Letters to the Editor
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Impaired Adult Worker Performance
Good Day Dr Felitti,
I just wanted to tell you how much I enjoyed the recent article on Impaired Adult Worker Performance (Perm J 2004 Winter;8(1):30-8). I sent out an e-mail to the group I work with here in Baldwin Park to recommend it. It also reminded me of how much I miss your energy and input. I try to march on in family practice talking about the principles you so relentlessly imparted on the HAC staff while I was there.
I enjoyed the crossword puzzle by Ken Berniker in the last issue (Perm J 2003 Fall;7(4):75). Especially the one about the thoracotomy being a way to a man's heart!
First 50 Years of SCPMG
Dear Mr Fifer,
I enjoyed your article in The Permanente Journal summarizing the First 50 Years of SCPMG (Perm J 2003 Fall;7(4):66-7). I would offer a small correction. The photo of Drs Kay and Garfield playing ping pong was actually taken (by Betty Runyen, Dr Garfield's field nurse) in 1933, when Dr Kay took some time off from LA County to travel the 120 miles or so to Desert Center and visit the hospital built by his friend, Dr Garfield. It was on visits like these, as the two men began to see the potential of prepaid group practice, that they began visualizing a new sort of health care delivery system. I take a special interest in this spot because, after having been "lost" for almost a half-century, I located it and had it declared a State historic site. I also "found" Betty Runyen, who had lost touch with Dr Garfield when he moved up to Grand Coulee Dam. She gave me hundreds of photos of life at the hospital that I have donated to KP.
As a historian who has taken a special interest in the development of the Permanente model as well as the life and impact of Henry Kaiser, I am delighted at the increasing interest being shown in your history by the people who are writing the next chapter of it.
With best wishes,
A Focus on Preventive Care
I read The Permanente Journal: A Focus on Preventive Care, 2004 Winter;(8)1, and I especially liked the following three articles:
1. "Human Embryonic Stem Cells and Type I Diabetes: How far to the Clinic" by Gillian M Beattie and Alberto Hayek (p 11). I had read about more or less successful attempts at pancreas transplants. I had also read about pancreatic islet transplants. But I was impressed by the various attempts of stem cell culture and selection. It was very interesting and very logically presented. As I teach in a Biomedical Engineering Faculty, it gave me a good research subject to think about.
2. "Childhood Abuse, Household Dysfunction, and Indicators of Impaired Adult Worker Performance" by Robert F Anda, Vladimir I Fleisher, Vincent J Felitti, et al (p 30). I was impressed by the large number (over 9000) of subjects examined and by the conclusions.
I had one specific patient today. I simply looked in her papers, saw the environment she came from, and recognized at least four phenomena of adverse childhood experiences: emotional abuse, physical abuse, battered mother, and household substance (alcohol) abuse. She was a housewife and had never been employed. She also was quite difficult to cooperate with. Having read this article made me understand her much better.
3. "PEACE SIGNS: A Sustainable Violence Prevention Collaboration Between Managed Care and School Health Programs" by John Fontanesi, Jill Rybar, Neil Alex, et al (p 67). Although I teach in the University and not in school, I admit I had some students who tried to behave incorrectly. For example, when I entered the classroom one day, there were two new boys hitting a computer as if they played the piano. I disliked it totally because they were destroying the computer. Still, I smiled and made a joke. "Well, it does sound like Mozart, doesn't it?" We all burst into laughing, and they were eager to listen to whatever else I said, lesson included. So I learned that a nice word can change a student's mind, and they understood that I would not reject them.
These are the articles I liked best this issue. I am looking forward to reading the Spring issue too.
The Beloved Community
I think the manuscript, "The Beloved Community: From Civil Rights Dream to Public Health Imperative," (Perm J 2004 Winter;8(1):58-62) is very interesting! In a perfect world, this would be what we are all searching for--that poverty, hunger, bigotry, and all forms of discrimination and prejudice would vanish; that all people would look out for the welfare of everyone else; that it would be human nature to protect everyone else. This is something that may happen, but I cannot see it happening in my lifetime.
I think that love for one's fellows is a good thing, and most societies have some form of this idea embedded, mainly through religion, but not necessarily. On the other hand, most great or powerful societies tend to reward people/groups who espouse "Manifest Destiny." Britain, America, Japan, and other powerful nations have all felt it was okay to be brutal in the name of Manifest Destiny. It's this idea that we have the duty to control other people who are "different" from us that will never allow The Beloved Community idea to occur. In my opinion, we, as Americans, still have this feeling (it's not limited to America, however). Right now we want to have Arabs think like us. In my opinion, it will not work.
As for the theory that disease follows the gradient of one social hierarchy, I think this is true and false: nothing is absolute, ever. The situation is multifactorial. In America the average lifespan of Native Americans is about 45. There are Native Americans who live into their 80s and 90s, but these people are not necessarily wealthy. Unemployment on most reservations is about 50%-60%. Alcoholism, homicide, and suicide are all high. Stress of life on reservations and the hopeless and helpless feeling most people have is a big factor.
African Americans are another group for whom the gradient theory has some true and false components. For example, during the 60s through the 90s, some African Americans made large gains in income and position in society. However, the overall lifespan of African Americans has actually declined during this same time period. It is interesting to me that the lifespan of African-American males has steadily declined during this time. AIDS was the major factor related to the decline in the lifespan of African Americans. What's more, the lifespan of African-American physicians also went down significantly during this time period. I think this was multifactorial, however. African-American physicians are usually working in African-American communities where patients are more ill, and this places these physicians under greater stress.
The other leading cause of mortality and morbidity in the African-American community is violence. Gun-caused mortality and morbidity isn't limited to the African-American community; America has the honor of having the highest rate of morbidity and morality related to guns than any other industrialized nation.
The stress theory to me has some strengths, but I cannot see it as a pure cause of all that ails America. I feel Japan is a much more stressful society than America. People work six to seven days per week; most work 12 or more hours per day. The living conditions are crowded. Conformity, uniformity, and honor are the rules for Japanese society (actually society is more important than the individual). I think this is close to the Roseto effect of a community the article talked about. Japan has one of the longest lifespans of any industrialized nation. On the other hand, it also has one of the highest suicide rates of any industrialized nation. Japan would fit the picture of a country where one shows love and honor for one's fellow man, but I'm not sure Japan would fit the perfect picture to be the model for the "Beloved Community."
I think the "Beloved Community" is the ideal and the goal of what the world should be like. We should take care of our poor, our needy, the weak, and it should be the responsibility of everyone to take part in doing so. Not everyone thinks the same way I do, and, in fact, some people think it's their destiny to take advantage of those who are weak and in need. The thing is they don't see what they might be doing as something wrong. They see it as a duty, and, in fact, they feel they are actually helping those same people that I think are being hurt. It's a matter of culture and perspective. There is no absolute right and there is no absolute wrong. Life is both right and wrong--it's a contrast. Culture in America is continually changing. There is not just one answer but many different answers. What is right is going to depend on the timing.
After reading your most lucid article in the recent Permanente Journal (Hemochromatosis Update, Perm J 2004 Winter;8(1):39-44), I feel comfortable for the first time in my understanding of genetic or hereditary hemochromatosis. From screening for it, diagnosing it, and treating it (or not treating it), I now know what it is all about.
I was intrigued by your making such good use of blood obtained by phlebotomy. I wish we were doing the same at Sunset.
With great appreciation,