Saturday, November 19, 2011

August 2011-A

Sunday, August 7, 2011

Nature or Nurture: Venezuela & Resurrection

In 1975, Venezuelan economist and musician José Antonio Abreu founded Social Action for Music and became its director. Abreu has navigated the program for the past 35 years through ten different administrations, flourishing under both the presidents of the 1980s and the leftist administration of Hugo Chávez. Combining political shrewdness with religious devotion, Abreu has dedicated himself to a utopian dream in which an orchestra represents the ideal society, and the sooner a child is nurtured in that environment, the better for all.

On 6 June 2007, the Inter-American Development Bank announced the granting of a US$150 million loan for the construction of seven regional centers of El Sistema throughout Venezuela. Many bankers within the IDB originally objected to the loan on the grounds that classical music is for the elite. In fact, the bank has conducted studies on the more than two million young people who have been educated in El Sistema which link participation in the program to improvements in school attendance and declines in juvenile delinquency. Weighing such benefits as a falloff in school drop-out rates and a decline in crime, the bank calculated that every dollar invested in El Sistema was reaping about $1.68 in social dividends. Supported by the government, El Sistema has started to introduce its music program into the public-school curriculum, aiming to be in every school and to support 500,000 children by 2015.

Why Classical:
In the midst of that poverty, the system uses classical music to instil in the kids self-esteem and confidence. Popular music, Rafael says, wouldn't work.

"What they have on at home is popular music all the time. Their father, who drinks every day, he gets drunk with that music," he told Simon. "So you have to give them something different. When they sit in one of these chairs in the orchestra, they think they're in another country, in another planet. And they start changing."

El Sistema

We were so lucky to be at the BBC Proms concert on Friday, 5th August - amazing performance of Mahler's Second Symphony ( Resurrection) by the Simon Bolivar Symphony Orchestra, conducted by Gustavo Dudamel. We went to queue at 6:15 am and had a day long chat with some very interesting music lovers. The 74 year old was No.4 and C.C. was No. 8! One went to Bayreuth in 1963!!! One is a budding conductor!!!

Royal Albert Hall certainly broke all rules and brought a chair and even tea for No. 4.

The whole performance was electrifying!!!

The concert is available on iPlayer until 12 August, broadcast on BBC4 on 28 August at 7.30p

And behold, it is no judgment;
there are no sinners, no just….
There is no punishment and no reward.
An overwhelming love illuminates our being.
We know and we are.

Thursday, August 4, 2011

Defying The Gods: Or???

“There is a God for everything! Everything!”

Plutus, the Greek god of wealth, did not have an easy life. As the myth goes, Plutus wanted to grant riches only to the "the just, the wise, the men of ordered life." Zeus blinded him out of jealousy of mankind (and envy of the good), leaving Plutus to indiscriminately distribute his favours.

A reprint:

Thursday, June 30, 2011

Defying The Gods or I.M.F.: Argentina, Iceland & Greece.

The Yangtze River is rising. Man is on the roof. A traditional pigskin boat rowed along: let me get you off.
“No, Buddha will protect.”
Man is now knee-high in water. Naval boat came along: old man, let’s get you off.
“No, Buddha will protect.”
Man is now up to his neck in water. Rescue helicopter came along: let’s winch you off, stubborn old man.
“No, Buddha will protect.”
Man died and saw Buddha. “Why didn’t you come when I needed you most?”
I did, I sent pigskin boat, Naval boat and even my best helicopter, but you refused!

So first the Gods sent in Antigone:
So Antigone had a part in this tragedy too. That's ­Antigone Loudiadis of Goldman Sachs, who ­arranged a complex ­currency swap deal that helped Greece to conceal the scale of its debt, in what the Financial Times delicately calls "an optical illusion", as the country snuck into the eurozone.

