Ten Pork Chops On The Platter

President Obama's State of the Union address last night struck a responsive cord in me. Predictably, many Republicans objected to the President's plan to finance upgrading the nation's infrastructure, educational system, etc. by increasing the taxes on the richest of the rich. Or by imposing federal taxes on those Americans who move their business offshore and pay no taxes at all.

Such objections bring to memory certain of my fellow Idahoans a decade ago, who insisted on driving their cars on public roads without paying to register those cars. Some even designed their own unique license plates to proclaim their freedom. The roads are there, they reasoned, free for everyone to drive. Whoever built them or maintains them is irrelevant to the present moment.

The claim has been made that the richest 80 individuals in America own as much as the whole lower financial half of the American population combined. Seems pretty wild. Be that accurate or not, there are quite a few billionaires, increasing their wealth by several million dollars per year, while millions of working Americans do not earn enough to feed their children adequately or pay the rent. Let alone those in many foreign nations who subsist on less than two dollars per day.

Many business higher-ups explain that they are worth what they receive because of all the jobs they create, or the charitable foundations they fund. And in some cases they really have enabled whole nations to be free of, say, river blindness or guinea worm, or have funded better education or small business start-ups.

I think that the basic conundrum such explanations ignore is best illustrated by a problem brought to light in the Wisconsin summer resort where I worked in my student days. We served two sittings each meal, about 300 people at a sitting. The view over Green Lake was spectacular, the cooking was good, the people congenial, ten at each table, served family style.

A conference speaker once noted that each table was served a platter of ten pork chops, (or whatever was on the menu), passed from person to person. If one person helped himself to four of the chops, that meant three other people got none, despite his assurance that he gave a lot to charity. Or management's promise to order more pork chops next time.

I think that's what, in Bible times, was called a parable.

The Sleeping Watchman

Making hospital rounds late one night, I happened to find the night watchman lying on a bench, his eyes closed. My first impulse was to wake him up and fire him for sleeping on the job. I spoke with the night-duty nurse, asking how long he had been lying there. She said about an hour; he had complained of a stomach ache earlier, and she had given him some aspirin. We woke him up, I talked with him and checked his abdomen. Two hours later he was in a hospital bed minus his severely inflamed appendix. I was glad I had not given in to my first impulse. I was doubly glad, many years later after I had moved on to other work, to hear from a reliable source that he was now the pastor of the town's church and had increased its membership ten-fold to about one thousand.

I reflected on that incident last night (January 11, 2015) after watching TV's Sixty Minutes presentation about  the ongoing conundrum of how to fix the Affordable Care Act. One interviewee said the good news is that ten million more people now have medical insurance. The bad news is that there's no way to pay for the increasing cost of medicine. I thought at first that the man merely had a knee-jerk Tea Party reaction to increased taxes, but no.

But he went on to enumerate what both parties in Congress have failed to do in the past six (or more) years. No price controls on pharmaceuticals, in order to placate the pharmaceutical lobbyists. No ceiling on lawsuit punitive damages except in Texas and a couple other states, where it has worked very well to keep down cost of medical malpractice insurance. That was to please the lawyers. Hospital overcharges, usually summed up in a few lines on your bill. All three of my own daughters are RN's with executive hospital experience, and they give me long lists of ways to cut hospital charges, from the price of a single pain pill, to the cost of "spare no expense, doctor!" in prolonging the life of an obviously terminal patient in the critical care unit. Read your hospital bill, and ask for an itemization. Question the necessity of multiple tests.


Is there any logical reason why a medicine manufactured in USA should be twice as expensive as it is across  the border in Canada (or anywhere else)? Is there any reason why the VA or any other government agency should be forbidden from seeking mass discounts on purchases of drugs or medical equipment?

Americans do not have "the best medical care in the world." By and large it's good care, but not the best. Congress often behaves like I almost did with my "sleeping watchman." More often they act like sleeping watchmen themselves, be they Republican or Democrat .

These topics and others are expanded in my 2008 book Access to Medical Care, available on line and on Kindle.
Your comments are welcomed.  Keith Dahlberg MD

The Cold War Comes to Burma

Given the present interchange between Russia's Vladimir Putin  and President Obama, the following true story from 1961 may be of interest.

