Septic Tanks, Immigration, and Social Justice

Hong Kong - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

Social justice is based on the concepts of human rights and equality and involves a greater degree of economic egalitarianism through progressive taxation, income redistribution, or even property redistribution. These policies aim to achieve what developmental economists refer to as more equality of opportunity than may currently exist in some societies, and to manufacture equality of outcome in cases where incidental inequalities appear in a procedurally just system.
-- Wikipedia

It is all about perspective and how the message is conveyed, so news agencies which promote social justice are clever about shifting responsibility away from the individual and onto the back of the beleaguered tax payer.

On a recent radio program on NPR’s “California Report,” the reporter was hot on the trail of another injustice in California’s Central Valley.  Ostensibly, the plumbing in the homes of a group of families from Mexico living in a rural part of the Valley is not connected to the sewer, and the septic tanks are overflowing.  During the inevitable interview, a Spanish speaking head of one of the households lamented about the continuing problem of not having adequate sewer facilities.

“Mexico is a very poor country,” he offered.  “But the government always builds a sewer system for houses before people can use them.  Why can’t they do the same in this country?”

He went on to add, “It’s embarrassing, but my family puts our feces in plastic bags and dumps them in the garbage.”

Before my father and mother died, I took my wife and children to visit the ranches where my parents were born and raised in eastern Wyoming and western Nebraska.  Both families were large and poor, but hygiene was taken very seriously.  If one of the outhouses was close to capacity, another one was dug and the old one sealed.  Allowing it to overflow and indiscriminately dealing with the excess was something my grandparents never considered.  Sloppy disposal of refuse meant disease and death on the frontier. 

“There's nothing left.  The barn and silo are completely gone.  Nothin' but ashes.  What can we do, Ma?"

“We'll wait for the government to rebuild it, Pa, and they'll give us plenty to eat until its done.  There’s nothin’ we can do.”

The attitude expressed in the preceding dialogue was the least probable exchange between a husband and wife running a farm or ranch after a lightning strike burned a barn to the ground.  Neighbors came from far and wide to help rebuild the structure well and quickly.  The concept of the self reliant citizen taking initiative in the face of hardship is foreign to the liberal press.  Excuses are plentiful and expectations low.  The advantage of setting sights below the horizon is that it is difficult to be disappointed.  

Three questions come to mind: 

What type of person is so indifferent that he or she will not dispose of their own human waste in a proper fashion and would continue doing so for an apparently unlimited amount of time until someone else did it for them?

If Mexico takes such good care of its citizens, why would one choose to remain in California, where trash bags are used for toilets?

This could not have anything to do with California’s overly generous welfare payments, or could it?

Have Uterus Will Travel

New Mexico - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

“Teenage pregnancies continue to be a problem throughout the country. It perpetuates the cycle of poverty and makes it difficult to achieve educational and professional goals.” -- Essay subject given to medical scholarship applicants from a local high school.

Each year our medical group provides a four year academic scholarship to aspiring physicians, and each year the applicants are required to write an essay proposing a solution to a complex medical or social problem. This year nearly all of the finalists felt sex education and parental influence were most crucial in solving the teenage mother problem -- reasonable answers, but birth control is widely available and many teen mothers do not have an influential parent to guide them through these difficult years.

Last month while working on the hospital’s obstetric floor, I cared for a 20 year old single mother who was having her fourth cesarean section. She was 4 foot ten inches tall and weighed 210 pounds, dropped our of high school at age sixteen, and chose to raise her family without the fathers of her children. During the operation with her mother at the bedside, her obstetrician announced she had delivered a baby girl, and he would see her again next year when she tried for another boy.

Put yourself into the shoes of a poorly educated teen mother without a positive role model who is destined to work in low paying service industry jobs for a lifetime. There is no prospect of travel, owning a home, or living a life unlike her mother. Given the circumstances, having children is not an unattractive alternative if the government provides cash, housing, medical and child care, food stamps, and transportation, while not having to deal with employers who insist on punctuality and demand a certain level of performance.

Obstetrics is one of the few specialties where a welfare Medical provider physician can earn as much for a procedure as a private physician caring for a commercially insured patient. The financial enticement insures low income women will receive obstetric care, but it also encourages providers to manage practices based on high patient volume. Whereas as private physician will typically deliver twelve to fifteen babies per month and know their patients well, a MediCal doctor will deliver sixty babies in the same time frame but may not have seen the patient until delivery time.

