2011 - %3, May

Return to Kurdistan - Part 1

| Tue May. 31, 2011 10:37 PM PDT

Several years ago I published a series of blog posts from Jonathan Dworkin, a medical student at Mount Sinai School of Medicine in New York. He spent a year organizing a collaboration between Kurdish and American doctors in order to assess the long-term consequences of Baathist chemical attacks on the Kurdish civilian population of Halabja, and in 2006 he spent several months travelling in Iraqi Kurdistan and sending occasional dispatches about his travels. You can find them here (scroll to the bottom for a complete list).

Jonathan is now an infectious diseases fellow at Brown, and has spent the past few weeks in Kurdistan working to develop the public health infrastructure. He's back now, and has written a series of three posts on how things have changed since his first visit, hitting on themes of transparency in the economic system, willingness of the government to peacefully transfer power, freedom of journalists, independence of public institutions (like the university), and relations between Kurds and Arabs. Kurdistan has pretty much fallen off the radar of the U.S. media, so this is stuff you won't find anywhere else.

Part 1 is below. The next two parts will follow on Thursday and Friday.


“Basis of life is sleep, sex, nutrition. I am nutrition.” That’s what the cook said, and then he handed me a meatball. Kurdistan has changed a lot in five years, but the cook at the dar is an example of how it hasn’t changed, and hopefully never will change. After spending two days in a hotel I moved to the residence for medical house officers, which everyone here calls the dar. This is one of Kurdistan’s primary mechanisms for alleviating the economic hardship of prolonged training and the social hardship of deferred marriage. The dar is a place for young doctors to live together, study together, and tease one another. And in a characteristically class levelling way, the teaser in chief of this dar is the cook. “Doctor is survivor of electro-shock therapy,” he explained while puffing on a cigarette and indicating the young psychiatrist sitting to my right. “He is very crazy man. He will sleep next to you tonight.”

The ostensible reason I’m in this situation is to conduct public health research for Brown University. The research is part of my training as an infectious diseases doctor. During my previous visit to the Kurdish autonomous region of Northern Iraq in 2006 I saw several cases of typhoid fever, but our small team wasn’t equipped to characterize them in any systematic way. This time we are armed with data collection tools and grant funding. Burden of disease studies — a simple form of public health work — are often precursors to interventions such as vaccine programs or infrastructure investments. But all of this is largely beside the point. The real reason I’m back, doing this typhoid project in this province, as opposed to another, is because I love Kurdistan. In medicine it’s the people that draw you in, and the work is an expression of solidarity.

The dark side of this trip begins with the fact that it almost didn’t happen. In February, during the beginning of the Arab spring, protests erupted in Kurdish Sulaimania. The reasons for the opposition were varied, but at its core the protests were against the patronage system established by the ruling Kurdish parties. For two months the opposition occupied Sara Square, in the center of the city, and the protests ended when the authorities deployed Kurdish units of the Iraqi Army. Hundreds were wounded and several people died in the worst internal violence since the 1990s.

The original plan for my trip was to come with my family and live for a month in an apartment my friends had picked for me. The apartment was in a comfortable neighbourhood called German Village. After the protests erupted unidentified gunmen stormed the area and burned down an opposition television station. Nothing will ruin the reputation of a nice neighbourhood faster than a secretive militia affiliated with a political party. The German Village becoming more like Beirut, I changed my plans and arrived alone.

Now the streets are quiet. German Village is well-kept and calm, deceptively German. There is no heavy security presence in Sara Square, though party buildings are well defended. The economic and cultural life of the town appears uninterrupted, at least on the surface. In fact the city is larger and more vibrant than five years ago. Electricity is better. Water quality, though imperfect, is better. Construction projects and new businesses are everywhere. The hospital is functioning on a much higher level. Not only are routine diagnostic tests available 24 hours per day, but advanced interventions such as cardiac bypass surgery and kidney transplantation are now offered. One of the ironies of recent history here is that the government’s moment of crisis ought to be a moment of triumph. The Kurdish region never descended into violence, despite what happened in the rest of Iraq. There was a contested election, opposition parties, and a critical press. All of that success is threatened by the recent violence.

Spending a weekend with my friends before beginning data collection, it’s easy to pretend this is the Sulaimania of five years ago. You can still walk the streets safely and encounter friendly smiles as an American. You can still go to a cafe and talk politics over rice, vegetables, and grilled meat. There’s an openness one feels around Kurdish people, particularly in Sulaimania, that reminds me of why I fell in love with this town in the first place. But probe deeper and you find a poisonous pessimism that is taking root. It is that despair, and the realization that a bold attempt to build a new Kurdish civic society may end in failure, that is the real story this spring in Sulaimania.

