A Doctor Talks About Why US Health is in Decline

[NurseHardee]

Health and Poverty in the US

by Stephen Bezruchka; December 09, 2003

I want to talk about how healthy the people are in the United States of America, why we are less healthy now than we should be, how we used to be much healthier, in comparison to other countries, and what we need to do to regain our health ranking. To consider the reasons, we have to address issues of poverty for that is the critical concept that is related to health. I will talk a great deal about one critical form of poverty, relative poverty, how you compare to others, and how that affects our health. I will say that more than bringing the bottom up, we have to bring the top down. I will give a prescription for health.

It is really difficult to talk about poverty in the United States of America, because many people don't identify with being poor. We are mostly all middle-class here, right? Being poor is a bad choice of words to use because it stigmatizes. So I will deal with you who are families and working people, and people with low income but who may still be struggling to make ends meet.

To admit that you are poor in America might mean that you will be permanently poor, especially in the land of the American Dream, namely that before we die, we will all achieve wealth, happiness and prosperity--own our home, the big car and other symbols of success. It all depends on us, that we have to pull ourselves up by our bootstraps, work hard, and we can achieve anything we want. Arent we entitled to that?

That is all that Bill Gates did. Or Magic Johnson. Or Oprah Winfrey. I don't know if that is true, some people would say that Bill Gates was born into a very privileged family. The facts show we have much more poverty in the USA today than in all the other rich countries. That is not good.

In the 1950s, my father repaired shoes, and we lived above the shoe repair store in a tiny apartment. We didn't have a car for a long time. We also lived in a working class neighborhood, where everyone else was pretty much in the same shoes as we were. Although we had a TV by 1953, the programming back then was pretty basic, and didn't display lifestyles of the rich and famous, so we didn't get a sense of how little we had and we weren't made to want.

So I never thought of myself as having less than other people until I went to college and made friends with people who went off to Europe in the summer. Who had vacation homes. Then I thought of myself as working class or lower class. In fact, I remember well having a discussion with a friend of mine in graduate school at Harvard University in which I described myself as working class, or lower class. He said, there was no way you could get to Harvard and be working class as was the case in the 1960s.

After graduate school, I spent a year in Nepal, a little country sandwiched along the highest mountains in the world, where Mount Everest sits. There were no roads there then, and still there are very few so to get somewhere you had to walk. There were no lodges or hotels then, so the few travelers there stayed in people's homes, ate their food, and slept around the fire on the mud floor, just as the families did together with the children and grandparents. These people had next to nothing, yet they didn't seem to want anything. I know now why they didn't want anything. There was no advertising of the things they should want. I spent a whole year totally without any form of advertising. It was a profound experience. So these people had the basics, food, water and shelter, and the love and company of their family and community. And they shared this with me. They laughed, played, never let their children cry and seemed happy, and I know they were. But you would call them desperately poor if you saw their situation today.

Some of you might say I am romanticizing the situation, describing the noble savage. I used to think maybe I was wrong, but I'm now convinced that happiness and satisfaction are not something you buy.

What about poverty and health? I have been working as a medical doctor for 30 years, much of that spent in emergency rooms, trying to look after people's health problems that arise quickly, I started doing emergency care in 1977 because I thought that is was really helpful for people.

I've continued to practice in emergency rooms in the US for the ensuing 25 years. I occasionally thought about the kind of people that I would see in the ER, the kind of people having accidents, or heart attacks, or as parents of sick kids. Mostly they seem to have one thing in common, they are not rich people, they aren't wealthy.

Now much of my time has been spent working in ER's in Burien, White Center, Tacoma, and Lakewood, as well as near the Central District in Seattle. There are a lot of low-income people living there, struggling to make ends meet. But I also worked in Bellevue, near where the richest person in the world lives, as well as the home of other billionaires, and multi-millionaires. What kind of patients did I see in the ER in Bellevue? Were they rich? Well, occasionally, I would see someone that I would surmise was well off, but for the most part, the rich didn't come, even to a hospital in a rich neighborhood. You might say that when they were in a hospital gown, or strapped to a stretcher, that it would be hard to tell if they were rich or not. But even stripped naked, it isn't hard to tell. For one thing, people with low incomes often interact with people differently. Often they don't make eye contact with you, but look down. And when they do look at you, their eyes betray a tough life. Sometimes they are angry and rushed, wondering why they have to wait for so long. For another, they tend to be more obese, sometimes much more.

They tend to use words differently, when we talk. They might say "Doc I have this serious pain in my stomach," for example, rather than saying "Doctor, I'm having some discomfort in my abdomen that is associated with some loose movements." You might think I am saying that low-income people are dumb, and didn't do well in English at school. They are certainly not stupid, and they speak English different from the rich, but it ain't wrong to speak that way.

I began to think that maybe poorer people got sick more than rich people. You might counter that and say no, the rich have their own private doctors and don't go to ER's but call their doctors anytime of the day or night. Surely that wouldn't be true in the middle of the night, whether at a hospital that serves the poor or one that serves the rich. You have to come to the hospital when your appendix bursts in the middle of the night, whether youre rich or poor.

What do YOU think? Are rich people as sick as working class people or people with low incomes? Raise your hands if you think so?

The studies overwhelming show that for every health condition, for every disease, for every cause of death, those who have lower incomes have it much worse than those who have fatter paychecks. In other words, if you work where you have to see sick people, such as in emergency departments, you are going to see poorer people for the most part, no matter whether your hospital sits in a wealthy neighborhood, or a poor one. Coming to see that, namely that poorer people had poorer health, was a major revelation for me. Now I'm not saying that all rich people live long healthy lives and the people of more modest means live shorter sicker lives. We all know of counter-examples to that. The tragedy of Princess Diana comes to mind. But as a statement about populations, about communities, wherever you look at it, poorer people have poorer health. The next question I asked was WHY this was so.

So why do people with lower incomes get sick more? Is it because they smoke more, which they do? Is it because they drink more, which they may do? Is it because they shoot up more heroin, which is true? Is it because they eat more, which is true? Is it because they don't exercise as much, because they don't?

Well, the studies show, that such behaviors that we consider bad for health explain only about 10% of the reason that poorer people have poorer health. Learning this has been a revelation for me over the last ten years. I used to get complaints in the ER for keeping harping on people to quit smoking. For a chronic lunger who continues to deteriorate and keeps his two pack a day habit, patient's families would say to the administrator that all I would do is tell him to quit. Isn't there something else you could do, he's trying to quit but can't. Like most of us, I used to blame sick people for their behaviors that made them sick. But I don't now, I blame myself for allowing the rules that govern our society change to produce the behaviors that are bad for us.