Then God showed how it could be done in Argentina: defy the I.M.F.
When the Argentine economy collapsed in December 2001, doomsday predictions abounded. Unless it adopted orthodox economic policies and quickly cut a deal with its foreign creditors, hyperinflation would surely follow, the peso would become worthless, investment and foreign reserves would vanish and any prospect of growth would be strangled.
But three years after Argentina declared a record debt default of more than $100 billion, the largest in history, the apocalypse has not arrived. Instead, the economy has grown by 8 percent for two consecutive years, exports have zoomed, the currency is stable, investors are gradually returning and unemployment has eased from record highs - all without a debt settlement or the standard measures required by the International Monetary Fund for its approval.

He even took out the head of I.M.F. just to be on the safe side.

Then came Iceland:

Unlike other disaster economies around the European periphery – economies that are trying to rehabilitate themselves through austerity and deflation — Iceland built up so much debt and found itself in such dire straits that orthodoxy was out of the question. Instead, Iceland devalued its currency massively and imposed capital controls.

And a strange thing has happened: although Iceland is generally considered to have experienced the worst financial crisis in history, its punishment has actually been substantially less than that of other nations.

For good measure Iceland’s god huffed and puffed.

AP Photo/Brynjar Gauti

But no, the Greeks have not learned anything.

This was written last year:

Germany will agree to some form of eurozone bailout. However, it will only support the minimum needed to ­placate the gods, and only with the most astringent, Creon-like conditions being imposed on Greece. It is an ­important but ultimately secondary question whether this help comes in the form of bilateral loans, loans from the European Investment Bank, purchases of Greek government debt, EU ­spending transfers, jointly issued eurobonds or any of the other mechanisms ­suggested. EU leaders will deny that this is a ­bailout and everyone will know that it is a bailout. Guardian.

The Greeks will do well to go back to their own Gods and not the I.M.F.

Michael Lewis: The Big Short

NHS: Business Model? Spare Us Please!!!

Wednesday, August 3, 2011

From SSRI back to Lithium

Selective serotonin reuptake inhibitors and drugs in the group of other antidepressants were associated with an increased risk of several adverse outcomes compared with tricyclic antidepressants. Among individual drugs, trazodone, mirtazapine, and venlafaxine were associated with the highest risks for some outcomes. As this is an observational study, it is susceptible to confounding by indication, channelling bias, and residual confounding, so differences in characteristics between patients prescribed different antidepressant drugs that could account for some of the associations between the drugs and the adverse outcomes may remain. Further research is needed to confirm these findings, but the risks and benefits of different antidepressants should be carefully evaluated when these drugs are prescribed to older people. BMJ 2011; 343:d4551

Cade, John Frederick Joseph
(1912 - 1980)
Taking lithium himself with no ill effect, John Cade then used it to treat ten patients with chronic or recurrent mania, on whom he found it to have a pronounced calming effect. Cade's remarkably successful results were detailed in his paper, 'Lithium salts in the treatment of psychotic excitement', published in the Medical Journal of Australia (1949). He subsequently found that lithium was also of some value in assisting depressives. His discovery of the efficacy of a cheap, naturally occurring and widely available element in dealing with manic-depressive disorders provided an alternative to the existing therapies of shock treatment or prolonged hospitalization.

In 1985 the American National Institute of Mental Health estimated that Cade's discovery of the efficacy of lithium in the treatment of manic depression had saved the world at least $US 17.5 billion in medical costs.

And many lives too!

The anti-suicidal effect of lithium has been confirmed by a number of recent studies in both the U.S. and in Europe.

According to the results of a population-based study published in the 2003 Sept. 17 issue of The Journal of the American Medical Association (JAMA. 2003;290:1467-1473, 1517-1519), Lithium reduced suicide rates of patients with bipolar disorder but divalproex did not. Risk of suicide death was about 2.5-fold higher with divalproex than with lithium.

The JAMA paper highlighted the declining use of lithium by psychiatrists in the United States and observed that:

"Many psychiatric residents have no or limited experience prescribing lithium, largely a reflection of the enormous focus on the newer drugs in educational programs supported by the pharmaceutical industry."

