Jeff Tieman's cover story "Rebuilding an empire" (Nov. 17, p. 6) rings terribly true for me, echoing the observations I made during several days spent visiting the Baghdad University Medical School, a children's hospital and other medical facilities in Baghdad in January 2001 as part of a team sponsored by Conscience International.
In the children's hospital laboratory, 90% of the equipment was at least 15 years old, half of it wasn't functioning because of lack of repairs or supplies, and the lab was open only five hours a day, Monday through Friday. Similar deficiencies were found in the radiology department, central supply and the pharmacy. The majority of the lighting was not working, and as you have no doubt heard, windows were still broken and the air conditioning hadn't been functioning since the 1991 Gulf War, in spite of summer indoor temperatures often reaching 120 degrees. That situation was found everywhere we went.
As evil as Saddam Hussein is, the lack of medical journals and texts and pharmaceuticals and medical supplies was more a result of the United Nations' post-war sanctions, which were pushed by the U.S.
The geometric increase in incidence of leukemia and other childhood cancers and of birth defects in central and southern Iraq has been attributed by many experts to the depleted uranium shells, missiles and penetrating rods used on the Iraqis during that war. And the massive increases in deaths and illnesses are unquestionably the result of the targeted destruction of water and sewage treatment facilities during that war and the sanction-related inability of Iraq's local and central governments to repair those facilities.
It is quite clear to me that the U.S. bears a very heavy responsibility to rebuild the Iraqi healthcare system.
Clinical professor of pediatrics (emeritus)
University of Washington School of Medicine
Lack of opportunity
I'd like to offer another perspective to the nursing shortage ("Quality vs. quantity," Nov. 10, p. 8). Simply stated, the nursing shortage is proportionately related to the lack of educational openings for people who want to become nurses.
In 2002, there were 700 applicants for 175 openings at the associate degree nursing programs at the six community colleges in Maine. That means 525 potential nurses were turned away in one year in one state.
How many thousands have been turned away across the country as this same scenario is repeated year after year? Why so few slots for nursing education when there is such a tremendous shortage of nurses? Nursing education is expensive and requires a higher ratio of faculty to students.
This is not a new problem. In March 2001, I joined with 50 other congressional, healthcare and education leaders to address the critical shortage of skilled healthcare workers in Maine. Michael Michaud, then the state Senate president and now a U.S. congressman, led the forum.
Much was discussed, but one thing was clear-there needed to be more state money dedicated to educating larger numbers of skilled healthcare workers. What happened? Not much. One program increased its openings by eight; another actually reduced the openings for first-year nursing students from 40 to 20.
Most hospitals are willing to support nursing students, but most are not in a position to set up nursing schools. Much legislation has been issued to provide tuition support, but it does no good if there are no openings to accept qualified applicants.
Director of patient-care services
Waldo County General Hospital
Nursing and costs
The nursing shortage and the need to hire highly paid temporary nurses is affecting more than just patient care. It's also affecting hospitals' efforts to keep costs under the Medicare reimbursement level (Nov. 10, p. 8).
On the other hand, this situation has helped us to understand productivity ratios and keep us awake about staffing requirements. In fact, staffing grids have helped us tighten our belts just like the prospective payment system imposed order on hospital finances.
Larkin Community Hospital
South Miami, Fla.
CEO crime not routine
David Burda's Nov. 10 editorial, "True crime, true stories" (p. 21), though well-written, misses one key point. The real question is not whether we are paying attention to the misdeeds of some healthcare executives, but why we read these stories.
We do so for the same reason people used to buy tickets to circus freak shows, because of the lure of the unusual. As a healthcare executive, I will begin to worry when we stop reading those articles about unethical or illegal conduct of our colleagues, because at that point such activity will have reached the stage of being routine.
President and chief executive officer
Northern Rockies Cancer Center
Your Web-exclusive article, "Rural woes: Providers struggle to cope while Congress weighs solutions" (See modernhealthcare.com), brings to mind a recent phone call I received from a reporter for a prominent national newspaper. I was asked to prove that rural providers are doing a poor job and need the money to provide Medicare beneficiaries better access to care or admit that Congress need not address historic Medicare rural payment inequities. The question was at once reasonable and unanswerable.
As I struggled to respond, it became clearer to me why I could not answer the question as asked. There isn't a lot of specific data about rural Medicare beneficiaries and what there are tend to understate the differences because of what I believe are lower expectations among rural seniors.
Many of us see access to healthcare for Medicare beneficiaries as inseparable from the issue of communitywide access to care. If one looks carefully at the data that is available, it is hard to imagine that rural young people and seniors alike don't have significant challenges as they try to get local care.
The irony regarding Medicare payment reform is that rural communities have not been asking Congress to subsidize care for non-Medicare patients in order to support the rural infrastructure (which, by the way, large urban hospitals have done with great success for nearly 20 years). What they are asking is that Congress recognize that rural communities can no longer afford to subsidize the federal government's obligation to the Medicare beneficiary.
What is clear is that rural providers are entering any competitive scenario with a major disadvantage-the hidden tax or cost shift imposed by the current Medicare program through its pattern of paying less in rural areas. While the issue of fair competition is less relevant for the more isolated rural or frontier communities, it is very relevant for the majority of rural residents-those who live in markets adjacent to metropolitan areas.
If at the end of the day we cannot persuade urban America that the data show an actual or potential differential access problem for the rural elderly, isn't it equally fair to ask why Medicare pays more in urban areas (both in terms relative to rural costs and relative to the percentage of urban costs) without demonstrated impact on urban beneficiary access?
Rural Wisconsin Health Cooperative
Right and wrong on life
Regarding your cover story on government involvement in personal health decisions ("Separation of health, state," Oct. 27, p. 4): Let me point out something obvious: Some people-including the mass media-love to portray right and wrong as issues of personal belief.
Apparently the healthcare community and its professional journals are not immune to the 20th cen- tury phenomenon of "defining deviancy down." There is a definitive difference between letting nature take its course and willful actions.
Life has now become so subjective that the government must act on its responsibility of protecting citizens who cannot protect themselves, whether from disability, age or illness.
That professionals who have taken an oath to do no harm are now chiming in with the activists and journalists who label these actions as government intrusion is a sad commentary on the healthcare community.
I can only hope that it's more an issue of your biased reporting-I'm sure healthcare professionals who still know the difference between right and wrong can read between the one-sided lines.
Elizabeth Kurland Beer
Director of managed care
Fox Chase Cancer Center
Issue isn't black or white
When a sick person gets together with his or her family and doctor to decide how he or she wants to die, I agree that the state should not insert itself into a highly charged situation (Oct. 27, p. 4). But if the sick person is not able to be part of that discussion, who should then act as mediator and guardian of that person's interests?
Nothing is ever black or white when it comes to such decisions. This is why government sometimes must step in.
Having doctors say government has no place in healthcare decisions between a doctor and a patient is awarding absolute trust to physicians to make the right decisions. Is that right?
This is truly a conundrum.