now every room, and almost every wall in the hospital has one variety of sanitizer or other.

We know, of course, what stimulated that change: AIDS.  AIDS has been with us thirty years, too, or almost.  I remember the early days, when we first heard about “the Haitian disease,” and then about GRID.  Point by point we learned more about this disease.  Those who cared for the sick learned about one opportunistic disease after another.

Eventually, we learned about the virus, HIV.  However, all along we have been washing our hands.  We found by experience that it worked; that is, that health care workers who followed good procedures, including washing their hands and wearing gloves, didn’t get sick.

Not everyone got that message, even once the virus had been identified.  I remember attending the death of a young man from Kaposi’s sarcoma.  A good nurse almost lost her wits when I laid my hands on the young man’s head to pray.

Again, it wasn’t that we weren’t washing our hands before, or wearing gloves in circumstances we thought to need a sterile field.  However, we were making assumptions, and based on those assumptions were washing our hands less, and especially using gloves, less.

We were also washing them out of the sight of the patient.  While much of the time that was because the sinks were simply fewer and farther between, sometimes we did it intentionally.  We did it intentionally with AIDS patients.  Some AIDS patients, already suffering stigma related to their disease or hiding their disease to avoid it, felt that washing hands in their presence suggested that they were somehow “dirty.”  So, to avoid adding to the stigma, or making more uncomfortable patients who were anxious enough already, we didn’t wash our hands in front of them.  We certainly washed our hands, both before and after seeing the patient.  We just did it out in the hall.

We also began to speak of such precautions as being really appropriate all the time.  We began to speak of “universal precautions,” appropriate for all conditions and not simply for AIDS.  Precautions weren’t a comment on the patient, but an effort to keep all patients and all caregivers safe.

In the intervening years that provision has been shown to be wise.  A range of other conditions – resurgent TB, and its drug resistant forms; SARS; Bird Flu; and most recently Swine Flu – demonstrated the propriety of having precautions that were truly universal.  In the meantime, with new medications and better knowledge we discovered AIDS was a disease one could live with, not simply die of.  So, in thirty years even our language has changed.  We now speak not of “universal” precautions but of “standard” precautions; and good hand washing has been complemented with hand sanitizers in various forms in hospitals and homes and virtually everywhere.

And so my hands are always chapped and dry, but my patients and my colleagues and I are safer.  I’m conscious of that a certain prejudice contributes to that: I could use hand cream, but I was raised with the sense that rough hands were a sign that someone actually worked for a living.  I also wonder sometimes whether extending standard precautions from hospital and kitchen to everywhere won’t have other less favorable consequences (Hygiene Hypothesis, anyone?  I wonder….).  But I wash my hands, and rub on the alcohol foam and gel.  And I’m conscious of the changes I’ve seen in my work in thirty years – changes I can literally see in my hands.

Tuesday, December 29, 2009

One Story of a Market Oriented Approach to Health Care

I know that I’ve been quiet here, what with the holidays and all. That doesn’t mean, though, that I haven’t been paying attention. In the midst of all the holiday stuff there have been continued to be some good reporting on health care in the United States. While most of that has centered on the Senate’s bill, and now prospects for reconciliation of the House and Senate Bills in conference, there have still been some valuable stories on the provision of health care.

Like this one from NPR’s All Things Considered. Titled "How A Bone Disease Grew To Fit The Prescription," it’s worth your time (you can read or listen here). It describes how a drug company virtually created a market for a new drug. It’s not that there wasn’t a market at the beginning, but it was small and not very profitable. This is the story of how the drug company moved to create a market, with results we see in television ads virtually every day.

In the process, a number of things happened that are typical of how health care works in a "market approach." The company supported research – but primarily research that supported the need for drugs like the one they were marketing. It worked with doctors, but especially to induce them to prescribe radiology studies that weren’t necessarily all that valuable (and perhaps not worth the incremental radiological risk). It lobbied Congress, so that eventually Medicare and other insurers would pay for all of this. Note that in all of this the company did nothing illegal. As to whether it was unethical – well, that’s another question.

