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Medical Care
Section Newsletter
Summer 2006

Letter from the Editor


It’s hard to imagine all the ways medical care is failing in the United States.  That’s medical care with a small “m” and “c.”  The Medical Care Section of APHA of course is alive and well and kicking.  Whether we are a match for the magnitude and multitude of problems in need of reform in our health care system remains to be seen, but as long as there is a hope and vision, we have to be its protagonist.


As I write this, the New York Times today (June 10, 2006) has yet another article about how Hillary Clinton believes in health reform but “realizes” that “her cardinal sin in 1993-94 was overestimating the public's appetite for change” and is “intent on not repeating the error.”  Never mind that at the eve of the 1994 defeat of the Clintons' terrible managed competition plan (crafted by the big insurers at Jackson Hole, who then double crossed them, unscrupulously attacking the plan via Harry and Louise ads) that polls showed that more than 70 percent of the population favored universal publicly financed national health insurance — strong support that continues to the present.


It’s hard to know where to start in enumerating all of the dysfunctional aspects of our current system and misguided responses and reforms.  If (as the proverb goes) what the fool does  in the end, the wise person does at the beginning, our Section continues to serve as both the conscience and wisdom for public health and the medical care delivery system.  While the foolish urge piecemeal reforms (perhaps gestures would be a better word), profit driven competition, more “consumer driven” (meaning consumer “burden”), stripped down insurance plans (leaving patients uncovered, e.g., no maternity coverage for childbearing age women), “report cards” to lubricate market competition with misguided “pay-for-performance” schemes, Medicare Part D (what Ted Kennedy referred to as “the worst piece of federal health legislation ever”), etc., the Medical Care Section continues to be the voice — both inside and outside APHA — for rational and comprehensive reform.


Continuing a more than half century tradition of advocacy for progressive reform of medical care delivery and financing, our members and Section have continued to advocate for single payer health reform.  While we have no singular strategy of how to get from here to there, many of our efforts have worked to keep APHA on course in its commitment to this fundamental change in how we organize medical care and public health.  Our newly designed brochure (copies available from me and in future from our under-construction newly designed Web site) highlights our motto “Medical Care for All.”


So here, from the perspective of your new chair, are some of the day-to-day work we’ve been doing:


Program: Putting together a great program for the 134th Annual Meeting in Boston.  As our new Program Chair Kathy Virgo reports elsewhere, we have had a good response to the call for abstracts, and using our new review criteria and process, we have selected via a broad participatory peer review process the contributed papers we will feature.


We’re struggling with fitting our Section meetings in around the new more compressed Annual Meeting schedule (for the past several years the Opening Session on Sunday and the Closing Session on Wednesday).  Finding a time for the business meetings of the Section committees has been a particular challenge.  We also continue to struggle with how to cram in all of the more bureaucratic matters we need to cover (e.g., resolutions, candidates) with my (and others’) strong desire to open up more of our meeting times for discussion of issues and strategic advocacy debate.  I believe we have carved out a few more opportunities, but I am still not satisfied.  We’ll have to continuously try to rethink and do more re-engineering to open up more “space” for discussion as well as use members' scarce and precious time most effectively.


MidYear Meeting: I have only attended a few of these meetings in the past, but now see what I have been missing.  This is the real opportunity for give-and-take discussion amongst ourselves and with the APHA leadership.  We were joined by Drs. Georges Benjamin (executive director) and Walter Tsou (past APHA president) and a good representation of our leadership activists.  I prepared a more detailed set of minutes (probably more detailed than anybody desired, but I did want to capture as much of the discussion as possible) that are available either from me, or on our future Web site.  Thus, I will not dwell on details here.


Medical Care Journal: I had the somewhat intimidating responsibility of chairing the Search Committee for the next editors for our official journal.  We interviewed the leading candidates (during the Annual Meeting last December) and were, frankly, blown away; the proposal and applicants from the University of Alabama — Jeroan Allison and Catarina Kiefe — were unanimously selected as the next co-editors.  We were most impressed by their commitment to creatively reshaping the Journal, as well as their own record of working together on a number of impressive health services research endeavors.


