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The American Way of Medicine: Shirking Responsibility; Profiteering on Illness and Accident

By Patricia Lee Sharpe

My friend’s general practitioner, who was on vacation when my friend went to the hospital with a broken leg and got more than she bargained for, exclaimed: “This is the worst story I’ve ever heard!”

A hospital resident, no less horrified, confided, “I can’t believe this happened to you.”

But it did.  And neither hospital nor insurers want to take responsibility. 

On May 1 a healthy substitute teacher was admitted to a  hospital with a broken leg. She had suffered a very nasty compound fracture on the playground, and by the time the right bone man could be found to pin all the bones together, it was too late to send her home.  She definitely had to stay the night—and then, because her leg was so fragile and attendant dangers were so imminent, doctors judged that she should be kept under observation longer, through healing and rehab.  Look at the scar on her left leg.  The incision was huge, more than 12 inches long.  You can’t see the whole cut, but you can imagine why careful follow up was needed. 

So far, so good.  Then the horrors begin.

Two insurers are involved in this story: a Medicare Advantage plan and New Mexico’s Workman’s Compensation program.  Neither insurer disputes claims for costs directly related to treating the break itself.  But that's almost the least of it, and after that, the fights begin.  The hospital doesn’t want to take responsibility for complications clearly growing out of  the conditions under which the break was treated;  the insurers don’t want to pay for the cost of treating the complications.  Here is a an excerpt from a letter to New Mexico’s Workman’s Compensation program, which has been trying to shove the costs onto Medicare.  Medicare will pay, if necessary.  (This is one reason why selfish seniors are happy with the present medical system—which is pretty nice, for seniors.)  In the letter my friend is arguing that all costs arising from the break and its consequences should be covered.

I found myself in a double room with a patient who defecated on her bed, herself, and the floor next to me three times during the night.  The next morning I told the nurse that I didn’t feel “safe” in this room and that it was not sanitary.  It was one-two days later [my itals.] that I was moved to another room, and subsequently to the inpatient rehab unit. 

Some days thereafter, she writes,

I got severe diarrhea and a fever and was diagnosed with a  c. diff. infection. After a week and a half [in an isolation ward], the requisite 3 stool samples tested negative.  I was discharged...with a prescription for three additional days of antibiotics.

That was May 26, nearly a month after she’d been admitted for a broken leg.  By June 5th, she was back in the hospital. The c. difficile had recurred.  Recurrence is common, evidently, but no one had prepared her for that.  Soon after readmission,  “the c. diff. infection went septic,” another not infrequent complication.  She underwent an emergency tracheotomy and spent nearly a week in a virtually comatose condition.

A tracheotomy!  That means a scar on her throat for the rest of her life.  Well, she lived.  For that she can be grateful.  But without the broken leg and the ensuing c. difficile complications, there would have been no life-threatening sepsis, no hole in her neck, no scar. This chain reaction, so obvious to anyone with half a brain, seems to escape the profit-seeking, Scrooge-like  logic of of those who had her life in their hands and made a mess of it.

During her three-times-in-all hospitalizations, my friend had to spend many many days in intensive care and isolation wards.  Such treatment is extremely expensive.  Neither insurer wants to pay for it.  Each argues that the other is primary, as the lingo goes.  Worse, both hospital and Workman’s Comp have argued that c. difficile  exists in ordinary dirt.  Thus, those horrendously unsatisfactory hospital sanitary practices and conditions notwithstanding, the hospital should be off the ethical hook and Workman's Comp off the financial hook. 

As if my friend had suffered from the runs when she’d presented herself to the emergency room with a broken leg!  As if she had been gardening during those few days at home when she could barely move around her apartment with a walker.  She’d been to church once during that interlude, when home care was provided by a Workman’s Comp contractor.  She’d been once to visit her orthopedic surgeon.  But anything to avoid paying a patient's bills! 

What Pakistan Should Really Worry About in Balochistan

By Patricia Lee Sharpe

Pakistan is worried that India is gaining too much influence in Afghanistan.  New Delhi has established numerous consulates, already!  And information centers.  Thirteen now, according to Pakistan. 

Pakistan is worried that India is getting too cozy with the U.S. And vice versa.  Especially the vice versa.  At what point would better relations between the often antagonistic democracies lead to a severe  shrinkage in the American subsidy to Pakistan’s not entirely cooperative military?   