2 p.m. February 15, 1961: Squadron-Leader Tin Maung Aye, accompanied by the commander of the 5th Kachin Rifles, Major Aye Win, were flying reconnaissance in a Burma Air Force Cessna southeast of Kengtung. Over the Mong Hpayak area, they spotted a field with strips of cloth laid out to spell “D Z” and realized that the Kuomintang forces were preparing a supply drop zone. They returned to Kengtung airstrip and sent up three BAF fighter planes with orders to force any KMT aircraft they encountered to land at Kengtung. The squadron patrolled the area for about a half-hour with no success. Then, just when they were about to return to base, they spotted a green four-engine plane enter Burmese airspace from the south and make two air drops. Squadron-leader Maung Thein radioed the intruder to identify itself but got no reply. The three Burmese Sea Fury fighters closed in and were fired upon but not hit. When they fired back, the intruder made a U-turn, heading for Thailand. In a second pass, both the intruder and one fighter were damaged and crashed just inside Thai airspace. The Burmese pilot, Noel Peters, died in the crash. One of the other fighters managed to reach Kengtung with part of its tail shot away, the third fighter was undamaged..

The Burmese army and the KMT often fought on the ground but this was their only air battle, at least during the years I lived in Kengtung. The KMTs, of course, were the remnants of General Chiang Kai Shek’s anti-Communist Chinese forces supported by Taiwan. They had had little effect on the Chinese Communist army since the 1949 Communist takeover, but often harassed the Shans and mountain people of Kengtung State.

Radio Voice of America that night announced that the Burma Air Force had shot down an unarmed plane bearing relief supplies to refugees in Northeast Burma. I could see the damaged fighter parked beside the local airstrip, and the Burmese newspapers were full of reports of the battle and the death of Pilot-Officer Peters. I knew VOA had it wrong, possibly misinformed by Taiwan, its ally in the so-called “Cold War” of communism vs. democracy in the mid-twentieth century.

By the time Burmese officials could inspect the wreckage across the border in Thailand, KMTs had stripped the four-engine plane of identifying markings and equipment. It appeared to be a modified World War B-24.

A Taiwanese group calling itself the Free China Relief Association acknowledged chartering the plane to supply “Chinese refugees.” Taipei news editorials compared the overflight of Burma to America’s use of U-2 spy planes over Russia, said the flights would continue and “if we are caught, we are caught.”

A week later the Burma Air Force flew military attaches of the United States, India, Indonesia and Thailand to Kengtung to inspect the damaged BAF fighter, and then on to Mong Paliao near the Laotian border, where they had recently captured a KMT base. There, reporters saw 75 mm guns, machine guns, mines, ammunition, radios and fuel drums, all bearing United States markings. The Nation, an English-language Rangoon newspaper, printed a photo of one label: “Commanding Officer, Erie Ordnance Depot, Port Clinton Ohio, TO: Officer in Charge, Air Freight Terminal, Travis AFB, California”. A Burmese reporter noted the American officials paid closest attention to equipment several years old, and said it could be bought by anyone at any surplus store. The reporter said they made no comment on items manufactured within the past year.

Burma had enough trouble fighting its own insurgent armies in those years without involving itself in conflicts between world powers. It wanted no part either of the United States and its allies, or of China and the Soviet Union. It declined foreign aid from either side whenever possible, and distanced itself from both. References to the “American Way of Life” made little impression in Burma. Burmese could read reports of American racial problems as well as anyone else, and were familiar with Russian maneuvers as well. No one could prove the United States knew what Taiwan was up to. But some thought that if it didn’t know, then of what use was the CIA?

In any case, there were protest demonstrations in front of the U.S. Embassy in Rangoon. A crowd of 3,000 demonstrators got out of hand. Before police controlled the riot, two demonstrators died and fifty three were hospitalized. Things quieted down until two months later, when U.S. Senator Fulbright publicly declared that he didn’t think it a good idea to send American boys to the jungles of Laos. The terrain was not suited to them, he said; better for them to fight in Vietnam, Thailand, or Burma.

Russia showed the world that it could make equally bad foreign relations blunders. In April 1959 TASS, the official Soviet news agency, implied that a prominent Burmese newspaper editor was in the pay of the U.S. Embassy. The TASS correspondent must have been dismayed when many Burma newspapers published front-page blasts against him personally and started two lawsuits for libel, pointing out that the source he quoted didn’t even exist.

