Monday, September 30, 2013

The Lighthouse in a Black Hole of Calcutta

Just a little bit after high noon under the Calcutta sun, the Irish woman was telling me (a South Indian desi who has never been close to being sunburned) that I was looking pale.

4AM.  Wake-up call.  The rough and unwelcome ring rousts me from the first comfortable sleep I have had in 8 days. I have had a busy and challenging week of cornea transplants and surgical skills transfer in rural Haldia (pictures here) as a volunteer on an ORBIS mission.  I am exhausted and rather enjoying the creature comforts of a nice room at the ITC Sonar, a treat for our last night in India. I really do not want to get up, but have promised my new friend (and ophthalmic surgical nurse) Ann-Marie that I will go with her to Mother Theresa House at 540AM. Plus, by waking up this early, I can catch up with Friday afternoon email back in Utah before all my colleagues leave work for a gorgeous fall weekend back in Salt Lake.

6AM. We get to Mother Theresa House and attend Mass. Although I am Hindu, the service is nonetheless moving in its beauty, humility, and simplicity. The melodious chorus of the nuns is soothing against the raucous boulevard outside. After mass, we stop briefly at Mother Theresa’s tomb, and then make our way downstairs to the assembly area, where we have a small banana (one of those nice baby tropical bananas) and tea for breakfast. I see a posted prayer entitled, “in preparation for going to the Apostolate.” It asks the Lord for “skill in my hands, clear vision for my mind, and singleness of purpose.”  I think to myself – how similar to the silent prayers of many a surgeon before any case, and how similar to some verses in the Bhagavad Gita. Ann-Marie and I trade personal backgrounds; she is originally from Boyle in Ireland but now works in Cardiff in Britain to be close to her children and grandson. After we all have tea, the sister in charge of volunteers arrives.  She assigns us to a team of 10 volunteers headed to the Kolaghat. Our group includes a French couple on honeymoon, some Korean and Japanese tourists, a Romanian backpacker, and some college students from hither and yon. After a harrowing 20 minute bus ride on a rickety vehicle straight out of your favorite Africa movie with exposed floorboards and a ramshackle roof, we reach our stop. We walk up the street and promptly get lost.  There are so many beautiful colors amid the squalor. As an outsider looking in, I am struck by how the people seem happy despite grinding poverty and oppressive heat. A friendly tea house shopkeeper directs us to the right street and after a 40 minute walk, we arrive drenched and tired to the Nirmal Hriday (the Mother Theresa Home for the Dying and Destitute), where the local sisters and staff engage us in their normal morning schedule.

9AM. First job is washing laundry (mostly green-colored sheets and pillow covers).  I have no idea if I am any good at soaping, rubbing, and washing the sheets and clothes, but guess that I am probably not, as they send me upstairs within 10 minutes).  Dejected at my evident lack of skill with hand-washing, I dedicate the next hour to rooftop clothesline duty, and get drenched in sweat again. Arranging the laundry carefully to optimize rooftop clothesline space and stabilize the hangings makes me appreciate what my mom did when we were little kids. And seeing the neighborhood from above is a treat reminiscent of childhood summers with relatives in India.

We have a short break for tea and biscuits, and peruse the history and teachings of Mother Theresa, who moved to India in 1937 and founded the Missionaries of Charity in 1953. After break, we go downstairs, and turn over the male and female open wards (each with about 50 beds). Clean beds, sheets, pillows, and pillowcases. Now I understand the relevance of laundry duty.  Despite all the filth outside, this place is kept in tip-top and immaculate shape.

11AM.   An agitated woman is brought in by wheelchair by Tamara, a Mexican physiotherapist who found her lying at the station. She is whisked to the female ward. After helping a different elderly woman walk to the bathroom, Ann-Marie goes to peel eggs in the kitchen.  The French husband on honeymoon holds the hand of an emaciated man on IV fluids. I look around for a little bit, noticing an unnerving sign on a cabinet (Dead Body Clothes), a medicine cabinet with an odd assortment of medications, and a sign that says “This place is not a hospital, but rather a place where the dying and destitute can go for comfort and dignity.” 

Anne Marie comes down from the kitchen, and we chat for a little bit. One of the sisters asks if I am from India (I am the only Indian in the volunteer group that morning), and I let her know I was born in Vellore, but live in the US.  The sister moves on about her work, and then a few minutes later, finds me and asks me to go to the female ward, as the woman Tamara brought in is now unconscious. I go the female ward, but one of the attendants shoos me away, “no males here!” Ann-Marie, who has not raised her voice the whole week, counters, ”We need him, he’s a doctor.” Upon coming to the bedside, I am startled by an awful sight. This tiny, poor old woman is in acute respiratory distress, not responsive, foaming at the mouth, and struggling to breathe.  Tamara is crying and asks if the woman is going to die; I don’t want to answer that. I ask the head sister if we can transfer to a hospital; she says there is no such option. One of the sisters (Sister Adriana) has managed to put a nasogastric tube in, which is starting to remove kerosene from the poor lady’s stomach. Presumably she swallowed the kerosene in an attempt to kill herself. Her pulse is fast but thready. Listening to her chest reveals a lot of “junky breath sounds”, a racing heartbeat, and a fairly loud systolic murmur (I wonder if she has aortic stenosis).  I ask Ann-Marie to see if the staff can get suction (her British-Irish accent is much more understandable to the sisters than my thick American one), and she begins suction with resolve and grit.  The sisters ask how long they should keep irrigating the stomach, and having never dealt with kerosene before, I tell them to keep irrigating until clear, normal-smelling liquid comes back. I ask for activated charcoal but there is none.  Proceeding with the examination, I see that her pupils are small and non-reactive, and the sister informs me that the patient’s fingerstick shows a blood sugar of over 300. Crap. Not only are we fighting kerosene poisoning, this poor lady probably also has DKA (diabetic ketoacidosis).    I have to get an IV started, but haven’t done one in 16 years, let alone on a dehydrated patient in a poorly lit room in a crisis.  I find an antecubital vein in her right arm, and am handed the butterfly needle, tourniquet, and alcohol cotton ball. I put on gloves but they don’t fit and are the yucky, slippery, polyvinyl kind.  I position the needle, and before piercing skin, pray to God to please let me get this stick. Flash of blood in the cannula – thank goodness! I get the IV taped up and call for saline (the sisters ask whether it should be NS or DNS; this lady does not need any more sugar, so NS it is) and 10 units of insulin. “How much volume of insulin in a 1 cc syringe?”  Fortunately, just 2 days earlier in Haldia, I saw that an insulin syringe of 40 units corresponded to 1 cc, so that makes it easy to figure out the dose.  I listen to her lungs again, and she sounds better after suction but has probably aspirated stomach contents into her lungs.  Are there any antibiotics? Sister Adriana takes me back to the medicine room, and I am looking for a 3rd generation cephalosporin and clindamycin (to cover Gram negatives, upper respiratory flora, and anaerobes).  I search in the drawers – amikacin, nope, don’t need to risk kidney failure in this lady with DKA.  Sulbactam, nope, not powerful enough.  Ertapenem and piperacillin – totally awesome broad-spectrum antibiotics but probably overkill and don’t want to tempt resistance germinating to these “gorillacillins” in a Calcutta slum. Sister Adriana comes back – “ok, doctor, what antibiotics should we give?”  I find a cephalosporin drawer – great, but wait – cefotaxime, cefazolin, cefirizine, cefaperazone, ceftriaxone, cefipime, cefixime …Goodness gracious, why do cephalosporins all have to sound the same and why did they have to make so many new ones since I memorized the first 3 generations of them in pharmacology 20 years ago?! Ceftazidime – found it! – covers Gram negatives and Pseudomonas (which can cause a really nasty pneumonia) and Amoxicillin/clavulunate – a reasonable choice to cover oral anaerobes and upper respiratory flora.   I let Sister Adriana how often to give each one and go back to the bedside. I ask Tamara for a smartphone, and luckily one of the Koreans has a working internet connection.  After a little fumbling to get an English language interface, googling kerosene poisoning reveals that milk can be used to try to neutralize it (via the nasogastric tube).  Sister Adriana asks if we could put egg along with the milk, and pondering it, I remember that egg white has albumin, which is a molecular sponge, binding almost everything. Sure, I say, milk and egg it is.

