Tales of Republicans, Bonobos and Adultery

Rules of the Wronged

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Maureen Dowd

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Stay focused, ladies. Here is The Practical Guide to Help Spurned Political Wives Survive Old Problems in the Era of New Technology.

1. Skip the press conference, especially when your husband is copping to call girls, gay pickups in airport bathrooms or “tragic” and “forbidden” telenovela-style love stories. Stoicism at the skunk’s side is overrated and, as Larry Craig’s wife learned, sunglasses don’t help.

2. When there’s an Associated Press bulletin quoting your husband saying that he has found his soul mate but he’s going to try to fall back in love with you, change the locks. (At your second home, too.)

3. If you can’t maintain a dignified Silda Spitzer silence; if you can’t find a girlfriend, a shrink, a personal trainer, a hairdresser or a yoga teacher to confide in; if you must unburden yourself of your fury about your loser husband, go to Jesse Jackson, Al Sharpton or even Deepak Chopra before crying to The A.P. A news wire is not a spiritual adviser.

4. When your husband turns into a Harlequin romance, babbling to The A.P. — yes, even The A.P. thought it was T.M.I. — about a magical encounter on an open-air dance floor in Uruguay, “a soul that touches yours in a way that no one’s ever has,” and the “left brain and right brain” compartmentalization of “the world of ideas that impact this country and state” and “the pursuit of happiness, whatever that is,” just beat it.

5. If you think the worst is over, it’s probably only beginning. On Tuesday, after you thought Mark Sanford had already emoted and burbled more than any man in history, he volunteered to The A.P. (again!) that he had “crossed lines” with a handful of women on trips out of the country, but only “crossed the ultimate line” with his enchanting Maria. And just when you thought John Edwards could not sink any lower, there is news of a sex tape, in which Rielle Hunter shows off her skills not only in videography but pornography.

6. No matter how revolting your husband’s behavior is, don’t be passive-aggressive in public. Refrain from making any remarks that have a veneer of dignity but derogatory subtexts that sound like: “We’re trying to reconcile but it’s going to be tough because he has irreparably damaged my children” or “He has no integrity and I want my kids to have integrity” and “Sure, I’d like to give him a chance if he weren’t such a sleazeball.”

7. Don’t bring the children into it. They suffer enough being the kids of politicians. In the era of Facebook, texting, Google and iPhones, calling him out as a bad father will just go viral in the kids’ circles. Don’t trot out the family on “Oprah,” as Elizabeth Edwards did, or weepily show The A.P. the report cards of your two oldest sons from their elite private school in Columbia, S.C., as Jenny Sanford did.

8. Even if you’re a clever, competent woman, you risk sounding like a stereotypical harridan if you use the kids as a bludgeon and tell the press, as Jenny did: “You would think that a father who didn’t have contact with his children, if he wanted those children, he would toe the line a little bit.” When kids are involved, it’s best to chill when dishing out revenge.

9. Don’t slam his girlfriend for lying when you know she’s telling the truth. Don’t refer to the baby your rival had with your husband as “it.” Don’t trash a mistress, as Hillary and Elizabeth did, as a wacky stalker. No one — except the wife — blames the girlfriend as much as they blame the husband. Besides, you invite The Other Woman’s retaliation, as when Rielle decided — after watching Elizabeth spill to Oprah — that she might want that DNA test after all.

10. High-powered women like Hillary, Elizabeth and Jenny who give up their careers to focus on their husbands’ ambitions feel doubly betrayed. But it’s not your husband’s fault if you sacrifice more for the relationship than he does. Like an investor in a down market, you took a risk without a guarantee it would pay off. If you make your husband your career and you lose your husband, you lose your career, too.

11. Cut your losses and keep going. Don’t let yourself get dragged into his drama or your reputation may follow his down the well. Hillary refused to let that happen. She salvaged her long investment in Bill Clinton and turned a profit when she became a senator.

12. As you stay out of the spotlight that singes your husband, listen to whatever messages he is sending you through the press. When your husband says that is a world-class love story, ask him what this is. Just don’t do it through The A.P.

On reflection, it's a Me pandemic

Michael Jackson and the 'extreme' price of fame

(CNN) -- The celebrity flameout is a Hollywood cliché -- a mantel worn tragically by the likes of Lenny Bruce and John Belushi and handed down through the years to tabloid-populating stars such as Lindsay Lohan and Britney Spears.

Jackson arrives at his child molestation trial in 2005. A jury later acquitted him of the charges.

But Michael Jackson, dead at 50 after a life marked by unrivaled heights of pop brilliance and bizarre behavior that threatened to overshadow it, stood at the pinnacle of celebrity and embodied all the turmoil it can entail.

It's a perch experts say played a major role in his troubles in life and, perhaps, his untimely death.

"He sums up every aspect of it, having the ultimate fame, the ultimate power, the ultimate influence," said Patrick Wanis, a therapist and counselor who counts celebrities among his clients. "He also sums it up in every extreme aspect of the word."

Jackson, who died Thursday in Los Angeles, California, spoke repeatedly about the toll that a life spent in the public eye took on him emotionally, particularly as a child star singing with his brothers in the group Jackson 5. Compare Jackson's career to other major singers' »

"The public at large has yet to really understand the pressures of childhood celebrity, which, while exciting, always exacts a very heavy price," Jackson wrote in 2000 in a column for the religious Web site beliefnet. "More than anything, I wished to be a normal little boy. I wanted to build tree houses and go to roller-skating parties. But very early on, this became impossible."

Wanis said Jackson's experience is rare in its longevity. While a child star may shine brightly then disappear, or an actor or rock star may feel the first glare of the spotlight as a teenager or young adult, Jackson lived both experiences.

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His first public performance, at Mr. Lucky's nightclub in Gary, Indiana, came at age 6; at 50 he was rehearsing for a comeback tour. iReport.com: Fans in Gary remember Jackson

"The average life of a band or performer is five years. There's only a handful that break that rule," Wanis said. "Michael Jackson is the enigma. He started as a child and he was able to keep it going all the way because of his almost supernatural talent.

"The problem with that is he never really had a personal life. He never had a chance to live."

For Jackson, the pressures of celebrity "exaggerated and exacerbated" what likely already were some deep emotional and mental wounds, according to Wanis.

Multiple reports from the Jackson family, including Michael, described severe beatings and emotional abuse by Michael's father, Joseph Jackson, who relentlessly drove his children to become pop superstars.

Michael's actions in later years -- from his serial plastic surgeries, which removed all family resemblance, to his famous crotch-grabbing dance move -- can be seen as lashing out over that abuse, Wanis said.

"He resented his father," he said. "He was in rebellion, almost like a subconscious rebellion, against his father."

The behavior didn't stop with dance moves and surgery. There was the chimpanzee and the tigers and dangling his child briefly from a hotel balcony.

Most notoriously, and damaging, were the charges of sexually abusing the young boys he befriended, charges for which he was found not guilty in court, even as reports of a multimillion-dollar settlement with another boy's family persisted.

The high-profile trial, and its lurid testimony, drove Jackson further down the path of antisocial behavior, turning him into a hermit almost on par with famed billionaire Howard Hughes.

In the end, Wanis said, it may have been the desire to perform again that led to his death. He was training hard for a tour that was hoped to spark a musical comeback, as well as one more chance to bask in the glory of his fame.

"There were a lot of people with a lot of vested interest in making sure he would stay alive at whatever cost," Wanis said. "The people around him were intent on making sure he could get whatever he needed just so he could get through those concerts."

As the world responded to Jackson's death, some observers paused from the accolades to reflect on celebrity's apparent toll.

"It was an unusual relationship yes, where two unusual people who did not live or know a 'normal life' found a connection," Lisa Marie Presley, Jackson's ex-wife and the daughter of Elvis Presley, wrote Friday on her blog. "I wanted to save him. I wanted to save him from the inevitable, which is what has just happened."

Columnist Andrew Sullivan, on his blog for The Nation magazine, wrote that he grieved for Jackson "but I also grieve for the culture that created and destroyed him."