About the same time, the Russian military attaché entered Rangoon General Hospital and, according to news reports, tried to pass along information (nature unknown) to Burmese Intelligence. He then jumped from a hospital window in an apparent escape attempt. His Russian comrades caught him and hustled him back to the Soviet Embassy, and from there to the airport at Mingaladon. Several reporters tried to question him there while he was being put aboard a plane, and his Russian escorts beat them up. Even pro-Communist Burmese newspapers then united with other Burmese to denounce the Soviet Union, and about forty reporters gathered at the Soviet Embassy to hurl tomatoes. The Russians emerged armed with broken chairs and joined battle. Police soon stopped the fight, but the Burma press gleefully pointed out that in Russia, May 5th is celebrated as “Freedom of the Press Day.”

It is not surprising that for many years Burma’s attitude toward the world powers was, in effect, “A pox on both your houses!”

A Shan Christmas Greeting

My Internet connection has been shut down for three days for something in the regional system, but is apparently fixed tonight. I have been working on a new book during the past two months, and have had few new posts. While working on the new MS, I shall bring a few stories from the past for your interest: the following is a Christmas letter home from Kengtung in Myanmar's Shan State, that I wrote fifty-five years ago - a different slant on the holiday.

Christmas in Kengtung December, 1960

Merry Christmas to all of you! There is no snow and few Christmas trees in Kengtung, but we are all looking forward to a pleasant time. Here, everyone visits everyone else and the Shan Christians are holding open house for the whole city, whether Buddhist, Animist, Christian or Muslim, and have bought more than one ton of noodles to feed the crowd. (Shans' favorite dish, called hkao sein, is a sort of spaghetti and meat sauce, though the spices and flavor are different from the Italian kind.) At the same time, they will have exhibits and movies in the church to tell non-Christians about the birth and life of Christ.

Susie, Patsy and Johnny are very impatient for Christmas to come. Already Susie is getting suspicious of the Santa Claus theory, though she is only six. The trouble is that all her playmates have been skeptical from the start, since they'd never heard of such an idea till Susie told them, and certainly had never ever experienced a visit from Saint Nick. Susie is also in the school pageant, and Patsy would very much like to be, just as she always wants to go to school, but she is too little for either. John, at the age of two, still takes things pretty much as they come.

Christmas Eve brings to mind the unsettling experience we had last year of being serenaded by a large number of drums and Scottish bagpipes at three in the morning. (At that hour, even one of each is a large number but there were more than that.) We awoke to the crashing strains of "For He’s a Jolly Good Fellow" outside our window, led by a bandmaster who kept time by loudly clapping his hands to the beat. Presumably, some of the Regimental Band members whose children had been treated at the hospital got together to celebrate with a few drinks and decided, "Let's go serenade the Doc." At three a.m., I'm afraid I could do nothing more cordial than pull the blankets over my head and pretend I was sleeping through it--quite an illogical pretense now that I think of it.

Everyone in Kengtung enthusiastically celebrates any holiday, including Christmas. No one refuses an extra chance to celebrate, especially one with all the pageantry the Burma Christians put into their celebration of Jesus' birth. Electricity is limited, but Christians decorate the outside of their houses by hanging dozens of lighted candles inside colored cellophane cylinders, to rival the Buddhists' October festival of lights.

Everyone holds open house. No one could possibly attend everything. One Christmas we were fed at seven different homes, and regretfully turned down an equal number. And that's only in Kengtung. We try to spend Christmas eve or part of Christmas day with our colleagues Paul and Elaine Lewis, seventeen miles up the mountain at Pangwai, and there are more invitations from neighbors there.

Many groups come caroling; some know little more than "Merry Christmas To You," (same tune as the birthday song). Others try an American melody or two when they get to our house, maybe in tune, maybe not. One group offered, "I'm dreaming of a white Christmas, just like the ones you used to do," and then faded into confusion as they tried to recall what rhymed with that. The older students at the school which Susie attended stay up all night, warming themselves around a fire, serenading neighbors and gratefully accepting cups of hot tea or cocoa from those who were still up.