As the staff readies the milk-and-egg concoction, the patient soils herself. The sisters and Ann-Marie change the sheets, and Ann-Marie expertly inserts a Foley catheter, draining normal-looking urine (a good sign).  However, in the jostling, the IV comes out of her vein.  I try her left hand with no success.  Sister Adriana tries her right elbow again and then her right forearm. No luck. I try her left upper arm, and get the welcome flash of blood, but then the needle slips from my finger and I lose the vein.  I begin to spy the patient’s external jugular vein, but Adriana tries the patient’s right hand and is successful – whew!. I take my gloves off; looking down at my hands, they have never been clammier.

12PM. Our patient is breathing more comfortably and looks better; she is starting to blink and move her eyes a little.  The sisters ask if we can stay for the afternoon; unfortunately we both have planes to catch. After leaving recommendations on fluids and antibiotics with Sister Adriana, and hugs and thanks all around, Ann-Marie and I walk back into the slum to hail a cab.  Ann-Marie tells me that she did not think the patient would last the hour and that I should be proud;  I tell her I am just relieved at how things turned out and grateful that Tamara, Sister Adriana, and Ann-Marie were all there with the patient at the same time.  It was only by grace of providence that a physiotherapist from Mexico, a medically self-taught nun, an Irish nurse, and an Indian-American eye surgeon crossed paths with a poor woman in pain on a Saturday morning in Calcutta.

While outwardly I tried to project calm, I had been terrified the whole time that this poor woman was going to die in front of us because her doctor was an ophthalmologist who had not taken care of general patients for 12 years.  Ann-Marie has been a nurse for 43 years, and I a doctor for 18; it is reassuring that my mentors were right - the time spent learning general medicine was not wasted, for our skills and memories decades past are still there, ready and useful. My hands are trembling, and Ann-Marie says that I look pale.  She says lunch is on her.  Getting back to the hotel, I have a nice long hot shower after the morning’s drama, and enjoyed the first good water pressure in a week. I put on my scrubs for the flight home, and ironically realize I should have put them on when I woke up that morning.

Suicide is an irredeemable sin in both Catholicism and Hinduism, and even though I worry about all the potential complications of kerosene ingestion, hopefully we have given our patient a chance at redemption, and in so doing, redeemed, in some small way, our own existence in a fallen world. For service is the rent we pay for living. The Sanskrit saying “Manava Seva, Madhava Seva”  parallels Christ’s admonition that “whatever you do unto the least of my brothers and sisters, you do unto me.” The Grim Reaper and God were both in that ward that morning, and hopefully we bought some time for our lady’s body and psyche to mend.   The morning evoked the exchange between Katsumoto and Cpt. Algren in The Last Samurai, “Do you think a man can change his destiny?” “I think a man does what he can, until his destiny reveals itself.”

The Mother Theresa Home is a lighthouse in a modern-day black hole of dashed dreams (villagers seek opportunity in the big city but often are stranded in the slum; the original Black Hole of Calcutta was a dungeon). Together, the sisters and staff offer a beacon of hope that helps wounded souls to heal.  Along with images from Mother Theresa’s life, the centerpiece of the home is a statue of Jesus on the Cross, saying “I thirst”.  While our patient attempted to quench her despair by kerosene, we all thirst for some small measure of peace, and by giving unto others, may hope to achieve it.  It is my genuine and deep hope that readers can help contribute by volunteering time and perhaps organizing some training and support in basic emergency medicine and care, as well as equipment, medicines, and resources for the sisters and staff there, who endow the word missionary with new spirit and old meaning every single day.   The sisters who provides relief to the surrounding society in its darkest hour of need can use all the help they can get.  And for those who have the fortune and privilege to visit and give of themselves, life and its preciousness and the smallness of our daily vicissitudes are all put into clearer perspective. 

Saturday, September 07, 2013

Falling into Quicksand

Next week’s vote on Syria is shaping to be a pivotal decision point for Congress, the President, and America.  I applaud President Obama for submitting this action to a Congressional vote.  In the spirit of contributing to the discussion, I would like to lay out my rationale for why I think the Congress should vote no on what is being debated.

This may seem surprising in view of my long-standing position as a liberal hawk and as one who supported the Iraq war.  First off, let us stipulate that Assad is an extremely awful tyrant and that his use of chemical weapons is an affront to humanity. Leaving aside the historical fact that Saddam Hussein was an extremely awful tyrant and that he used chemical weapons in Halabja in 1988,  the real issue at hand is whether the American military response that is on offer will make things better or not?  As far as I can tell, the military action being contemplated does not have a plan for:
  •  “the day after and the day after that”
  • Removing Assad and installing a decent government
  • Securing or destroying chemical weapons in Syria
  • Setting up safe, no-fly, no-drive zones for civilians
  • Destroying Assad’s air-force, ports, and artillery
  • Defanging foreign (al Qaeda, Hezbollah, and Iranian) forces in Syria and supporting the “good guys” (e.g., the Free Syrian Army)

Hence, I must come to the conclusion that what we are planning to lo is little more than narcissistic message-sending about red lines. Not only will this not make things better, it has a very good chance of making things much worse with all the risks noted in the previous post.

I supported the Iraq war, not because of the inaccurate de jure rationale of getting rid of Saddam’s WMDs, but because I thought it would be in America’s strategic interest as well as improve the lot of Iraq’s people.   Reasonable people can disagree on whether the Iraq war served our strategic interest and helped Iraqis in the long run, and even if so, whether it was worth the cost. To digress for a moment, I maintain that the post-war planning for Iraq was handled abysmally and appallingly and that the emphasis on WMDs was disingenuous at best, yet nonetheless America’s strategic interests and Iraqis’ long-term welfare were served to some degree because:
  1. For decades after the Cold War, we had 2 major allies in the Persian Gulf, and after 9/11, as it was becoming clear we had to vacate Saudi Arabia, it was a real possibility that we had no allies in the Gulf. The War allowed us to leave Saudi Arabia and still maintain primacy in the Gulf until our North American oil revolution took off
  2. Direct consequences of America’s intimidation of others in the Middle East due to the crushing and apprehension of Saddam included the switching of Qaddafi to being cooperative with the West, which led to the roll-up of Pakistan’s A.Q.Khan “Nukes R Us” network, as well as Syria’s withdrawal from Lebanon.
  3. Grinding-down of al Qaeda forces which came to Iraq after the war to fight America in a flat desert
  4. While tens of thousands of Iraqis died due to American mistakes and incompetence post-war, Saddam was killing similar or greater numbers of Iraqis in his rule, a reign of terror which was ended in favor of a decent chance for Iraqis to make their government worthy to serve its people. Certainly the Kurds and Shiites (who together are a sizable majority of Iraqis) are a lot better off. 