Pakistan is worried that India is mucking around in Balochistan.  Yes.  Leaving aside the perennially picked scab, the never healing sore of Kashmir, the current Pakistani preoccupation is with Balochistan, the huge, underpopulated, desert province that borders Iran and Afghanistan.  India, supposedly, is stirring up the tribes in Pakistan’s western badlands. 

A year ago January Pakistan’s caretaker Information Minister Nisar A. Memon declared that those information centers in Afghanistan had been set up “with the objective to disturb peace in Balochisatan and hamper the construction of the Gwador Port,” which will be the terminus of a potentially very profitable transport corridor south from China. And just last week, the charges got even more colorful.  Rehman Malik, a prime ministerial advisor, tabled a document in Parliament in which he contended that thousands of Baloch separatists are training in Afghanistan "with the support of India and Russia."  A cache of Kalashnikovs is evidence, he insists, as if such weapons weren’t easily available to anyone on the international arms market. 

These charges raise such delicious questions. Assuming there were a Russian spoon in the Baloch soup, wouldn’t Russian motives be less directed toward supporting Baloch nationalism than toward obstructing  China’s project to build an energy corridor that might undermine Russia’s attempt to monopolize energy deliveries to Europe and elsewhere?  If so, why would  Afghanistan want to collaborate with Russia?  Kabul should benefit from efficient access to the sea through Gwador.   

Meanwhile, it’s worth noting that Malik’s charges earned objections from some Senators from Balochistan, who insisted that “the problems of Balochistan should not be linked to India and Russia.”   Moreover, the Baloch representatives argued, the role of Pakistan’s intelligence agencies within Pakistan itself often involves doing dirty tricks and misleading Parliament.

Although Pakistan claims to have “proof” that India is providing “tactical and financial support” to militants in Balochistan, Afghan Foreign Minister Rangin Dadfar Spanta “rubbished” the claim during a recent visit to New Delhi: “India has never used Afghan territory against Pakistan,” he said, going on to declare that “there is no truth to Islamabad’s claims of India fueling unrest in southwestern Balochistan province or that New Delhi was backing the banned Baloch Liberation Army (BLA).”  Kabul, of course, has been complaining that Afghan Taliban forces find refuge and reinforcements in Pakistan, while India has never had satisfaction from Islamabad for Pakistan-based terrorism in India.  The Pakistani pot is very busy, it seems, calling other kettles black.

India’s Foreign Minister P. Chidambaram put it another way: “The Balochistan leader has said that he gets no support from India.  Besides, why should we get involved when we have enough problems on our western borders with Pakistan.”  To say nothing of Indian Kashmir. 

Language Ability: A Litmus Test for the Foreign Service?

By Guest Contributor Ken Yates

The subject of language ability has dominated the discussion of the Foreign Service for much too long to the exclusion of other desirable abilities particularly on Capitol Hill where heart-rending comparisons are made of the US Foreign Service with those of other countries where language competence seems so much better. But is this wise? It sounds logical, but is intensive language study to a sophisticated level the sine qua non of the competent FSO?

What Came Before…?

I spent my three decades(+) of a Foreign Service career mostly at hard language posts and was subjected to a variety of endlessly patient linguists who tried to implant in my resisting brain some sort of competency in local parlance. Some things stuck, others did not. But, in tour after tour abroad, I came to the conclusion that becoming really competent in a local language and putting it to effective use in the day to day business of the Foreign Service, although a laudable goal, was not often achieved even by others who displayed above average language skills. For me, training in Japanese, Korean, Dari, Icelandic and Mandarin Chinese, in that order, resulted not in approaching the desired level aspired to in Congressional speeches, yet it did help to sensitize me to the important cultural and personal understandings that were essential to developing and maintaining professional contacts.

It soon became clear to me that just about all of my most important contacts had English competence far beyond what I could realistically hope to achieve in my scant months of study of their language. After all, many had studied English from their early school days, or even studied abroad. My linguistic struggles were more effective as an "icebreaker" than as a means to communicate substantively. When real substance was discussed, I found it essential to have a competent translator on hand. The advantages to that was a more formal discussion at a slower speed that could focus better on the issue at hand than on the imprecision resulting from my usually lesser competence in their language than they had in mine.