I have said before that part of the problem of our health "system" is a view that health care is a retail item, rather than a public service. That’s where a "market approach" to health care continues to take us, until we make some other provision. This story provides a good object lesson why simply "trusting the market" would likely continue to expand our costs and our exposure to care we just might not need. So, take a few minutes for the story.

Thursday, December 24, 2009

Merry Christmas to All

It has happened once again:

Once in royal Davids city,
Stood a lowly cattle shed,
Where a mother laid her Baby,
In a manger for His bed:
Mary was that mother mild,
Jesus Christ, her little Child.

He came down to earth from heaven,
Who is God and Lord of all,
And His shelter was a stable,
And His cradle was a stall:
With the poor, and mean, and lowly,
Lived on earth our Saviour holy.

For He is our childhood's pattern;
Day by day, like us, He grew;
He was little, weak, and helpless,
Tears and smiles, like us He knew;
And He cares when we are sad,
And he shares when we are glad.

And our eyes at last shall see Him,
Through His own redeeming love;
For that Child so dear and gentle,
Is our Lord in heaven above:
And He leads His children on,
To the place where He is gone.

Wednesday, December 23, 2009

As Advent Ends

It has been, this year, an – well, let’s say odd – an odd Advent. Something has been not quite right.

It has been different this year. After some years away from it, my Best Beloved is working in nursing again. That has changed our schedules – hers because of her work schedule, and mine because it’s rearranged how we divide up household responsibilities; and mine, too, simply because on many days my schedule is more flexible.

Veni, veni Emmanuel;
Captivum solve Israel,
Qui gemit in exilio,
Privatus Dei Filio.

Gaude! Gaude! Emmanuel,
Nascetur pro te, Israel!

It’s been busier, and so things haven’t happened at their accustomed pace. Our Christmas tree did not get brought in until 4th Advent. Now, once upon a time that was because of my insistence that really appreciating Advent required holding of on symbols of Christmas, including the tree. (One year we waited until 4th Advent to put it up, and until Candlemas to take it down. Boy, did we vacuum needles that year!) This year it was simply because when we weren’t too busy, we were too tired.

Gifts are purchase, and, blessedly, family members have made that easier. My sons have made me proud, asking for contributions to charity in their names rather than gifts. They’re certainly right that they don’t really need things, and that others do; but others in similar circumstances still have their lists of toys, adjusted for age and income. So, I appreciate them. Still, if it hadn’t been simpler I don’t know quite when or how I’d have done what I wanted to do.

Come, O come, Emmanuel,
and ransom captive Israel,
that morns in lonely exile here
until the Son of God appear.

Rejoice! Rejoice!
Emmanuel shall come to thee, O Israel!

But what I have noticed most is something smaller, more intimate. I haven’t been singing. I have written at other times of the importance of music, both to console a mood and to create one. In years past as I walked the halls of the hospital I would sing, softly but clearly. I sang for me, primarily, although not so softly that others couldn’t hear. I sang hymns, primarily, and carols for the season. And this year as I’ve run from place to place, I don’t recall singing.

Veni, veni Emmanuel;
Captivum solve Israel,
Qui gemit in exilio,
Privatus Dei Filio.

Gaude! Gaude! Emmanuel,
Nascetur pro te, Israel!

It has been better this week. There is something about the lessons for 4th Advent that turn the corner in my mood, as they are intended to turn the corner in our observance. I preached yesterday on the Visitation, and how it was in many ways our response to Thomas the Forensic (not “Doubting” so much as “Proving”). The concreteness of the kick of an unborn child is in itself confirmation of hope – a confirmation so intimate and so real, even for those of us in the half of humankind who can only feel it from the outside.

And there is today. There are still some 40 hours or so of Advent. There is still some time to hope and to sing and to prepare.

Come, O come, Emmanuel,
and ransom captive Israel,
that morns in lonely exile here
until the Son of God appear.

Rejoice! Rejoice!
Emmanuel shall come to thee, O Israel!

Watch. Wait. Hope; for the day of the Kingdom is at hand.

Friday, December 18, 2009

The Covenant Cometh

The Anglican Communion Office has released today the final draft of An Anglican Covenant, the one that we have awaited for some time. Section Four continues to be part of it. There is need for a more analytical comment, but now that it’s out I have my own thoughts about next steps. Let me say that these are things I hope for, however faint that hope might seem, and not a plan I might propose.