Was all that worth the cost in blood and treasure?  Most Americans would say no, but I would say the answer cannot be known for another decade or two. 

In stark contrast, President Obama’s mooted Syria intervention seems disconnected from improving our strategic position or Syrians’ welfare.  The goal seems to be to punish the use of chemical weapons. But this begs the question, “and then what”?   From the standpoint of an independent observer, we could just as well make an argument for punishing the use of drones or cruise missiles as dishonorable weapons of war that seek to escape risk for oneself.  Secretary Kerry claims he is not asking to take America to war; President Obama claims that he did not set a red line.  They are every bit as disingenuous, if not even more so, than the Bush administration’s pursuit of the Iraq war based on WMDs.  

The Middle East has been a mess for decades, if not centuries. The present conflict in Syria has its roots in the Sykes-Picot agreement after World War 1, where Britain and Syria mindlessly drew lines on a map, and indeed back to the assassination of Muhammad’s grandson in the 7th century.  If we are to involve ourselves, we should have some idea of what we want an outcome to look like – partition of Syria into smaller ethnic enclaves like what happened in Yugoslavia, occupation by Turkey and allied Arab states, installation of a government that is somewhat decent yet strong enough to manage a transition.  No such objective has been laid out or as far as I can tell even conceived by the administration. This failure of post-intervention planning is even more abysmal than that of the Bush administration’s happy-go-lucky attitude after the Iraq war in 2003.  Our economy and military are in far worse shape than 10 years ago as well.  Let us not step into quicksand for the sake of saving face. 

Monday, August 26, 2013

The Guns of August: Ninety-Nine Years On

It’s been a very busy year so I have not had the chance to write as I would like this year, but the presumably impending US military action against Syria merits more consideration and thought than is being evinced, so let me add my two cents while I still can. 

Last week, somewhere between 300 and 1000 innocent civilians were massacred by President Bashar Assad’s regime by the use of chemical weapons (by all reliable accounts).  This is an appalling and heinous atrocity.  That has triggered the Obama administration’s current march to attacking Syria. Is that wise? At the current moment, I must say no. 

The administration’s rationale goes something like this – use of chemical weapons is taboo, unforgivable, and must be punished, lest unanswered use enable future acts of genocide.  None of this is a strategic objective.  Rather, it is a declaration of war on chemical weapons.  If America is to go to war, it should not, and cannot wage war on a tactic.  The administration makes no claim of desire to oust the Assad regime, or even tilt the ongoing civil war to the rebels’ favor.  It plans to slap Assad’s military as punishment for use of chemical weapons, presumably to send a message about rules of war and to uphold President Obama’s use of the phrase “red line”.

This is a bizarre and indeed perverse illogic. If 1,000 innocent Syrians killed by chemical weapons merit American involvement, why not 99,000 Syrians massacred over the last 2.5 years?  Whether you are killed by nerve gas or a bullet or a bomb, you are equally dead.  Does the means of murder of a little boy or girl really matter to their family?   Motives, outcomes, the ends of violence may count for something, but surely not the means.  If Assad kills another 99,000 Syrians without using chemical weapons, will that be ok by us?  

Perhaps it would, at least to the administration. After all, on what basis has the foreign policy of the last 4.5 years been grounded – we have thrown cooperative leaders in Egypt, Tunisia, and Libya under the bus, while giving tacit approval to far worse atrocities by enemy governments in Syria and Iran (tragic mistakes which must be acknowledged if we have any hope of correcting things).  Our turning a blind eye to the brutal repression of the Green Revolution protesters in Iran in 2009 and to the Syrian protesters in 2011 have led in a direct line to current circumstance.  If George W. Bush had presided over that record, I wonder what epithets on his and his party’s intelligence would have been crafted by my Democrat friends, but I digress.

There are two logical strategies here – stay out of it, or fight to win (also known as the Powell doctrine).  
1. The isolationist argument for stay out of it goes like this: The Syrian civil war has evolved into a fight between Assad+Hezbollah+Iran’s Revolutionary Guards vs. Al Qaeda. Our enemies are fighting each other, and we really can’t afford another war.  Why should American soldiers die for someone else’s revolution anyway? Further, let the Middle East be someone else’s problem, e.g., China, which is more dependent on Persian Gulf oil than we are now. 
2. The interventionist position goes something like this: Assad, Hezbollah, the Revolutionary Guards and al Qaeda are all conveniently in one place.  They are all enemies of the US and her allies. Neutering them all and installing a decent government will weaken Iran & Russia, kill a lot of baddies, and stabilize the neighborhood (e.g., remove threats to Iraq, Saudi Arabia, Turkey, Jordan, and Israel).  Sitting out the Spanish Civil War in the ‘30s ultimately did the West no good.  Further, re-establishing US credibility and primacy in the Middle East will keep it from becoming a sphere of influence for Russia, Iran, and China, for an anti-American convergence of Russia, China, and Middle Eastern nations would threaten our allies in Asia and Europe, and ultimately us.

Both of these positions have the virtues of truth, consistency, and strategy; both give some respect to realpolitik, history, traditions, and ideals.  The first is a risk-averse acceptance of a stalemate and reduced US influence and involvement, the latter is a risky (and costly in blood and treasure) attempt to build a better future for Syria, the region, and us. The administration’s approach (advertised as a cruise missile and drone strike on Assad’s air force) has been billed as calibrated as a middle of the road approach, enough to “send a message” without actually risking troops or political capital. In Eliot Cohen’s words, it is seductive as it appears to offer gratification without commitment. While the Russians play chess and we used to play poker, the administration seems to be playing checkers,   will very likely backfire and drag us into a vortex of inescapable escalation. 

What consideration, if any, is being given enemy retaliation?  What if Hezbollah launches anti-ship missiles at the US Navy?  What if suicide bombers attack US ships in port in the Mediterranean or Persian Gulf?  What if Hezbollah launces rockets at Israel? What if Hezbollah or Iran launch a wave of terrorism against US targets around the world?  What if Syria launches SCUD missiles at Israel, Turkey, or Saudi Arabia?  What if Iran makes a break-out attempt at a nuclear weapon in an effort to give Syria a nuclear umbrella under which to attack its neighbors? What if Russian naval personnel or assets in Tartus, Syria get accidentally bombed?

The reader may wonder, well, all of these could happen with the interventionist strategy too (or for that matter, even with the isolationist approach).  True enough, but the difference is that either the isolationist or interventionist approach has a point backed up by US determination to achieve a concrete goal, as well as an argument that could justifiably earn the support of the American people, and their representatives, the US Congress.