The gifts are sometimes embarrassing. We have so much more of material goods than most of our neighbors, and are given so much more. People bring us baskets of oranges, eggs, or a live chicken on a bed of rice. We reciprocated with baskets of cookies or banana bread, and held a dinner for the hostel students. The ruler, Sawbwagyi Sao Sai Long himself, stopped by with a basket of avocados one Christmas, and our next-door neighbors sent us a live fish all Christmas-wrapped. (There was no doubt of its freshness at least). We put it in a tub of water where Susie and Patsy watched it wave a fin at them as it swam lazily back and forth.)

The more cosmopolitan mission compound church holds Christmas morning services in simultaneous translations into Burmese, Shan, Lahu and Chinese, but its main event is the Christmas pageant. Susie was in the angel chorus one year, her blond head standing out among the little Shans and Lahus, and Lois and I of course had to attend all three performances that season. The first night, the pageant ended very impressively, with people of all the ethnic groups of Kengtung bringing their gifts to baby Jesus as the music built to a climax. The second night, when VIP arm chairs had been assembled and the first two rows were filled with invited city elders and assorted officials, the pageant director seemed to feel that more was needed.

The curtain drew to a close on the final scene. Moments later it opened to reveal four schoolteachers, each with one foot propped on a chair, guitars at the ready. I had a premonition of disaster, which was confirmed when the quartet broke into a spirited version of "Old MacDonald Had a Farm" complete with sound effects. I don't know what the visiting officials thought. I privately thought the director had lost his mind.

Christmas is also a time for reflecting how many people here have still not been reached by God. The thirty-year-old man dying of cancer, the boy half-crazed with fear after threats of torture by rebel soldiers, the woman who believes her disease is an evil spirit eating her insides--what do you tell them? The idea of a loving God who cares for them is so foreign to all they have been taught, and seemingly is refuted by the very situation in which they find themselves. It's not easy to try to explain, even in one's own native language. Still, it's not all discouraging. This week, a ten-year-old boy opened his eyes to see for the first time in three years, after getting the vitamin A he had so badly lacked. A middle-aged clerk, out of work for seven years because of his swollen draining tuberculous knee, now walks free of pain because of what, with God's guidance and help, you and I have done for him. The salvaged are rather few, but we must continue to do what we can. May God bless you all during the coming year.

John Tharp, Coincidentalist

After closing my Pinehurst, Idaho, office medical practice in 1993, I spent the next eleven years as a part-time locum tenens ("rent-a-doc"), traveling to fill temporary vacancies in doctors' offices or hospital emergency rooms. In 1999, I worked several weeks in St. Francis, Kansas, a small town far in the northwest corner of the state.

 

It's a pleasant little town in semi-desert; the hospital took good care of me, providing free lodging in a home whose owner was on vacation. But the house badly needed cleaning and I later moved to a motel out on highway 36. I was up early next morning, and searching for some place to eat. I could see a gas station a quarter-mile down the highway, and figured I could at least find coffee there, so I started walking toward it. 

 

Midway, I met a man of about 50 coming toward me with a cup of coffee. He stopped and said in amazement, "I know you! We were at board meetings together in Philadelphia!" He was staying at the motel, traveling by bicycle from Utah to Illinois. We had served together on the American Baptist Foreign Mission board several years before, but had not met since then.

I know that New Yorkers boast that if you stand at Times Square long enough, you will see someone from back home. But in a town of 1,300 on a two-lane road where Kansas, Nebraska and Colorado meet? What are the chances that one day two acquaintances, one from Idaho and one from Illinois, will walk into each other along the shoulder of the highway?

John Tharp and I had breakfast together, and later that morning he rode his bicycle into town to see the hospital where I was working, before continuing his journey eastward.

I have occasionally wondered, in the ensuing fifteen years, whether God had had a purpose in that meeting. I have not perceived any reason in my own life, and finally, I wrote John to see if he was aware of any in his.

In his reply, he said he, too, remembered the incident and also wondered about a reason. He had not detected any, but said that, after a number of such coincidences in his life, it has often entered his mind that "God loves to show off." [I myself prefer to think of it as God's sense of humor, but anyway . . .] he went on to say that this may be a way that God alerts us to what He can do, to keep us ready for the occasional time when He does indeed want action from us.