First, I hope that the Episcopal Church as institution will make no immediate comment except to note the release and express interest. (Sure, a great many of us as individuals will comment with heat and at length. I’m talking about the institution here.)

Second, I hope that we will indeed study this carefully between now and General Convention in 2012. However we might feel about it at this point (and, no, I don’t care for Section Four either), out of respect for other national and provincial churches in the Communion, many of whom want to maintain communion with us and might also be interested in the Covenant, we need to take the time and make the effort. (Based on past history, I think we’re more likely to actually study it than many.) This should include exploring whether in fact we could theoretically sign on without affecting our Constitution and Canons.

Third, I hope we will bring this to the 2012 Convention. Specifically, I hope we will bring it piecemeal: that is, I think we should consider in separate resolutions the Introduction and Preamble, Sections One, Two, Three, and Four, and the Declaration. Frankly, I don’t think Section Four would have passed in this past Convention in Anaheim, and I don’t expect it will pass in Indianapolis, either. However, I see no harm and significant good in affirming each section that we can, even if we cannot affirm the Covenant as a whole and sign on.

It’s out. We can read what Canterbury wants us all to agree on. I hope our official responses will be measured and careful. In the meantime, let the shouting begin.

Wednesday, December 16, 2009

Some Reporters Just Make You Wonder (or Just Sigh)

Well, I said in my last post that I wanted to see the article on cholesterol and women, and now I’ve been able to. Well, sort of: I haven’t been able to access the article itself, but I have been able to read the abstract. Having done so, I’m left with one conclusion, one that I’ve expressed before: I continue to be appalled at how the public press picks up on research.

Here is the citation: Matthews, Karen A., Crawford, Sybil L., Chae, Claudia U., Everson-Rose, Susan A., Sowers, Mary Fran, Sternfeld, Barbara, Sutton-Tyrrell, Kim: “Are Changes in Cardiovascular Disease Risk Factors in Midlife Women Due to Chronological Aging or to the Menopausal Transition?” J Am Coll Cardiol 2009 54: 2366-2373 (Abstract here). The research actually was part of a study on women’s health. This is the critical paragraph of the abstract:

Methods: SWAN (Study of Women's Health Across the Nation) is a prospective study of the menopausal transition in 3,302 minority (African American, Hispanic, Japanese, or Chinese) and Caucasian women. After 10 annual examinations, 1,054 women had achieved an FMP [final menstrual period] not due to surgery and without hormone therapy use before FMP. Measured CHD [coronary heart disease] risk factors included lipids and lipoproteins, glucose, insulin, blood pressure, fibrinogen, and C-reactive protein. We assessed which of 2 models provided a better fit with the observed risk factor changes over time in relation to the FMP: a linear model, consistent with chronological aging, or a piecewise linear model, consistent with ovarian aging. (emphasis mine)
So, the point of the study was to determine which would be more predictive, and therefore more useful: whether the woman had entered menopause, or her age. Note that all the women who had experienced menopause had done so “not due to surgery;” nor had they delayed the experience of menopause with hormone therapy. So, these were women who experienced menopause specifically in their natural course.

In fact they determined that for several measures of cholesterol, menopause was more predictive than age, while for other risk factors age was more predictive. However, in neither case was there any implication that menopause wasn’t “natural;” only that in the natural course of things different women experienced it at different ages.

So, the bizarreness of the article (picked up apparently uncritically by was a misreading of the journalists instead of a misstatement by the scientists. That’s not a surprise to me, but it highlights the continuing issue: good research gets misreported in the public press in a way that doesn’t serve the public.

Sunday, December 13, 2009

Some Stories Just Make You Wonder

My Best Beloved brought this to my attention.

CNN picked up this story from “Cholesterol jumps with menopause, study shows.”  It begins thus:

Doctors have known for years that a woman's risk of developing heart disease rises after menopause, but they weren't exactly sure why. It wasn't clear whether the increased risk is due to the hormonal changes associated with menopause, to aging itself, or to some combination of the two.