Which brings me to the other disturbing dimension of current events.  The President is making no moves for a declaration of war or even authorization to use force from Congress.  The retort is that Mr. Obama already bombed Libya without Congressional approval; yes, but that was improper (and violated the War Powers Act). The Constitution gives the President the position of Commander-in-Chief, and the Congress the authority to declare war. Both political branches should be involved in a decision to attack another country, as there are many ramifications that should be carefully considered and thoroughly debated. In the case of Libya, at least there was the excuse that there was an imminent threat to the citizenry of Benghazi. In this case, the chemical weapons have already been used (and in fact, have been used before several months ago on multiple occasions).  If the President attacks Syria without Congressional debate or approval, it will be but the latest in a series of frankly lawless actions – the Obamacare employer mandate waiver, NSA interception of content of domestic emails and communications, the DREAM Act by fiat, politically selective IRS targeting, gun-running to Mexican drug cartels.  All of these paint a picture of an administrative mindset without coherence or strategic vision, a ship of state rudderless and adrift, steered only by intellectual sloth that pays attention only to the most recent event on the news.  England is said to have acquired the British Empire in a fit of absent-mindedness, enabling a Pax Britannica that was beneficent to the global commons for decades until multiple miscalculations and blunders destroyed it in World Wars that originated in an August 99 years ago.  The US diligently and consciously built the institutions of Pax Americana, also of great benefit on the whole; sadly, it is now being eroded and frittered away on the narcissistic altar of naivete and myopia, and I fear what is to come.

Wednesday, December 12, 2012

Interludes & Reflections

Like many others, I was wrong in expecting that the election would lead to a Romney victory or a close result. The Obama campaign built a successful coalition in almost every single battleground state. While Mr. Romney won handily among independents, he did not build a winning coalition.  Since Nov. 7, I have focused on understanding why, speaking with citizens of many political persuasions and many walks of life.
First, let me share several observations.  First, it’s hard to beat something with nothing.  Mr. Obama’s record and spoken priorities show what he would do in a second term: while the prescription of higher taxes, regulation, and staying the course is unappetizing to many, it is a path. Although Mr. Romney towards the end came up with a 5 point plan, most people never really had a handle on what he would do or how his measures would help.  He likely did not go into specifics out of caution not to antagonize voters, but that was not a good thing for a candidate already thought of as a flip-flopper or slippery.  Gov. Romney reminded me of Kerry vs. Bush in 2004, where a flip-flopper from Massachusetts was running with the principal message that the incumbent is doing a bad job on the issue of the day.
Second, Mr. Romney did not run an inclusive campaign.  His primary opponents did not unite behind him, which goes a long way to explain why his vote total this year was less than Mr. McCain’s in 2008. And while Mr. Obama ran a negative campaign and Mr. Romney had to respond in kind, there was not a sense of positive vision offered by Mr. Romney.  The Republican party periodically had vile outbursts that were antagonistic to women and Hispanics, and Mr. Romney was never able to counter or dissociate himself from those elements of his party. One of the most striking things about the election results was that Asian-Americans broke 3 to 1 for Mr. Obama.  In my own friend circles, Asian-Americans tend to be professionals with good jobs, not on welfare, and fully understanding of the higher taxes that will hit them under Mr. Obama.  Further, quite a few of them are social conservatives as well. Nonetheless they vote for Mr. Obama because they felt that Republicans had an uncomfortable proportion of irresponsible firebrands who were tribalistic in their antipathy and xenophobia.   While I am sure Mr. Romney personally does not espouse the views of Messrs. Akin, Mourdock, Broun, he really hurt himself by not distancing himself from that segment of the party strongly or early enough. 
Third, Mr. Romney was not the right candidate to take on Mr. Obama on health care or foreign policy. He alternated between ineffectual attacks or blurring the differences between them.  His tendency to try to figure out what an audience wants to hear and then saying it is not unusual among politicians; in this case, it backfired, as he came across as Obama-lite.  With a reputation for having the backbone of a jellyfish when it comes to convictions, this was probably the last straw. 
Of course, I should not put everything on Mr. Romney.  The Republicans failed in the ground game and wasted a lot of money in ineffectual ads when they should have been party-building in both traditional and new ways.  The party never lent its enthusiastic support to the campaign and egregious statements of a few of its members cost Mr. Romney dearly. 
Enough with the post-mortem. What to do? Although I count myself as a classical liberal, sadly the Democratic party has largely left those principles behind, and the country badly needs a constructive conservative counterbalance.  Let’s start with some ideas on core areas of jobs, economics, energy health, education, environment, and foreign policy.

1.       Jobs:  Current policies discourage employers from creating jobs and workers from taking them.  For example, payroll taxes (employer and employee Social Security and Medicare contributions) cost about 16% on top of salaries upto $108,000, and health insurance often tacks on an additional 15% or more.  Meanwhile, extended unemployment benefits, traditional welfare, food stamps, disability, and housing benefits have become $450 billion of incentives not to work.  Medicaid is another substantial benefit to not working.  We need to reverse many interlocking parts here and realign them to craft a pro-jobs , pro-growth set of policies:
·         Remove the caps on payroll taxes while cutting the total payroll tax rate to 10% (equally distributed between employer and employee)
·         Let employees see how much health insurance costs and let them have the option of using employer-based health funds (along with their own money) to buy private insurance, Medicare, Medicaid, or have higher take-home pay.  This would be part of a larger health care overhaul (see below).
·         Make the criteria for unemployment and disability benefits far more stringent with stronger verification of assets/income and real disability status to forestall abuse
·         Tie food stamps, housing benefits, and traditional welfare to work or public/civil service (e.g., infrastructure projects). 
The focus here is on increasing jobs and stable employment, growing the pie and creating wealth for the long term, and shifting the argument away from how to slice up a dwindling pie.

2.       Economics:  Taxes should serve 2 purposes: discourage “bad” activities and reflect a return on investment to the government for state programs which serve the public good.  They should not serve for one person to take advantage of another’s productivity, and everyone should pay a fair share across the board. When you tax something, you get less of it. As we tax work and investment and far higher rates than consumption or stock market gambling, we have a lot more consumption and stock manipulation than we do work or investment, hence the staggering levels of public and private debt which will slowly but surely strangle our economy and future prospects. My plan can be called the 10-10-10 plan:
  • ·         Let’s cut taxes on income, saving, and long-term investment (defined as >5 years) to 10%. Remove all deductions except for charity and children. Let’s tighten up the charitable deductions to only organizations that don’t engage in political campaigns and make the child deduction a deduction (not credit) upto $30,000 per child.  
  • ·         Let’s eliminate corporate income taxes but also eliminate corporate welfare and subsidies (such as for sugar, corn, and oil companies). 
  • ·         Let’s add taxes on sales and imports of 10% (produce and non-processed groceries exempted).  This could be paired with foreign policy to reduce or waive these duties when appropriate on a most-favored nation status basis.
  • ·         Let’s also add taxes of 10% on exotic financial transactions (credit default swaps, collateralized debt obligations, derivatives, etc.) and tax short-term investments at 26% (decreasing steadily with each year of investment to 10% after 5 years of holding). 
  • ·         End federal incentives to take on debt (e.g., home mortgages, student loans). For the truly needy or meritorious, provide increased grants in the spirit of a hand-up, not hand-out, e.g., scholarships for programs of study that increase long-term economic potential (e.g., science, technology, engineering, business, math, law, health care, English)
  • ·         Let’s raise taxes on alcohol, tobacco, processed foods, high-fructose corn syrup, trans-fats, and marijuana (where it’s been legalized) and start increasing federal gas taxes by a penny a month, indefinitely.
  • ·         Let’s add a 10% tax on lobbying and campaign political ads for corporations, organizations, or entities that don’t pay any taxes.  This is not a speech issue, but rather organizations/entities that don’t pay income taxes (and hence don’t vote) should not seek to influence tax policy, or at least should pay a toll to do so.  Just as there should be taxation without representation, I do not feel there should be representation without taxation.
  • ·         On the entitlement side, Social Security and Medicare were initiated were longevity was far less than today.  We should increase retirement age slowly but steadily, perhaps 1 year every 5 years.  Benefits should be means-tested for both these programs as well, while increased opportunities for private retirement and private health accounts (with some matching government contributions) should be developed for younger Americans. 