One might ask why there has been such a shift from Lithium.

Could it be the simplicity of the salt that is causing problems for the younger generation of psychiatrists brought up on various neuro-transmitters?

A reprint:

I have just received a query from a reader of this blog about Lithium, and I thought it worth me reiterating my views here. It is no secret that I am a traditionalist who believes that lithium is the drug of choice for Bipolar disorders.

The following is an extract from The Cockroach Catcher:
“Get him to the hospital. Whatever it is he is not ours, not this time. But wait. Has he overdosed on the Lithium?”

“No. my wife is very careful and she puts it out every morning, and the rest is in her bag.”

Phew, at least I warned them of the danger. It gave me perpetual nightmare to put so many of my Bipolars on Lithium but from my experience it was otherwise the best.

“Get him admitted and I will talk to the doctor there.”

He was in fact delirious by the time they got him into hospital and he was admitted to the local Neurological hospital. He was unconscious for at least ten days but no, his lithium level was within therapeutic range.

He had one of the worst encephalitis they had seen in recent times and they were surprised he survived.

Then I asked the Neurologist who was new, as my good friend had retired by then, if the lithium had in fact protected him. He said he was glad I asked as he was just reading some article on the neuroprotectiveness of lithium.

Well, you never know. One does get lucky sometimes. What lithium might do to Masud in the years to come would be another matter.

I found that people from the Indian subcontinent were very loyal once they realised they had a good doctor – loyalty taking the form of doing exactly what you told them, like keeping medicine safe; and also insisting that they saw only you, not one of your juniors even if they were from their own country. It must have been hard when I retired.

Some parents question the wisdom of using a toxic drug for a condition where suicide risk is high. My answer can only be that lithium seems inherently able to reduce that desire to kill oneself, more than the other mood stabilizers, as the latest Harvard research shows.

Lithium has its problems – toxic at a high level and useless at a low one, although the last point is debatable as younger people seem to do well at below the lower limit of therapeutic range.

Many doctors no longer have the experience of its use and may lose heart as the patient slowly builds up the level of lithium at the cellular level. The blood level is a safeguard against toxicity and anyone starting on lithium will have to wait at least three to four weeks for its effect to kick in. In fact the effect does not kick in, but just fades in if you get the drift.

Long term problems are mainly those of the thyroid and thyroid functions must be monitored closely more so if there is a family history of thyroid problems. Kidney dysfunction seldom occurs with the Child Psychiatrist’s age group but is a well known long term risk.

Also if there is any condition that causes electrolyte upset, such as diarrhea, vomiting and severe dehydration, the doctor must be alerted to the fact that the patient is on Lithium.

Could Lithium be the Aspirin of Psychiatry? Only time will tell!

Related Posts:

Chile: Salar de Atacama & Bipolar Disorder.

Tuesday, August 2, 2011

These Doctors: So Annoying

Elephant: I have listened. So now go away! So Annoying!

©Am Ang Zhang 2005

Jobbing Doctor: Pop-ups

I have had this document pop up in my inbox. It is from the Government.

A simple guide to Payment by Results.

It is a complex tariff-based system where one part of the NHS (Primary Care Trusts) pays another part of the NHS (Hospital Trusts) for looking after the sick.

This is the bare bones of how transactions occur and the relative costs.
You can see from the "History of PbR" on p.46 onwards that this process has been slowly and steadily marching towards a marketised health care system that is the precursor to the break up of the NHS into fragmented, part-privatised parts.

The one part of the NHS employs considerable number of administrators, coding clerks, validators, finance directors and accountants to work out bills to send to another group of administrators, coding clerks, validators, finance directors and accountants. Then they work assiduously at arguing about the bills. Meantime there are doctors and clinicians who will spend their time poring over the details to say "we should charge more for this" or "we shouldn't be paying for that".