Is it because lower income people can't afford health care? Is that why they get sick more? It is tempting to say that is the reason, but it isn't. I know some of you here may not have health insurance. Perhaps some of you have huge medical bills that you are struggling to pay. Health care, or the lack of it, doesn't explain why poorer people have poorer health. Consider the Hispanic population. They don't access health care much, they tend to not have medical insurance, they tend not to go to the doctor. Countless studies show this and it represents a cause for concern. What is often not stated is that Hispanic people tend to be healthier than non-Hispanic whites. And it isn't because they don't go to see doctors, although that is a tempting thought. As a rule, most Hispanics are comparatively less well off than non-Hispanic whites, so later we will consider why they may be an exception to the poorer people have poorer health concept.

I expect you to be skeptical on this, but I would like to proceed with the observation that it is people of lesser means that are sicker, and it is not their behaviors such as smoking or diet that makes them sicker, for the most part. And it isn't access to medical care, or the kind of medical care people receive that accounts for the difference. Again, there are a lot of studies and science on the subject, and I'm asking you to suspend your disbelief and let me go on.

By its very nature, medical care can't have much to do with health. To consider why, I make the analogy that medical care's role is the same as that of the army medical corps in keeping us healthy. You've been reading about all these soldiers that are coming home from Iraq with legs blown off, or other serious injuries. Our media has been forbidden to show coffins of our troops coming home, but there have been many deaths, as you know. Now the army medical corps goes in after the blast and picks up the victims, splints the limbs, starts IV's, transports them to where they can get blood, and then to a field hospital station where bullet holes are closed. There heroics are carried out and hopefully the stricken soldiers survive. We feel grateful in such cases. But most casualties, those who die, are killed outright by the blast, by the bullet or bomb. The army medical corps can't do anything for them. The army medical corps did not decide that we were going to invade Iraq, they didn't decide the battle strategies, that we were going to bomb targets including civilians, from the air, that later we would send in ground troops. They didn't decide on the day-to-day combat decisions. They didn't decide on the protective gear that troops would wear. All they do is go in and pick up the pieces, those fortunate ones who still have signs of life. That is the best that medical care can do, try to keep the survivors alive. So by its nature, medical care can't have much of an impact on health, despite what you are led to believe. In my courses at the University of Washington, I go into great detail about this, and as a practicing doctor, I believe this is true. Colleagues of mine, who have considered the issue of what medical care does in making communities healthy, agree, as do the experts who write papers and books on this subject. That is not to say that I don't believe in medical care. I work as a doctor providing medical care, and I teach young doctors as well. And if I get sick, I see a doctor. And if I collapse here on the podium, I want you to call 911. But we should not deceive ourselves that this is what makes us healthy as a population. I'm sure you think this sounds weird, counter-intuitive if you will.

I expect you to be skeptical on this, but I would like to proceed with the observation that it is people of lesser means that are sicker, and it is not their behaviors such as smoking or diet that makes them sicker, for the most part nor is it access to health care.

I hope by now you are asking why poorer people have poorer health. That is the right question to be thinking of. Thomas Pynchon wrote in Gravity's Rainbow: "if they can get you asking the wrong question, the answers don't matter." I think we ask too many wrong questions in America today. What does matter most is the nature of our relationships with each other, the social nature of ourselves, the psychosocial element, if you will. Let's explore that.

Think of health as the expression of our life experiences. We all know the physical effect that stress has on our minds and bodies, our immune systems and our ability to fight off diseases. The reason poorer people have poorer health has something to do with the basic nature of living with and in poverty, especially what you live amidst plenty and have that rubbed in your face. That is what being a family living with low income is all about.

If I were to ask you in this room, how many of you consider yourselves poor, I think fewer hands would go up, than if I asked you if you were middle class. What is that all about? If you admit you are poor, you are shaming yourself, and feeling shamed is the essential human emotion when it comes to understanding an important aspect of health. Now many people with lower incomes, many disadvantaged people, won't admit feeling shame, but feel the shame deep inside, nevertheless. Doesnt it make sense that these feelings would have a strong impact on our physical, as well as mental health?

So what does being poor mean? What is poverty, or living with lower incomes all about in the USA? Or in Seattle? Let's start by leaving out the homeless. There are more than a million homeless children in the USA, the richest and most powerful country in world history. I don't know how many homeless there are in total in the US, but I've seen statistics quoting 1.5 million in California alone. The 2001 One Night Count accounted for 7,350 people who are homeless in King County. I would imagine the number for the whole country is probably somewhere between 10 and 20 million, and could be a lot higher. For those of you who are older like me, if you think back 25 years and reflect on whether or not you saw any homeless people, you would probably find that you didn't. And the studies show that as well. Not that there weren't any then, but you might see one in a week or a month instead of one every few minutes in some areas. . The reason for the homeless is that Ronald Reagan cut funding for low-cost housing in 1981, and right after that, there they were on the streets. But I said I wasn't going to delve into poverty among the homeless and will stop at this point.

So what about the poor, people who are almost homeless, for that is what the situation is like. These people are often one paycheck away from being evicted. In Washington, a worker earning the minimum wage (7.01 per hour) must work 86 hours per week in order to afford a two-bedroom unit at the states median Fair Market Rent But even if you are not so poor, is it because you don't have enough to eat? A roof over your head? Central heating? Is it because you don't have a microwave, or a refrigerator? Is it because you don't have a TV and VCR? Is it because you don't have a cell phone? No, many low income people have all these items, they aren't close to being evicted, and yet they feel disadvantaged. Fifty years ago, the rich didn't have microwaves ovens, or VCR's or cellular phones. But now many low-income families have them. So it is important to note that being less well off is not about not having stuff such as items like cellular phones and VCR's that might have been considered science fiction devices fifty years ago. Being less well off is about feeling that you don't have the choices that the more well off do. It is not about the stuff you have. I said that it is people with low incomes who are obese, so they have enough to eat. People in the subsidized housing areas have a lot of stuff. Still they feel disadvantaged, and as my years of experience in emergency departments demonstrated, they are the ones who get sick. And so in a very profound sense, these people are disadvantaged in the most important way, namely they don't live as long or as healthy lives as do the rich.