They officially start their term at the end of 2006, but both joined us (Jeroan for the entire day) at the Midyear Meeting in February along with Colleen McHorney (outgoing current co-editor along with Carol Ashton) for a far ranging and reaching discussion of the future of the Journal.  Topics covered included the future of “special supplements,” relevance and approach to the “impact factor” of the Journal (Medical Care was #1 among health services research journals in 2003), how Medical Care should respond to the “open access” paradigm, and how to increase the connections between Medical Care and the Section (including the Section contributing ideas for theme issues and writing policy-oriented editorials and commentaries).


I’m eager for other members of the Section to meet Catarina and Jeroan (one of many good reasons to attend our future business meetings) as well as to try to live up to their high expectations about what our Section can contribute to the Journal (e.g., improvement ideas, position papers, editorials, outreach).  Thanks to the ongoing editors Colleen and Carol as well as the search committee members: Arlene Ash (search committee co-chair), Julie Zito, Olie Fein, and Morris Weinberger (another former editor).


Section Membership and Leadership:  Like the majority of Sections in APHA, Medical Care has seen a decline in membership, in our case from 1,330 members in 2004 to 1,271 members in 2005. We have seen such 4 percent annual declines for each of the past five years, for a variety of reasons we both recognize and anticipate as well as reasons we need to better understand.  As federal and local public health budgets have been cut, so has funding for participation in APHA in general, particularly for travel and attendance to the Annual Meeting.  Membership dues are costly. And benefits are hard to quantitate or fall short of what we would hope (for example, why can’t a free or very low-cost subscription to Medical Care be included with a Medical Care Section membership rather than a subscription costing nearly $300/year additional).


A number of members have found “professional homes” in other discipline-specific organizations — a phenomenon which particularly affects membership in Medical Care, as we represent and are comprised of many disciplines.  Despite the misimpression that Medical Care is predominantly physicians, only a minority of our Section members and leadership are MDs.  One of the most inspiring moments in our Midyear Meeting was when, in introducing themselves, attendees gave unsolicited comments on why they joined.  For example, Darryl Gaskin (our Solicited Program chair) talked about being “apolitical” when he came to APHA but found our Section, which “stood for universal access, single payer, social justice issues, and tackles issues that really resonated with me,” finding a spot within APHA which he is both “comfortable supporting and admires the people he works with.”


How to convert this sentiment echoed by many of our members, into more generalized outreach and organizing, to help the Section realize its fullest potential is one of our greatest challenges.  Jim Wohlleb, our continuing and dedicated Membership Chair, is working with me and others to get under that hood of what drives members to join and leave, and to help implement strategies to get more gas in the tank.


Continuing quality Section leadership has been given a boost with our latest slate of nominations for offices and officer.  Past Chair John Wayne worked with a number of individuals to both volunteer and recommend others.  He prepared a great slate.  I’m particularly pleased that Gail Bellamy has stepped forward for the chair-elect position. She is someone I feel a special kinship and respect for, being “kin” in the patient safety and quality improvement movement (we had overlapping AHRQ grants) and whose views (often refreshingly different from my own) I have especially valued at our meetings.


Section Communication: Website, List Serve, Newsletter, Members Electronic Voice, Conference Calls, and More.  The nuts and bolts of building and maintaining the Section as well as effectively organizing our advocacy efforts hinge on these communication functions.  Presently (except for the monthly conference calls) they are more under-construction than in good shape.  This is where I plan to invest the lion's share of my efforts in order to practice the campers ethic in my two year tenure as Section chair (campers ethic = leave the camp site cleaner than you found it).  Along with a Task Force that we have set up to work with the new APHA IT initiative, I have a number of ideas of where we need to go to make big leaps in this area.  These include a content-rich, user friendly site, unencumbered to the greatest extent possible by some of the limitations to free speech that have become recent issues in APHA.   The site should feature links to each member and their interests, views, and recommendations (what to read, where we should go) and help to link people with similar interests or areas of work.   I will even include various outlines I have prepared for our recent meetings and leadership conference calls (so for now, you can e-mail me directly if you wish to see a copy).


Concluding Comments: I want to end with an important e-mail I received this spring from Carol Miller (Section member, rural health activist, and former New Mexico Green Party Candidate for Congress) which I reproduce with her kind permission.  It articulates why she has not been active in APHA in recent years: 


 


Thank you all for helping me keep a shred of interest in APHA. I gave up my APHA activism about 5 years ago because it was endlessly frustrating. I served 14 years on the Governing Council, years on my section council, two terms as affiliate president, etc.