"That culture is ours, and it is a lethal and brutal one: With fame and celebrity as its core values, with money as its sole motive, it chewed this child up and spat him out," Sullivan wrote. "I hope he has the peace now he never had in his life. And I pray that such genius will not be so abused again.

Michael Jackson, a man apart

(CNN) -- He was lauded and ridiculed. He broke down barriers and built them around himself. He soared to heights unimaginable with his music, and he made the ignominious front page of gutter tabloids worldwide.

Michael Jackson broke down musical and cultural barriers his entire life.

For Michael Jackson, the spotlight was always present, and the rest of the world followed.

With "Billie Jean" and "Beat It" -- the latter with Eddie Van Halen's scorching guitar solo -- he was almost single-handedly responsible for getting videos by African-American artists on MTV and helped revitalize the moribund Top 40 format in the early 1980s.

"Michael Jackson made culture accept a person of color way before Tiger Woods, way before Oprah Winfrey, way before Barack Obama," said the Rev. Al Sharpton, a friend. "Michael did with music what they later did in sports, and in politics and in television. No controversy will erase the historic impact." In Depth: Michael Jackson special report

"Thriller," a 14-minute video extravaganza directed by John Landis, paved the way for the elaborate music videos to follow -- including Jackson's "Scream," recorded with sister Janet in 1995, which cost a reported $7 million and may be the most expensive video ever. Audio slide show: Michael Jackson and his music »

His incredible dance talent, a modern twist on the Motown moves he witnessed as a child, led to a heightened focus on choreography in pop music videos and stage shows.

His 1982 album "Thriller" smashed records. It was No. 1 for 37 weeks and, at its peak, sold a million copies a week. To date, it has sold nearly 50 million copies worldwide. The achievement set a high bar for Jackson; when his 1995 greatest-hits CD, "HIStory," sold 7 million copies, it was considered a relative failure.

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Jackson was also a fashion icon, his heavily zippered leather jackets a de rigueur 1980s fashion accessory, his single, spangled glove beyond compare.

On the down side, Jackson also led in making pop stars the subject of the paparazzi and tabloids in a way, perhaps, equaled only by such icons as Frank Sinatra, Elvis Presley and the pre-"Sgt. Pepper" Beatles. Rumors abounded, from his pets to his sleeping habits to his cosmetic surgery, all fodder for the press. After stories arose of possible child molestation, he never got back in the media's good graces; he was treated as a traveling circus. Watch reaction to his death

From the time he was a child, it was obvious Michael Jackson was something special. In 1966, when he was 8, he joined his brothers in the band his father put together and started singing lead with brother Jermaine.

Though Motown Records was the top label of the 1960s, inventing what it called "the Sound of Young America," by 1969 -- when Jackson and his brothers in the Jackson 5 first hit the charts -- the label was finding itself out of step with the psychedelic and hard-soul sounds of the times. Watch reaction from Motown »

Enter the quintet from Gary, Indiana.

Motown signed the group in 1968 and poured its all into the Jackson 5's first single, "I Want You Back" -- the writing and production team were credited as "The Corporation" -- and Jackson's imploring, dramatic vocal rocked America. The song hit No. 1 in January 1970, and was followed by three more No. 1s in quick succession.

Thanks to their squeaky-clean image, the Jackson 5 became teen idols, unusual for a group of African-American youngsters. Michael Jackson's face appeared on the covers of teen magazines; the band even became the subject of an animated Saturday-morning TV show, another first for an African-American group.

But it was in the 1980s, when Jackson became a worldwide phenomenon, that his impact really began to be felt.

He was much imitated, from his hair to his clothes to his dance moves. The music was superbly crafted pop, produced by Quincy Jones and often written by Jackson himself. Even rock critics approved; the album "Thriller" earned an A from the picky Robert Christgau, among others. Watch a clip from "Thriller" »

There came a moment, around that time, when pop music went into a Jackson era. "Thriller" had nine songs; seven of them became singles. Jackson teamed with Lionel Richie to write the fundraising song "We Are the World"; it was his presence, as much as that of Richie, Bruce Springsteen and Stevie Wonder, that propelled the song to No. 1.

Jackson reteamed with his brothers for an album, "Destiny," and accompanying tour. It was the hottest tour of the year, despite complaints about sales practices. (Partly because of the controversy, Jackson announced publicly he was donating all his money from the tour to charity.)

He was a role model. At the peak of his fame, there were reports of a humbly dressed Jackson ringing doorbells as part of his Jehovah's Witness faith.

Though Jackson's image eventually became sullied by the molestation allegations and stories of eccentricity, there was never any doubt about his entertainment legacy. "Thriller" and "Bad" are still among the top sellers of all time. His fluid dance moves and stage presence set standards that rising stars -- often compared to Jackson -- struggle to equal.

"Of all the thousands of entertainers I have worked with, Michael was the most outstanding. Many have tried and will try to copy him, but his talent will never be matched. He was truly one-of-a-kind," said Dick Clark, who would know. Watch reaction from another musical legend, Cher »

And then there's the music, from the early, explosive joy of the Jackson 5 hits to the elegant ballads, down-and-dirty grooves and ecstatic dance hits of his solo years. "The Love You Save," "Billie Jean," "Beat It," "Bad" -- they are pop music boiled down to its best essence, with a good beat, an engrossing melody and even, sometimes, a message of love and fellowship.

It's enough to take a listener to the moon.

Human Nature Today

Has there ever been a time when there were so many different views of human nature floating around all at once? The economists have their view, in which rational people coolly chase incentives. Traditional Christians have their view, emphasizing original sin, grace and the pilgrim’s progress in a fallen world. And then there are the evolutionary psychologists, who get the most media attention.

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For 99 percent of human history, they observe, our species lived in small hunter-gatherer bands. The people who survived developed certain mental modules, which have been passed down to us through our genes. Some of these traits serve us well in the modern age. Children have the capacity to learn language with astonishing speed. Some of these traits don’t. Humans have an insatiable craving for fatty and sugary foods.

In 2000, Geoffrey Miller, a leading evolutionary psychologist, published a book called “The Mating Mind,” in which he argued that the process of sexual selection among early human groups hardwired many of the behaviors we see in humans today. Some of the traits are physical. Men generally prefer women with a 0.7 waist-to-hip ratio (that’s a 24-inch waist and 36-inch hips, for those of you reading this at the gym). Women generally prefer men who are taller and slightly older.

Some of these traits are more subtle. Men, Miller argues, tip better in restaurants, because they’ve been programmed to show how much surplus wealth they have. The average American adult knows 60,000 words, far more than we need. We have all those words because we like to mate with people who caress us with language.

Now Miller has published another book, “Spent,” in which he takes evolutionary psychology to the mall. The basic argument is that each of us is born with our own individual level of six big traits: intelligence, openness to new things, conscientiousness, agreeableness, emotional stability and extraversion. These modules are built into humans and other animals (apparently squid can be shy).

We are all narcissists, Miller asserts. We spend much of our lives trying to broadcast our excellence in these traits in order to attract mates. Even if we’re not naturally smart or outgoing, we buy products and brands that give the impression we are.

According to Miller, driving an Acura, Infiniti, Subaru or Volkswagen is a sign of high intelligence. Driving a Cadillac, Chrysler, Ford or Hummer is a sign of low intelligence. Listening to Bjork is a sign of high intelligence, while listening to Lynyrd Skynyrd is a sign of low intelligence. Watching Quentin Tarantino movies is a sign of high openness. He theorizes that teenage girls may cut themselves as a way to demonstrate their ability to withstand infections.

Evolutionary psychology has had a good run. But now there is growing pushback. Sharon Begley has a rollicking, if slightly overdrawn, takedown in the current Newsweek. And “Spent” is a sign that the theory is being used to try to explain more than it can bear.

The first problem is that far from being preprogrammed with a series of hardwired mental modules, as the E.P. types assert, our brains are fluid and plastic. We’re learning that evolution can be a more rapid process than we thought. It doesn’t take hundreds of thousands of years to produce genetic alterations.