Take me at this point. I'm certainly not poor now. As I said, I grew up in a working class neighborhood, and my father repaired shoes. We lived above his shoe store. I mentioned how I didn't feel poor until I left my neighborhood and was amongst people who had more than me and had greater choices than I did. Then I began to feel poor. In other words, I began to feel poor when I began to make comparisons of myself and my situation, with other people. By now, I have flooded you with the concept of class, I'm waging class warfare as some politicians might say. We have to be honest, this is what today is all about. It is class warfare. There is a war going on right now and it is the rich who are attacking everybody else. In fact this war has been going on for the last ten thousand years. Class Warfare is worse these last few years although our leaders would deny that it even exists. The weapons of class warfare are symbolic missiles, shot through our media-- TV, movies, magazines, and the internet. And it starts at a very young age. What are really Mediaography internet sites that our children are exposed to are not the crass sex that dirty old men like me would like to look at, but the Nike websites, or the movie stars web sites. The Nike sites display their shoes and the stars their environments. These are signs that the rich are winning the class warfare battles. Another sign is that people with low incomes are naming their newborns Gucci and Armani and other icons found on designer labels. In ER's I see people who have been attacked and robbed, and the key thing the robber got away with were their fancy new Nike tennies.

The essence of class warfare is that the rich make you compare yourself with others that you consider better off than you are. That is their weapon, their scud missile. IF you are rich, it doesn't mean you have more stuff, necessarily. It means that you can have it if you want it. You can do what you want. My friend Raymond, who made a lot of money, said he took care of his problems with the check principle. If he had a problem, he would find someone to take care of it and write them a check. Most of us can't do that.

Our societies today are like baboon troops in Africa, for example. There is the alpha male, or the top dog, and there are those in the pecking order below the alpha male. The alpha male gets the best food, and the pick of the females to mate with. The beta and gamma males have very different lives. Those lower down are always on alert that the alpha male will take the choice bit of food they have found, or chase them away from the female they were going to mate with. Their lives are under constant stress. We know that the alpha male is healthier than the beta and gamma males, the alphas have different physiology, a different stress response, than the baboons lower down. The gamma males, the lower ranking baboons are less healthy than the high ranking ones. Human studies show the same thing, that is people with low incomes have the stress responses of low ranking baboons.

So with baboons or humans, being lower down in the status ladder means you suffer more from chronic stress. This results in higher blood pressures, less ability to control glucose in the blood and so more adult onset diabetes, which we are seeing in younger and younger children as they are under more stress. This results in fat deposition around the waist and hips. This results in more plaque in coronary arteries that supply the heart and so we have more heart attacks in poorer people. Those lower down the status ladder have less ability to fight infection because their immune systems aren't as efficient. They are less able to search and destroy cancer cells.

So having low income in America is knowing that you aren't in the same league with those having higher status in our society. You generally don't do as well in school. You are more likely to be raised in a home where your mother has to work at several jobs to make ends meet. You may not know who your father is. You won't have the fancy car, or designer-label clothes, and won't go to France for the weekend. Or more likely, you will have the status Nike shoes, and will spend for those icons of status, and not be able to afford health care. You will tend to eat at fast food places, and shop in convenience stores. If you have a car, you will pay more money for gasoline, unless you travel to the cheaper gas stations, which are often not in poorer parts of town. If you don't have a car, you will be riding the shame train, or the bus. And you won't feel so secure walking down the street.

It begins way back when you were just a gleam in your parent's eyes. That is the effects of class and ranking and social status began to effect your parent's physiology and thus your biology to have an affect on your health. The most important time is from conception to age 2.

Perhaps you have a job, doing work that needs to be done. You do it well. Jobs that some might consider menial, such as working as custodian in a building after hours when the executives go home. Or you may work as a nurses aid in a nursing home. Or you may work at that convenience store, or be flipping burgers. You may find yourself suppressing your rage when the boss goes by. But if you are nice enough, you might get a Christmas present at the end of the year. Even if you are nice enough, you might get laid off in the next economic downturn. Most likely, you will have two or three jobs, all of them part-time, with no security or benefits. Alan Greenspan, the chairman of the Federal Reserve Bank, talked about the booming economy in the 1990s being partly because of a flexible labor force. Namely, workers worked for very low wages and could be laid off at will. I'm sure you will agree that it is good for the economy to be flexible like that but it sure isn't good for you or for your health to feel that insecure.

One thing that has happened in the last 30 years is that more people are not doing well in America. Not only are the homeless out in droves, but poverty, no matter how you measure it, has increased dramatically over this period of incredible prosperity in America. This isn't just true in America, but worldwide as I'm sure you are aware. There are many more poor people, the biblical promise is true "the poor ye shall always have with ye" only it might say the poor shall be ever more with you. This in a time of phenomenal wealth.

So my main point is that the culture of poverty, the culture of inequality that surrounds us is what has the most significant effect on our health. Let me clarify this idea a little bit. Those at every rung of society's ladder from the top to the bottom will have their health determined by where they stand in the ladder of social status in society. The poorer you are the worse your health in comparison to others.

Stated very simply, societies with a bigger gap between those on top and those on the bottom will be less healthy than societies where there is a smaller gap. To illustrate this, let us look at the health of the United States of America, measured by life expectancy, say, the average number of years lived in this country. Fifty-five years ago, we were one of the healthiest countries in the world by this measure. Today, there are some 25 countries that are healthier than we are. Think of it, all the other rich countries are healthier than we are, and a number of poor ones as well. It isn't just this one measure of health--life expectancy-- in which we do poorly, but in every other measure, when we rank ourselves with other countries. We are living longer but not so long as people in 25 other countries, all of them poorer than we are. For example, we have the highest infant mortality rate, the highest child poverty rate, the highest teen pregnancy rate, the highest child abuse death rate, and so on. There are no indicators in which we excel, except in spending money on health care, for we spend half of the world's total health care bill. Think of it - for every dollar in the world spent on healthcare, 50 cents is spent here. Yet our citizens are less healthy than those in all the other rich countries. And by less healthy, I don't just mean in how long we live, but in so many other indicators of health, such as teenage pregnancy rates, such as in homicides, or incarceration rates. Indeed we house one quarter of the world's prisoners in America, which says something quite significant about how we deal with petty crime in this country.

What has happened to cause this huge disaster? Stated simply, it is because we have changed the rules in this country as to who gets what share of the pie. Back fifty years ago, it was the poorest families that saw the biggest gains in income. Now, as you all know, it is only the rich and super-rich that are seeing gains in income, while the rest of us all have to tighten our belts. This may not seem right in explaining the reason for our poor health, yours and mine. However, it is true, it is because we have changed the rules in society and created many more poor people and that is why your health and my health is not as good as it could be.

