_Nickel and Dimed_, Barbara Ehrenreich

Subtitled: On (Not) Getting by in America

Ehrenreich's tour(ism) of duty in low-wage jobs in three turn of the century US cities (Key West, FL; Portland, ME and Minneapolis, MN) takes her from restaurants, through housekeeping and a nursing home to Wal-Mart. Her rules include getting to use her car, and arriving in each city with a certain amount of cash. Once she arrives, she sets up in a hotel for a few days to try to find cheap digs and work. Because of the time frame, she doesn't have a cell phone, so she is hampered in her job search in ways that might or might not be mitigated by a pay-as-you-go phone today. She specifically does not take any job that would rely upon her skills and credentials from Her Real Life.

As one would expect, Ehrenreich draws attention to the plight of her coworkers in each gig -- parents struggling with child care and dodgy housemates/partners/spouses, health problems, etc. She opts not to find a room-mate, which materially handicaps her in some ways (she notes that virtually everyone who had a stable living arrangement was sharing it with another income-earner) and spares her grief in others. She concludes with a discussion of why the poor are under much more pressure now than in the past, how welfare reform made it worse, why it's very difficult for the poor to "act like Economic Man" and ends with an ambivalent paragraph about someday it's all gonna change.

She doesn't display any sense of place -- she recognized after the fact that she did pretty well in Portland, and Minneapolis pretty much did her in, but she didn't see that coming. Her optimism going into the Twin Cities in particular was bizarre to me, given how legendarily expensive they are from a cost-of-living perspective. Her middle-class perspective was at times odd; I wasn't sure if she was affecting a certain perspective to make a point, or her epiphanies were genuine. The one that really stood out starkly was her realization that poor women really have a lot more to be afraid of than women with better access to resources.

She does recognize that not-working-as-fast-as-you-can is a matter of budgeting energy and avoiding more egregious exploitation, which is a plus. Other tourists in low wage jobs frequently mistake the strategy for the reason that the low-paid worker is paid poorly.

Throughout, her own family history colors her perspective on the jobs she takes. Her mother's approach to cleaning informs her contempt for the cleaning done by The Maids. Her family history in union organizing has obvious results when she collides with Wal-Mart.

There's a fair amount of journalism that amounts to: gosh, I should go try that and really understand it and then write about it. While I _really love_ non-fiction that's about someone tracking down experts and learning about something, this particular style of journalism is unsatisfying to me. I think I know why: the author is maintaining too much distance from the subject matter. Throughout her project, Ehrenreich thought of herself as deceiving those around her. She acknowledges that this isn't the case -- you don't fake waiting tables or cleaning a hotel room. The tables are served and the room is cleaned or it isn't. But she constantly perceives herself as Not Being Like the People Around Her, and that's jarring. Maybe it's respectful. Maybe it's honest. But it's jarring.

I owned it and had meant to read it years ago; it's up for book group tonight, so I may post again about other folks take on it and how that influenced mine.

a paragraph from _Prescribing by Numbers_

I don't know if it's possible to over-recommend this Johns Hopkins published work by Jeremy A. Greene. Sure, it violates one of my cover metrics (all quotes are from journals/magazines, with no one person's name on the line). And okay, yeah, you could argue that it's a little wonky. Maybe a lot wonky.

After a few chapters describing the rise of diuretics to treat hypertension and how that changed the definition of hypertension as a disease category, Greene moves on to the first of the oral anti-hyperglycemics (diabetes drugs for Type II folk who may or may not also be taking insulin): Orinase. After describing the massive throwdown when a couple studies showed increased mortality associated with long-term usage of a drug that was supposed to decrease risk of vascular disease (yeah, _that's_ an all too familiar story these decades), Greene produces this sentence which, I swear, is the kind of thing I live for.

"As they complained about malpractice implications of changed labeling, physicians were not only thinking about lawsuits based on their future actions but also grappling with the theoretically far broader culpability for their past decade of participation within a therapeutic system now being considered potentially harmful."

As if that gem were not enough, he adds in the next paragraph:

"The pharmaceutical mobilization and expansion of a disease category -- whether hypertension or asymptomatic diabetes -- is a complex process involving the coordination of many stakeholders...But as labor-intensive and plodding as the expansion of a disease category from symptomatic to asymptomatic might be, the process of _restricting_ a disease entity once it has successfully been expanded is an effort on an entirely different order of magnitude....Once those actors have been mobilized, once physicians have formed their practice around such labels and once pharmaceutical consumers have formed corresponding disease identities, any process of disease contraction must be contested by the embodied inertia of these newly diagnosed populations. After a decade of pharmaceutical therapy, it is difficult to tell a patient that he never really had a treatable disease without calling into question the entire edifice of medical knowledge and previous trust in the doctor-patient relationship."

I am not being sarcastic. That's basically the thesis statement for the book ("This observation is central to the argument of this book."). He's describing exactly my problem with the medical industry. Yeah, there are access problems. Yeah, doctors miss real, symptomatic diseases. People don't wash their hands. Hospitals and doctors spread serious and at times incurable diseases. The wrong limbs get amputated, risk is amplified everywhere, blah, blah, bleeping blah. None of it matters if everyone is taking pills because they believe in a disease that isn't real, and the pills are killing them, or at least making them sicker, than they would otherwise be. If a big chunk of our country's GDP is tied up in doing that, it almost doesn't matter what else we are or are not doing.

I would say it is far from clear what to do to reverse it, but it's actually quite clear. Keep pointing out the naked emperor and hope people start listening. Some day.

snarking on lifeboats, then I'm off, I swear

http://well.blogs.nytimes.com/2009/01/19/how-should-obama-reform-health-care/

Pointing to this:

http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande?currentPage=1

Atul Gawande is the guy whose book _Complications_ I enjoyed, but whose book _Better_ I felt (like some other reviewers on Amazon) was worse. I've watched/listened to him speak on BookTV; he seems personable and intelligent. His commentary on medicine is a bit hit or miss, but distinctly different in his misses than Sanjay Gupta (the guy over at CNN rumored for the Surgeon General post -- if you got them mixed up, you aren't alone). Gupta misses in ways that make me wonder if he's awake and paying attention; Gawande, I feel, is overly optimistic about his chosen profession.

In any event, this is the quote I will snark on:

"On the start date for our new health-care system—on, say, January 1, 2011—there need be no noticeable change for the vast majority of Americans who have dependable coverage and decent health care. But we can construct a kind of lifeboat alongside it for those who have been left out or dumped out"

Once upon a time, the state of Florida had a bit of a crisis on their hands, as home insurance companies were exiting the state in droves or quoting policies that were clearly out of reach. So the state of Florida created a stopgap, a state owned insurance pool you could get home owners insurance through when you couldn't afford to get it anywhere else.

Guess what? Everyone now gets their insurance through the state. (For suitable values of everyone.)

https://www.citizensfla.com/

Here's one perspective on how that's going:

http://www.sun-sentinel.com/business/sfl-flzcitizens0107sbjan07,0,7388596.story

I'm all in favor of reforming health care. I have yet to hear a proposal that I think is really great. Me, I think we should institute a wealth tax and use it to fund health care for everyone and implement it in conjunction with draconian regulation of Pharma, Medical Devices, etc. I also think we should do something Really Really Dire to the AMA, and pull licensing of medical professionals into the government; having a trade association do that is just silly.

I recognize that no one else is going to sign on to this program, so I basically don't much care what else we do, but I would like to improve access. Gawande's idea (like Obama's, Hillary's and everyone else's) that we start small and expand is plausible. Every other metastasized aspect of the medical-industrial complex started small.

But that lifeboat is either going to sink or bloat.