As a package, these measures will remove the distortions in our market and rebalance our economy towards work and productive long-term investment and away from consumption, destructive behaviors, stock market gambling, and rent-seeking behavior through the tax code.  Further, the measures in points 1 and 2 would repatriate and attract capital and jobs from overseas.  Very importantly, all of the above should be accompanied by transparency in budgeting – each American should receive an easy-to-understand budget and balance sheet each year reflecting what tax dollars are being used for and what the future liabilities are for our nation. Further, both houses of Congress (on penalty of sequestered pay) should be required to pass a budget each year.
3.       Energy: Our goals here should be maximizing energy independence, reducing environmental harm, and increasing our economy’s efficiency in using energy.  Crafting a policy geared to these objectives will take time and thoughtfulness but is doable.  While we should remove obstacles to oil and gas exploration, fossil fuel exploration and use has externalities (adverse impacts) that should be accounted for – e.g., the need for overseas military expeditions to keep the Persian Gulf secure, pollution in the air and sea, etc. The best way to account for such externalities is a carbon tax, and I have proposed a gas tax that increases a penny each month to promote a gradual efficiency over time and reduced dependence on fossil fuels.  With respect to renewable sources, the government should engage in subsidies to specific companies but rather offer prizes for specific objectives (efficiency in energy conversion, storage, or transportability) and increase research funding for such objectives.
4.       Health: I have described my ideas for health care reform previously (get rid of the employer health coverage tax benefit to make it an even playing field for individuals, promote transparency in costing, enable cross-state competition, and tort reform). Some of the key problems facing us in health care include lack of incentives for doctors and patients to prevent and save for chronic disease, and lack of discussion regarding costs of end-of-life care. To address these, let’s:
  • ·         Change incentives for primary care practice to encourage more physicians to enter it and focus reimbursement of primary care on keeping patients healthy as opposed to fee-for-service. Physicians could help here by starting a “guild fund” donating 1% of income to ensure medical students would graduate with minimal or no debt, in exchange for new graduates committing to a minimum 2-4 year program of primary care service in underserved areas. 
  • ·         Start a health information card for each person as a portable electronic record and get rid of the onerous EMR requirements but have prizes for interoperability and reductions in errors
  • ·         Health savings accounts where federal dollars would match individual savings (to be used for medical expenses over time and every decade, a distribution could be taken as a reward for savings). Over time, this would get insurance companies, government bureaucrats, and lawyers out of the doctor-patient relationship, and let doctors work directly for patients rather than for third-party regulations, documentation, or mindless box-checkers.
  • ·         Allow basic health insurance plans that cover just catastrophic events
  • ·         Increase costs to egregious adverse behaviors (e.g., driving drunk, not vaccinating one’s children, etc.) while incentivizing good behaviors (e.g., by reducing premiums for keeping a healthy weight, quitting smoking, etc.)
  • ·         Give pharmacists the ability substitute in-class (not just same chemical) generic drugs for specific indications unless the doctor specifically wants a brand, and the chance for individuals to buy into Medicare, Medicaid, or private insurance if they so please.  
  • ·         Make the patent protection clock for drugs/devices start from FDA approval as that is when they can be marketed. This would allow drug companies a longer period of time to recoup their R&D costs and reduce the immediate price pressures that occur after approval.
  • ·         Let patients know that the longer they wait to buy into health insurance, the higher their premiums would be (much like Australia’s health coverage system or America’s life insurance policies).  Also, for specialists, let there be a free market in services.
  • ·         Increase research funding for optimizing patient care and translational/innovative programs geared for bringing new treatments forward.

5.       Education: Curricular and teacher standards need to be improved.  Set national standards for English, history, math, and science based on the achievement tests sponsored by the College Board and Advanced Placement exams sponsored by ETS. This will redirect education towards teaching of content and actual knowledge.  Increase teacher salaries by offering starting salaries of $80,000 or $100,000 or more for teachers with a bachelor’s in the subject they are teaching (education should no longer be a major but a module of pedagogy); perhaps there should be certification-level exams based on GRE or Achievement Tests for subjects teachers desire to teach. Tie raises to performance (as measured by student improvement over the course of each year).  Let parents have choice, and let education dollars follow the student. Further, disconnect education funding from local property taxes – let each student get the same number of dollars from state/federal level income/sales/property taxes.  Promote physical  and vocational education again in schools.  Increase funding for gifted and talented education.  Increase funding for research and development at the university level and for business-academic partnerships in innovation. Last but not least, move towards a stakeholder society by giving every citizen on their 20th birthday either $20,000 for college, professional, or trade school (contingent on good grades in a viable program of study at an accredited school), $20,000 for starting a business (contingent on a credible business plan), or $10,000 for a long-term savings/investment account (not withdrawable before age 40)
6.       Environment: Some of this I discussed above in energy but the key concept has to be accounting for externalities. Taxes on air, water, and land pollution should account for damage done by energy, mining, corporate, and individual use.  Companies which take on catastrophic risk should have appropriately sized insurance (e.g., deepwater drilling, nuclear plants).   A key element of environmental policy should be to focus on preservation of the global commons – reefs, rainforests, wildlife preserves and ecologic diversity. This is ultimately best done not only through multilateral agreements and pollution taxes but on spreading property rights through the Third World (see Hernando de Soto’s seminal work), and on pricing water, electricity, and gas use appropriately. 
7.       Foreign Policy: What would an alternative foreign policy look like?  To start with, our priorities should be to promote freedom,  economic growth, broad-based human and societal empowerment, liberal democracy, human rights, and free trade around the world while helping our friends and weakening our enemies.  The Millenium Challenge started by George Bush should be expanded – this program directed foreign aid to countries striving for good governance; we should also expedite free trade agreements to reward good governance and ensuring freedom and empowerment for peoples around the world. We should not be enslaved by pessimism and withdraw from tough places around the world. Rather we should ally with fortify, and make robust and muscular alliances with true democracies whenever possible. This requires a strong military with sensible long-term defense spending. And some tough questions need to be posed. Did we hand or are we in the process of handing Egypt, Libya, or Iraq to forces that are inimical to the US? Are we about to do the same in Syria or Afghanistan?  Why did we abandon the green revolution groups in Iran? How will we maintain military supremacy in the air, oceans, sea lanes, and pivotal regions?  Do we have the capacity to maintain our treaty commitments to our friends around the world? How will we minimize and shield against nuclear and missile proliferation? These are difficult questions but they need to be asked and cogent strategies formulated.