This has been going on slowly and consistently under successive Governments (Labour-Blair, Labour-Brown and Conservative-Lib Dem).

If anyone really wanted to check if the neoconservative agenda for break up of the NHS is on the horizon, then just study this. It is a simple guide.

All this activity and the resultant costs (?now 20% of the whole budget) will not treat a single extra patient.

Why, then, have all recent Westminster governments been obsessed with, and enforced, a market system on NHS England? Why is the current Westminster government determined to force through, on top of these existing pro-market changes, a radical bill that will expand existing market molehills into mountainous commerce?
The stock answers are that it is all about choice, no change is not an option, and efficiency. Yet each of these answers is baloney. The ‘choice’ is of the ‘any colour you like, so long as it is black’ variety. NCINAO makes about as much real world sense as its acronym. And efficiency – well, we only have to look at America to see market ‘efficiencies’ in full force.
So it is all a bit odd. There is no need for the reforms, compelling or otherwise. The majority of professional opinion, and much public opinion, are against the reforms. Yet the Tories are determined to force them through. Why?

Mark Porter: Chairman of the British Medical Association's consultants committee.

NHS services in some parts of England could be "destabilised" by private firms taking advantage ……….to win contracts for patients with easy-to-treat conditions. This could lead to some hospitals no longer offering a full range of services and ultimately having to close.

The worst-hit patients would include those with chronic diseases such as obesity, diabetes and heart failure, Porter added. They would have to travel longer distances for treatment.

The government is taking unnecessary risks by imposing market measures on the NHS, as competitive healthcare cannot deliver high quality treatment to everyone.

The NHS could become "a provider of last resort" for patients whose illnesses are of no interest to private firms, added Porter. Once independent providers have signed contracts with the consortiums of GPs they could deny care to patients who would be costly to treat, Porter warned.

The NHS, he told us, is simply not sustainable in its present form and its commitments can no longer be met from taxes. This controversial claim is far from true.

Cameron's twin strategy is to continue with market competition on the assumption that it improves cost-efficiency, and raise new forms of funding by facilitating the introduction of private insurance and patient top-up fees. While competition is now proclaimed by government as an unqualified good, the second prong of the strategy – moving to user charges and insurance funds – dare not speak its name. But key to both are the consequences for redistribution or fairness.

…….The bill, as designed, will allow commissioners (purchasers of healthcare or insurers) to pick and choose patients and services. It abolishes the duty to secure or provide comprehensive care, and permits GP consortiums to recruit members, and introduce charges and private health insurance, as well as enter into joint ventures with private companies.

In a market, insurers and commercial providers must be able to limit their risks by carefully selecting members on the basis of ability to pay and predictable costs.

Across the country primary care trusts, in advance of their own abolition, are closing NHS hospitals.

It heralds a return to pre-1948 arrangements
of inequitable charitable and private provision,
mixed funding –
and a return to fear.

Monday, August 1, 2011

NHS: Market Forces & Genuine Medicine


©2010 Am Ang Zhang

It is still fresh in most of the ordinary citizens’ minds that market forces were the main driver behind “dis-genuine mortgages” that eventually led to the near total collapse of the first world’s financial system. In the meantime, our government is considering the use of market forces to keep the cost of health care funding in check.

Allowing private providers into a relaxed competitive market funded by the tax-payers is likely to lead to escalating costs and “dis-genuine medicine” being practised. Private companies need to make profits, and if set up as non profit making, need to pay their CEOs huge salaries. Where is all that money going to come from?

Some years ago (in fact nearly 30 years ago) I was faced with caring for a highly disruptive manic adolescent at home, as none of our psychiatric units (adolescent or adult) had room for such a patient. With only a very junior social worker in attendance, I had to sedate the boy at home with injections of major tranquillizers. Our hospital secretary, having heard of my heroic attempt to manage the patient at home, decided that he should be admitted into a private psychiatric hospital. The hospital concerned was agreeable as long as I remained his consultant. They would provide the nursing and junior doctor support.

