Dynamist Blog

The Aesthetics of Diabetes


It's not so great. From Aiming for Grace, the blog I quoted in my Atlantic column.

The more I think about the sorry state of health care aesthetics, the more I think part of the problem is that we have an "acute care" model of medicine in a world where chronic diseases are increasingly the rule. If you only go to the doctor occasionally, you won't care nearly as much about how things look as you will if you're spending a large part of your life in clinics of various sorts. The same is true of medical devices. A diabetic who uses a pump all the time for life will benefit far more from something that looks good than someone who has a one-time, or even short-term, encounter with some kind of medical gizmo.

National Kidney Month Cont'd

Drew Carey's latest Reason.tv video makes the case for allowing markets in kidneys. It also reveals what yours truly looks like in a wig.

The video is excellent, even though all of us look pretty awful. The only thing I'd fault it for is not making the point that--I cannot say this often enough--EVEN IF EVERY SINGLE ELIGIBLE CADAVER KIDNEY WERE DONATED, THERE WOULD NOT BE ENOUGH. This shortage cannot be fixed by changing the law to override families' wishes and turning everyone who hasn't explicitly said no into a deceased donor. All that would do is sow further mistrust of the organ transplant system, particularly among (calling Barack Obama) already-suspicious African Americans. (Even if you don't care about individual rights, Michele Goodwin's book Black Markets is extremely convincing on this point.)

If the 1984 law criminalizing organ sales were simply repealed, here's what I think would happen. In the short term, neither public (Medicare, Medicaid) nor private insurers would cover the cost of paying vendors. Many hospitals would not accept them either, just as many until recently would not accept donors who learned about their recipients from media accounts or sites like MatchingDonors.com. But some transplant centers would accept vendors, assuming they passed other medical and psychological tests. Recipients would have to pay out of their own pockets or perhaps with the help of charitable institutions or community fund-raising drives. This short-term situation would indeed benefit affluent kidney patients the most. But by taking these patients off the waiting list for cadaver kidneys, it would also help poorer people, just not as much.

Over the long run, however, we could expect payments for kidneys (and possibly liver lobes) to become as much a part of the normal transplant process as payments for surgery, anesthesia, or immunosuppressant drugs. Instead of making a deal with an individual patient, someone who wanted to sell a kidney would contract with a transplant center, which would screen vendors and match them with recipients. (Since screening is expensive, one proposal is to have a national or regional standard for "qualified vendors," so that someone who didn't pass muster couldn't just go from hospital to hospital.) Insurers, whether private or governmental, would establish the prices they were willing to pay, with, I would hope, a strong desire to find the market-clearing price that would eliminate the waiting list. In the video, I make the point that since the federal government already pays for everyone's dialysis, even a price of $90,000 a kidney would save the taxpayers money.

In the meantime, the best hope for kidney patients is a much stronger emphasis on living donors, including better matching systems to take advantage of "paired donation." One such effort is the National Kidney Registry, which was founded by the father of a young kidney recipient after he and other family members proved incompatible as donors to his daughter. The National Kidney Registry seeks to facilitate living donation by creating "donor chains" and covering some of living donors' expenses. The registry's goal: "Every living donor in the world will pass through a common registry to be matched with the most compatible recipient, providing over 90 percent of the world's kidney recipients with well-matched kidneys, extending the functioning life of these transplanted kidneys by an average of ten or more years over the current average while simultaneously reducing the deceased donor waiting lists."

Here's an inspiring story from a kidney donor.

Health Care Aesthetics

My latest Atlantic column was actually proposed long before my cancer diagnosis, inspired in part by this old blog post. But I took advantage of my personal experience in writing it.

chemoview.jpgI'm sitting in a mauve vinyl recliner facing a mauve laminate counter and cabinets. On the countertop are a couple of candy jars, five peacock feathers leaning around a black wall phone, a small plant that may or may not be real, three boxes of medical-exam gloves, and a radio tuned to smooth jazz. A curling five-by-seven-inch photo of the participants in a 2000 fund-raising walk hangs below a sign warning guests not to use cell phones. Someone has pinned three teddy bears to a small strip of cork on the grayish-white wall. "I'm gonna be Okay," says the slogan on the orange bear's chest. The yellow bear wears a blue scrub outfit with an 800 number and the slogan for a cancer organization. On the white bear, hot-pink embroidery declares, "Cancer sucks."