Racism is another way that the gap operates to create worse health. Racism is all about difference and power. Minorities have always been put down, and feel the shame, even if they don't think about it. The rich want to continue to put people down, but use ever more subtle means. If you can put people down, if you can make them afraid, if you can make them want things, then you have power over them. An African American male in Harlem lives less long than a man in Bangladesh, one of the world's poorest countries. Or that a black man in Washington, DC lives less long than a man in Ghana, a country in West Africa.

Women tend to be healthier and live longer than men. As well, studies show that where women play a bigger role in political life of communities, they are even healthier. What is more astounding is how men's health improves in those situations even more than the gain for women. In other words, we all do better where women do better, and I'm sure most of you here know that.

It is important to recognize how much our health relative to other countries has deteriorated in the last 55 years. Consider that if we won the war on heart disease, the plague that will kill almost half of us in this room, if we had no more deaths from heart attacks, we still wouldn't be the healthiest country in the world. And yet 55 years ago, we were one of the healthiest. The difference now is that we live under more stressful conditions, a stress caused by the big gap between the rich and the rest of us. And when we go shopping at The GAP, that symbolic store, we don't even realize that this is the key problem in America.

Go to second message to read concluding portion of talk...

[NurseHardee]

Part 2...

How is it that a bigger gap society has worse health than a more egalitarian society. Consider two extremes: an egalitarian society where everyone is more or less equal, and a very hierarchical one where there are a few fabulously wealthy rich and the rest of us, sort of like the USA. What is life like in an egalitarian society? What are the prevailing relationships and feelings. Wouldn't they be those of friendship, support, trust, caring, helping, sharing, and community? Don't those words sound healthy? What about the other extreme, a very hierarchical society? What is it like inside such a population? Well, those on top with the wealth have power and can dominate, compel and coerce those beneath them to get things done. The rest of us resign ourselves to our job and role, but feel humiliated and shamed. Shame is the important emotion at work. None of these feelings such as shame or relationships of power and domination sound healthy, do they? But in countries such as the USA, these are the prevailing mechanisms at work, even though we think we are all middle class there is an ever increasing gap between the rich and poor here. In a society with a bigger gap, those above put down those below, and this is related to the amount of violence in society and helps explain why we have so much homicide. Costa Rica is an example of a nearby country that is pretty egalitarian, and even though it is much poorer than the US, it is healthier than we are. Canada is another example, our neighbor to the north, which is much much healthier than the USA. The final example is Cuba, a country that we have been strangling for 44 years with trade sanctions and embargoes. Cuba is as healthy as we are, despite, or maybe because of our policies.

Consider the healthiest country in the world, Japan. Fifty-five years ago when we were one of the healthiest countries in the world, right after World War II, Japan was less healthy compared to other countries than we are today. Yet the USA gave it the medicine it needed to become the healthiest country in the world by 1978. The medicine was prescribed by the greatest population health doctor who ever lived, General Douglas MacArthur. The medicine administered during our occupation of that country from 1945 to 1950 had 3 ingredients and I will review them here. The first was demilitarization. Japan was forbidden to have an army. The second ingredient was democratization, as MacArthur wrote the country's constitution, providing for a representative democracy, free universal education, the right of labor unions to organize and engage in collective bargaining, and the right of everyone to a decent life. The third D was decentralization, as MacArthur broke up the 11 family zaibatsu that ran the huge corporations that controlled the country. He legislated a maximum wage for the country of the equivalent of $4333 in US dollars. He also carried out the most successful land reform program in history. What this did is bring down the economic hierarchy, and level the playing field. The resulting rise in health is the most rapid ever seen on the planet.

Japan presents some interesting issues about population health. Japanese men smoke the most of all rich countries. Yet they are the healthiest population on the planet. It seems you can smoke in Japan and get away with it. It's not that smoking is good for you, but that compared to other things, it isn't that bad. Smoking is much worse for you in the US than it is for the Japanese in Japan, where the gap between the rich and poor is much less. So I tell people that if they want to smoke they should be born in Japan. Similarly, it isn't Japan's health care system that is responsible for its remarkable health. Anyone who has looked at their system will tell you it isn't much to write home about. I talked before about designer labels, and if you probe, you will find that everyone in Japan shops at designer stores and buys the Gucci icons. That is the key element, everyone wears them. In the USA, everyone wants them, and that is the difference. Japan is a caring and sharing society that looks after everyone and that matters most for your health.

Let me give my opinion now on why Hispanics have better health in the USA than non-Hispanic whites. It has to do with the support they give one another and their strong family lives that counter the adverse effects of the gap and their poverty. Much has been written about this so-called Hispanic Paradox. I came to understand the reasons by reflecting on Hispanic patients I see in the ER. I never see a single Hispanic patient. There is always a group of people huddled together. I have to go and figure out who the patient is, for everyone comes to offer support. By contrast, I'm much more likely to see a white person lying there writhing in pain alone. So we can conclude that it is the nature of psychosocial relationships, the support people have and give in a society, that is more responsible for their health as communities, than any other factor.

So what has happened in America to bring about our health decline? We have changed the rules in America that decide who gets what share of the pie. How we decide where to spend tax dollars, how we decide who to tax and how much, how we decide to fund basic research and development. How we decide to give subsidies to various elements of our society. Instead of trying to make the rules level the playing field, we have decided to let the rich have as much as they can grab, and we'll be happy to share the crumbs. I say we'll be happy, because if you ask many if not most Americans whether they feel the rich should get as much as they do, you'll get an answer something like: "of course the rich deserve it because they work hard, and are better than we are" or something like "yes I'm in favor of having a big gap between the rich and the poor, because someday I'm going to strike it rich and I want to have it all then."

We have been seduced into believing in the American Dream, the rags to riches myth, the Horatio Algier stories, where if we just work hard enough we can attain anything we want. The American Dream, ladies and gentlemen, is a nightmare. Among all countries studied, we have the lowest percentage of people making it, in the sense of going from rags to riches, whether in one generation or two. That is what the economists who have studied this show.

And the price we pay for believing in the American Dream is, I say, the ultimate price. Namely, you and I die younger than we need to, so much younger that it is equivalent to winning the war on heart disease. Our president, speaks of the estate tax as the death tax, and it really should be called the Death Averting Tax, since it helps narrow the gap a little and avert deaths. As he signs more tax cuts on the rich into law, he should be honest and tell you that this is a small price to pay for living in this richest and most powerful country in world history, namely you live less healthy and die much younger than you need to. But the rich are appreciative, all the way to the bank. What even they don't know is that even they die younger than they need to by living in this country.