Moreover, we’ve evolved to adapt to diverse environments. Different circumstances can selectively activate different genetic potentials. Individual behavior can vary wildly from one context to another. An arrogant bully on the playground may be meek in math class. People have kaleidoscopic thinking styles and use different cognitive strategies to solve the same sorts of problems.

Evolutionary psychology leaves the impression that human nature was carved a hundred thousand years ago, and then history sort of stopped. But human nature adapts to the continual flow of information—adjusting to the ancient information contained in genes and the current information contained in today’s news in a continuous, idiosyncratic blend.

The second problem is one evolutionary psychology shares with economics. It’s too individualistic: individuals are born with certain traits, which they seek to maximize in the struggle for survival.

But individuals aren’t formed before they enter society. Individuals are created by social interaction. Our identities are formed by the particular rhythms of maternal attunement, by the shared webs of ideas, symbols and actions that vibrate through us second by second. Shopping isn’t merely a way to broadcast permanent, inborn traits. For some people, it’s also an activity of trying things on in the never-ending process of creating and discovering who they are.

The allure of evolutionary psychology is that it organizes all behavior into one eternal theory, impervious to the serendipity of time and place. But there’s no escaping context. That’s worth remembering next time somebody tells you we are hardwired to do this or that.

Farrah Fawcett, a Sex Symbol Who Aimed Higher

She really tried. And for a sex symbol that alone can be like an accomplishment.

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Farrah Fawcett in the 1970s. More Photos »

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Farrah Fawcett in 2003. More Photos >

A scrim of sadness covers Farrah Fawcett’s career. Her stardom traced that cautionary Hollywood arc: meteoric fame followed by years spent trying first to overcome it, then, too late, seeking to recapture it.

Cancer interrupted Ms. Fawcett’s attempted comeback in 2006 and put her on a different, more didactic track — pursued by a careful-what-you-wish-for flurry of publicity. She put the incessant tabloid intrusion to the service of her illness, making a video diary of her struggle with anal cancer that, among other things, allowed her to feel that she had some control over the coverage. NBC, never shy about exploiting a celebrity tragedy, overproduced and overpromoted her film in “Farrah’s Story,” but never made the public service point that, besides abstinence, the HPV vaccine is the most promising form of prevention against this type of cancer, which in most cases is sexually acquired.

Ms. Fawcett died Thursday at 62. And her last poignant appearances sometimes obscure a smaller, more gratifying story line of a celebrated beauty who worked against type to construct a more dignified second act. Long before Charlize Theron gained weight to make “Monster” and Nicole Kidman put on a fake nose to play Virginia Woolf, Ms. Fawcett scrubbed off her tawny good looks to play battered — and battering — women in “The Burning Bed” and “Extremities.”

There were many less successful performances as well and cameo roles in B movies, but Ms. Fawcett kept trying, and that’s more than can be said of many of today’s fading stars who coast on surgically preserved looks, cable reality shows and the culture’s insatiable hunger for celebrity abasement.

Bea Arthur, who died at 86 after a long, varied and joyous career, accomplished many things, perhaps most notably making the case on “Maude” and “The Golden Girls” that an older woman with a large frame, beak nose and stentorian voice could be an object of male desire. Ms. Fawcett was not as talented or as versatile. Still, while at the peak of her career she tried to show skeptics that an object of male desire can hold her own in roles usually reserved for less glamorous, better trained actresses.

Though, of course, it was her early work that kept her famous. Nobody in recent memory comes close to the giddy heights Farrah Fawcett reached in the mid-’70s with one season on “Charlie’s Angels” and That Poster. The pinup of Ms. Fawcett in a red one-piece bathing suit, tanned, head tossed, body lithe yet curvy, was a revelation. She looked delicious but also a little carnivorous, her gleaming white teeth frozen in a friendly but slightly feral smile. That poster ended up on every teenage boy’s bedroom wall and in the annals of pop culture — Farrah was the face, body and hair of the 1970s

More recently Ms. Fawcett became almost as well known as fame’s camp follower after a dizzy, incoherent interview on David Letterman in 1997..

That bad moment was reinforced by an ill-advised 2005 TV Land reality show, “Chasing Farrah,” the kind of doomed career defibrillator that was parodied so brilliantly by Lisa Kudrow in “The Comeback.” A camera crew followed Ms. Fawcett as she giggled and tossed her golden mane at movie openings and on shopping sprees — more Blanche DuBois than “Charlie’s Angels.” In one scene, as Ms. Fawcett strode ahead in a cloud of fans and paparazzi, a stocky, balding man in a T-shirt told the camera with a leer, “I’d do her,” as if that would be doing her a favor.

Ms. Fawcett left “Charlie’s Angels” after only one season, the queen of “jiggle TV.” She had a dazzling smile underscored by a whispery baby voice, a sweetness that allowed young male fantasists to believe that she would be a forgiving sex goddess. Bo Derek and Pamela Anderson, physical prodigies who took her place on dorm-room walls, seemed less approachable — they were positioned more as parodies of sex symbols than the real thing and seemed perfectly content in that niche.

Ms. Fawcett was built on a more human scale, a cheerleader from Corpus Christi, Tex., who radiated a healthy athleticism just ahead of the aerobics revolution led by Jane Fonda and Jamie Lee Curtis.

She made movies like “The Cannonball Run” but also set her sights on Broadway long before it became fashionable and profitable for theaters to boost ticket sales by recruiting television and movie stars to perform onstage. And in 1983 she dared to take over a role originated by Susan Sarandon in “Extremities,” in the grueling role of a rape victim who seeks revenge on her attacker. That performance led to “The Burning Bed,” a 1984 TV movie in which she played a battered wife and which was a television milestone; it helped her secure the lead in the 1985 film version of “Extremities.”

She took on other ambitious roles, not as persuasively perhaps, but they were brave choices nonetheless: the Nazi hunter Beate Klarsfeld in a 1986 television movie; the heiress Barbara Hutton a year later; and in 1989, the wartime photojournalist Margaret Bourke-White.

Her career took a detour in 1997 — that was the year of a Playboy spread and her infamous David Letterman interview, but it was also the year she played Robert Duvall’s wife in “The Apostle,” an affecting performance that was well received by critics, if not widely seen. She kept at it, though the offers kept shrinking; her last movie was a small part in “The Cookout,” the 2004 Queen Latifah comedy.

Toward the end, her private life — her son’s drug problems, her on-and-off relationship with the troubled Ryan O’Neal — eclipsed decades of work. Cancer brought it to an end.

Not all of her performances will stand the test of time, but what is worth remembering is how hard Farrah Fawcett tried.

The evolutionary origin of depression

Mild and bitter

Jun 25th 2009
From The Economist print edition

Depression may be linked to how willing someone is to give up his goals

CLINICAL depression is a serious ailment, but almost everyone gets mildly depressed from time to time. Randolph Nesse, a psychologist and researcher in evolutionary medicine at the University of Michigan, likens the relationship between mild and clinical depression to the one between normal and chronic pain. He sees both pain and low mood as warning mechanisms and thinks that, just as understanding chronic pain means first understanding normal pain, so understanding clinical depression means understanding mild depression.

Dr Nesse’s hypothesis is that, as pain stops you doing damaging physical things, so low mood stops you doing damaging mental ones—in particular, pursuing unreachable goals. Pursuing such goals is a waste of energy and resources. Therefore, he argues, there is likely to be an evolved mechanism that identifies certain goals as unattainable and inhibits their pursuit—and he believes that low mood is at least part of that mechanism.

It is a neat hypothesis, but is it true? A study published in this month’s issue of the Journal of Personality and Social Psychology suggests it might be. Carsten Wrosch from Concordia University in Montreal and Gregory Miller of the University of British Columbia studied depression in teenage girls. They measured the “goal adjustment capacities” of 97 girls aged 15-19 over the course of 19 months. They asked the participants questions about their ability to disengage from unattainable goals and to re-engage with new goals. They also asked about a range of symptoms associated with depression, and tracked how these changed over the course of the study.