Thank God for intravenous Bena­dryl, which knocks me out in just a few minutes. The cancer treatment is state-of-the-art, but the decor is decidedly behind the times.

Over the past decade, most public places have gotten noticeably better looking. We've gone from a world in which Starbucks set a cutting-edge standard for mass-market design to a world in which Starbucks establishes the bare minimum. If your establishment can't come up with an original look, customers expect at least some sleek wood fixtures, nicely upholstered chairs, and faux–Murano glass pendant lights.

Unless, that is, your establishment is a doctor's office, medical clinic, or hospital. Mounting clinical evidence suggests that better design can improve patients' health—not to mention their morale. But the one-sixth of the American economy devoted to health care hasn't kept up with the rest of the economy's aesthetic imperative, leaving patients to wonder, as a diabetes blogger puts it, "why hospital clinic interiors have to feel so much like a Motel 6 from the '70s."

Read the whole thing here. Thanks to all the readers who sent in thoughts about health care design in response to my earlier post. Here are a couple of photos of the imaging waiting room mentioned later in the article. Lovely, huh?


And, from the latest issue of Healthcare Design magazine, here's an article about how a simple (non-aesthetic) design improvement can substantially improve patient well-being.

Neighborhood Effects

In chapter five of The Substance of Style (excerpted here), I grappled with a fundamental problem of urban living: the conflict between establishing or preserving a neighborhood's look and feel and allowing individual homeowners to build to suit their own desires. There is no completely satisfactory solution. This Dallas Morning News article demonstrates the particular difficulties posed by trying to establish new rules, even in the best-case scenario where they're fairly general.

The signs, pro and con, have come down, and neighbors who didn't speak for months are reaching out to one another, trying to put the warfare over building restrictions behind them. Still, there are lingering bad feelings, tension as people pass each other on the sidewalks, and a question from both sides about whether the struggle was worth it.

"The ugliest McMansion in the world could be built, and it wouldn't rip neighborhoods apart like this process does," said Josh Doherty, who with his wife, Dawn, and others successfully fought the so-called Maplewood overlay.

Overlay is shorthand for what the city has officially dubbed a "neighborhood stabilization overlay," a zoning device that planners hoped would end unrest over new construction in established neighborhoods.

Instead of peace, overlays in many areas have sparked neighborhood civil wars.

Conceived in 2005, the idea was to give older, established neighborhoods a way to preserve their scale in places where lots have become more valuable than homes and giant new houses have sprouted up, dwarfing their neighbors.

But what resulted in many cases are knock-down, drag-out fights that land before the City Council with the nasty thud of neighbors at each other's throats. [Thanks to reader Tom McKendree for the tip.]

Meanwhile, in my own neighborhood, the folks who lobbied to have the duplexes across the street declared landmarks (discussed in this Atlantic column) are fighting to stop the owner of one of the buildings from adding on two new apartments. While the original plan to tear down three buildings and replace them with new condos did not require a zoning variance to alter setbacks--hence the resort to landmarking--this more-modest plan would. All my neighbors are signing petitions against the change and there's no argument I can make that would convince them the change is in their interest, because it isn't. Forbid any new construction and we preserve our nice view and keep the housing stock tight and our condo values inflated. But, of course, if the same rules and attitudes had prevailed in 1974, we'd have no condos to begin with.

The Speech

Barack Obama's speech on race in America was remarkable: simultaneously honest and diplomatic, personal and historical. It was empathetic and sought to inspire empathy in its audience, not for Obama but for Other Americans. It also gave evidence, for the first time since Ronald Reagan, of a presidential candidate with an active mind and eloquent voice engaged with big questions. In the mountain of commentary that followed, I found Robert George's reaction most similar to my own. To Robert's comments on the speech's bravery, I'll add that it is most unusual to hear a Democratic politician recall that one of the great barriers to black advancement during Jim Crow was that "blacks were excluded from unions." (What's next, a denunciation of Woodrow Wilson?)