As an Embassy official, I also had the responsibility to maintain a level of decorum and professionalism that the person I was speaking with would take as complementary to his or her own professional status.

But is “Good Enough to Get By” Really Sufficient…?

Let USAID be USAID – Not Let Confusion Reign

By Patricia H. Kushlis

Whatever happened to the U.S. Agency for International Development? Wasn’t it supposed to play a key role in the Obama administration’s accent on diplomacy as a major tool of US foreign policy? Didn’t Hillary Clinton emphasize development as a crucial part of diplomacy – in fact, as important as traditional diplomacy and defense – in dealing with the world? Didn’t Robert Gates support this enthusiastically? Or am I missing something.

After learning last week from an NPR broadcast entitled Diplomacy Under Fire that new State Department Foreign Service Officers should be agronomists, counter-terrorism experts, civilian development, anti-narcotics and democratization specialists rather than masters at traditional State Department skills like political and economic reporting and analysis, negotiation or even running embassies or consulates and dealing with host governments, I wonder what the development officers at USAID are supposed to do. Or, for that matter, if anyone’s home there?

Who is supposed to do traditional diplomatic work?

And if the State Department Foreign Service Officers don’t do the traditional work of running Embassies and Consulates and interacting with host governments and peoples – who is supposed to do it?

I guess this might be one way to eliminate the need for those unsightly fortresses that have sprung up like mushrooms after the rain beginning in 1984.

Just fire – or pension off - the political, economic, administrative, consular and public diplomacy officers who currently staff them or alternatively turn these people into USAID officers who set up shop in remote corners of a country. Then send in demolition squads in a kind of “cash for clunkers embassy” program. This would not only provide work for those proficient in the use of dynamite and nothing better to do with their dubious skills. It might also change America’s face abroad. Who knows, this might just be for the better.

What happens to Consular Services and Public Diplomacy?

That doesn’t address, however, the ongoing need to issue (or not) visas, passports and look after Americans abroad in trouble. This, by the way, is a full time occupation of State Department Consular Officers.

Or, heaven help us, what about those few FSOs who still engage in public diplomacy, e.g. interact with foreign media on a regular basis (and those few American correspondents still abroad), administer educational and other exchange programs, English teaching programs, run the few libraries and cultural centers that still exist and support and enhance visits by American cultural figures? This all used to be done by the US Information Agency before those tasks and staff were slurped up by State and shrink-wrapped and diluted big time.

But back to the USAID crisis and it is a big one.

The problem begins with the lack of leadership. No, I should write LACK OF LEADERSHIP – all caps.

Llama Drama in Valle Vidal

By Patricia Lee Sharpe

Oh, ye who are totally dependent on instant cell phone connection with anyone anytime, read no further. Valle Vidal is cut off from the world: 100,0000 acres in the middle of the Sangre de Cristo range, south of the Colorado line, east of Taos, west of Raton.  Little Costilla Peak, a 12,500 mountain that tops out 1000 feet above the tree line, presides over pine and aspen forests, grassy meadows sprinkled with little flowers, enticing trout streams and meandering  little brooks too remote and insignificant to attract fishermen. Ten of us camped at one of these idyllic spots barred to motorized transport, at 10,700 feet, this past week.  Six adults. Four boys. And did we luck out!  No rain packing in.  No rain at all—until we’d packed out and were saying goodbye to our fellow campers—and to our llamas.                                                                                  

Yes, we were llama trekking.  I love to walk, to hike, to trek, but I do not take kindly to carrying huge loads on my back, so I am always happy to have any means to transport to get my gear from point to point.  I’ve trekked with van back up, with sherpas, with horses, and this time I got to have my stuff carried by llamas.  You know: yamas, not lamas, who are Tibetan Buddhist adepts.

To get to the trailhead for this hike my grandson and I had first to drive 70 miles north to Taos, then 40 miles trending northeast to Questa and Amalia, and finally mostly east and mostly on gravel, gravel—with billows of dust!  If we ended up following another vehicle, that is, which always seemed to happen, despite the dearth of traffic, probably because I drive—um!—confidently on bad roads and always manage to catch up  to dust raising pickups.  However, even before we hit the bad stuff, the stuffing had fallen out of my car: a plastic protective thingumajig came unfastened and began sweeping the roadway, making a horrendous noise.  Other drivers gestured.  Pedestrians pointed.  It was very dramatic.  This happened, of course, after 6:00 pm the night before our morning appointment with the llamas.  First aid involved duct tape to hold the gizmo in place—applied by grandson, of course.  Surgery with B & B scissors followed.  Also performed by grandson.  Good kid. Next week: a consultation with people in the know.