While this is not a comprehensive plan, hopefully they form the cornerstones for a new Republican policy strategy.  I should take a moment to comment on social issues.  While I do not view this as important as priorities in a national election context as the above, for a lot of people they are.  And unfortunately both sides define themselves and demonize the other on the basis of what they are against: Democrats are against guns, tobacco, oil, religious influence, restrictions on abortion or marijuana, while Republicans are against abortion, gay marriage, gun control, etc. Anathema and caricature have dumbed down our political discourse.
On the hot button issues of abortion, gay marriage, gun control, immigration, etc., I think Republicans can do a lot more to  be inclusive while yet upholding their principles.  For abortion, almost everyone has charged emotions about this.  In my case, I was strongly pro-choice for many years because a classmate confided her horrible circumstances when we were in high school. Over the years, things became grayer, as I came to realize that the right to a chance at life probably should outweigh the right to convenience in many cases. But in any case, Republicans should convey an understanding of how traumatic and challenging such a situation could be for any particular woman, and guarantee access to it in situations of rape, incest, and threat to a mother’s life, and increase support for prenatal, postnatal, and adoption services. While firmly making the argument that an unborn child has more than zero moral value, stay away from idiocies like mandated transvaginal ultrasounds, call out extremist Democrats when they would ban support for viable infants born after abortion, and leave any other debates on restrictions to the democratic process in states.
On gay marriage, again, many of us, myself included, have personal friends who are gay and we want them to be happy. Is gay marriage a civil right issue, and should it be called “marriage equality’?   The Supreme Court will rule on that in the coming months, but unlike interracial marriage in the 1960s or before, there is not an issue of criminalization – the landmark Loving vs. Virginia case arose from an arrest and prison sentence for the “felony” of interracial marriage.  Freedom from criminalization is not what gay marriage advocates are seeking; rather, what is being sought is a societal seal of approval in the form of a marriage license, and by definition, a license is a privilege, not a right.  Many, perhaps most states, will legalize gay marriage – that is the province of the voters’ wisdom.  No matter what, Republicans should and need to impart a concern for the happiness of couples who don’t happen to be straight by guaranteeing rights on inheritance, hospital access, health proxy, etc. and leave decisions on tax benefits, nature of marriage, civil unions, or domestic partnerships, etc. to states. At the same time, firm lines against polygamy or adult incest should be drawn.  
On gun control, honor and respect the second amendment while closing the gun-show loophole, requiring all gun owners to take background checks, safety, and usage classes comparable to what is required of concealed weapons permit holders in most states.  Acknowledge the risks of guns, but also discuss how many unreported times concealed weapons holders stop crime, yet are often occurrences.
 On immigration, acknowledge the tremendous contribution of immigrants to America and that almost all of us have an immigrant heritage.  At the same time, craft an immigration policy that values skills and education and limits family reunification to immediate family members and minimizes taxpayer benefits to immigrants until 5 or 10 years after becoming citizens. Enforce current laws and seal off areas of illegal entry, and then explore earned amnesty 5 years after a secure border is ensured. Regulate the process of entry to make it fair to all countries without discriminating on the basis of geography, while bringing employers and universities into a system where they bid for the right to hire immigrants.
 On the critical area of reconciling science and faith , understand and appreciate that science and faith do not have to contradict each other and be reasonable about what is taught in what context.   Why not have a conversation premised on the beautiful concept that God could have created evolution? Why not come to a common sense position that faith and reason are like a pair of shoes – you can get farther with both than just one?

Essentially, I hope the Republican Party re-energizes to helping America achieve equality of opportunity, whereas the Democrats have chosen to focus on equality of outcome. To do that, we need a sound platform that restores our country’s financial health, sparks economic growth, creates jobs (while maintaining a safety net that gives a hand-up not a hand-out), and invests in the future (education, health, energy, environment), while maintaining our standing in the world.  I hope the above may serve as a road-map for forward-thinking Republicans and Democrats to right the ship of state, focus on and meet the major challenges facing America, and minimize the tribalization and polarization of our people.  

Sunday, October 21, 2012

In 2008 we made history. Now it's time to build a future: Romney for President

I’m proud to be a classical liberal. I’ve been a liberal since I was a child, espousing civil rights, environmental protection, fiscal prudence, energy independence, gun control, educational uplift, stands against military dictatorships, etc.  I’ve never voted for a Republican for President.  Guess there’s a first for everything.  After thorough consideration and much discussion, I must, reluctantly but forcefully, endorse Mitt Romney for President. Let me first make a disclaimer, then lay out my long-held reservations about Governor Romney, the case against re-electing President Obama,and then explain how and why the case against Romney is overcome by the case for him .

Disclaimers: My decision is greatly influenced by my views on Obamacare, which I think is detrimental to patients, physicians, and American medicine.  Therefore, I am sure that biases my decision. At the same time, I endorsed Mr. Obama in 2008. Hence, I believe that my choice is based more on what I think is good for the country than what is good for me.

The Case against Romney: I started out this campaign season joining the effort for Jon Huntsman, but unfortunately Mr. Huntsman’s candidacy never gained sufficient traction or resources.  Gov. Romney’s candidacy was never attractive as he is an intellectual chameleon: he supported abortion, gay marriage, and gun control (and of course the template for Obamacare) in Massachusetts, but is against them now. Now, politicians notoriously tack with the wind, but nonetheless I would like to know, at least a little bit, what and who I am voting for.   He can often have a tin ear, and his record as Governor was, at best mediocre (47th in jobs creation).  An equally important thing to consider is the potential that a Romney presidency could enhance the power of the fringe elements in the Republican party – the supporters of Todd Akin, and Congressman Broun, who calls evolution, call embryology and the Big Bang theory “lies from the pit of hell”, and assorted crackpots. But there are crazies and nutcases on the other side as well.  

The Case Against Obama
The reader no doubt will ask why I do not discuss the case for Mr. Obama. Quite simply, he himself has not made one: he has not laid out a second-term agenda. “More of the same” is just not much of a case. Certainly, the President has had significant achievements. The killing of Osama bin Laden certainly should garner him much credit – both Mr. Bush and John McCain endorsed treating the Pakistani government as an ally (McCain attacked Obama in 2008 for saying he would bomb in Pakistan if necessary), coddling the Pakistanis’ duplicity. Mr. Obama has been much more clear-eyed when it comes to Pakistan, and that is no mean achievement after decades of American wrong-headedness. Further, “flipping” Burma from being a Chinese satellite to a path of democracy, deepening an alliance with Australia, weakening Iran’s currency and gasoline supplies, and mending relations with certain European nations have been good things.  However, “leading from behind” in doing little to help guide the Arab Spring or help the people of Syria, weakening our strategic protection of and relationships with Eastern Europe (Poland, Czech Republic). It makes no sense why we should intervene against governments in Egypt and Libya in 2010-2011 when we had no basic fight with them, while we abandon the citizens of Iran in 2009 and the people of Syria in the last 2 years to governments that are far more brutal and actively opposed to our interests. Essentially, the message that has been communicated to governments around the world is that if you are our enemy, you have our green light to do whatever you want to your people, but if you are our friend, watch out as we may very well throw you under the bus. In summary, on foreign policy, we have a mixed bag. 