Now, we have at least part of the answer: A new study shows beyond a doubt that menopause, not the natural aging process, is responsible for a sharp increase in cholesterol levels.

This seems to be true of all women, regardless of ethnicity, according to the study, which will be published in next week's Journal of the American College of Cardiology.

My best beloved read this and came to find me, laughing.  Let’s take a look at that second sentence:

Now, we have at least part of the answer: A new study shows beyond a doubt that menopause, not the natural aging process, is responsible for a sharp increase in cholesterol levels.

So, just when, we asked one another, did menopause cease to be part of the natural aging process for all women?  And if we needed any reaffirmation of that question, the next sentence is, “This seems to be true of all women, regardless of ethnicity, according to the study,…”

I have to tell you, I just can’t wait to get a look at this study….

Friday, December 11, 2009

At Episcopal Cafe: Another Difficult Question

My newest post is up at the Episcopal Cafe.  It's another of the hardest questions, but one that I think we as Christians have to face, and especially as we consider how to provide health care for all.

My friend and colleague Rosemary Flanigan of the Center for Practical Bioethics says that ,"there is no objective “harm” or “benefit” in utilitarianism."  Well, perhaps that's true in the abstract.  I would suggest, however, that when we get to application, and especially when we as a body politic get to application, issues of "harm" or "benefit" become very personal; and so do the decisions.

Tuesday, December 08, 2009

Flashing Lights Across the Sky

We have received today the communiqué released at the end of the meeting of the Inter-Anglican Standing Commission on Unity, Faith and Order (IASCUFO). They have completed today a meeting that began on December 1. The release is certainly timely. Yet somehow I wonder if it isn’t already too late.

The communiqué recalls the origins of the Commission:

The Commission has been established by the Lambeth Conference, the Primates’ Meeting, and the Anglican Consultative Council. It builds on previous work done by the Inter-Anglican Theological and Doctrinal Commission, the Inter-Anglican Standing Commission on Ecumenical Relations, and the Windsor Continuation Group. It reports to the Standing Committee of the Anglican Communion.
Now, like many, this origin story is a bit expanded. The Commission was approved at Canterbury’s request by the Joint Standing Committee of the Anglican Consultative Council and the Primates’ Meeting. While one could argue that that suggests representation by all the Instruments of Communion, it really bypasses full representation (and when did we start calling the Joint Standing Committee “the Standing Committee of the Anglican Communion?”).

Over all, the communiqué is largely a report saying, “We met.” This was a first meeting, and the most important activities were matters of getting to know one another and to learn about one another’s contexts. They met, of course, with the Archbishop of Canterbury, and shared with one another in Eucharist. Beyond that (and as meaningful as those activities were), they didn’t do a lot of work in this meeting.
The Commission had a daunting enough task at its inception:

Mandate of the Inter-Anglican Standing Commission on Unity, Faith and Order
The Standing Commission shall have responsibility:
• to promote the deepening of Communion between the Churches of the Anglican Communion, and between those Churches and the other Churches and traditions of the Christian oikumene

• to advise the Provinces and the Instruments of Communion on all questions of ecumenical engagement, proposals for national, regional or international ecumenical agreement or schemes of co-operation and unity, as well as on questions touching Anglican Faith and Order

• to review developments in the areas of faith, order or unity in the Anglican Communion and among ecumenical partners, and to give advice to the Churches of the Anglican Communion or to the Instruments of Communion upon them, with the intention to promote common understanding, consistency, and convergence both in Anglican Communion affairs, and in ecumenical engagement

• to assist any Province with the assessment of new proposals in the areas of Unity, Faith and Order as requested.

However, in this meeting it found some additional issues requiring “immediate” attention:

1. to undertake a reflection on the Instruments of Communion and relationships among them;

2. to make a study of the definition and recognition of 'Anglican Churches' and develop guidelines for bishops in the Communion;

3. to provide supporting material to assist in promoting the Anglican Covenant;

4. to draft proposals for guided processes of ‘reception’ (how developments and agreements are evaluated, and how appropriate insights are brought into the life of the churches);

5. to consider the question of ‘transitivity’ (how ecumenical agreements in one region or Province may apply in others).