Their conclusion was that those who experienced mild depressive symptoms could, indeed, disengage more easily from unreachable goals. That supports Dr Nesse’s hypothesis. But the new study also found a remarkable corollary: those women who could disengage from the unattainable proved less likely to suffer more serious depression in the long run.

Mild depressive symptoms can therefore be seen as a natural part of dealing with failure in young adulthood. They set in when a goal is identified as unreachable and lead to a decline in motivation. In this period of low motivation, energy is saved and new goals can be found. If this mechanism does not function properly, though, severe depression can be the consequence.

The importance of giving up inappropriate goals has already been demonstrated by Dr Wrosch. Two years ago he and his colleagues published a study in which they showed that those teenagers who were better at doing so had a lower concentration of C-reactive protein, a substance made in response to inflammation and associated with an elevated risk of diabetes and cardiovascular disease. Dr Wrosch thus concludes that it is healthy to give up overly ambitious goals. Persistence, though necessary for success and considered a virtue by many, can also have a negative impact on health.

Dr Nesse believes that persistence is a reason for the exceptional level of clinical depression in America—the country that has the highest depression rate in the world. “Persistence is part of the American way of life,” he says. “People here are often driven to pursue overly ambitious goals, which then can lead to depression.” He admits that this is still an unproven hypothesis, but it is one worth considering. Depression may turn out to be an inevitable price of living in a dynamic society.

Patients in Therapy, Therapist in Trouble

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Gabriel Byrne as a psychotherapist and Aaron Shaw as a patient whose parents are going through a divorce, in the second season of "In Treatment," beginning on Sunday on HBO.

People go into therapy to learn from their mistakes, then make mistakes about what they’ve learned. And if viewers have learned anything from the HBO series “In Treatment,” it’s that therapists can also get tangled in half-truths.

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Gabriel Byrne and Hope Davis in the new season of “In Treatment,” set in New York.

The show’s second season doesn’t pick up exactly where the first left off; Paul Weston, the psychotherapist played by Gabriel Byrne, has divorced and set up a practice in Brooklyn with new furnishings and a new roster of patients. But the issues he left behind seep into his fresh start: a malpractice suit on top of marital discord on top of childhood grievances.

If it is possible to find pleasure in other people’s psychic pain — and obviously it is — there is no better place for it than in the therapy sessions that begin on Sunday night. This season of “In Treatment” in particular seems uncannily suited to the times: Paul’s patients include an unfulfilled litigator at a fancy Manhattan law firm and the anxious chief executive of a scandal-ridden corporation.

When first introduced, “In Treatment” looked like an unlikely bet. The scripts were taken, nearly word for word, from a successful Israeli series, “Be’ Tipul.” Almost every scene was set in a therapy session — Paul’s with a patient, and Paul’s session with his confidant and former supervisor Gina (Dianne Wiest) — essentially a chain of two-person, one-act plays without action, sets or pop-music cues.

Despite a few awkward cultural adjustments, the transposition from Tel Aviv to suburban Maryland worked, partly thanks to the seductive power of the therapeutic process — psychotherapy: the home game. Classic theories of repression, transference and countertransference were artfully compressed into verbal jousts between doctor and patient. Characters’ inner workings were signaled with an ill-chosen word, an offhand gesture or a prolonged silence. And when Paul went to Gina with his own troubles (and ethical transgressions), he left his benevolent authority behind and morphed into a typical patient — defensive, self-pitying and blinkered. And Gina, in turn, proved to have baggage of her own.

The first season was riveting partly because it was so flattering; the viewer was the real supervisor in the room.

In many ways the second season is richer. The stories are again lifted from “Be’ Tipul,” but set in New York, the epicenter of post-Freudian civilization and its discontents. Paul was in crisis in the first season; now he’s also in legal trouble. The premiere begins, as mornings in the Big Apple so often do, with a rude awakening. Alex Prince Sr. (Glynn Turman), the father of Paul’s former patient Alex (Blair Underwood), a Navy pilot who at the end of last season crashed his plane, is at the therapist’s door to hand-deliver his revenge. The father is suing Paul for failing to alert the Navy that his patient was not yet fit to fly. Paul is shocked but invites him to come in and talk. “That’s what killed Alex in the first place,” Prince says. “Talking with you.”

Paul, dazed and distressed, hires a lawyer and finds himself in the hands of Mia (Hope Davis), a 40-something single woman who 20 years earlier had been his patient. That Mia has her own motives for grabbing Paul’s case goes without saying, but Ms. Davis is unnervingly convincing in the role and brings resonance to her character’s every word.

Paul doesn’t want to believe he is responsible for Alex’s death, or that it really was a suicide. But he has reason to feel guilty, and that remorse bleeds into his other cases as he tries to take a more interventionist role in his patients’ lives. He oversteps in his first meeting with April (Alison Pill), a fiercely independent architecture student with a problem that is literally unspeakable: she can’t describe it to Paul in words, and writes it on a scrap of paper.

John Mahoney, who played the father of a shrink for laughs on “Frasier,” is now on the couch in deadly earnest as Walter, an embattled chief executive who comes to Paul for help with panic attacks. Walter wants a quick fix to his problems and is contemptuous of anything that smacks of psychobabble, and Paul, less passive than in the past, occasionally loses patience with Walter’s resistance.

Oliver (Aaron Shaw) is an overweight teenager whose parents are getting a divorce, and their recriminations, which they air in the middle of their child’s sessions, oppress Oliver — and Paul. He hears echoes of his own broken marriage in their squabbling, which makes him all the gloomier — and combative — when he travels back to Maryland to talk to Gina.

Nobody’s perfect, and even shows that explore human imperfection have flaws. Some of the patients’ underlying problems seem too pat for a series that traffics in ambiguity and nuance, while Paul’s personal history crosses over into Lifetime movie territory. But nimble, powerful acting and well-wrought dialogue outweigh the weaknesses.

The first season was shown for nine weeks, with one session per half-hour episode nearly every weeknight. This one unfolds in back-to-back episodes, two on Sunday and three on Monday, over seven weeks. It may seem like a daunting commitment. But the spectacle of other people unraveling moves quickly, particularly when it’s the viewer who gets to look at a watch and say, “I think our time is up.”

IN TREATMENT

HBO, Sunday nights at 9 and 9:25, Eastern and Pacific times; 8 and 8:25, Central time; Monday nights at 9, 9:25 and 9:55, Eastern and Pacific times; 8, 8:25 and 8:55, Central time.

Directed by Paris Barclay (“Mia,” “April,” and “Walter”), Ryan Fleck (“Oliver”) and Terry George (“Gina”); written by Warren Leight and Jacquelyn Reingold (“Mia”), Sarah Treem (“April”), Keith Bunin (“Oliver”), Pat Healy (“Walter”) and Marsha Norman (“Gina”); Stephen Levinson, Mr. Leight, Ms. Barclay, Hagai Levi, Rodrigo Garcia and Mark Wahlberg, executive producers; Noa Tishby, co-executive producer; Sarah Lum, Leonard Torgan, Alysse Bezahler and Ms. Treem, producers. Produced by HBO Entertainment.

WITH: Gabriel Byrne (Dr. Paul Weston), Dianne Wiest (Dr. Gina Toll), Hope Davis (Mia), Russell Hornsby (Luke), John Mahoney (Walter), Alison Pill (April), Sherri Saum (Bess) and Aaron Shaw (Oliver).

Healthcare legislation in countries in transition, emerging economic, and developing countries should permit - and use economic incentives to encourage - a structural reform of the sector, including its partial privatization.

KEY ISSUES

·        Universal healthcare vs. selective provision, coverage, and delivery (for instance, means-tested, or demographically-adjusted)

·        Health Insurance Fund: Internal, streamlined market vs. external market competition

·        Centralized system – or devolved? The role of local government in healthcare.