Meanwhile, the essentials of the car were in fine shape, so we reached our meeting point: Clayton Corral, elev. some 9500 feet, where eight llamas and a trip leader were waiting for the clients. Llama names: K2, Matchu, Pitchu, Rusty, Onyx, etc.  Some all white; some—yep! rusty, some mottled brown and white, some almost black.  Some sporting dread locks, some with nice curly coats, all with up-pointing, in-curving ears, on swivels. One ear could listen forward while the other focused on some person’s attempt to be friendly—or commanding.  All of the llamas were standing around and humming, almost inaudibly, at different pitches. Well, they were hitched, by short leads, to their carrier truck, so they had to stand around, and singing may have made the boredom more bearable.                                                             

Eventually all clients arrived and all gear got lashed to one llama or another, crammed into weight-matched panniers filled with about 30 pounds each of clothes, personal effects, tents, sleeping bags, sleeping mats, food—including a clumsy-looking pair of coolers K2 had to carry, utensils, water for the first night, etc., etc.  The llamas took it all very patiently—as if they had a choice. 

But then, I’m told llamas have been carrying loads for people in the Andes for some 6,000 years, so I suppose they’re resigned to the servitude.  As are their very remote cousins, the camels and dromedaries of Asian and African deserts.  Llamas fold their legs like camels when they are resting and they have the same  herky-jerky three stage process for getting back onto their feet.  Note also the head carriage.  The disdainful nose-in-the-air look.  And the eyelashes. 

In Navajo Country: Canyon de Chelly

By Patricia H. Kushlis

On August 8th, I wrote about the Monument Valley, the valley in Arizona – and a tiny slice of Utah – not California, that film director John Ford made famous. But there’s another site on the Navajo Reservation that is just as spectacular. This is Canyon de Chelly. It’s located to Monument Valley’s south and east. It is still in (Photo: Canyon de Chelly from Tsegi Overlook - Photo by PHKushlis 2009) Arizona but much closer to the New Mexico border than Monument Valley.

Maybe Canyon de Chelly (corruption of the Navajo name Tseyi) is less well known because it did not figure in twentieth century Hollywood film lore. Or perhaps because it’s off well traveled grand-tours-of-the-Southwest-tour-company routes. Or because – well - how many canyons can a tourist visit without one blurring into the next. After all the Grand Canyon has many more tourist amenities and is far closer to “civilization” via the major cross country Interstate (I-40) that makes visits there far more accessible for the greatest numbers.

Lack of crowds a plus

But the lack of crowds is part of what makes Canyon de Chelly - designated a National Monument not National Park – so appealing. A private visitor can take the self-drive tour along the rim road stopping at well marked look outs with plenty of time and space to see, photograph and read about the Anasazi ruins, the various tribes that inhabited the canyon – one replacing the other over time - as well as just enjoy the natural beauty of the geology still well preserved by both the US Park Service and the Navajo.

Canyon de Chelly is also unique because it is the only US National Monument that is run in cooperation with the Navajo Nation. The Navajo Tribal Council voted in its favor in 1925 and the bill passed Congress in 1931. Navajos still live within – and, of course, beyond - the boundaries, farm its valley in spring and summer and guide visitors down and back up the steep canyon walls to the rivers below.

Perhaps the most famous picture of Canyon de Chelly is one by the early photographer Edward S. Curtis taken in 1904 that the New York Times sold as a limited edition print earlier this year. Since I discovered the same or a similar photograph – or I think it is the same – as a free-bee on Wikipedia, (photo left) I don’t really see the need to buy a copy from the Times – or anyone else. Or maybe the Curtis photo the Times is selling is different – but it sure looks like the one on Wikipedia to me. Regardless, I took my own photos. And since I don’t collect historic photos anyway, I plan to forgo the Times offer.