These tasks, which will be taken forward by working groups consulting electronically between meetings, aim to strengthen the unity, faith and order of the Communion.
Unfortunately, even an immediate response may not be fast enough. Things are changing that will, I fear, overtake the work of the Commission. The Commission itself made note of the election in Los Angeles of two bishops suffragan, one of whom is a partnered lesbian woman. The communiqué echoed Canterbury’s response to the election with a request for “gracious restraint” (and I would be very interested in comments on that statement from the Commission members from the Episcopal Church, as well as from Southern Africa and Aotearoa/New Zealand/Polynesia). Should the election of Bishop-elect Glasspool be confirmed (and I think it will; and for full disclosure I think it should), how will Canterbury respond?

Remember, too, that his response will have consequences. If he condemns the Episcopal Church outright (not something he’s been inclined to do so far), there will be reverberations in Canada, Aotearoa/New Zealand/Polynesia, Scotland, Wales, and elsewhere. Should he fail to condemn the Episcopal Church sufficiently, there will be reverberations in Nigeria, Kenya, Uganda, Southern Cone, and elsewhere. If, as he has in the past, he tries to follow a fine line, parsing a statement that is precise but measured, there will be reverberations in all directions. Even in the face of an outright condemnation, I don’t think the Episcopal Church will declare communion with Canterbury broken; but for lack of sufficient condemnation some provinces might.

As a consequence, the Anglican Covenant will be largely pointless. There may still be an effort, but there will likely be too few national and provincial churches willing to sign on for the Covenant to be meaningful. This will become more true the longer “constitutional processes” take for national churches and provinces to even decide whether to sign on or not.

They may still have time for a study of definition and recognition of “Anglican Churches,” if they hurry. However, discussion of anything with as long a horizon as “reception” may well be moot (if that weren’t going to be moot anyway due to the Covenant process).

The communiqué of the Inter-Anglican Standing Commission on Unity, Faith and Order has a hopeful tone about it, even with its paragraph on the election in Los Angeles. Still, for important parts of the Commission’s mandate it may well be too late already. With circumstances changing so rapidly, this “UFO” may well be as elusive as any seen in the night sky.

Sunday, December 06, 2009

Reflection on the Gospel for 2nd Advent, Year C

“In the fifteenth year of the reign of Emperor Tiberius, when Pontius Pilate was governor of Judea, and Herod was ruler of Galilee, and his brother Philip ruler of the region of Ituraea and Trachonitis, and Lysanias ruler of Abilene, during the high priesthood of Annas and Caiaphas, the word of God came to John son of Zechariah in the wilderness.” (Luke 3:1-2)

When I read these verses in preparing to preach, they sounded so very familiar.  Now, in part that was because Luke does this a number of times.  He begins his gospel speaking about Zechariah, John’s father, and notes that events happened when Herod was King in Judea.  More famous is the beginning of his story of the Nativity, when he notes that Augustus was Emperor, and Quirinius Governor of Syria.  This is clearly something Luke just does.

But, I felt there was more to it than that.  This was familiar behavior on Luke’s part, but it also seemed significant for some other reason.  And then it hit me: this was familiar to me because it was evidence that Luke was a physician.  Luke was dating his entries!

Friday, December 04, 2009

Not Gone; Just Doing Other Things

No, I haven't disappeared or lost interest.  I took the whole week off for Thanksgiving, and more; and the short week that I've been back at work has been interesting, to say the least.  However, I'm still here, and there's new stuff on its way.

So, I just finished The Necessary Beggar, a novel by Susan Palwick.  Susan volunteers in chaplaincy, and sometimes writes about her experience at her blog, Rickety Contrivances of Doing Good (which is why I always have her linked to your left).  There's more to know about her, but that's just more reason to link over.

Beggar is science fiction/fantasy, but gives a very interesting take on issues of compassion, love, and faith.  From a clinical perspective, it has a powerful theme of the consequences of shame and secrets in families.  It also portrays the experiences of refugees well, and how folks from other cultures encounter one another (really analogous to the familiar "man from Mars" thought experiment).

So, take a look at Susan's blog, and look into her books.