·        Ministry of Health: Stewardship or Micromanagement?

·        Customer (Patient) as Stakeholder

·        Imbalances: overstaffing (MDs), understaffing (nurses), geographical distribution (rural vs. urban), service type (overuse of secondary and tertiary healthcare vs. primary healthcare)

AIMS

·        To amend existing laws and introduce new legislation to allow for changes to take place.

·        To effect a transition from individualized medicine to population medicine, with an emphasis on the overall welfare and needs of the community

Hopefully, the new legal environment will:

·        Foster entrepreneurship;

·        Alter patterns of purchasing, provision, and contracting;

·        Introduce constructive competition into the marketplace;

·        Prevent market failures;

·        Transform healthcare from an under-financed and under-invested public good into a thriving sector with (more) satisfied customers and (more) profitable providers.

·        Transition to Patient-centred care: respect for patients’ values, preferences, and expressed needs in regard to coordination and integration of care, information, communication and education, physical comfort, emotional support and alleviation of fear and anxiety, involvement of family and friends, transition and continuity.

The Law and regulatory framework should explicitly allow for the following:

I. PURCHASING and PURCHASERS

(I1) Private health insurance plans (Germany, Czech Republic, Netherlands), including franchises of overseas insurance plans, subject to rigorous procedures of inspection and to satisfying financial and governance requirements. Insured/beneficiaries will have the right to apply contributions to chosen purchaser and to switch insurers annually.

Private healthcare plans can be established by large firms; guilds (chambers of commerce and other professional or sectoral associations); and regions (see the subchapter on devolution under VI. Stewardship).

Private insurers: must provide universal coverage; offer similar care packages; apply the same rate of premium, unrelated to the risk of the subscriber; cannot turn applicants down; must adhere to national-level rules about packages and co-payments; compete on equality and efficiency standards.

(I11) Breakup of statutory Health Insurance Fund to 2-3 competing insurance plans (possibly on a regional basis, as is the case in France) on equal footing with private entrants.

Regional funds will be responsible for purchasing health services (including from hospitals) and making payments to providers. They will be not-for-profit organizations with their own boards and managerial autonomy.

(I12) Board of directors and supervisory boards of health insurance funds to include:

-         Two non-executive, lay (not from the medical professions and not politicians) members of the public. These will represent the patients and will be elected by a Council of the Insured, (as is the practice in the Netherlands)

-         Municipal representatives;

-         Representatives of stakeholders (doctors, nurses, employees of the funds, etc.).

(I13) The funds will be granted autonomy regarding matters of human resources (personnel hiring and firing); budgeting; financial incentives (bonuses and penalties); and contracting.

The funds will be bound by rules of public disclosure about what services were purchased from which providers and at what cost.

Citizen juries and citizen panels will be used to assist with rationing and priority-setting decisions (United Kingdom).

(I2) Procurement of medicines to be done by an autonomous central purchasing agency, supervised by a public committee (drug regulatory authority) aided by outside auditors.

All procurement of drugs and medications will be done via international tenders.

The agency will submit its reimbursement rates for drugs on the PLD to external audit in order to accurately reflect pharmacists’ overhead costs. At the same time, the profit margins on all drugs, whether on the PLD or not, will be regulated.

This agency should be separate from the Health Insurance Fund and the Ministry of Health. This agency will also maintain national drug registries. It will secure volume discounts for bulk purchasing and transparent, arm’s-length pricing.

(I21) Use of reference prices for medicines. If the actual price exceeds the reference price, the price difference has to be met by the patient.

(I3) The Approved (Positive) List of Medicines will be recomposed to include generic drugs whenever possible and to exclude expensive brands where generics exist. This should be a requirement in the law. Separately, an Essential Drug List will be drawn up.

(I31) Encourage rational drug prescribing by instituting a mixture of GP and PHC incentives and penalties, or a fundholding system: budgets will be allocated to each GP for the purchase of drugs and medications. If the GP exceeds his/her budget, s/he is penalized. The GP gets to keep a percentage of budget savings. Prescription decisions will be medically reviewed to avoid under-provision.

(I4) Payments and Contracting

Payment to providers should combine, in a mixed formula:

BLOCK CONTRACTS

Capitation - A fixed fee for a list of services to be provided to a single patient in a given period, payable even if the services were not consumed, adjusted for the patients' demographic data and reimbursement for fee-for-service items.

Inflation-adjusted Global budgeting (hospitals) and block (lump sum) grants (municipalities)

COST and VOLUME CONTRACTS

Provide incentives and reward marketing efforts which result in an increase in
demand/referral beyond the limit set in a block contract.

COST PER CASE CONTRACTS

Apply Diagnosis Related Group (DRG)/ Resource-based Relative Value (RBRV) / Patient Management Categories (PMCs) / Disease Staging/Clinical Pathways

Levels of reimbursement, case-mix adjusted to be decided by external auditors.

Contracts with providers should include:

·        Waiting Times Guarantee

·        Single Contact Person (“Case Officer”) for the duration of a stay at the hospital

·        Hospital benchmarking (individual-level data on costs, diagnoses, and procedures during entire case episodes: inpatient admissions and outpatient visits; cost-effectiveness of services.

·        Performance targets in performance agreements with all healthcare facilities, both public and private.

·        All payments - wages included - will be tied to these targets and their attainment as well as to healthcare quality as determined by objective measures (internal, external, and functional benchmarking), clinical audits (sampling), as well as customer satisfaction surveys and interviews and discussions with patients.

·        Provider and Staff Bonuses and penalties tied to exceeding/under-performing targets and contract variance

·        Patients’ rights, including their rights to litigate

Selective contracting will be allowed on all levels (including specialist ambulatory care and hospitals), although all providers, private and public, will be permitted to apply for contracts with health funds and insurers. The funds will choose from among private providers either following a process of deliberation, or via an auction, or public tender (United Kingdom).

(I5) Commissioning preference will be given to the purchase of Primary Healthcare over secondary, or tertiary Healthcare.

II. PROVIDERS

The Law and regulatory framework should explicitly allow for the following:

 (II1) Hospital Management

(See separate document)

The law should allow:

I. Co-location of a private wing within or beside a public hospital

II. Outsourcing of non-clinical support services

III. Outsourcing of clinical support services

IV. Outsourcing of specialized clinical services

V. Private management of public hospitals

VI. Private financing, construction, and leaseback of new public hospitals

VII. Private financing, construction, and operation of new public hospitals

VIII. Sale of public hospitals as going concerns

IX. Sale of public hospitals for alternative use

X. Consolidation of redundant public healthcare facilities by merging them or closing down some of them

XI. Privatization of Primary Healthcare (PHC) clinics within medical centers

XII. Healthcare institutions will be granted autonomy regarding matters of human resources (personnel hiring and firing); administering financial incentives or penalties, budgeting; and contracting.

XIII. Privatization pharmacies inside medical centers and hospitals.

(II2) Primary, Ambulatory, and Secondary Care and General Practitioners (GP)

(II21) Limit the number of patients per GP

(II22) Stimulate and financially incentivize the following activities, which should be declared national priorities within a National Needs Assessment:

·        Group practices and networks (for continued, around-the-clock services)

·        Day and minimally invasive surgery

·        Dispensaries

·        Home and day care services

·        Long-term care (nursing homes, visiting nurses, home I.V. and other services provided to chronically ill or disabled persons)

·        Patient hotels

·        Rehabilitation facilities and programs

·        Provision of merit goods (also through mass campaigns)

·        Conversion of hospital units to outpatient services, and day-care centers

Example of such financial incentives:

·        Physicians will be entitled to see patients who receive services free-of-cost
in the public sector in the morning, and private patients who pay the full
cost of the medical consultation in the afternoon.

·        Allow private beds in public hospitals and private financing of hospital stays (NHS, UK)

·        Subsidize or fully cover transaction costs (legal fees of contracting, compliance, accounting, etc.)

(II23) Allow hospitals to administer packages of outpatient services and be reimbursed by the Health Insurance Fund (or funds).

