What defines Quality in Health Care?

In the furor over the health care legislation there have been comments about 'destroying the world's best health care system' by some pundits, while others say America as fallen behind in health care as shown by longevity statistics in countries with government health care. Is longevity the best measure? Is short waiting time for procedures the best measure? Those 2 measures would give opposite rankings when comparing America and western Europe.

I was discussing this with a colleague at work who related his story. In 1989 he tore a tendon in his leg and had surgeons describe to him the incision that would be made from his knee to his ankle to repair it and the resulting 3 months on crutches. Not liking this, he found out that there was a new surgical group here and the founder used to play on the rugby team he was playing for when injuring his leg. This surgeon provided tendon repairs to the Atlanta Falcons and Braves with a then brand new procedure, an arthroscopic method with a very small incision and ability to walk without crutches in a day or two. He contacted him, and the surgeon was willing to take him on because of the rugby team connection. In 1993, the other leg was injured. This time, all the surgeons in town were using the new procedure. In 1999, he was Denmark on business and met a man on crutches who had been injured playing soccer, and there the surgeons were still using the old procedure. They were only 10 years behind. And he had to wait 3 months to have it done, so he 3 months to wait before the surgery then 3 more on crutches.

I have heard similar tales from folks that have moved here from Canada. These kinds of new procedures typically are developed in America and spread from here, though they apparently spread slowly to some countries. Why? Because here there is a payback for new procedures that are less painful, faster, and that return you to full productivity both without a long wait and with faster recovery. Yet none of this would show up in longevity. Is it better?

I don't think we have the right measures to evaluate it. The European approach appears to cost less, but doesn't the loss of 6 months of full productivity have a cost, in this example? The newer method may cost more at first, but does the improved quality of life have a value as well as the improved productivity by less lost time from the job, etc?

Someone has said (Churchill maybe?)that capitalism is the unequal sharing of prosperity and socialism is the equal sharing of misery. That comes close. In this case I think there is also something to be said about freedom having costs as well as benefits. Freedom is risky: this was true in the Garden of Eden, but God considered freedom to be worth the risk, even knowing it would result in the crucifixion of His Son. Freedom is highly valued in the U.S. despite its risk and its cost. In this example, when my friend returned home from Europe he met another athlete in a leg brace with crutches. The arthroscopic surgery was available, but he had no insurance and did not have the funds available just then to pay for it.

My opinion is that the U.S. has the best procedures in the world available, and with the least wait. That does not affect longevity outcomes for a variety of reasons, most of them having to do with diet, obesity, and overall sedentary lifestyles. The U.S. also has the most expensive healthcare in the world, pricing some folks out of the market. A better balance is needed: neither a move to be like Europe and abandon innovation and short waits, nor keeping the current situation. I don't think the current legislation does what is needed; I hope it can cause enough debate to get us on a better path.

The Virtues of Spittle

I recently read Pagan Christianity by Barna (the pollster) and Viola, and while I was generally unimpressed by their arguments about the pagan origins of many church traditions, along the way there was some discussion of how Jesus intentionally confronted many of the traditions and practices of His day. One example of this is when He healed the man born blind by making clay with spittle and rubbing it on the man's eyes (John 9). A few days later, our pastor preached on this same passage. Both the book and the sermon pointed out that this healing was done on the Sabbath, which confronted the Jewish traditional teachings from the Mishnah that prohibited work on the Sabbath, including healing. In the book, however, they noted in a footnote that the Mishnah, which is the rabbinic interpretation of the Torah, includes a passage in the section about the Sabbath (Sabbath 108:20) in which spitting to make clay to anoint eyes (as well as pouring wine into the eyes) are specifically prohibited. How weird is that?



So what is with this fixation on spitting? How could spitting be important enough to anyone that the rabbis would make a specific rule about it regarding the keeping of the Sabbath? In searching around the internet to find out about this I came across some information that surprised me. It turns out that both Jews and others in ancient times considered that saliva could have healing properties (see JewishEncyclopedia.com under 'saliva'). This is recorded by the Roman historian Pliny as well, and Tacitus ascribes to the emperor Vespasian the healing of eye diseases with his saliva. The Greeks also held this view. The Jews held that a man who kept the law and had just been fasting as well could have special power in his saliva. In some contexts spittle was considered unclean, but for the most part it was not and was even viewed as having special powers. In this context, for Jesus to spit and anoint eyes would have been very much expected for a healer. While this passage strikes my modern sensibilities as very weird, Jesus was doing exactly what a healer would be expected to do in that time.