So if we are going to ask the right question at this point, it may be something along the lines of "what happened, how did we let things get to this point?" Our story begins at the end of the Second World War. It was a difficult period for the world, and for Americans. We lost many lives in that conflict, and many people suffered without dying by serving in the war effort. So it was felt that such people needed to be taken care of. The oldest amongst you may remember GI-loans, housing loans, education bills that allowed vets to go to school. Our tax structure was very different then. Compared to today, the rich paid over 90 % on their top chunk of income instead of around 35% today. The tax rate on the bottom income category has remained about 25% through all this time period. So the rich have taken proportionately more home, than the rest of us have. And the gap grows.

After the Second World War, our businesses and industry did very well, with technological advances, and work in rebuilding Europe. They enjoyed high profit margins on revenue. They were happy. But towards the end of the 1960s and in the 1970s, their profits declined because of competition from Japan and other East Asian economies that began in earnest then. In 1940, corporations paid 40% of the federal tax bill. But with declining profits, they managed to demand lower tax rates, just as the rich did, so by 1960 they paid 26% of the federal tax bill. But with further declining profits, they wanted even more government handouts, and so by 1990 they were paying 13% of the federal tax bill. They also enjoyed huge government subsidies, in other words the taxes we paid went into their coffers in many ways that are probably familiar to you here. Of course the rich and powerful have only wanted one thing through history, and that is everything. So by 2002, last year, corporations paid only 7% of the federal tax bill. As Greg Palast says, we have the best democracy money can buy, and so these rich corporations buy themselves tax breaks and huge government subsidies by funding so-called democracy.

Another way to look at this is how much we pay our CEO's - the heads of our corporations. In 1980, we paid them 40 times what an entry level worker made. By 1999, they were being paid 478 times what an entry level worker made, and in 2001, for the Fortune 100 companies, the CEO's made a thousand times what an entry level worker made. If we ask what is the maximum wage in the US, it is around $150,000 an hour, and this person got a $10,000 an hour pay raise over the year before, while his company performed poorly and the stock price dropped 67%. As we say in America, nice work if you can get it, and you can get it if you try. Now in Canada, our much healthier neighbor to the north, the CEO/worker pay gap is twenty to one, while in Japan, the world's healthiest country, it is eleven to one. In the recent economic downturn in Japan, what did CEOs and managers do? Lay off workers and take pay raises? No, they took pay cuts rather than laying off workers. This isn't what our CEOs do. They lay off 40,000 workers and give themselves a bonus for increasing efficiency. This is not good for our health!

If corporations used to pay 40% of the tax bill and now only pay 7%, where is the rest coming from? Look in the mirror. Since the 1950s, the working class have paid proportionately more taxes than the rich. And today's tax relief for the rich, boy the rich are really hurting and need tax relief, is just the latest example. As an example, I'm sure that all of you in this room paid more income tax than our biggest employer in Washington State did in 1995. You all paid more tax than Boeing did in 1995. That is, unless you received or than a $33 million tax credit that year. In other words, we paid Boeing, you and I paid Boeing, $33 million as their tax bill that year.

It is one thing to talk about income, the take home pay-check, which you are all familiar with. But what really matters is assets, wealth. Remember, you are sitting on your assets. The gap in wealth is even more obscene than the gap in income. The richest ten percent have almost 80% of the assets in this country. The richest one percent have almost half. So there isn't much left for you and I. In fact, from 1983 to 1995, the bottom 40% of families in America actually lost assets. The cushion under you became harder to sit on during that time period.

At the same time, we have done everything we can to make life worse for the working class. As I mentioned, we cut funding for low cost housing, throwing millions on the street. We have cut funding for public schools with the result that our students score worse on international achievement test comparisons. We have done everything to decimate the family, at the same time as we preach family values. We have the highest percentage of single-person households among all rich countries and the great number of children being raised in single-parent families. It would be nice if the parent was there to raise the child, but instead we force the parent to work at several low-paid, insecure jobs, and leave the child rearing to the wolves. Studies have shown in Sweden that being raised in a single-parent family is bad for the child's health. Not only do such children become sicker, spend more days in hospitals, and have more behavioral problems, they also have higher mortality. In other words, in a country like Sweden, which has social supports unimagined in the United States, kids being raised in single-parent homes die more. Why? Well, as I said, in Sweden, it isn't that these homes lack enough stuff. But the mother isn't there to provide the time with the child, and in the end that is the critical factor. For early childhood to lead to health as an adult, secure attachment to a parent is a strong, health promoting, factor. It is important preventive medicine. Perhaps the most important aspect of preventive health care we could ever do. But Clinton decided to end welfare as we know it, and our children are paying the price with their poorer health and the greater likelihood of ending up in a coffin. If you are a single mom please don't think I'm trying to make you feel guilty for doing so by suggesting your child won't do as well as if you were married. My son, now 21, was not raised in a two-parent family and I wish it were otherwise, as I think he would be healthier. But the reasons families split up are most basically political and economic, and could be changed. But most of us would think that personal reasons are involved. While this is true at an individual level, it is the structure of society that makes it happen and helps us understand why family breakup has become more common.

In other words, in the last 55 years we have drastically changed the rules of who gets what share of the pie in the United States of America. For our health, yours and mine, and that of the rich, we have to change them again, so we all get pretty equal pieces of the pie.

To summarize at this point. Poverty is bad for your health. Relative poverty, living in a large gap society, is the worst part of poverty. Poverty is not a certain amount of goods, but a form of invidious comparison between those who have more and those who have less. If the gap between the rich and poor is smaller, then the comparisons we make are milder. When the playing field is more level, it is easier to play. This is what justice is all about, avoiding having one part of society bearing all the burden but reaping none of the benefits.

So what can we do about this? As I said, I learn a great deal from comparing ourselves with people in other countries. I was surprised to learn that we have the lowest voter turnout of all democracies. In other words, fewer people vote in this country than in any other democracy. In the last King County election only 29% of the voters cast their ballots. Who doesn't vote you might ask? The answer: the young and those with less income. Think of it. Poorer people don't vote. If they don't vote, then there is no need to have any policies that favor those with less income, and the president can limit his actions to those that benefit the voters, namely the rich. Hence we have the tax relief for the rich, the end of the death tax which only benefits the very rich, and handouts for Enron, Bechtel and Haliburton among others. We need to have our voices heard!