But the key argument against Mr. Obama is domestic policy.  Obamacare I have argued against previously, and I think it is bad for patients and doctors, and incredibly bad for the federal budget.  The piece d’resistance of this administration's failure is jobs.   Mr. Obama’s administration borrowed and spent >$800 billion in a stimulus bill, predicated on the premise that this spending would reduce unemployment to 5.4% by now. By his own standard, he has failed.  Even worse than the headline unemployment rate, the civilian labor-force participation rate has declined from 65.7% in Jan. 2009  to 63.6% today, the worst record on encouraging work of any Presidency since data has been kept, in large part because current policy (both for employers and individuals) taxes jobs and discourages job creation. Further, when Mr. Obama ran for office, he lambasted President Bush for a horrible fiscal situation, calling the national debt run up by Mr. Bush “unpatriotic”. Mr. Bush added $5 trillion in his 8 years to the national debt.  Mr. Obama hit the accelerator, adding $5.3 trillion in less than 4 years. For the first time since World War II, this has made our national debt larger than our GDP!  And for what? The economy remains in the tank, and Mr. Obama has made no credible budget for years (nor has the Democratic Senate), and his budget projects more trillion-dollar deficits in years to come.  Mr. Obama came in and rather than focusing on the economy, he got 2 pieces of legislation – Obamacare, and the stimulus, and neither of them was intended to, nor has, helped the economy.  The stimulus was a bailout of unions and states, not a jobs program, not investment in infrastructure, or long-term R&D, or improving education quality.  

Furthermore, what is evolving is a growing nationalization of various sectors of the economy – finance, medicine, automotive, real estate, etc.  Is that a good thing? What has always distinguished America from Europe is that nationally (and in most states), are biggest cities are not our capitals – there is a separation of government not only from church but from the cathedrals of finance and power. Yet Washington DC is one of the few booming areas in the countrynow, due to increasing concentration not only of power but revenue streams (which will only increase in a second Obama administration).  The increasing incestuousness of government with industry has resulted in not just Solyndra and A123 (spectacular failures of misallocated capital) but regulation creep that strangles new competitors.  Government should focus on monopoly/oligopoly-busting and leveling the playing field, not increasing bureaucratic complexity that favors only big companies with armies of lawyers or individuals/companies with the right politicians’ ear.    Four years is proof enough that Mr. Obama is not, and likely never will be, focused on growing the pie, but on achieving his vision of social justice through central planning. 

The standard defense by Mr. Obama's defenders (and himself) on his dismal economic record is that he inherited a bad situation. Leaving aside that it is unseemly to whine about a bad hand for 4 years and that it is customary for Presidents to take blame or credit for the economy on their watch (as well as their own metrics for success), let's examine Mr. Obama's performance against those of Presidents FDR, Reagan, and Clinton, who also inherited bad economies.  Mr. Obama received an unemployment rate of 7.8% in Jan. 2009, which is where it is in Sept. 2012; civil labor-force participation rate fell from 65.7% to 63.5% in that period. Mr. Clinton received an unemployment rate of 7.3% in Jan. 1993 and brought it down to 5.2% by Sept. 1996, while increasing labor-force participation from 66.2% to 66.9%. Mr. Reagan was greeted by 7.5% unemployment in Jan. 1981 which he brought down to 7.3% in Sept. 1984, while increasing labor-force participation from 63.9% to 64.4%.   FDR brought the unemployment rate down from 25% in 1933 to 14.3% by the end of his first term.  By any standard, Mr. Obama has failed, and should not chalk up his failure to his predecessor.

Last but not least, a little-discussed topic in this election has been respect for rule of law.   I find it quite disturbing that the US bombed Libya without any congressional authorization, that the Dept. of Justice smuggled weapons into Mexico without that country's knowledge (Fast and Furious), that President Obama has unilaterally and selectively waived enforcement of laws in immigration, welfare policy, and even Obamacare, and that he has authorized what can only be characterized asassassination of a US citizen on foreign soil.  Say what you will about President Bush, he did get congressional approval for military actions overseas and never assassinated US citizens.  In a second term, without reelection, one would imagine that Mr. Obama would only feel even more unbridled by matters of law. Indeed, the history of second terms (Nixon; Reagan; Clinton) is not reassuring on this score. 

The Case For Romney:
As I mentioned at the outset, I am not a big fan of Mr. Romney. But I do have confidence that he will enact pro-growth policies and be more fiscally responsible than Mr. Obama.  I think he will focus on jobs, open up energy from Canada, promote free trade, and move towards a tax code that is more fair for everyone. I think the Republicans will repeal Obamacare and its hideous regulations and hidden taxes (which besides its impact on medicine, are a major drag on economic growth) and move towards useful entitlement reform.   Could I be wrong? Sure. But in this particular case and this particular time, I really think that the current path is very wrong. And what Mr. Romney is offering is an economic prescription that, at least in theory, is pro-growth. 

The President has repeatedly contrasted the Clinton years vs. the Bush years, strenuously trying to tie himself to Bill Clinton’s aura and Mr. Romney to George Bush. But the truth of the matter is that in 2012, neither Bill Clinton nor George Bush are running for President. In 2008, the country was not better than it was in 2000, and we changed direction. In 2012, the country is not better than it was in 2008. The question is in 2016, will we better off with a Romney Presidency or 4 more years of the current course; I believe Mr. Romney offers more hope for credible and useful change. In 2008, Americans made history by electing President Obama.  In 2012, it’s now time to build a future, and I believe the best choice this year is Mitt Romney. 

Friday, September 30, 2011

When do US citizens forfeit their rights?

The US government killed Anwar Al-Awlaki today. This was a premeditated liquidation – Al-Awlaki, a US born citizen turned leader of Al Qaeda of Arabian peninsula, was put on a list for targeted killing last year. I do not mourn for this man – he was a traitor and a terrorist and got what was coming to him. Some people and some ideas in this world, especially the radical Islamic fundamentalists, should be wiped out.

And yet. What was done today, while a significant tactical victory, sets a horrible and dangerous precedent. The US President just ordered and the US military executed an assassination of a US citizen in a foreign country with whom we are not at war. Granted, this man was a bad guy and an enemy of the state, and a threat to America. Yet this killing was not done during the course of a battle nor was any judicial process or congressional oversight involved in the targeting of this US citizen. Citizenship means something. The USA is distinguished from most other nations in how it treats its own citizens. In my humble opinion, how this killing was done is comparable to how Russia killed Alexander Litvinenko in London a few years ago – a targeted assassination of their own citizen who they considered an enemy of the state in a foreign country. It is a very dangerous concept that should not be legitimized.

The justifications given for this killing ring hollow. Some cite the case of Herbert Hans Haupt, a US citizen turned Nazi saboteur who was executed after infiltrating America in 1942. Yet Haupt received a military tribunal hearing prior to his sentence. Some state that a court considered al-Awlaki’s father’s challenge to the placement of his son on the hit list and that the court duly rejected the father’s plea as he had no standing and that the son was free to seek the protection of the court; would you return to a court of a nation whose President has put you on a hit list? This same court said that the government requires a warrant to tap Americans overseas, but extrajudicial killings of Americans are beyond judicial review; such a statement is patently absurd. Others state the 2001 Authorization to Use Military Force gives the President authority to use all necessary force to destroy Al Qaeda and its affiliates, and that the Article II investiture of the Commander-in-Chief powers (including powers to suppress armed insurrection) in the Presidency is beyond question. Yet this a short road to carte blanche murder – do we want to invest one man with the power to designate US citizens at will as enemies of the state as part of the war on Al Qaeda?