My visits took the better part of half a day in those days. Before then, I had never set foot in a private psychiatric hospital. When we had some spare time, the junior doctor took me round the complex. I was suitably impressed with the buildings, the décor and the apparent pleasantness of the whole milieu. Then I passed a ward where quite a number of patients were on drips and each with a nurse in attendance.


"No, modified narcosis! They came from all over the world, 30 days at a time."

What, this was the late 70s and I have only read about this treatment method in ancient text books!

"What do you use?"

"Barbiturates mainly!!!"

This was well before Michael Jackson’s era.

“You can join us if you like. We are short on Child Psychiatrists and there is a huge demand in areas of anorexia nervosa. You will earn three times, if not more, than what you do now!”

Soon after, I talked to a friend and my patient was transferred to the Maudsley, where he stayed for another 9 months.

I preferred to practise “genuine medicine” in the NHS.

News came of a doctor in America giving unnecessary stent operations to patients.

Abbott Laboratories hired a Baltimore-area cardiologist as a sales consultant after he was barred from practicing at a local hospital last year for allegedly putting heart stents in hundreds of patients who didn't need them, say Senate investigators probing the medical-device industry.
Their report, to be released Monday, shines a light on one of the most lucrative procedures for hospitals and medical-device makers, at a time of spiraling health-care costs. Medicare paid some $25.7 billion for stent surgery in the six years through 2009, according to the report.

This is the danger. When doctors are paid for on a case by case basis by private health providers, they will find it hard to practise “genuine medicine”.

No wonder doctors are paid salaries at Mayo Clinic, Cleveland Clinic and Johns Hopkins Hospital: some of the most respected names in American Medicine.

Christmas came and went: 50% discount at the stores is now followed by 75% discount.

Would one of the private providers be offering: have one hip replacement, get the other one free! Two cataracts for the price of one etc.


We check the prices of other insurers and we will match them!

Is that what the government think will keep health care cost down?

Some doctors that probably prefer to practise “genuine medicine” wrote:

We have had a passionate and lively debate at BMA Council today about the Health and Social Care Bill.

The following motion proposed by myself and seconded by Jacky Davis was debated.
That this meeting of Council
(a) recognises the medical profession’s lack of support for the Health and Social Care Bill CARRIED
(b) recognises the lack of support from the majority of GPs for involvement in GP/clinical commissioning as proposed in the Health and Social Care Bill CARRIED
(c) rejects the idea that the Government’s proposed changes to the bill will significantly reduce the risk of further marketisation and privatisation of the NHS CARRIED
(d) agrees that the Government is misleading the public by repeatedly stating that there will be “no privatisation of the NHS” CARRIED
(e) calls for the BMA to start a public campaign to call for the withdrawal of the Health and Social Care Bill CARRIED
(f) calls on the BMA to ballot the membership with regard to the BMA taking a position of opposing the bill, rather than critical engagement LOST*

*An amendment to change ‘ballot’ to ‘survey’ was accepted, but that part of the motion was still rejected.

This was an excellent outcome for us. We now have a mandate for a campaign to call for the bill to be withdrawn.

Thanks to you all for your continued help and support. The fight goes on…..

To help keep an NHS that puts patients before profits, please join Keep Our NHS Public today!

Sir Roger Boyle: 'It is horrific that the NHS's future is threatened'
NHS : Andrew Lansley, his Doctors and MPs.

Hello Summer 2

© Am Ang Zhang 2011

Nikon 180/2.8 ED on Nikon D70

Sunday, July 31, 2011

Monitor: All recent posts.

May 11, 2011

“……Tom Clark our leader writer says the real problem with the bill is the fact that the new regulator has a duty to promote competition where appropriate. He points out that in a previous life as a special adviser the regulator used his powers to squeeze state bodies in order to open up the space for private providers. It's why he is so against competition.”