John's observation brought to mind an incident in Mae Sariang, Thailand in 1965, when the new hospital was ready to open except that we lacked nurses. The following report is from my journal of that year:

"We had a bit of drama in the three mission families’ weekly get-together two weeks ago. We were praying that the hospital would soon have some nurses, only to be interrupted by a man at the door asking where he should put some girls' luggage. One of the girls, our friend Orawan who spent some time with us last month, was only visiting, but the other, Yawalak, is now our first full-time graduate nurse-midwife. This afternoon (nearly two weeks after that prayer, for the scientifically minded) a motorcycle pulled up with another nurse riding on the back. Gaysala is just looking the place over today, but will be back permanently on Saturday. Later in the afternoon, two others appeared entirely unexpectedly. They said they were graduate nurses working in Mae Hongson [the provincial capital, about a hundred miles north] and were interested in transferring to MaeSariang where their homes are. The upshot is, one will probably come and work; perhaps the other will come later. With one or two others we expect in the next several months, we will soon have a full nursing staff (and an empty hospital bank account.) As for unskilled workers, two or three new ones apply every day and we can afford to be a little choosy for that group."

My dad sometimes would remark, "When people pray, coincidences happen more often." I'm inclined to agree.

The Medicine She Never Took

"My doctor gave me a new medicine for my stomach pain," a friend answered when I expressed hope that she was feeling well. "It works fine, but I can't take it." 

"I'm sorry to hear that," I said. "Too many side effects?" 

"No, the samples he gave me helped a lot. But when I took his prescription to the pharmacy, a month's supply was four hundred dollars. That's almost half my Social Security check! How am I going to pay my utility bills and buy my groceries? So I'll just keep on with the antacids."

"Did you tell your doctor you couldn't pay that kind of price?"

"I phoned him, and he said he had no idea it was that high."

"Did you ask him about any of the over-the-counter medicines? Some of them are about one-tenth that price, or less."

"No, I didn't know anything about that. He had his nurse make me an appointment for two weeks from now for follow-up. But I never had the prescription filled when I found out the cost."

If you think that's an isolated example, another patient had had at least six back surgeries over the years (laminectomy) and no surgeon would now touch his scarred back. His local doctor was trying to manage the pain with various pills and patches, some of which eased his steady pain, but not the "lightning spasms" that struck when he moved wrong. Additonally, over the years, he had developed unacceptable reactions to some of the medicines, and the doctor was trying a new one. His medical insurance refused to pay for it. The doctor's office clerk said she would try and straighten the matter out, and would call him back. She never did, nor even to let him know the problem. He finally called his pharmacist to see if he could afford to pay for it himself, and found to his horror that a month's supply was $525.00, half his entire monthy income. Presumably, the doctor's clerk could have found that out, but if she did, she never let him know. 
 

These illustrate a basic flaw in the American way of marketing medicines. The manufacturers have well-paid "detail persons" who make regular calls at each and every doctor's office to inform him/her about their company's latest and most advanced product. They sometimes used to appear around noon, with enough pizza for the whole office staff. Friendly people, well trained and informed in their field, they are a principle source of information for busy doctors who don't spend as much time as they might with medical journals and Internet search. The pharmaceutical rep has free samples to leave with the doctor, along with note pads or pens bearing the product's name.

Sometimes they really do have valuable updates for the doctor, but they rarely mention the price of their product, or that the older remedies still work as well as they always did. And the doctor will try the samples on his patients because (a) he doesn't want them to buy a whole month's supply of any medicine unless he knows it works for them, and/or (b) he may want to help a patient he knows is having difficulty affording care. 
 

Most doctors don't keep up with the present-day price of what they prescribe. But they could. Every doctor gets an annual free update of Physician's Desk Reference listing all prescription medicines with their uses, side effects, and precautions (about 4,000+ pages—old copies make good doorstops), and a supplement with all the non-prescription medicines is available as well. Plus an annual update of Redbook (not the women's fashions one, but current drug retail prices) with the option of subscribing to monthly updates.

So - here's what a patient can do. Don't be afraid to ask what a new prescription will cost, and if necessary, ask if there is a less expensive generic that will be adequate. Sometimes there will be, sometimes not. 

And Doctors, here's what you can do. Be aware that the latest drug is pushed by the drug rep because that's what he/she is hired to do. It's good to keep that product in mind, but ask yourself, "Is this what this patient sitting here in front of me really needs, or will an older, less expensive drug be effective?" And stay away from reps who want to buy you meals or pay for a vacation trip. Your patients have to pay for that in the cost of their medicine.