Has any major leader every drawn attention to the fact that the working class doesn't vote, and tried to encourage them to vote, or designed programs to get poorer people more involved in the process of democracy? No way, why would they want to shoot themselves in the foot. So no, your leaders are not going to look out for your interests, unless you force them to do so. They aren't going to make voting day a holiday, as is the case in most other rich countries. They aren't going to make it easier to register to vote. And they will continue to have laws excluding people such as felons from voting. The rich are not dumb. Low income people are not dumb either, but they have been demoralized and think their vote doesn't count.

Some of you may recall the 1960s when riots occurred in inner cities in America, there was the anti-Vietnam war movement, and the civil rights movement was in full swing. The leaders of the free world considered that this was a crisis of democracy. The Trilateral Commission published a book entitled the Crisis of Democracy in which they pointed out that if people continued to take matters into their own hands, it would be a continuation of this crisis. They wrote about the problems when you have an excess of democracy. So the Trilateral Commission laid down the steps we had to take to avoid this excess of democracy, and these have been followed so we have the present problem of low voter turnout, but no crisis.

Things are only going to change when we work together for our interests, not the interests of the rich. We must say NO to more handouts for the rich. They have enough, and they really don't need more, although whenever I am around rich doctors, all they ever do is talk about how they need more money. The rich are always like that, after more.

If the poor organized, if the working class got together, it would be a piece of cake to change things. After all the poor and the working class are the majority in this country. If you remember that, if you recognize that all you have to do is talk amongst yourselves about these ideas, to speak up and begin to voice your needs, and push for policies that restore the status that working class people had in America before we gave it all away to the rich, then our health will begin to improve compared to other countries.

We need to shape the world that creates our life experiences and, hence, shape our health. This is not the land of equal opportunity. Unless you believe that a few people are naturally born to ride while most of us are born to be saddled, it's a sign that opportunity is less than equal. The only way out that I know of for those of us who are saddled today, is to throw off those saddles, and chase after the riders and put them in their place. We vastly outnumber those riders. Working together and organizing is our hope for improving our health as a nation. We need to bring back the crisis of democracy.

In other words, people like those of you gathered today and those you speak for, those who aren't rich, those who work, are this country's population health doctors. You are the people who need to prescribe the medicine that will get more assets into the hands of your children, that will increase the taxes on the rich, that will break down the power of the corporations, that will restore power to labor, that will give subsidies to those who need them rather than those who already have too much. The way to fight organized money is with organized people.

It was Mahatma Gandhi who said First they ignore you; then they laugh at you; then they fight you; then you win. And Martin Luther King Jr. said "True compassion is more than flinging a coin at a beggar; it comes to see that an edifice which produces beggars needs restructuring."

I talked about Doctor MacArthur, the greatest population health doctor ever. You out there can administer the MacArthur Medicine, remember the three ingredients: the three D's of demilitarization, democratization and decentralization--bring down the Walmarts. We can take the same medicine we gave Japan, that is we can take our own medicine, or we can ask Japan to administer it to us.

I will end by reading a poem

THE LOW ROAD

By Marge Piercy

What can they do to you? Whatever they want. They can set you up, they can bust you, they can break your fingers, they can burn your brain with electricity, blur you with drugs till you can't walk, can't remember, they can take your child, wall up your lover. They can do anything you can't stop them from doing. how can you stop them? Alone, you can fight, you can refuse, you can take what revenge you can but they roll over you.

But two people fighting back to back can cut through a mob, a snake-dancing file can break a cordon, an army can meet an army.

Two people can keep each other sane, can give support, conviction, love, massage, hope, sex. Three people are a delegation, a committee, a wedge. With four you can play bridge and start an organization. With six you can rent a whole house, eat pie for dinner with no seconds, and hold a fund raising party. A dozen make a demonstration. A hundred fill a hall. A thousand have solidarity and your own newsletter: ten thousand, power and your own paper: a hundred thousand, your own media; ten million, your own country.

It goes on one at a time, it starts when you care to act, it starts when you do it again after they said no, it starts when you say WE and know who you mean, and each day you mean one more.

Thank you.

Stephen Bezruchka MD, MPH Senior Lecturer: International Health Program Department of Health Services School of Public Health and Community Medicine University of Washington Box 357660 Seattle, Washington 98195-3576, [phone], Fax [phone] [email protected]

[NurseHardee]

Another Doctor's Opinion on The Same Situation

Published on Tuesday, December 30, 2003 by the Boston Globe

Better Doctors, But Worse Care

by Steve Bergman

TWENTY-FIVE YEARS ago I published "The House of God," a novel of my medical internship. It described a brutal, authoritarian system of training that dehumanized doctors and patients alike. Since then I have spoken with medical students and doctors at almost every medical school in America and have observed the historical movement of the training process. The irony is that as medical training has gotten better, patient care has gotten worse. Medical students are now better prepared. Many schools require "externships" where the student functions as a first-year resident. Some schools, like North Dakota, require that much of the student's final year be spent in a clinical practice with a senior doctor. Students are now more worldly -- they might have worked in a Cambodian refugee camp, an AIDS clinic in South Africa, or done rural health in Haiti. Given the fall in doctors' incomes and status, they are not going into medicine for the money or the prestige.

The training system is becoming more human. Traditionally it was run with a "power over" system where your rank gives you power over the next doctor down. This led to cruelty and even abuse. The lower-downs got isolated from each other and from their experience of the system itself. Now the system is more "power with," emphasizing dialogue and mutual decision-making. The recent cap on on-call hours is a great improvement. In the past, your doctor was so sleep-deprived that he might be seeing double and mistaking a heart murmur for a bowel rumble. The recent limit of hours to 80 a week is progress.

Now 50 percent of residents are women, who, as carriers of relationship in our culture, try to bring these priorities into medicine. Residents now get instruction in ethics, especially around the terminally ill. Emphasis is shifting from knowledge to understanding. With Palm Pilots in our pockets, there is an opportunity to shift from the clutter of information to the crux of understanding. Residents now have more time to think -- or, better, connect with patients and with each other.

Why have these improvements in doctors' training not significantly upgraded the overall care of patients? Three recent examples:

A pregnant woman goes into premature labor and is bounced from one emergency room to another until she starts hemorrhaging and is admitted, comatose.

A young woman faints in the heat and is brought to a large city hospital where the resident does blood tests and gets a CAT scan -- all because of the hospital policy to practice "defensive medicine" and avoid lawsuit.

An alcoholic, at the end of his three days of insurance coverage in Boston, tells the claims person -- a teenager in Topeka -- that he's afraid to leave and asks: "What am I gonna do?"