The speech was not just a meditation on race, however. It was also a campaign speech by a candidate with particular policy views, views that place him well to the left of the political spectrum. With lines like "this time we want to talk about the fact that the real problem is not that someone who doesn't look like you might take your job; it's that the corporation you work for will ship it overseas for nothing more than a profit," the speech offered no place in its vision of racial concord for Americans who support open markets, economic dynamism, and limited government. In a serious meditation on race, as opposed to a campaign speech, that's a problem. (Besides to "ship it overseas" is, in fact, just another way of letting "someone who doesn't look like you...take your job." Obama's public empathy doesn't extend to Chinese or Indians. Megan McArdle is very good on this.)

Finally, on a historical note, the speech made me think of another famous oration, Frederick Douglass's 1852 address What to the Slave Is the Fourth of July? And it made me wish that Edith Efron had lived to hear and discuss it.

An Instinctive Regulator

Jonathan Chait's recent TNR article masterfully traces John McCain's migration from right to left to right on economic issues.

Even though it is in the public record, McCain's voting behavior during Bush's first term is almost never mentioned in the press anymore. Yet McCain's secret history is simply astonishing. It is no exaggeration to say that, during this crucial period, McCain was the most effective advocate of the Democratic agenda in Washington.

In health care, McCain co-sponsored, with John Edwards and Ted Kennedy, a patients' bill of rights. He joined Chuck Schumer to sponsor one bill allowing the re-importation of prescription drugs and another permitting wider sale of generic alternatives. All these measures were fiercely contested by the health care industry and, consequently, by Bush and the GOP leadership. On the environment, he sponsored with John Kerry a bill raising automobile fuel-efficiency standards and another bill with Joe Lieberman imposing a cap-and-trade regime on carbon emissions. He was also one of six Republicans to vote against drilling in the Arctic National Wildlife Refuge.

McCain teamed with Carl Levin on bills closing down tax shelters, forbidding accounting firms from selling products to the firms they audited, and requiring businesses that gave out stock options as compensation to reveal the cost to their stockholders. These measures were bitterly opposed by big business and faced opposition not only from virtually the whole of the GOP but even from many Democrats as well.

McCain voted against the 2001 and 2003 Bush tax cuts. He co-sponsored bills to close the gun-show loophole, expand AmeriCorps, and federalize airport security. All these things set him against nearly the entire Republican Party....

McCain was best described as a progressive--like Teddy Roosevelt, whom he cited constantly. McCain tended to see politics as a contest between the national interest and the selfishness of private agendas, and he favored a role for government in counterbalancing the excesses of organized wealth. In 2002, for instance, he was asked about the Bush administration's view, with regard to the Enron scandal, that "[t]he company had a duty to inform its shareholders and its employees about things that were going on inside the company. That's not a federal government responsibility." McCain thundered in response, "Well, Theodore Roosevelt would not agree with at least that rhetoric....We have had regulatory agencies always to curb the abuses or potential abuses of the capitalist system."

McCain is an instinctive regulator who considers business a base pursuit. It doesn't help that the senator's personal connections with commerce are largely limited to a highly protected local industry (distributing beer) and outright corruption (the Charles Keating scandal). And he's every bit as moralistic as Hillary Clinton, our would-be national nanny. His first response to something he doesn't like--particularly something commercial he doesn't like--is to ban it. The most extreme, and effective, case of this instinct was his holy war against ultimate fighting, a peculiar cause for a boxing fan and one McCain took up when he was still in his "conservative" stage. Back in 1998, Slate's David Plotz, a fan of the sport, recounted his run-in with the senator:

When I tell people I'm an ultimate fighting fan, they invariably respond: "Don't people get killed all the time doing that?" But no one has ever been killed at the UFC--though boxers are killed every year. No one has even been seriously injured at the UFC. On the rare occasions when a bout has ended with a bloody knockout, the loser has always walked out of the ring.

But this does not impress boxing fans, who are the most vigorous opponents of extreme fighting. McCain sat ringside at a boxing match where a fighter was killed. When I asked him to explain the moral distinction between boxing and ultimate fighting, he exploded at me, "If you can't see the moral distinction, then we have nothing to talk about!" Then he cut our interview short and stormed out of his office.

And, again, I recommend Matt Welch's underrecognized book on McCain The Myth of a Maverick

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