(II24) Impose an admission quota on medical schools; reduce the obligatory number of doctors per 1000 population; and make GP a medical specialty.

(II25) Strengthen the gatekeeper function of GPs and healthcare provision in outpatient settings.

Encourage gatekeeping  by instituting a mixture of GP and PHC incentives and penalties, or a fundholding system (United Kingdom, Estonia, Spain):

Budgets will be allocated to each GP for the purchase of secondary and tertiary healthcare (as well as to cover salaries, premises, diagnostic tests). If the GP exceeds his/her budget, s/he is penalized. The GP gets to keep a percentage of budget savings.

Referrals will be medically reviewed to avoid under-provision.

(II26) Introduce GP target income and adjust services and fees to reach it (perhaps by using tax credits).

(II27) Provide GPs and other types of primary and secondary healthcare providers with financial incentives to relocate to remote and rural areas

(II28) Render clinical and best practice guidelines mandatory (not merely recommended)

(II29) Encourage managed care (peer review panels, pre-approval procedures for surgery, case management for the chronically ill, formularies limiting pharmacy reimbursement to an approved list, and other contractual provisions).

III. PRIVATE SECTOR

Risks of privatization and private non-managed, imperfect competition: market failure, as patients received too many unnecessary services, due to fee-for-service reimbursement and information asymmetry.

The Law and regulatory framework should explicitly allow for the following:

 (III0) Allow private primary healthcare physicians to offer preventive care, treatments and interventions after office hours, emergency dental and medical care, emergency home treatment, preventive checkups for preschool and school children, patronage and polyvalent patronage services, and all other elements of comprehensive healthcare.

 (III1) Arrangements with the private sector and Private-Public Partnerships (PPP) for the provision of healthcare:

(III11) Service Contract (Dominican Republic), or Contracting-out

The government pays private entities - including doctors - to perform specific healthcare tasks, or to provide specific healthcare services under a contract. The private service providers can make use of state-owned facilities, if they wish, or operate from their own premises.

Payments by the government are usually based on capitation (a fixed fee for a list of services to be provided to a single patient in a given period, payable even if the services were not consumed) adjusted for the patients' demographic data and reimbursement for fee-for-service items.

(III12) Management Contract Outsourcing (Cambodia)

The government pays private entities to manage and operate public health care facilities, like clinics, or hospitals.

(III13) Lease (Romania since 1994)

Private entities - including doctors - pay the government a lump sum or monthly fees to use specific state-owned equipment, state-employed manpower, clinics, or complete public health care facilities.

The private entity is entitled to all revenues from its operations but also bears all commercial risks, is responsible for management and operations and liable for malpractice and accidents.  

The state is still responsible to make capital investments in the leased facility or equipment, but maintenance costs are borne by the private entity.

(III14) Concession and Build-Operate-Transfer (BOT) (Costa Rica)

Concession is exactly like a lease arrangement (see above) with one exception: the private entity is responsible for capital investment. In return, the contract period is extended and can be voided only with a considerable pre-advice.

In BOT (Build-Operate-Transfer) and ROT (Rehabilitate-Operate-Transfer) the capital investment involves the construction or renovation/upgrade of new healthcare facilities. The private entity uses the constructed facility to provide services. After a prescribed period of time has elapsed, ownership is transferred to the government.

(III15) Divestiture and Build-Own-Operate (BOO) (Texas, USA)

The law should permit the outright sale of state- owned health care facilities to a qualified private entity, including physician groups who band together to purchase previously state-run facilities.

Another possibility is a BOO scheme, in which the private entity contractually undertakes to add facilities, improve services, purchase equipment, or all three. 

(III16) Free entry

The law should allow qualified private providers to operate freely. Though regulated, these private firms will have no other relationship with the state.

Such entities would have to be licensed, certified, overseen, and accredited for expertise, safety, hygiene, maintenance, track record, liability insurance, and so on.

The state may choose to encourage such providers to locate in specific regions, to cater to poor clients, or to provide specific healthcare tasks or services by offering tax incentives, free training, access to public facilities, etc.

(III17) Franchising (Kenya, Pakistan, Philippines)

A private firm (franchisee) acquires a license from and shares profits with the franchisor (a domestic, or, more often, foreign firm). The franchisee uses the brand name, trademarks, marketing materials, management techniques, designs, media access, access to approved suppliers at bulk (discounted) prices, and training offered by the franchisor. The franchisor monitors the performance and quality of service of the franchisee.

This model works mainly in preventive care, family planning, and reproductive health.

The World Bank ("Public Policy for the Private Sector", Note number 263, dated June 2003):

"Franchisers in the health sector, often supported by international donors and nongovernmental organizations (NGOs), establish protocols, provide training for health workers, certify those who qualify, monitor the performance of franchisees, and provide bulk procurement and brand marketing."

(III18) Allow Charities and Not-for-profit organizations to run health insurance funds and a variety of providers (including full-scale secondary and tertiary healthcare institutions).

(III9) Voluntary Health Insurance (substitutive; complementary; and complementary), subject to open enrollment periods and mandatory coverage of dependants (to prevent cream-skimming and adverse selection).

IV. FINANCING

The Law and regulatory framework should explicitly allow for the following:

 (IV0) Institute co-payments for examination by a GP, emergency medical care, and certain preventive programs.

(IV01) Introduce negative co-payments: rebates or credits (to be deducted from future contributions) to insured persons who, in the preceding year, did not use services and did not consume interventions or drugs from the positive list above a level determined by the Ministry of Health.

(IV02) Introduce provider co-payments for hospital stays above the European Union average. Whenever the length of stay exceeds the EU average, the provider (hospital) will make a co-payment to the Health Insurance Fund or to the insurer.

(IV1) Voucher System (Nicaragua)

The law should allow for experimenting with novel payment and resource allocation techniques, such as vouchers or prepaid health cards distributed to needy populations and guaranteeing free basic service packages provided by a limited list of clinics or other healthcare facilities. Such schemes can also be managed by the private sector.

(IV2) Medical Savings Accounts (Singapore)

Allows or mandates people to place money in (tax-free) savings accounts to be used only for medical expenses, usually in conjunction with the purchase of a catastrophic stop-loss health insurance plan.

Contributions by employers and employees accumulate over time and are used, tax-free, to pay for hospital expenses in public and private hospitals, national supplementary health insurance premiums, special procedures (including abroad), and expensive outpatient treatment and drugs for the saver and his immediate family.

(IV3) Consumer Organizations and Community Healthcare Financing

Consumer organizations in the healthcare field (such as buyers' clubs or Health Maintenance Organizations-HMOs owned by cooperatives, NGOs, municipalities).

These groups will shop and tender for the best, most reasonably priced, and most efficient healthcare services for their members (Switzerland).

Example: HMO in USA – Integrated Model of Healthcare

(Source: WHO)

Health maintenance organization (HMO) is US health care sector term. It is an organization that contracts to provide comprehensive medical services (not patient
reimbursement) for a specified fee each month.

The term health maintenance organization arose because doctors under this arrangement have a financial incentive to keep their patience healthy, since they are not paid more for providing more services.

Health maintenance organizations, which focus on providing patients comprehensive medical care and pay doctors a specified monthly fee, have become increasingly popular in the United States, prompted by high costs from the previous fee-for-service, traditional indemnity health insurance plans.

In this model, doctors are typically paid by salary and hospitals are typically funded by global budgets. Benefits are supplied to patients in-kind, often free of charge. The public version of this model involves government financing and provision of health care and is often funded mainly out of general taxation. In the US, the voluntary form of this model is better known as the staff model of the health maintenance organisation. “Integration” as such is not only used for integrated model, but also for types of care provisions in which providers offering differing services (e.g., ambulatory care, inpatient care, rehabilitative care) provide them in an integrated way.

(IV4) Voluntary Health Insurance (substitutive; complementary; and complementary) with the right to apply one’s contributions to pay the premium and the right to switch insurers annually.