"Go out and get drunk," she says, "and we'll readmit you for another three."

These examples reflect the larger picture. None is cost-efficient or an example of good care. Preventive care is not valued. Hospitals are less available -- in the past several years approximately 1,000 hospitals (of a total of 6,000) closed their doors. The ones still in business are overwhelmed, cutting costs. Because of cost cutting and insurance industry pressure, the time a resident can spend per visit with any one patient is severely limited. The hospital stay is dangerously foreshortened, so the resident never really gets to know the patient well, never gets to use these new humanistic skills. Paperwork and defensive tests consume the resident -- about 25 percent of the $1.66 trillion per year health budget goes to administrative costs -- $399.4 billion a year for pushing paper instead of patient care. Because of all this, mistakes are rising: Your chance of being a victim of a mistake during your hospital stay is over 50 percent.

The reason doctors can't provide good care is that the American health care system prevents it. Doctors can't give the care they aspire to; patients feel the limited care.

Health care in America is a national disgrace. Many doctors my age are leaving medicine; many patients are irate. A national disgrace demands a national solution. Change will not come from the private sector. Insurance executives, after all, are the oil men of medicine. Only when things got really bad in medical training did we doctors act. The cap on on-call hours came from the combined pressure brought by patients and doctors. We doctors need to organize and resist -- perhaps announce an intent to strike, a year from today, unless there is a plan for a national system in place -- to revolutionize health care as we have tried to humanize our profession. America can afford it. It's a matter of priorities, efficiency (nationalizing could reclaim $325 billion annually of the $399.4 billion spent on "paperwork"), and finding a leader who understands that "compassionate" health care is more than a sound bite. The administration's war on Medicare ("We had to destroy it to save it") is a cynical election year ploy, a slip down the slope to privatization and profiteering. Ironically, one of the few issues the Bush administration has not misled the American people about is an overall health care plan -- it has none.

Dr. Steve Bergman is author of "The House of God" and "Mount Misery," which were published under his pen name, Samuel Shem.

© Copyright 2003 Globe Newspaper Company.

###

[fiestynurse]

San Francisco Chronicle

December 29, 2003

Time for single payer?

By Ruth Rosen

Don't be surprised if health care turns out to be the sleeper issue in the 2004 presidential campaign and if a majority of Americans eventually decide that a single-payer system is the most cost-efficient way to provide health care for everyone.

Why? Because our health system -- a fragmented hodgepodge of private and public-health plans -- is broken.

HMOs -- which pay huge amounts for administrative and bureaucratic costs, advertising and skyrocketing drug prices -- no longer can contain costs. They have also turned the health-care system into a blizzard of paperwork.

Physicians who recently resisted a single-payer system have grown increasingly resentful of HMO bureaucrats who micromanage their medical decisions. Inadequate reimbursements are driving some out of business. They also dislike having to consult dozens of drug lists or formularies before

they can prescribe medicine for their patients. They'd rather spend time caring for sick people.

Businesses, which seek a level playing field, may also become supporters of a single-payer system. Consider the inequities they face. General Motors, which has a huge group of retired workers, must pay for their lifetime health costs. Newer companies, however, either don't offer health-care benefits to workers or retired workers or don't yet have any retired workers to worry about.

Labor, too, is a natural constituency for a single-payer system. The three-month long grocery workers' strike in Southern California against major supermarkets has highlighted the burden businesses now bear for paying for their workers' health care. How can Safeway, which has paid decent wages and benefits, compete with union-busting Wal-Mart, which pays subsistence

wages and offers health-care insurance at unaffordable premiums?

It can't. To avoid a race to the bottom, each employer should not have to pay for their workers' health care. Instead, through an equitable tax, they should contribute to a single-payer health system.

And don't forget the 40 million uninsured Americans. Soon after the Medicare bill passed, Senate Majority leader Bill Frist announced that Republicans would next try to address the medical needs of those who lack medical insurance. These are people whose votes could be captured by any candidate who promises to reduce their anxieties about getting health care.

The wealthy, too, may come to view single payer as a better alternative. Why? Because one of the best kept secrets in the United States, according to the American Hospital Association, is that 80 percent of our emergency rooms are overcrowded and the average wait is four hours. The poor, of course, already know this. But when middle class and wealthy Americans with heart attacks or serious injuries discover that they, too, may be diverted from one hospital to another, they may reconsider the value of their "excellent" medical insurance.

The fact is, most hospitals operate with "a just-in-time inventory" that works just fine for an average Tuesday evening in May. But on a Saturday night during the winter flu season, emergency rooms are filled with children and elderly people with high temperatures, along with heart attack victims and people bleeding from knife or gunshot wounds. (Don't even think about

what might happen after a bio-terrorist attack, a fire or an earthquake.) Triage nurses must decide who will receive medical attention. When all the emergency rooms are filled to capacity, some patients lie on gurneys in the hall, waiting for an intensive-care bed and monitor.

By contrast, a single-payer system would reduce the burden on emergency rooms by providing everyone with primary care in physicians' offices and outpatient facilities.

A single-payer system would also cost less. The overhead for Medicare is only 2 percent; for private insurance it is up to 25 percent.

Health care is a human right, not a privilege. If you don't believe this now, you might change your mind if and when you find yourself in need of life- saving care in a hospital emergency room.

[Hellllllo Nurse, BSN, RN]

Good articles, but I would have liked them better had they mentioned nurses and how overworking and understaffing nurses contrubutes to poor care.

[fiestynurse]

Write an article for your local newspaper and give them a nurse's point of view!

[Hellllllo Nurse, BSN, RN]

Originally posted by fiestynurse

Write an article for your local newspaper and give them a nurse's point of view!

I have, but they have chosen not to publish them. I have been in touch w/ a couple of newspaper reporters who have taken my suggestions on writing about nurses and nursing. I've posted about it on this bb.

Also, I spoke about problems with nurses' working conditions and how this impacts health care at a Dean Meetup in Dec.

[fiestynurse]

I have found it easier to get articles published during National nurse's week in May. They have also printed pictures that I have sent them. When all else fails I write to the editorial page.

My point being: The above articles were written by doctors, who have their own agenda. They don't know what it's like to be a nurse in today's managed care system. Us nurses have to tell our own stories and let are voices be heard also!

Best Wishes to you!!

[Hellllllo Nurse, BSN, RN]

Point taken.

[ainz]

All of this comes together and affects nurses' working conditions. Nurses do not work in a vacuum, these issues affect everyone. The doctors hit the nail on the head just fine.

When are nurses going to do something about complaining about being overworked and understaffed? It really is tired.