There are 3 passages that involve Jesus spitting to heal: this one in John 9, plus Mark 7:33 and Mark 8:23. It was not a 'one off' event. The gospels report these without comment, just as if it is behavior that one would expect, and such it is. Once again I was reminded of how separated our habits of mind are from that time and place, and how much more we would understand the subtleties of the gospel if we better understood the culture of that time and place.



As I discussed this with my daughter, she brought up a related case around baptism. Here is an interesting link discussing the Jewish mikvah (or mikveh): www.myjewishlearning.com/life/Life_Events/Conversion/Conversion_Process/Mikveh for reference. Mikvah is the cleansing by immersion that is used for several purposes in Judaism, but it is notably used as part of the process for a Gentile to convert to Judaism. It must be complete immersion so that every part and every hair is immersed. It is to be done in specified water, 'living' water, not stagnant or impure water. The comparison to being re-born is explicit, as one enters the water a Gentile and emerges a Jew, just as one born a Jew. So when Jesus confronted a devout Jew like Nicodemus in John 3 and tells him that he, too, must be 'born again' He was referring to something Nicodemus already knew about. However, Nicodemus would not have thought that what was required for a Gentile was needed for himself. He had already been born a Jew. But Jesus confronted him that a major, life altering change of heart was needed for the Jews to be truly God's people, just as is required for a Gentile to become a Jew in seeking the true God. This is not the sprinkling of babies that eventually emerged in the West at all. How much else do we misinterpret by westernizing the gospel teaching?

Call Me Ichabod

I don't remember when I first read or heard Washington Irving's 'Legend of Sleepy Hollow' but it is a story I have always enjoyed, especially in the fall. When we moved to Lee, MA, to start up the first Hydroknit(r) machine we moved at Labor Day and it was a glorious New England fall that year. We were living just a few miles from the Hudson valley where the story takes place, so of course I dragged out an American Lit book from college and re-read it that fall. The description of Ichabod Crane is one of the memorable parts of the story, and his nose is among his many exagerated features. It is described as 'a long snipe nose, so that it looked like a weather-cock, perched upon his spindle neck, to tell which way the wind blew. To see him striding along the profile of a hill on a windy day, with his clothes bagging and fluttering about him, one might have mistaken him for the genius of famine descending upon the earth, or some scarecrow eloped from the cornfield.' With my ongoing nose problems of this past week, I was of course reminded of him with such a famous nose!

Ichabod is a biblical name, and its meaning in the Bible contributes all the more to the description in Irving's story. In I Samuel 4, the ark of the covenant is taken from Israel by the Philistines, and the battle included the death of the high priest Eli's 2 sons as well as Eli's death from shock at the loss of the ark and his sons. His daughter-in-law then dies in childbirth upon hearing of her husband's death and the loss of the ark but before she dies she names the child Ichabod, which means 'the glory has departed' or 'no glory'. Ichabod Crane's nose was just one contributor to his appearance having 'no glory'!

I suspect my colleagues at work and my family who have seen me the past few days with various things stuffed in my nose, hanging out of my nose, and taped to my nose would certainly be thinking that 'Ichabod' sounds about right! I flatter myself , no doubt, to think that my nose was not all that weather-vane like otherwise. A little crooked maybe, but not quite up to Ichabod Crane's standards, at least until the last few days. The extra adornment the past few days has put me 'over the top', though.

Having gone 4 of the past 5 days to see the Ear/Nose/Throat doctor (we took Sunday off), and 2 more days before that getting urgent care to try to stop the nosebleeds, I have a newfound respect for the poor nose. My deviated (deviant?) septum is now a matter of more thoughtful consideration. And poor Ichabod Crane gets more sympathy from me than I ever gave him before.