Nothing ever changed. No wonderful policies ever became the mission of the organization as a whole. No great president or executive board member ever brought lasting change to the organization as a whole. Centrism is APHA and we activists are tolerated at best.  I have accepted that APHA is a dinosaur and that the good people within the association have never been able to push it or change it.   I'm feeling cynical today, so feel free to prove me wrong.


 


While this may seem to be a “down” note on which to end these comments from the chair, I believe Carol’s views soberly represents the profound challenge for those of us who want to work with and within APHA.  They should serve as a starting point for future and ongoing discussions.


Edwardo Galeano (wonderful Uruguayan poet and historian) spoke in Chicago last month and was asked what is fundamentally the same question:  “Mr. Galeano, given what is happening in the world and what you have written about the amazing spirit and movements of people in Latin America, are you optimistic or pessimistic?”   He answered (something to the effect) that his sense of hopefulness vs. discouragement changes every hour of every day.  He wakes up hopeful, gets discouraged in a few hours, only to become more optimistic and hopeful again at a later hour.  Buoyed by real things that he sees accomplished by real people, his spirits and optimism lift despite the seemingly omnipotent power of the anti-people (and anti public health) forces we are up against.


Pete Seeger recently mused that he sees exactly 50/50 odds that the human race will be around in 100 years.  This means, according to him, that the odds are so precariously balanced that each and any of us could help tip it in the right direction.  So to Carol’s challenge, and our current and future members, the question is not just being hopeful or cynical but figuring out how to direct our advocacy and activism, our research and outreach and how we can best make APHA part of the solution.


 

APHA Action Board: Brief Report


The Action Board has been involved in assisting and promoting the policies of APHA in several areas.  One area, policy archiving, is one in which I am directlyi nvolved.  The concept is for concerned APHA members with expertise (or experience/ knowledge) of selected policies to review them for relevancy, and timeliness/ scientific accuracy. This is being done in order to help update useful policies, eliminate dated ones and merge others.  The surface has just been scratched, and there is much more work to be done, but the process has been started.


Much of the work of the Action Board has been focused around advocacy related to Congressional action with regard to promoting or cutting funding for public health programs.  There has been encouragement from the AB with the help of Governmental Affairs of APHA to suggest visiting of members of Congress to express our concerns about budget cuts that affected us and to proactively encourage support for the bill sponsored by Senator Obama of Illinois and Representative Solis of California with the Health PLACES legislation.  The reauthorization of the Ryan White CARE Act is critical, for example to many programs we are involved in.  There is another legislative recess in July which could provide another opportunity to communicate our concerns.


This gives you some idea of Action Board activities.  I plan to provide more detailed information in the September newsletter.  Until then, feel free to contact me at scpiller@mindspring.com.

The Scapegoats of Torture in Iraq and California


Sometimes it is helpful to leave the United States in order to get information about what we are doing.  While on a business trip to England, I heard and read a lot on what is going on in Iraq.  When the stories of torture of detainees in Abu Ghraib broke, I found the European news more clear and more detailed than most in the United States.  Particularly interesting was a front page story on Saturday, May 22, 2004 in The Independent (UK) that headlined: “Abuse and torture in Iraq: Where does the buck stop?”


The Independent places responsibility for the Abu Ghraib torture on Defense Secretary Donald Rumsfeld.  “The key to the torture scandal lies in … Rumsfeld’s decision to expand a highly secret operation aimed at breaking Al Qaiida suspects to the interrogation of Iraqis.”  Methods used in the prison in Guantanamo were to be used in Iraq.  To accomplish that, Rumsfeld ordered the Commander of Guantanamo, Major General Geoffrey Miller, to go to Baghdad in August of 2003 and institute interrogation techniques used at Guantanamo such as sleep deprivation, hooding and exposure to extremes of heat and cold.  Rumsfeld’s intelligence advisor Dr. Stephen Cambone “set up an ultra-secret operation of several hundred operatives in the Pentagon.”  This “unit encouraged physical coercion and sexual humiliation of Iraqi prisoners in an effort to generate more intelligence.”  The Independent goes on to say that…”President Bush knew of the secret programme, although, in the time honoured tradition of secret U.S. operations, there was no paper trail and no budgets or Congressional oversight.  When a military policeman first reported the abuses and handed over a CD full of images and videos on Jan. 13, it was reported to President Bush within days.  Rumsfeld reportedly tried to reassure the President that the scandal would die down.”