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Congressman: Why Is TSA Skipping Arabs?

| Tue May. 31, 2011 4:20 PM PDT

The Atlanta Journal-Constitution has a video of Rep. Paul Broun (R-Georgia) talking about the TSA. According to Rep. Broun's statement on C-SPAN's Washington Journal, he saw the TSA pat-down a grandmother and a young child and let a man in "Arabian dress" sail right through. From Rep. Broun (10 minute mark in video embedded below): 

"And then right behind him [small child], was a guy in Arabian dress who just walks right through. Why are we patting down grandma and kids? We need to focus on those people who want to harm us. We have to identify those people, we do that through human intelligence, we do that through trying to get into the inner circle... and then focus on those individuals, not on the general public. Unfortunately, I think the Department of Homeland Security has focused more on the general public and has been afraid of political correctness: we've got to forget political correctness. We've got to start focusing on those people who want to harm us as a nation."

I'm not sure exactly what Arabian dress is (maybe baggy pants and a vest like Aladdin's?), but I actually agree with some of the things Rep. Broun is saying. I'm with Rep. Broun on the idea that the TSA needs to stop invasive searches and scans of the general public (which miss a lot of stuff anyway) and devote resources toward identifying actual, intended terrorists and their targets. However, Rep. Broun loses me when he implies that a dude in Arabian dress isn't part of the "general public". I can't tell if Rep. Broun wants the TSA to crack down only on men in ethnic dress, or on grandmas in Arabian dress too, but at any rate, stereotyping people and treating them differently based solely on their appearance isn't just "politically incorrect": it's discrimination.

In case Rep. Broun doesn't realize it, profiling has been happening for a while now, actually: many people of Middle Eastern and South Asian descent have been erroneously suspected of terrorism, either by the TSA, pilots, flight attendants, or even fellow passengers. However, these amateur profilers fail to differentiate between a possible terrorist and, say, an economics professor at California State University. If Rep. Broun needs more examples, I'm sure the ACLU would be happy to provide them.

Is the WHO Saying Cell Phones Cause Cancer?

| Tue May. 31, 2011 3:31 PM PDT

There's been much freaking out about a World Health Organization announcement (PDF) about the link between mobile phone use and cancer: The group now considers radiation from cell phones a possible carcinogen. Sounds scary, but what does it actually mean?

Over at BoingBoing, there's a good post that explains why the WHO news isn't really news at all. It doesn't represent any new scientific findings; rather it basically tells us what we've known for a while: that while very limited evidence suggests there might be a connection between some brain tumors and radiation, there isn't enough to say for sure that cell phone use causes cancer.

Frustrating though this may be, it's par for the course for epidemiology. The fact of the matter is that proving causation is just really hard. Indeed, as the New York Times points out, other examples of "possibly carcinogenic" substances include some dry cleaning chemicals and pesticides, but also coffee and pickles.

Even the results of the Interphone project, the largest and most highly anticipated epidemiological study of cell phones and cancer to date, were maddeningly inconclusive when they came in last year. The researchers from the 13 participating countries did find that although very heavy cell phone users were about 40 percent more likely to develop glioma, but there were so many potentially confounding methodological issues that the ultimate conclusion was that cell phone use does not significantly increase cancer risk for the vast majority of people.

Unfortunately, all of this means we're pretty much just as in-the-dark as we were about the subject when I was reporting on cell phones and radiation a few years back. And frustratingly, as I noted before, we probably won't know more for at least a few years:

Finding subjects who have brain tumors and who have used their cell phones for more than 10 years is difficult, especially considering that the tumors typically take 10 to 20 years to develop. What's more, people are notoriously bad at remembering how much they've used their phones and which ear they hold their cell phone up to—especially if they're looking around for something to blame a brain tumor on. 

In the meantime, does that mean that you're all clear to sleep with your cell phone next to you on your pillow? Of course not; it just means that the researchers haven't yet proven anything one way or the other. As a precaution, the WHO panel suggests you'd do well to limit talking time, especially for kids.