And all you readers in the general public, pressure your reps in Congress to reasonably regulate the charges for medicines. Why should a drug that has been on the market eleven years now cost fifteen dollars per pill when the company was raking in high profits at the original price of ten dollars per pill? Why should an injection aimed at mass use be selling for thirty-five dollars, when it originally wholesaled forty years ago at one dollar? Or why should a drug, manufactured in USA, sell for less in Canada or Europe than it does here where it was made?

Even in a free market economy, the customer should get as much consideration as the company's stock holders get.

Understanding an Unchanging God

One concept shared by many of the world's major religions - Christian, Muslim, Jew, at least - is that of God, eternal, unchanging, creator of the universe (in the Bible, for example, in Psalm 90, v 2; or Isaiah ch 40 v 28). Instinctively, we accept the basic forces of the universe - gravity, motion, heat, light, etc. - as dependably stable and unchanging. Such things, as best we can learn, always behave the same, day after day, year after year.

There are some sincere Christians who believe that the Bible is word-for-word [in the original language] direct dictation from God, not subject to interpretation: "The Bible says it, I believe it, that settles it!"

This raises some questions: Have they ever read the whole Bible themselves? And for those who have, do they ever think about what they have read? And do they take into consideration how much the meaning of words change from generation to generation, let alone century to century?

A Pharisee asked Jesus what is the greatest commandment in the law; Jesus readily replied (in Mt 22: 37 - 40 NRSV): "Love the Lord your God with all your heart, with all your soul, and with all your mind." It is okay to use your mind, to think about what you read, and ask questions about interpretation.

Consider the story of Creation in Genesis Chapter 1: "the earth was a formless void and darkness covered the face of the deep, while the spirit of God swept over the face of the waters. Then God said, 'Let there be light'; and there was light." Modern scientists would agree with the beginning of the creation story; they would envision a plasma of subatomic particles, but in ancient times "waters" would be the closest word in human vocabulary, and the "big bang" certainly produced an instantaneous, massive burst of light.

The Bible itself modifies the concept of all creation taking place in six days: (Psalm 90 v 4: For a thousand years in your [God's] sight are like yesterday when it is past, or like a watch in the night.

Some of Moses' laws in the Old Testament have changes even by the time of the New Testament:

Exodus 21, the next chapter after the Ten Commandments: the laws about slave ownership. The history of slavery goes from "anything is permitted" to "owner and slave both have the same master . . ." And nowadays, slavery is not permitted at all in most nations.

In Leviticus ch 11: the laws about food declare many animals unclean and not to be eaten. Has God changed his mind about these? In Mark 7:19, Jesus declared all foods clean.

Deuteronomy 21 v 18 - 21: The law for a disobedient son: Stone him to death. Not legal nowadays in any country that I know of.

Deuteronomy 22 v 28 - 29 - The law about rape victims. The rapist shall pay the girl's father a fine; The rapist shall then marry her, and cannot ever divorce her. But where is justice for her?

Slavery was justified for centuries by quoting Genesis 9, where one of Noah's sons, Ham, somehow offended his father, and his descendents were cursed to forever be the slaves of the descendents of Noah's other two sons. Did Noah's curse justify slavery, thousands of years later? Southern Baptists, many of whom are descendents of slave owners, finally issued an official apology 120 years after slavery was abolished in America.

The history of vengeance, from maximum force, through eye-for-an-eye, to forgiveness and loving your enemy: Is the world ready yet for peace? Can we handle it? There are many such questions that could be discussed.

But the central question is, Does God change?

Is not the Bible a history, rather, of the changing human understanding of the eternal unchanging God, down through the ages? (and also, perhaps, the history of God eternally reaching out to humans, waiting for them to trust and obey?)

And on into the future? There is a hymn sung by some Christians; not a quotation from the Bible, but a thought worth pondering, nevertheless. Written by poet James Russell Lowell, one verse goes:

By the light of burning martyrs, Christ, Thy bleeding feet we track,

Toiling up new Calvaries ever with the cross that turns not back;

New occasions teach new duties, time makes ancient good uncouth;

They must upward still, and onward, who would keep abreast of truth.