Another quirk of the welfare obstetric business is a program which allows the obstetrician to bill the State of California for nutritional counseling during pregnancy. The service is offered through the physician’s office and is intended to teach the patients to eat properly and maintain weight control during pregnancy. Who could quarrel with a goal which is good for mother and good for baby? Anyone who works in labor and delivery would agree that there are more MediCal patients who weigh over 250 pounds than weigh less than 150. It is not uncommon to care for patients weighing 350 pounds who suffer from diabetes and high blood pressure, but have had tax payer paid nutritional counseling during pregnancy.

What about the obstetrician's flippant comment that he would see his patient again next year for another cesarean delivery? There is a powerful financial incentive to encourage parity. Obstetricians exercise profound influence over their patients and perhaps more so in the case of patients without husbands or a supportive, discerning family. Large, production based practices favor less personal engagement with patients who tend to be unsophisticated and susceptible to manipulation.

Before dismissing these thoughts as a misogynous tirade, the real culprit is the social welfare system which insures these young women and many of their children will fail and fall deeper into dependency. There are substantial financial rewards for welfare mothers and the physicians who care for them. Programs to help welfare mothers break the cycle of poverty were discussed in a previous article. (Makin Babies) In the physician case what would happen if reimbursement was based on successful family planning rather than the number of babies delivered? For example, after the first delivery the obstetrician’s fee would be drastically cut for subsequent deliveries within the next five years, but reimbursement for family planning would increase to make this part of the practice economically viable. Reimbursement for “nutritional counseling” during pregnancy would only occur if the patient met certain weight restrictions during pregnancy. Document the patient’s weight in a hospital at the beginning of pregnancy and weigh her at delivery time. If the weight gain is satisfactory as stipulated by the American Board of Obstetricians, then reimbursement occurs, otherwise nothing for sham programs which do not ensure results.

The scholarship applicants felt education is key to solving the teenage pregnancy problem. However, their concept of education is sex education, and none of them addressed the importance of educated mothers. Women with a marginal academic backgrounds often raise their children in areas where the quality of public instruction is abysmal. The chance their children will succeed unless they are fortunate enough to attend a charter school is vanishingly small. (Waiting for Superman) Educated women tend to limit the size of their families, and their children are more apt to be educated and independently employed, while less likely to use drugs and have criminal records. This goal is more difficult to achieve if welfare mothers and the physicians caring for them are rewarded for behavior that digs a hole so deep that only an exceptional woman can extricate herself.

Doctor for A Day - The Governator Visits Labor and Delivery

Mount Kilimanjaro - Tanzania

Scott Sturman
fliesinyoureyes.com

“The road to Hell is paved with good intentions.”

Sometimes when working on the labor and delivery service I want to scream, “Does anybody outside the medical profession know what is going on here?” I've fantasized about Governor Arnold Schwarzenegger or some high ranking official in the California Legislature spending some time in the hospital to witness the events experienced on a daily basis. I have the impression most politicians responsible for implementing large government social programs either have no idea how they function in the real world or simply ignore nagging problems they wish would go away. The hospital service guaranteed to shock them into some semblance of despair would be the obstetric service, traditionally acknowledged to be the happiest department in the hospital. True, it is a place of great joy, but over the years most deliveries in our institution do not include a mature, responsible mother and a nervous but committed father. A good share of society's social problems start here with a single, poorly educated teenager or an older woman with a history of multiple pregnancies by different fathers. There is a unifying theme – all too often the father of the baby is only a temporary player who abrogates his parental and financial responsibilities to the tax payer.

The following parody details a variety of obstetric cases which would raise the eyebrows of a layman but are routine to the clinician. If the cycle of poverty and hopelessness is to stop, then politicians and academicians need to leave their posh parlors and ivory towers and visit the trenches. It would be a sobering experience to discover the programs which sound so good in theory are dismal failures; in many cases they have made matters worse and driven another generation into decline.

“Welcome to the labor and delivery floor, Governor Schwarzenegger. I can't recall having a political leader join the on call anesthesiologist to observe how the obstetric system functions – much less to volunteer for the full 24 hour shift. Our job is to provide anesthetic services for Caesarian sections, labor epidurals, and obstetric emergencies. We care for a wide variety of patients. Although this hospital is not county affiliated or designated as an indigent care facility, over 70% of our patients are on public assistance, and a substantial percentage are single mothers. As the day progresses you'll notice many of the laboring patients are teenagers who are not necessarily delivering their first child. Teenage pregnancy rates are rising in our community. Children having children if you will. It is a cycle of poverty and hardship where a daughter's future is her mother's past.”