Time to Get Off the Bus

| Tue May. 31, 2011 3:18 PM PDT

I think I've now read at least half a dozen mainstream media figures lamenting the absurd level of coverage that the mainstream media is giving to Sarah Palin's bus tour cum summer vacation cum presidential campaign tryout. Note to the nation's editors: your own reporters think that chasing her around like a starstruck junior high school kid is nuts. Isn't it time to pull the plug and let her tour the United States with the privacy she allegedly wants?

The Top Media Policy Stories of the Week: Your So-Called Private Life

| Tue May. 31, 2011 2:27 PM PDT

Editor's note: Every other week, The Media Consortium rounds up the latest media policy news in a blog called the The Wavelength, posted below.

Smart phones are hip, trendy, and loaded with user-friendly apps. But these devices also collect and store your personal information, leaving huge security gaps.

The prevalence of spyware in mobile technology and social networking sites has huge implications as a privacy issue, since users have no way of knowing who's peeping, or for what purpose. New concerns over mobile and Internet privacy have been raised at the federal and state level, and there's already push-back from some of the major players in the tech industry.


Privacy Please

As Sen. Al Franken (D-MN) writes for Care2, recent studies indicate smart phones and other mobile apps are being used as remote spyware. Franken, one of the leading advocates for Net Neutrality and other media policy issues on Capitol Hill, notes that researchers found that "both iPhones and Android phones were automatically collecting certain location information from users' phones and sending it back to Apple and Google—even when people weren't using location applications."

Did a Pork-Coated Bullet Kill Bin Laden?

| Tue May. 31, 2011 1:52 PM PDT

Did a Navy SEAL kill Osama Bin Laden with a pork-coated bullet, thus denying him entrance to paradise? That's the highly unlikely claim coming from a shady website selling gun lubricants that it guarantees to be "13% USDA liquefied pig fat."

According to the purveyor of Silver Bullet Gun Oil, the product is "a HIGHLY EFFECTIVE Counter-Islamic terrorist force multiplier." Here's why: 

When fired, BULLETS are coated with SILVER BULLET GUN OIL containing the PIG FAT. The PIG FAT is transferred to anything the BULLETS STRIKE. The coating of OIL CONTAINING PIG FAT effectively DENIES entry to Allah's Paradise to any Islamo-Fascist terrorist KIA with a bullet coming from a firearm using SILVER BULLET GUN OIL in the barrel. SILVER BULLET GUN OIL uses the belief system of Allah's Islamo-Fascist terrorists to put fear of death into them, a fear they haven't had until NOW.

On his site, the anonymous figure behind Silver Bullet says his intentionally un-halal lube is quite popular among armed employees of the US government, stating that "Thousands of bottles of Silver Bullet Gun Oil have been distributed since July of 2004 by its creator to members of ALL U.S. Military branches." He also claims that the gun oil is used in tank and helicopter weapon systems and that "a number" of air marshals use it as well. On a Marine message board, he asserts (along with some harsh racial epithets) that his gun oil is helping win the war on terror: "I've been putting out SBGO for 5 and 1/2 years. I pushed the Pork additive [13%] long enough for the rags to get the message, which according to those that are using it in their [area of operations] puts some real FEAR into these mutts."

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The Top 5 Longreads of the Week [17]

| Tue May. 31, 2011 12:49 PM PDT

Mother Jones guest blogger Mark Armstrong is the founder of Longreads, a site devoted to uncovering the best long-form nonfiction articles available online. And what better time to curl up with a great read than over the weekend? Below, a hand-picked bouquet of five interesting stories, including word count and approximate reading time. (Readers can also subscribe to The Top 5 Longreads of the Week by clicking here.)

What's Your Problem?

| Tue May. 31, 2011 11:52 AM PDT

Gallup says today that doctor-assisted suicide is the "most controversial cultural issue" in its recent poll. Why? Because it's the issue where opinion is divided most closely. I'm not sure that's really much of a proxy for "most controversial," but I guess it's their poll, not mine.

What struck me about their list, though, was how few of these things I object to. Out of 17 issues, there were only four I objected to, and even there my objections depend on circumstances. There really wasn't a single one that I just flatly, always think is morally unacceptable. I'm not sure what this says about me.

Anyway, here's the list. See if you can guess the four I found kinda-sorta unacceptable. (Hint: I don't really have a problem with human cloning, though I suppose I might change my mind if a cloned race of superhumans takes over the world and enslaves the rest of us.)

Building Better Teachers

| Tue May. 31, 2011 9:35 AM PDT

Dana Goldstein, writing about our need for better teachers, sums up my skepticism over the entire ed reform agenda in one sentence:

But what if the United States is doing teacher reform all wrong?