A humbling site

Curtis’s photo of a small group of horses and riders at the base of the canyon walls evokes a quiet solitude of a far off place more than a century ago that did not become a National Monument until 1931. This photograph depicts what insignificant specks humans really are in comparison to the enormous rock formations that tower above.

What makes Canyon de Chelly unique is that this essence of insignificance is still there. The ancient dwellings at the canyon’s base and carved into caves in its walls are specks. Telescopes or telescopic lenses are needed to see them from the rim. So too the farms, people, cows, cars and horses along the river’s edge or even fording the river itself.

Two of the best known sites within the canyon are the White House Overlook and Trail and the magnificent Spider Rock. Both views (and the White House Trail) are accessible from the south rim drive – plan to spend several hours because each of the seven overlooks off this 16 mile paved road offers a unique vista. Canyon del Muerto – another part of the Canyon de Chelly National Monument is yet another experience which we will need to return to another time.

(Photo right: South Rim Drive - fording the river 2009 style by PHKushlis and photo left: Spider Rock by PHKushlis 2009).

As with Monument Valley, lather on the sun screen, wear good walking shoes and a sun hat and take plenty of water with you. Unlike Monument Valley, however, the drive is on paved roads (only the short segments to the overlooks are not) and Canyon de Chelly is open all year.

Getting there: Take Route 3 North from I-40 at Gallup to 191 west of Ganado. Drive north on 191 to Chinle and east on Route 7 to the Canyon de Chelly US National Monument Visitor Center to pick up maps, history and the Motoring Guide. The South Rim drive ends at Spider Rock Overlook. The North Rim drive is along Route 64 when ends at Route 12. Like Monument Valley, Canyon de Chelly is surrounded by the Navajo Nation.

Diplomacy Under Fire and the USAIDification of the US Foreign Service

By Patricia H. Kushlis

I spent nearly an hour Monday morning listening to NPR's special on the trials and tribulations of the State Department and the Foreign Service and whether or not the people and the institution will be able to meet the challenges required in the 21st century under the Obama administration.

The good news was that the broadcast lasted far longer than the all too usual 20 second sound-bite - the media’s Twitter equivalent - so the program could and did go into far greater depth than is usually the case when anything but the latest crisis, earthquake, typhoon or shoot’em up is put before the public and repeated ad nauseum 24/7.

The program was entitled “Diplomacy Under Fire” and divided into four segments. Kudos to NPR for producing and airing it – this is just one tiny part of the foreign affairs education or reeducation that needs to take place in this country if we’re ever to restore our relations with other countries on a firm, not to mention, more economical footing.

That’s on the one hand.

On the other, the program’s contents left much to be desired. That problem begins with the initial false dichotomy posed by interviewer Deborah Amos: Namely that critics argue that State has not earned its keep while supporters argue it has been starved for years.

In reality, both observations are correct.

How is it possible, pray tell, for State to “earn its keep” if – as is the case – it has been starved for years? This year’s budget of $36 billion – according to the NPR program – is less than the military spends on health care.

State has also been horribly mismanaged by a series of political appointees – excluding Colin Powell. They not only drove the institution into the ground but also destroyed the flexibility of civilian foreign affairs bureaucracies once outside State’s hierarchical iron thumb through an ill-considered consolidation while refusing to obtain the requisite financial and organizational support from either the White House or the Congress to make the nonmilitary side of this country’s foreign affairs equation function adequately.

It’s Official: The Global War on Terror Is Over

By Patricia H. Kushlis

About time, too.

At a meeting last Thursday at the Center for Strategic and International Studies (CSIS) in Washington, DC, John Brennan, Obama’s top White House advisor for Homeland Security and Counter Terrorism formally declared America’s Global War on Terror over. The 23 page transcript is here and it’s well worth reading.

Brennan’s declaration was favorably reported by Doug Saunders in Toronto’s Globe and Mail and lauded by blogger Richard Smith onVet Voice. The New York Times carried the AP story and the Washington Post ran a stage-setter, pre-speech exclusive interview the day before.

Brennan’s reasons for the death of this controversial phrase are right. It was always loony to declare war on an a tactic (noun or adjective) and reprehensible to send ever more of America’s youth abroad to pursue an elusive and ill-defined enemy (terror) in the name of a questionable “doctrine” that called for the invasion of another country that had not declared war on or otherwise harmed the US.