The Governator was quick to respond, “It is good to be here, Dr, Priskna, but I think you are painting an overly pessimistic picture of the situation. The State of Cal-ee-for-nee-a spends substantial resources on welfare benefits, and even though there are problems, I think we get our money's worth. As Governor I want to witness a clinical environment first hand to reassure myself that the state is on the right track. I am looking forward to being here to see the parents and little children when they come into this world.”

“Let's get started, Governor. Before the first scheduled Caesarian section, an obstetrician has requested a labor epidural for her 15 year old patient.”

We entered the room and saw a large adolescent sitting up in bed. Her mother, who could have been 30 or 50 years old, was sitting in the corner and did not say a word. “Good morning, Miss. I'm Dr. Priskna and we have a famous visitor, Governor Schwarzenegger, who will be observing. I understand you would like a labor epidural. Is this your first baby?”

“I've been pregnant three times but this is only my second baby.”

The Governator interjected, “Holy Cow! You're fifteen, and this is your third pregnancy? Where are your parents? This is bogus!”

“Please, Governor,” I reminded him. “We try to keep personal feeling to ourselves. This situation is not that uncommon. A considerable number of these very young patients have been sexually active from an early age. They come to the hospital expecting labor epidurals and receive the same care and benefits as patients who pay for these services. They either have had an epidural beforehand, or one of their friends have told them about it.”

“Now that we've finished with the procedure, let's interview the next patient who is scheduled for a Caesarian. You noticed when we left the room the patient did not thank us for helping her. This is not at all unusual. The service is free and involves an element of risk, but a lot of these patients expect the treatment as a right.”

“Our next patient, Governor, is 24 years old. She is single and this is her fourth baby – all by different fathers. Today's operation will be her fourth Caesarian operation.”
We entered the patient's room to conduct a preop interview and found her to be poised and articulate. She and her boyfriend had been together for a year and a half, and he was at the bedside. At the conclusion of the interview, the patient went to use the bathroom while the Governor, a newly assigned registered nurse, and I chatted with the father. The nurse was doing some last minute charting and asked him to spell his girlfriend's last name.

“I don't know.”
“Well, what's her name then? I can look it up in the computer.”
“I'm not sure.”
The Governor exploded, “You've been with your pregnant girlfriend for 18 months, and you don't know her name? This is bogus!” -- so much for the value judgments in the company of patients and family members policy.

We accompanied the patient to the operating room and placed a spinal anesthetic. To ease the governor's incredulity, I asked the patient, “Did you know your boyfriend does not know your last name?”

“It's not that he doesn't know it. It's just hard to pronounce.”
The Governator jumped on this comment, “Your name has six letters and none of them are silent! How can he not be able to pronounce it? I'm from Austria. English is my second language. I have known you for less than five minutes, and I have no problem pronouncing your name.”

A nurse called into the operating room, “Dr. Priskna, as soon as you finish with the C section we need three more epidurals.”

The first patient was unmarried in her late twenties with one child at home and taking chronic methadone for heroin addiction. Her well dressed and heavily jeweled mother was at the bedside and continually interrupted the interview. She volunteered unsolicited information about herself and tried to answer all the questions directed to her daughter.

The governor pulled me aside, “How can she get pregnant? She's a drug addict, and the State of Cal-ee-for-nee-a is paying for her drug rehab. Her baby will be an addict because of the methadone! Now we will be treating two patients with drug problems – one who is an innocent victim and the other who is highly irresponsible. This is bogus!”

We rushed to the next room and found a twenty-six year old patient in active labor and demanding an epidural. A cursory review of the medical chart revealed an extensive obstetric history. Although in her mid twenties, the patient had been pregnant nine times. She had undergone three therapeutic abortions, had five living children of which four were in foster care, and now was delivering her sixth child. I glanced at the Governor who was sitting in a chair in the corner of the room with his head in his hands and mumbling quietly in German.

Our last epidural request was unusual even by our standards. The patient was an obese woman who was involved with an altercation with her boyfriend a few hours ago. She awakened him in the middle of the night and told him to go to a convenience store to buy her some cigarettes. He was a diminutive man who none the less felt it was wrong for his pregnant girlfriend to smoke. He refused to go, but she found some stashed away in the house and began to smoke. An argument ensued and he attempted to take the cigarette from her. Being only half her size, she grabbed him by the collar, threw him to the floor, and pummeled him with her fists. He called the police, who arrived only to find the woman in labor due to the stress from the altercation. She was taken to the hospital in the squad car. When the Governor and I entered the labor room, we found a huge woman in labor handcuffed to the bed with two law enforcement officers in attendance. The first words from her mouth was, “Gimme an epidural NOW!”