Well, yes. What if we are? Unfortunately, this is a question that hangs over practically every initiative to improve our schools. We just don't know for sure if they work, and studies to prove things one way or the other are almost impossible to conduct properly.

So what's the problem with our efforts to build better teachers, anyway? Are we doing it all wrong?

That’s the suggestion of a new report from the National Center on Education and the Economy, a think tank funded mostly by large corporations and their affiliated foundations. The report takes a close look at how the countries that are kicking our academic butts — Finland, China and Canada — recruit, prepare and evaluate teachers. What it finds are policy agendas vastly different from our own, in which prospective educators are expected to spend a long time preparing for the classroom and are then given significant autonomy in how to teach, with many fewer incentives and punishments tied to standardized tests.

OK, fine. Here's some anecdotal evidence that this might be true. It comes from my mother, who was talking to one of her old teacher buddies, who recently got a job teaching teachers how to teach students to write critically about literature. Apparently it's to improve the performance of kids in AP English classes, who have been immersed in the wretched five-paragraph format their entire lives and don't know how to write coherently about abstract subjects.

And that's fine. But my reaction was the same as my mother's: aren't AP English teachers supposed to know how to do this already? Why do they need a coach? What have they been doing their entire teaching careers if they haven't been teaching their kids how to write about literature?

So that's that. But of course, the plural of anecdote is claptrap, so this doesn't mean anything. The real question is whether better trained teachers in the Finnish mode are really what we need to get better schools. Considering the almost universal contempt that teachers and everyone else have for ed schools, that's either hard to believe or else self-evidently true. I can't quite tell which. But there are a lot of other reasons that Finnish and Chinese schools might produce better test scores than ours, and adopting their models of teacher training would be fantastically expensive. So we had better figure it out before we commit to some massive nationwide program to train better teachers.

But how do we figure it out? Good question. See the beginning of this post for my non-answer.

Healthcare Reform and Political Coalitions

| Tue May. 31, 2011 8:18 AM PDT

Robert Pear reports that hospitals are unhappy over new federal regulations that pay them based on the cost of care they provide to Medicare patients compared to other hospitals:

For the first time in its history, Medicare will soon track spending on millions of individual beneficiaries, reward hospitals that hold down costs and penalize those whose patients prove most expensive....Hospitals could be held accountable not only for the cost of the care they provide, but also for the cost of services performed by doctors and other health care providers in the 90 days after a Medicare patient leaves the hospital.

....Under the new health law, Medicare will reduce payments to hospitals if too many patients are readmitted after treatment for heart attacks, heart failure or pneumonia. In addition, Medicare will cut payments to hospitals if they do not replace paper files with electronic health records, and it will further reduce payments to hospitals with high rates of preventable errors, injuries and infections.

In related news, Aaron Carroll reports that physicians, who used to be rabidly opposed to national healthcare, are now substantially in favor of it:

Remember, this was support for federal legislation to establish National Health Insurance. That’s far more radical than the PPACA. And 59 percent of physicians supported it. That was an increase of 10 percent from what we found five years earlier, and it was statistically significant. More than half the respondents from every medical specialty supported it, with the exception of surgical subspecialties, anesthesiologists and radiologists. That means support included a majority of general surgeons, medical subspecialists and obstetricians/gynecologists.

Aaron calls this a problem for the AMA, and I suppose it is. But I think it's also a problem for hospitals: to a large extent, the interests of hospitals and physicians are not only diverging, but becoming actively opposed. In the past, physicians probably would have been as opposed to these new Medicare regs as hospital administrators, but I'll bet that's largely not the case anymore.

As an analogy, this strikes me as having mirror-image similarities to No Child Left Behind, another piece of legislation designed to force efficiency on a particular sector of the economy. At first, parents were largely in favor of NCLB while teachers and school administrators were largely opposed. But as time has passed and suburban schools have started to suffer from the law (either because they're given failing grades or because inner city schools start competing effectively for the best teachers), the ground has shifted: parents and teachers now find themselves frequently in agreement that NCLB has gone further than they like. This provides a growing political coalition to change or water down the law.

In healthcare, it's the same dynamic in the opposite direction: a political coalition is breaking up. Doctors and patients are starting to align one way, while hospitals and insurance companies are aligning in another way. The good news is that this makes it less likely that healthcare reform will be repealed. There just isn't a united political coalition in favor of it.