The account in The Independent is supported by statements made on June 16, 2004, on the Canadian Broadcast Company’s news program “As It Happens.”  General Janice Karpinsky was in charge of all detention facilities in Iraq.  She confirmed that Paul Bremer, the head of the Provisional Authority, ordered that units 1A and 1B at Abu Ghraib be removed from her command in early September 2003 and placed under the authority of military intelligence.  Karpinsky reported that General Miller said that he was going to “gitmoize” Abu Ghraib, meaning turn the prison into an interrogation facility like Guantanamo.  Karpinsky believes she is being set up as the fall guy for this scandal, when in fact she had no authority over the units where the abuses occurred.  She stated that she is a convenient target being the overall commander of detention and the first woman to command soldiers in an active theater of war.  Karpinsky has been demoted in rank.


From these reports, it appears that Secretary Rumsfeld was directly responsible for ordering the changes in command and procedures at Abu Ghraib.  His advisor Dr. Cambone set up the torture techniques, and he ordered General Miller to “gitmoize” the prison.  President Bush knew by mid-January about the cruelty and torture.


General Karpinsky stated further that all of her Military Police Officers were well trained in the Geneva Convention rules on treatment of prisoners of war.  She believes the MPs were ordered by military intelligence to commit the atrocities.


The San Francisco Chronicle reported on Saturday, June 12, 2004, that “5 GIs had protested abuses at Abu Ghraib.”  Some of the complaints came as early as November 8, 2003 when the prisoners “were forced to masturbate and were stacked, naked, into a human pyramid.”  There were probably many more complaints during the Fall of 2003.


I am reminded of the torture that was ongoing at California State Prison at Corcoran between 1988 and 1995.  During that time, five gang labeled prisoners housed in the supermaximum lockdown Security Housing Unit were shot dead by guard gunfire.  The prisoners were set up to fight each other by staff during outdoor exercise on small group concrete enclosed exercise yards called “shooting galleries” by the prisoners.  After engaging in weaponless stand up fist fights for less than 30 seconds, guards would fire lethal 9mm assault rifles at the prisoners.  Over the seven years, five prisoners were killed and scores seriously injured.  So frequent were the shootings that one yard was called little Vietnam.  This was all done under strict policies developed in the central office in Sacramento.  Staff supervisors who refused to set up the fights were threatened with loss of their jobs.  Reviews of the killings were sanitized by administrators and all called “good shoots.”  No one in Sacramento has ever taken responsibility, or been officially asked to take responsibility for the lethal policies that were designed to suppress prison gang activity by pounding the prisoners into concrete with gunfire.  Eight guards were indicted by the U.S. Department of Justice for the shooting death of one prisoner.  They were found not guilty by a hometown jury in Fresno.  But they were, in fact, just following orders and participating in a carefully designed and orchestrated lethal assault on prisoners.


It should be noted that since the Corcoran gladiator fight days there has been more prison gang activity and more violence in California prisons than ever before.


The unintended consequence of abuse and torture is that it adds violence to any system in which it is employed, and creates deep hatred of the perpetrators that often demands retribution by the injured.  So far the only people brought to task for Abu Ghraib have been low level MPs and Karpinsky.  We will see how far up the actual chain of command responsibility is assigned.

Abolish the Security Housing Units and All Control Units


            Over the weekend of April 1, 2006, 40 people answered a call by the American Friends Service Committee to “build a sustainable control unit abolition campaign based on prisoners’ voices."  Many groups and organizations were represented including California Prison Focus, Critical Resistance, CURE, Coalition for Prisoners’ Rights, ACLU, Heartland Alliance, Human Rights Coalition, Prison and Gang Program of the National Community, etc.


            The foundation of the effort is to be organizing at a community level with prisoners, family members, affected communities and others.  Popular education about control units and the need to close them will be ongoing throughout.  A human rights framework will be used in ways appropriate to each group and audience.  Community-based tribunals will serve an important role in the education and monitoring process.