Nurse staffing laws I don't think are the long-term answer. If the system cannot handle it economically or if the nursing shortage causes hospitals to not be able to meet it then the law will be repealed or simply not enforced and nursing will have major egg on its face. Some big victory for the CNA, NOT!!

[NurseHardee]

ainz..

>

It may be tired, ainz, but it is true. However, a great part of the reason that nurses are put in this position is that the US health system constantly misuses ALL its assets.

A reformed medical delivery sytem probably already has more than enough nursing personnel on hand, same as it has more than enough doctors available. We can deliver better medical care without nurses being abused, and probably using fewer nurses than are already on hand. All power to nurses complaining yet more about this broken system we currently have.

NurseHardee

[pickledpepperRN]

Originally posted by NurseHardee

...a great part of the reason that nurses are put in this position is that the US health system constantly misuses ALL its assets.

A reformed medical delivery sytem probably already has more than enough nursing personnel on hand, same as it has more than enough doctors available. We can deliver better medical care without nurses being abused, and probably using fewer nurses than are already on hand. All power to nurses complaining yet more about this broken system we currently have.

NurseHardee

First please let me praise you for finding the articles by physicians because they present fresh ideas we can all benefit from.

Nurses are doing great work too.

Perhaps a similar pshchology affects nurses. Do we unite for better healthcare and respect for direct care nurses?

Are we demoralized by the "just a nurse" thinking?

Do we behave like the "Most respected" group in the USA? Well we are!

The ratio law has been in effect for less than a month.

The whining doom and gloom of the industry shows either a concerted effort to sabatoge safe staffing or a problem with their locus of control.

Check out some facts:

http://www.califnurses.org/

http://sacramento.bizjournals.com/sacramento/stories/2004/01/19/story6.html

From the January 16, 2004 print edition

Agency bogs down as nurses rush to register

Kathy Robertson

Staff Writer

With hospitals across the state scrambling to find enough workers to meet new nurse-to-patient ratios, a record 220 nurses showed up at the Bureau of Registered Nursing in the first week of January to get state approval.

Most were out-of-state nurses seeking temporary licenses. If appropriate credentials were sent ahead of time, most got what they wanted in a few hours.

Permanent licensing is another matter.

The wait time for that has grown to six weeks or more. Budget cuts at the state agency that licenses registered nurses reduced staff by 15 percent last year, creating a backlog of work at a time when demand for its services is at an all-time high.

"We don't want to be a bottleneck in the process, that's for sure, but we are having to do things a little different," said assistant executive officer Susan Brank. "Licenses are not issued as quickly as we'd like."

In October 2003 -- the last time the backlog was reviewed -- there were 2,100 applications pending. The oldest dated back five months.

The board's goal is to issue most permanent licenses in 10 days to two weeks, although complex cases can run three or four months, Brank said. Due to the backlog, the work now takes four to five weeks longer than usual.

A 60 percent increase in applications: Staff cuts are partly responsible for the delay. A big jump in demand is another.

A state agency within the California Department of Consumer Affairs, the board is charged with protecting the public by regulating the practice of almost 300,000 registered nurses in California. The board enforces laws relating to nursing education, licensure, practice and discipline.

There's been a 60.4 percent increase in applications in the last three years. The numbers swelled to 35,887 in the fiscal year ended June 2003, up from 22,372 in fiscal 1999, the year the nurse-to-patient ratio law was signed by former Gov. Gray Davis. Experienced out-of-state nurses can use temporary licenses for six months, but then they, too, have to get permanent certification.

The new staffing law, the first in the nation, kicked in Jan. 1 and affects all general acute-care hospitals in the state. When fully implemented in 2008, ratios will range from one nurse per patient in trauma units to one to every five patients in medical/surgery units.

It's a good problem, union says: The mandate comes amid a national nursing shortage, prompting hospitals to start new nursing programs, beat the bushes for temps or go outside the state -- and nation -- to find them.

Meanwhile, the state budget crisis prompted a staff reduction at the Bureau of Registered Nursing last year from 97 to 82. It remains unclear whether 2004 will bring more cuts.

"This affects hospitals across the state," said Dorel Harms, vice president for professional services at the California Healthcare Association, a hospital trade group. "It's a sign of the times, these budget cuts, but it's coming at a time when we need as many nurses as possible."

"Frankly, we think this is a good problem to have," countered Donna Gerber, legislative director for the California Nurses Association, the union that sponsored the new ratio law.

The union has argued for years that the nursing shortage stems from poor working conditions in California hospitals and that improved conditions will attract nurses back to the market.

"The nurse-patient ratios are a critical vehicle in bringing more nurses to California," Gerber said. "We are aware of the budget cuts last year, but the executive director assured us that staff was working overtime and other changes were made to help reduce the backlog."

The licensing unit, which typically responds to 1,500 phone calls a week, cut back its phone hours to spend more time processing back applications.

The board lost three of its 10 nursing education consultant positions. These nurses respond to nurse practice questions, analyze complaints, regulate nursing school programs and evaluate proposals for new programs.

To cope with rising demand and fewer staff, the board gives top priority to enforcement and now refers more calls to the "frequently asked questions" section at http://www.rn.ca.gov http://www.rn.ca.gov/>, its Web site.

The agency also suspended its quarterly newsletter, which costs $75,000 to $100,000 to print and mail.

State borrows from agency: Ironically, the Board of Registered Nursing is self-supporting. Funding for its $16.7 million budget this year comes from license and other application fees, but the state budget crisis is so bad that all state agencies have been hit.

The state has dipped into the coffers of many "special fund" agencies to offset the budget deficit. It "borrowed" $12 million from the board last year. Repayment is promised; when remains unclear. The reserve fund is projected to be down to $6.49 million by June, for a 4.7-month operating reserve, Brank said.

Meanwhile, demand on the agency is up in all areas, not just applications.

Complaints rose 41 percent in fiscal 2003, while formal enforcement accusations jumped 77 percent. Total licensee discipline declined 44 percent, but much of that was due to cuts and delays at the state Attorney General's office, the agency that investigates the cases, Brank said.

Efforts to reduce the backlog there spurred a jump in action late last year. Overall, discipline (disciplinary actions?) is projected to rise 166 percent this year.

"We recognize it's important for the public and consumers to do these things in a timely way," Brank said. "We can contribute to the economic recovery of the state because nurses are needed, most make at least $45,000 a year and we typically process 1,600 licenses a month."

At that rate, one month's delay in licensing translates into $6 million in lost wages.