(IV51) Earmark a percentage of vice (sin) taxes, customs duties, VAT, and excise (on alcohol and tobacco; drugs and medications) for healthcare purposes.

(IV52) Reform healthcare budgeting. All healthcare budgets (including the budgets of the Ministry of Health; of hospitals, clinics, and primary healthcare facilities) will include amortization (and capital investments), goodwill and intellectual property, and intangibles (such as environmental externalities).

(IV6) Allow providers to retain a percentage of the user-fees they collect.

(IV7) Means-tested system: affluent and certain constituencies will be excluded from coverage (Netherlands, Germany) or pay much higher co-payments, co-insurance, or deductible (cost-sharing).

In such a system, private insurers administer compulsory insurance for the excluded groups (e.g., civil servants in Netherlands).

(IV8) Introduce VAT on hospitals to encourage investment, the purchase of medications, the retention of external services (e.g. training, skilling, continued education, management consultancy, auditing, etc.), where the hospitals can deduct VAT and retain it as an addition to their own budget.

(IV9) Community rating system vs. Demographically-adjusted or experience-rated premiums (e.g., the old and sick pay more than the young and healthy or vice versa; people with dependants pay more than insured or subscribers without dependants, etc.)

(IV10) Blind Fundholding: Financial resources for health care are allocated on a per capita basis; financial resources are held in a fund; and the general practitioner is usually the decision-maker for allocating the funds to purchase hospital and community services (with the patient choosing the providers, not the GP as was the case in the United Kingdom).
V. E-HEALTH

The Law and regulatory framework should explicitly allow for the following:

(V1) Citizen-centered and Mobile Healthcare

(V12) Provide a legal framework for health data transfer

(V13) Harmonize confidentiality and privacy laws

(V14) Establish legal liability or waiver thereof for e-treatment

(V15) Settle issues of entitlement and reimbursement

(V16) Encourage Medical e-Tourism (inbound telemedicine)

(V17) Provide for infrastructure and interoperability

(V18) Permit and licence Web Health and (outbound) Telemedicine (laws, regulations, forms)

(V19) Establish early warning systems

(V110) Foster patient-driven comparative indicators (e.g., online rating of professionals and providers) and empower patient organizations

(V111) Electronic European Health Insurance Card

(V112) Each citizen (or his/her custodian) will have full access to a personal Health Home Page with his EMR (Electronic Medical Records)/EPR (Electronic Patient Record)/EHR (Electronic Health Record)

VI. STEWARDSHIP

The Law and regulatory framework should explicitly allow for the following:

 (VI0) The Benefits Packages (basic and supplementary) to be decided by a conference of all stakeholders: Ministry of Health, patient groups and advocacy groups, and medical doctors associations, assisted by healthcare economists and experts.

(VI01) Consider the introduction of a Negative Benefits Package, listing only the interventions and services that are excluded from coverage. The interventions and services not on the Negative List are automatically covered.

(VI02) Consider exclusion of dental and oral care from the Benefits Package.

(VI03) Make preventive occupational health and safety measures, equipment, and training in the workplace mandatory. Re-establish occupational dispensaries in all workplaces with more than 100 workers.

(VI04) Generate annual National Needs Assessment reports (including technological needs assessment), including prioritized allocation of funding and foreign aid.

(VI05) Transform teaching hospitals into publicly-owned independent trusts (Italy, United Kingdom): the corporate type of hospital (hard budget; autonomous managers accountable to board; board accountable to government).

(VI1) Licencing and accreditation (including periodical renewal and relicencing by the doctors, dentists, and pharmacists chambers) will depend on continuing medical education (CME) and on education in management and finance for certain jobs (such as ward, clinic, and hospital directors).

All positions from ward doctor upwards will be subject to periodic review and open, public tenders.

(VI2) Private Sector Healthcare Monitoring and Regulatory Agency

The law should provide for the establishment of an agency to monitor and regulate private sector healthcare provision: compliance with contracts, servicing the indigent and the uninsured, imposing sanctions or "step-in" rights, and dispute resolution.

This agency will also maintain and supervise the operation of internal open-markets in the public sector; the outsourcing of primary care functions; and the purchase of primary care packages from private providers.

(VI3) Devolution (Finland)

Responsibility for the provision of some types of healthcare services (health promotion; preventive care; occupational health; mental health) and the allocation of inputs should be devolved to local authorities (municipalities), which will be required to produce budgets of needs vs. costs.

Consider possibility of turning municipalities to purchasers of secondary and tertiary healthcare from providers of their choice.

Local government will cover primary healthcare capital expenditures out of municipal taxes and fees and weighted capitation-based transfers from the central budget

The MoH will maintain a Fiscal Equalization Fund to ensure consistent quality and availability of healthcare provision across regions and localities.

(VI4) Health Academy

The Ministry should establish an Academy to train healthcare administrators with emphasis on systems administration and reform. The Academy will invite foreign experts as guest lecturers and teachers.

In conjunction with the Republic Institute for Health Protection, the Academy will co-maintain databases of case studies and evidence-based practices (feeding into the Cochrane Network) and the Medical Map of Macedonia.

(VI5) Campaign to encourage the public to consume generic drugs will be launched.

(VI6) External audit and cartel (antitrust) investigation regarding tertiary healthcare facilities.

(VI7) Wait Time Reduction Fund (Canada, 2004)

(VI8) National Waiting Times Guarantee

(VI9) Minister of Health Award of Excellence, presented annually to individuals and institutions of outstanding merit and excellence among healthcare professionals, purchasers, and providers of all types.

(VI10) Appoint a Health Ombudsman and consumer advocates in each major healthcare facility. Strengthen patients’ rights and the Patients’ Charter. Provide all patients (Or their custodians) with full access to their medical records; compensation for iatrogenic diseases; a statutory role for patients’ associations; and the establishments of commissions with patient representatives in all hospitals (France).

(VI11) SPECIFIC PROJECTS

Uniform Emergency Number

Neonatal Emergency Ambulance

Health cabinets in schools

Health Tourism

(VI12) National Inventory of Medical Assets

Extend the current central registry of all medical equipment in publicly-owned healthcare facilities to include private healthcare facilities.

The Inventory should also profile medical personnel, real estate, fixtures, infrastructure, and other capital assets.

(VI13) Coordinative Council for Social and Health Services: to plan and guarantee inter-sectoral action (together with the ministry of Social Welfare and Labor).

(VI14) Publish standardized contracts, forms, and performance criteria (including qualitative clinical pathways and benchmarks) to reduce transaction costs.

Example: the National Health Service Frameworks in the United Kingdom provide a health strategy; list priority interventions, treatment guidelines and performance targets; and proffer model contracts.

(VI15) Medical and Health Technology Assessment Board (examples: NICE in United Kingdom or SBU is Sweden) to decide all purchases of technology in secondary and tertiary facilities;  to publish “Positive Lists” of technology for GPs and PHC facilities; and to obtain discounts on bulk purchases.

The WHO defines Health Technology Assessment as:

“Comprehensive evaluation and assessment of existing and emerging medical technologies including pharmaceuticals, procedures, services, devices and equipment in regard to their medical, economic, social and ethical effects.

The systematic evaluation of properties, effects and/or impacts of health care technology. Health Technology Assessment defines a multidisciplinary activity that systematically examines technical performance, safety, clinical efficacy and effectiveness, cost, cost-effectiveness, organisational impact, social consequences, legal and ethical aspects of the application of a health technology (European Commission, 1999, from EUR-ASSESS 1997).”

(VI16) National Health Accounts Institute

(Sources: WHO, OECD, USAID)

Will publish the Healthcare PPP (Purchasing Power Parity), taking into account prices of imported healthcare inputs. Indicators may include total health expenditure, public
expenditure, private expenditure, out-of-pocket expenditure, tax-funded and other public expenditure, social security expenditure, public expenditure on health.