            The as-yet-untitled organization will provide resource materials through research needed in the various regions and include art and adjunct resources to help support prisoners and their loved ones.  An emergency response network is planned.


            National and regional conferences are being organized including a kick off national conference within one year.  A national resource center is to be developed to assist everyone in their work.


            AFSC will initially fund one full time organizer, and parts of their regional criminal justice programs, and will raise funds for the first conference.  Those attending agreed that the Chicago meeting was a successful launch of the new national and regional effort to abolish control unit prisons.


           


Welcome to the New Editors of Medical Care!


For more information, contact:


Kevin Anderer, Senior Marketing Manager, Wolters Kluwer Health–Lippincott Williams & Wilkins at Kevin.Anderer@wolterskluwer.com


  


Catarina Kiefe, PhD, MD, and Jeroan J. Allison, MD, MS


Named new Editors-in-Chief of Leading Healthcare Services Research Journal


 


Philadelphia (May 23, 2006) – Lippincott Williams & Wilkins, a leading medical publisher and information services provider and part of Wolters Kluwer Health, has named Catarina Kiefe, PhD, MD, and Jeroan J. Allison, MD, MS, new editors-in-chief of Medical Care, effective January 2007. Together, Drs. Kiefe and Allison will continue to ensure the editorial integrity of Medical Care, while leading the journal into the future of the rapidly changing field of healthcare services research. A free sample issue of Medical Care, the official journal of the Medical Care Section of the American Public Health Association, can be viewed at http://www.lww-medicalcare.com.


Catarina Kiefe, PhD, MD, professor of medicine and biostatistics at the University of Alabama at Birmingham, is a clinical epidemiologist and general internist with considerable methodological expertise. Her main research interests are in health services and outcomes research, specifically ethnic disparities in healthcare, and measurement and improvement of quality of care, areas in which she has published widely. Dr. Kiefe has served on numerous AHRQ and NIH study sections, as well as VA Merit Review Boards. She was Associate Editor of Annals of Epidemiology from 1995-2000 and is Founding Director of UAB’s Center for Outcomes and Effectiveness Research and Education as well as the Birmingham VA’s Deep South Center on Effectiveness. She is a Senior Scholar in the VA National Quality Scholars Fellowship Program, a training program for physicians who wish to become leaders in health care improvement implementation and research. She is also the PI on an AHRQ funded T-32 institutional training grant in clinical effectiveness research.


Jeroan J. Allison, MD, MS, is associate professor of medicine at the University of Alabama at Birmingham with appointments in General Internal Medicine and Preventive Medicine. Dr. Allison is the associate director of the UAB COERE and the Associate Director of the UAB Center for Education and Research on Therapeutics of Musculoskeletal Diseases. Dr. Allison’s main research interests include implementation research, with a focus on quality measurement and eliminating ethnic disparities. Dr. Allison has served on several expert panels, advisory committees, and federal study sections, publishing widely in the peer-reviewed literature. For the past five years, he has also served as deputy editor for Medical Care.


Drs. Kiefe and Allison will take over the editorial reigns from current Editors-in-Chief Carol Ashton, MD, MPH and Colleen McHorney, PhD with the January 2007 issue of Medical Care.



About Medical Care


Rated as one of the top journals in healthcare  services research, Medical Care is devoted to all aspects of the administration, delivery, and improvement of healthcare. This scholarly journal publishes original, peer-reviewed papers documenting the most current developments in the rapidly changing field of healthcare. This timely journal reports on the findings of original investigations into issues related to the research, planning, organization, financing, provision, and evaluation of health services.



About Lippincott Williams & Wilkins


Lippincott Williams & Wilkins (www.LWW.com) is a leading international publisher of professional health information resources for physicians, nurses, specialized clinicians and students. Nearly 275 periodicals and 1,500 books in more than 100 disciplines are published under the LWW brand, as well as content-based sites and online corporate and customer services. LWW is part of Wolters Kluwer Health.