Flexing his massive chest, the Governor ripped off his scrub top and hurled it against the wall. “I'm outta here!” he shouted. He was only 3 ½ hours into the twenty-four hour shift, but he was headed to Malibu to a more sheltered world where most everyone thought the system was working just fine.

Did I Miss Something?

Roman Ruins at Volubulis, Morocco - photo by JoAnn Sturman

Scott Sturman
fliesinyoureyes.com

I accelerate down the ramp to enter the freeway. Within ten seconds six vehicles with handicapped license plates roar past me. I remark to my wife, “Does it seem to you there are a disproportionate number of disabled drivers in California?”

Out of curiosity I follow a high horse power pickup truck with a construction company logo off the highway until the driver parks in a disabled parking spot in front of a convenience store. A middle aged man bounds out of the truck and strides toward the store's entrance.

We all know someone who abuses the disability system. Programs intended to help the truly needy frequently become an avenue of deceit for those who manipulate them. Government agencies in charge of these institutions are too big, too lax, and too free with public funds.

Much of my medical training occurred in a Veterans' Hospital. The system was profoundly inefficient, but the veterans received good care primarily due to house staff working a hundred hours per week. Some veterans suffered from medical conditions due to combat wounds. Many suffered from the travails of alcoholism and tobacco abuse. A few were malingerers who received disability compensation for maladies that were either not service connected or for bogus diagnoses stemming from vague symptoms.

Part of our job as internal medicine house staff was to evaluate patients receiving disability. Continued receipt of benefits depended upon these periodic examinations. One clinic day another resident and I examined a robust thirty year old man receiving 50% disability for Reiter's Syndrome, a type of arthritis. As hard as we tried, the diagnosis did not fit the history or physical examination. I asked the patient, “What kind of work do you do?”

“I can't work. The pain is too much to handle.”
“How do you make a living?”

It was the smirk which accompanied the answer that is most memorable. “I'm drinking from the lemonade spring. The VA will pay my way forever.”

We decided to recommend disapproval for disability and thoroughly documented our findings. The next day the head of the hospital called us to his office. We could either withdraw our conclusions or look for another training program.

While working in the operating room at the conclusion of an operation, I look at the information sheet of a seemingly healthy young adult only to find he or she is disabled. There is nothing in the history or physical examination to warrant such a status – no major injury, chronic debilitating disease, or congenital illness. I ask the surgeon, “Did I miss something? This patient is covered by Medicare, but there is no evidence of incapacitating disease.” When the answer surfaces, the problem usually involves stress, back pain, depression, a history of drug abuse, or an old problem which resolved but never received follow up to remove the patient from disability status.

I have a close friend who has suffered from disfiguring joint disease and unremitting pain for over thirty years due to rheumatoid arthritis. He works 70-80 hours a week, has never accepted disability benefits, and pays for those who have these benefits but whose medical problems pale in comparison to his. It is ironic someone who legitimately could qualify for disability benefits pays taxes to support those who should be taking care of him.

To put this ethos of entitlement in perspective, one only needs to look at the “Greatest Generation,” a group hailed by liberals and conservatives alike. The two defining events of this generation were the Great Depression and World War II. These times of great stress and deprivation forged a philosophy based on hard work and sacrifice. This generation paved the way for the freedom and prosperity subsequent generations enjoy. In the process, however, the message became distorted. The concept of delayed gratification and self reliance were deemphasized and replaced by a system intended to keep people from failing. Never mind the aphorism of faltering repeatedly, learning from one's mistakes, and ultimately rising a stronger person. The government's ability and resolve to differentiate between those who truly need help and the slackers has been lost.

Functioning among us are a cadre of politicians, medical professionals, lawyers, social workers, and advocacy groups who compound the problem. They are no longer stewards of a system meant to assist those legitimately in need of help but enablers who squander limited financial resources and make endless excuses. To reverse this decline will require a new type of leader who will not pander to the masses and will demand accountability from those receiving benefits from the government. In times of prosperity it is too easy to ignore frivolous behavior, but as times become more difficult there will be a day of reckoning when the country can no longer bear granting generous gratuities to the not-so-disabled.