With the one caveat that I am not privy to any knowledge of Al-Awlaki’s imminent threat capabilities, I would think that the right way of handling this case would have been to long ago try al-Awlaki in absentia for treason with appropriate counsel for his defense and strip him of his citizenship if conviction resulted. We certainly had the time; this guy was placed on the President's kill list over a year ago. Treason is something we don’t try anymore, and I don’t understand why.

This is qualitatively different than Guantanamo, waterboarding, or collateral damage. Constitutional rights do not extend to foreign citizens (lawful enemy combatants are entitled to Geneva protections, and unlawful enemy combatants aren't; they should receive basic human rights and, like pirates, fall under enemies of humanity rules). But US citizens do not forfeit their rights against the US government when they go abroad. They would forfeit in active combat with the US military, or upon conviction of a crime (and treason is certainly a crime). Law enforcement and the military have the right to self-defense. But the US government doesn't get to do what it wants to a US citizen and throw out the Bill of Rights when it's inconvenient. The President is not an elected king. US citizens at a minimum have the negative rights (what the government should not do to them) enumerated by the Constitution and the Bill of Rights; they are not forfeited by being abroad. They are forfeited by treachery which is established by due process - the American Communists Julius & Ethel Rosenberg were executed after a trial, not by assassination.

The Obama administration has set all kinds of dangerous precedents this year – going to war with Libya without any congressional debate comes to mind. Then it was the Bureau of Alcohol, Tobacco, and Firearms (which reports to the Attorney General) distributing guns to Mexican drug cartels. Now it’s assassination of a US citizen. This goes against the Declaration of Independence, the Constitution, and the Fifth Amendment. This is unbridled executive arrogance. This is wrong. Something wicked this way comes.

Monday, April 25, 2011

Sight for the Sightless

I just got back from an intense week serving on a medical mission through the Sight for the Sightless Initiatve based at KK Eye Institute in Pune, India. This was a very different experience from any of my ORBIS missions or my Zambia mission in many respects. India is fascinating from a medical perspective in that it has first-rate physicians with some centers comparable to those of America but the population has masses of patients who have the health status of Africans. The country is in transition, with medical personnel & infrastructure highly capable yet simply overwhelmed by the sheer number of those in need, as well as hobbled by a lack of top notch equipment, instruments, and supplies.

For background, there are likely 20 million patients with at least one blind eye from cataract in India and about 8 million with corneal blindness. There are only 13,000 ophthalmologists in India, as opposed to 18,000 ophthalmologists in the US (which has only a quarter of the population). From a corneal perspective, donor tissue is much less available in India (unfortunately there is not as yet a well-developed culture of donation on passing away). So my objectives for the week were to do both service in terms of medical and surgical treatment of cornea and complex cataract conditions and skills transfer in advanced techniques and technology.

It was a physically grueling and emotionally exhausting week. With lectures, clinic, and surgery, we got done pretty much at 8 or 9pm each day (starting each day at 8am). Business dinners on future planning and needs followed, so I pretty much was going on 5 hrs of sleep each day. The most poignant moment was clinic on the first day during which we saw about 20 kids from the local blind school. For most of these children, I was a decade late and a dollar short. While I am a bit of a dinosaur in medicine (having finished medical school before the Internet and residency before cell phone), I was confronted by even more ancient demons this past week: children who had scarred corneas following measles infection when they were infants, children with wrecked eyes from Vitamin A deficiency. There are few things more heart-wrenching than telling child after child there is nothing we can do. There were 3 children who we thought we could help so we proceeded with transplantation later in the week.

Over the next several days, we performed (3 of these were children, the rest adults):
• An artificial cornea on a child who had lost one eye, and had a badly scarred cornea (barely able to see motion) in the remaining eye that was not a candidate for a standard transplant
• A combined cornea transplant with cataract extraction
• A partial thickness cornea transplant of the front of the cornea
• Two partial thickness transplants of the back of the cornea (one combined with cataract removal)
• A full thickness cornea transplant
• Several hard cataract cases and some amniotic membrane procedures

By comparison, I usually do 1-2 transplants a month in the US. These were all challenging cases given the complexity of the tissue damage on the eyes and the circumstances of available and (unavailable) equipment. But the best part (in addition to fixing the conditions and hopefully helping the patients) was teaching. I spent a lot of one on one time at the Institute with a very talented surgeon, Dr. Kapoor, and it was very rewarding to see her rapid progress over the course of the week mastering the techniques of chopping cataracts and picking up key elements of cornea transplantation. We also did some live surgery teaching the surgical maneuvers of some complex cataracts and the artificial cornea to a group of local ophthalmologists, and there were several excellent interactive small group sessions, surgeon-to-surgeon.

There were some funny moments during the trip. The hospital had arranged a press conference noting the complex cases being done that week and highlighting the need for corneal donation. During this, one of the reporters, whose first name was Nozia, came up to me and introduced herself as “Hi, my name is nausea.” It was all I could do to not burst out laughing and think of where else that joke could go. Then there were the episodes in the OR with the cotton buds with extra lint (which are a pain during eye surgery) which I nicknamed after the host and MC for live surgery, Ashiyana Nariani, who in turn promised to send me Q-tips for Christmas. Later on, I was trying to tell the patient to look down in broken Hindi, "Kali Baga Baba"; I apparently was not understandable and told Ashiyana my Hindi was worse than hers, and she told me I was actually speaking in Marathi (which I don't know either :( ). And then there was the ophthalmologist attending the live surgery and lecture workshop who requested to share his experience and promptly proceeded to regaling the audience with his life story, including the name of his childhood neighborhood street.

All in all, it was a fantastic trip. It was enabled by several groups and people to whom I owe great thanks and appreciation. The leadership of KK Eye Institute (Renu Wadhwa – CEO, who helped make things possible) and the international NGO Sight for the Sightless (founded by Dr. Ashiyana Nariani), the clinic and operative staff of the local hospital (especially Dr. Kapoor, Mr. Rohit, Ms. Madhu, Sister Pradhan, and Mr. Sachin), my mentor Dr. Claes Dohlman (the inventor of the artificial cornea who donated one for this trip), Sameera Farazdaghi of Tissue Bank International and Kelby Koop of Utah Lions Eye Bank, and my home team from Utah who organized things on this end: Jackie Simonis, Chandler Crane, and Tina Szarek.

I hope my fellow ophthalmologists and those interested in vision care will join the fight against needless blindness by contributing their time to service and teaching and making a difference where both short and long-term impact can be made. I also hope that developing societies as they develop focus resources on preventing needless blindness through awareness, encouraging eye donation, fighting diseases like the measles and malnutrition. Saving and restoring vision is probably one of the most important and cost effective things we in health care and societies as a whole can do. Especially for children, who are all too often neglected in the developing world.