About Wolters Kluwer Health


Wolters Kluwer Health (Conshohocken, Penn.) is a leading provider of information for professionals and students in medicine, nursing, allied health, pharmacy and the pharmaceutical industry. Major brands include Lippincott Williams & Wilkins and Facts & Comparisons for medical and drug reference tools and textbooks; Ovid Technologies, Medi-Span and SKOLAR for electronic information; and Adis International and SourceTM for pharmaceutical information.



Wolters Kluwer is a leading multinational publisher and information services company.  The company's core markets are spread across the health, corporate services, financial services, tax, accounting, law, regulatory and education sectors. Wolters Kluwer has annual revenues (2005) of €3.4 billion, employs approximately 18,400 people worldwide and maintains operations across Europe, North America and Asia Pacific. Wolters Kluwer is headquartered in Amsterdam, the Netherlands. Its depositary receipts of shares are quoted on the Euronext Amsterdam (WKL) and are included in the AEX and Euronext 100 indices.


Subscribe to Medical Care Online Today for only $150!


Devoted to all aspects of the administration and delivery of health care, Medical Care publishes original, peer-reviewed papers documenting the most current developments in the field. Because Medical Care is the official journal of the Medical Care Section of APHA, Lippincott Williams & Wilkins is pleased to offer members a special $150 rate for online-only subscriptions to the journal.


 


With your online access to Medical Care, you’ll discover findings of original investigations into issues related to the research, planning, organization, financing, provision, and evaluation of health care services. Each month at http://www.lww-medicalcare.com, you’ll find the latest information to keep you current: editorials that provide perspective for important issues or research findings and numerous supplementary issues that focus on specialized topics. Plus, you’ll have access to all back issues and a powerful search engine. This $150 rate is a 56 percent savings off the regular online rate of $341!


 


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Visit: http://www.lww.com/product/?1537-1948. At checkout, enter promotion code W6Q968ZZ.

Veterans' Health Care Needs Care!


The Medical Care Section's Committee on Veterans' Health needs a new chair who is involved with the Veterans Healthcare Administration (VHA) or the Pentagon's Surgeons General or (best of all) both.  Or would like to be.


I want to step down because I no longer am in "the loop" and can't really contribute to the cause as I did.  My own veterans organization, the American Veterans Committee (AVC) has dissolved.  We were almost entirely a WWII group and collectively we just wore out.  So, I am no longer connected to an AVC Veterans and Military Affairs Commission for information about what is happening.


Still, we know things are going on (and not going on), and that some of them badly need APHA's "influence."  In the last few weeks, for example, the president's budget for the VHA was revealed to be several billion dollars short of the need (Am I the only person who remembers when "Nothing is too good for our boys in uniform!" was every politician's battle cry?).  Then, we found that at some Army posts soldiers who were injured in training were being given a hard time.  And, there are still shortcomings in the healthcare provisions for women both in the service and as veterans.


The Veterans' Health chair, then, has plenty of opportunity to lead the way toward APHA action to correct these problems and in bringing VHA advances in care to a broader professional audience via: 1) Annual Meeting sessions; 2) resolutions and policy statements; and 3) reports of appropriate DVA and DOD health care matters in our journal, Medical Care, to take just the obvious avenues.  Contact our Section Chair if you're interested.

Other Announcements


Has your research made a difference or do you know research that has?
The HSR Impact Award recognizes health services research that has made a positive impact on health policy and/or practice that has been successfully translated into health policy, management, or clinical practice.


Submit your nominations today!



  • Lead researcher receives $2,000.
  • Winning research is published and disseminated as part of the AcademyHealth "HSR Impact" series.
  • Award is presented at the 2007 National Health Policy Conference, Feb. 12-13.

Selection Criteria:



  • Quality of research.
  • Effectiveness of research dissemination and translation approach.
  • Impact of the research.

Nominations must be received by Friday, July 28, 2006.


For more information on the HSR Impact Award, please visit http://www.academyhealth.org/awards/hsrimpactsnominations.htm or contact Jennifer Muldoon at jennifer.muldoon@academyhealth.org or (202) 292-6700.   


 


 


Register to vote with absentee ballot


This year's election day (Nov. 7, 2006) will happen during the APHA Annual Meeting in Boston.  Make your voice heard in the ballot box by registering to vote and requesting an absentee ballot before your state deadline!  Click here for more information: https://ssl.capwiz.com/apha/home .