For my money, the most important line in the whole of the health and social care bill is found – if I have the chapter and verse citation system right – at clause 56 1(a). It lists the first duty of the regulator Monitor, which is being transformed from the Foundation Trust hospital's overlord into being the economic regulator of the whole healthcare market, as being "promoting competition where appropriate".
May 03, 2011
Oooops, did I say monitor? Yes, Monitor may be re-launched as a QinetiQ styled company as there is so much money to be made from fining NHS Foundation Trusts. Dr David Bennett is not a medical doctor. ...
Mar 06, 2011
How many scientists do they have and indeed how many doctors do they have at Monitor or do they all have to have MBAs. Instead we had 100 million fake eggs. They are not even changing the name of DEFRA this time. ...
Sonia Brown: I think we can identify areas where we can see that the Department’s analysis has not gone to the point of being able to quantify the numbers. A really good example of that is that the NHS tends to treat much more complex cases. At the moment, the NHS is rewarded at the same rate for doing that as the private sector is for treating less complex cases.

Apr 04, 2011

Q466 Grahame Morris: My question is in relation, Secretary of State, to the role and the costs of Monitor. On 8th February, I received a written answer about the costs of the new economic regulator which were estimated ...

Why spend £500 million on an economic regulator-and the figures were revised last week-if we are not going to have price competition?
Apr 11, 2011
Q 195 Jeremy Lefroy (Stafford) (Con): I have a couple of questions about the role of Monitor. The first is about the Mid Staffordshire trust into which the Francis inquiry is looking at the moment. It seems to me as the local Member of Parliament that Monitor approved the foundation trust status without going into sufficient detail as to the status of that trust, particularly the quality of care at the time. What assurances can you give us that Monitor’s approval of foundation trusts will be more rigorous in the future than it was in the case of Mid Staffordshire?
Mar 20, 2011
Tory MP and practising GP Sarah Wollaston has set out why she wants her own party to drop plans for a radical reorganisation of the National Health Service.

It is not Greeks that could destroy the NHS, but if Monitor, the new economic regulator, is filled with competition economists with a zeal for imposing competition at every opportunity, then the NHS could be changed beyond recognition.

It is no use "liberating" the NHS from top down political control only to shackle it to an unelected economic regulator.”

Mar 11, 2011
Q115 Rosie Cooper: Yes, if I may. Under the Bill, the Secretary of State will no longer have a statutory duty to provide health services and will only have to act with a view to securing the provision of health services in relation to the Board. How accurate is it to see this as spelling the end of a state provided National Health Service?

Nigel Edwards: That is precisely what it is, is it not? That is what it says. It is there in black and white. That is my reading of it as well. In fact, when every NHS hospital is a foundation trust, apart from the fact that the state would be a residual owner of roughly £36 billion of assets which belong to the taxpayer, there is no direct state control over the provision of health care except indirectly through the commissioning process. That is my reading of it.
Apr 25, 2011
NHS & Monitor: Accountants, A & E & Disasters. Thursday, March 17, 2011. Dr Bennett: On the armies of accountants point, Anna is right that one of the things that is needed is a more detailed and even clearer ...
Mar 17, 2011
…….Dr Bennett: On the designation question, the issue there is what happens if the provider of the service is the only provider of that particular service that is available to its local community but the provider gets into difficulty. ……………..If you finish up in a situation where you define the boundaries around A&E as being the whole of the DGH, then you have somewhat frustrated the policy, but I don’t think that should be necessary.
Mar 05, 2011
Emily Thornberry: I am tempted to press you further, David, given the profound implications of what you said in relation to work force pensions. We are about to pass this legislation and you are saying, “Take it on trust, as it will all be sorted out.” But we are talking about millions of people’s pensions here, and it is difficult not to push you at this stage.

Worse than that, you said in an incomplete answer earlier that there were other obvious distortions and advantages that the NHS had over the private sector. I wonder whether you could list anything else, on top of pensions, that you might think might of?

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