The National Health Accounts will also provide the following annual data, analyses, and indicators:

Sectoral opportunity costs, the value of benefits foregone by failure to apply the
resources to the most productive alternative cost;

Sectoral marginal costs, the extra cost of increasing output by one unit;

Sectoral variable costs: costs that vary with changes in output volume, such as the material required to provide a service versus

Sectoral fixed costs: costs which do not vary with quantity or volume of output provided, at least in the short run (e.g. rent for space).

Sectoral direct costs: all the goods, services and other resources that are consumed in the provision of a particular service or area (e.g. hospital supplies), including medical costs (e.g. payments to providers, material) and non-medical costs (e.g. transportation to hospital);

Sectoral indirect costs: total sum of morbidity costs (goods and services not produced by the patient because of the illness), mortality costs (goods and services the person could have produced had the illness not been incurred and the person not died prematurely), and productivity cost (related to lost productivity incurred by an employee who leaves work to provide care for the patient);

Sectoral intangible costs: usually used in economic evaluation, to indicate features like pain, anxiety or grief, which cannot be directly quantified in monetary terms.

Sectoral resource costs are the resources used in the production of goods and services; user cost: cost to the user of purchasing or making use of a product.

Sectoral cost-effectiveness analysis (CEA), a type of analysis that compares interventions or programmes having a common measurement of health outcome in a situation where, for a given level of resources, the decision maker wishes to maximise the health benefits conferred to the population of concern;

Sectoral cost-utility analysis (CUA), a type of analysis that measures benefits in utility-weighted life-years (QALYs) and which computes a cost per utility-measure ratio for comparison between programmes;

Sectoral cost-benefit analysis (CBA), a type of analysis that measures costs and benefits in monetary units and computes a net monetary gain/loss or a cost-benefit ratio.

Outcomes research: the Institute will evaluate the impact of health care on the health
outcomes of patients and populations, including an evaluation of economic impacts linked to health outcomes, such as cost effectiveness and cost utility. Outcomes research emphasises health problem- (or disease-) oriented evaluations of care delivered in general, real world settings; multidisciplinary teams; and a wide range of outcomes, including mortality, morbidity, functional status, mental well-being, and other aspects of health related quality of life.

Total expenditure on health: Total (or national) expenditure on health based on: Personal
health care services + Medical goods dispensed to outpatients = Total personal expenditure on health + Services of prevention and public health + Health administration and health insurance = Total current expenditure on health + Investment into medical facilities = Total expenditure on health.

Another formula is: total expenditure on health = * private health care expenditure + * public health care expenditure.

(VI17) Hospital League Table and star ranking (like with hotels and restaurants) to include information made publicly-available in various media: number of patients treated; complication rates; waiting times; data about procedures; food and amenities; other quality measures.

(VI18) Annual National Health Survey: will measure attitudes; customer satisfaction; emerging trends among purchasers and providers; and the increase or decrease in quality and performance standards as well as in capital investments.

What can we do to ensure that generations to come have a sustainable future?

Nothing much. The question, as it is posed, caters to our narcissistic presumptuousness and grandiosity in that it implies that we can predict the future with a modicum of certainty and act to subvert it or change its course. This, of course, amounts to delusional thinking. There is very little we know about complex systems such as the weather or human societies, let alone about the confluence of both. Remember how Malthus's dire scenarios were refuted (hitherto) by the advent of the green (agricultural) revolution?

As the White House Science Advisor said (in a 200-pages report released in June 2009), there is "unequivocal and primarily human-induced" rise in global temperatures. This, to quote the CNN, "threatens to stress water resources, challenge crops and livestock, raise sea levels and adversely affect human health ... Longer and more intense heat waves; increased heavy downpours likely to cause widespread complications such as flooding and waterborne diseases; reduced summer runoff, creating greater competition for water, especially in the West; rising ocean water temperatures that will threaten coral reefs; an increase in wildfires and insect infestations; and more frequent coastal flooding caused by rising seas."

There is also no doubt that we need to act to reduce emissions and ameliorate localized adverse reactions to and outcomes of climate change. But our reactions should and can amount merely to damage control in the here and now. Any future-oriented intervention (based on considerations of inter-generational equity) may do more harm than good because of a basic information asymmetry: we know a lot more about the past and the present than we could ever hope to learn about the future.

There is also the implicit assumption that future generations are going to share the same values, preferences, and priorities as we do and, therefore, will be appreciative of our efforts on their behalf. This is "generational centrism". If history is any lesson, nothing can be farther from the truth. Each generation develops its own mindset and adapts to its physical environment (in the long run, our descendants may even relocate to other planets.) Our forefathers, for example, would have been horrified by our penchant for inhabiting polluted, congested, crowded, filthy, and crime-ridden cities. There was no way they could have predicted urbanization, what with their rustic and pastoral predilections.

Finally, sustainability implies a preference for plenitude over scarcity. Yet, abundant natural resources and endowments are rarely conducive to creative and disruptive innovation. The accomplishments and assets our civilization prides itself on are all the outcomes of hardship and dearth.

There remains the ethical question of whether we owe anything (for instance, a sustainable environment) to persons who have yet to be born. Even if we assume that such persons will surely exist, what is the contract that binds us together? What obligations - moral or otherwise- do we have towards future generations? That we wish to do something does not mean that we ought to do it (in the moral sense).

Rights - whether moral or legal - impose obligations or duties on third parties towards the right-holder. One has a right against other people and thus can prescribe to them certain obligatory behaviors and proscribe certain acts or omissions. Rights and duties are two sides of the same Janus-like ethical coin.

This duality confuses people. They often erroneously identify rights with their attendant duties or obligations, with the morally decent, or even with the morally permissible. One's rights inform other people how they must behave towards one - not how they should or ought to act morally. Moral behaviour is not dependent on the existence of a right. Obligations are.

The potential of future generations to become alive is not the ontological equivalent of actually being alive. A potential life cannot give rise to rights and obligations. The transition from potential to being is not trivial, nor is it automatic, or inevitable, or independent of context. Atoms of various elements have the potential to become an egg (or, for that matter, a human  being) - yet no one would claim that they ARE an egg (or a human being), or that they should be treated as such (i.e., with the same rights and obligations).

Future generations, in other words, have no rights and we have no obligations towards them.

The propensity to extrapolate from past events to future trends is especially unfortunate in the discipline of History. Thus, the existence hitherto of a thriving multicultural polity does not presage the preponderance of a functioning multiculturalism in its future.

On the very contrary: in an open, tolerant multicultural society, the traits, skills, and capacities of members of different collectives converge. This gives rise to a Narcissism of Small Differences.

In heterogeneous societies, its components (religious communities; socio-economic classes; ethnic groups) strike implicit deals with each other. These deals adhere to an organizing or regulatory principle, the most common of which, at least since the late 19 century, is the State (most often, the Nation-State).

These implicit deals revolve around the allocation of resources, mainly of economic nature. They assume that the growth of the economy ought to be translated into individual prosperity, irrespective of the allegiance or affiliation of the individual.

There are two mechanisms that ensure such transmission of national wealth to the component-collectives and thence to the individuals they are comprised of:

(i) Allocative prosperity achieved through distributive justice (usually obtained via progressive taxation and transfers). This depends on maintaining overall economic growth. Only when the economy's cake grows bigger can the poor and disenfranchised enjoy social mobility and join the middle-class.

(ii) Imported prosperity (export proceeds, foreign direct investment (FDI), remittances, mercantilism, colonialism). In contemporary settings, these flows of foreign capital depend upon the country's membership in various geopolitical and economic "clubs".

When the political elite of the country fails to guarantee and engender individual prosperity either via economic growth (and, thus, allocative prosperity) or via imported prosperity, the organizing principle invariably comes under attack and very often mutates: empires disintegrate; uniform states go federated or confederated, etc. The process can be peaceful or fraught with conflict or bloodshed. It is commonly called: "history".

TWO CASE STUDIES

The Case of the Balkans

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The Narcissism of Differences Big and Small

A Dialog about Anti-Semitism

The Merits of Stereotypes

Herzl's Butlers