E Harrisons Internal Medicine Principle Set Two Volume

Indonesia confirms two more bird flu deaths

Jakarta (VNA) - The Indonesian Health Ministry on August 13 confirmed the deaths of a woman and her daughter in Bali as a results of bird flu, bringing the country's total death toll from the disease to 83.

These were the first human deaths from bird flu on the resort island, where the H5N1 virus was identified more than a year ago.

The 29-year-old woman died on August 12 and her five-year-old daughter on August 3, Bayu Krisnamurti, head of the national commission for bird flu, said.

Laboratory tests provided by the Eikman Institute and the Health Ministry confirmed the presence of H5N1 in both cases, Bayu told reporters.

NANTUCKET, Mass. — For an island flush with the financially fortunate, Dr. Timothy Lepore is a great leveler.

When Jimmy Buffett crashed his seaplane, Dr. Lepore (pronounced LEH-pree) made sure the singer could strum. When the news anchor John Chancellor smacked his head into a door frame, Dr. Lepore fixed him up.

And when Senator John Kerry, another Nantucket denizen, showed up in the emergency room during the 2004 presidential race, Dr. Lepore was called at home, where he was watching football. Mr. Kerry, the Democratic candidate for president, had a tick bite.

A Nantucket institution for almost a quarter-century, Dr. Lepore, 62, is not just sawbones to the summer rich. Sure, his office handles Botox, Jet Ski collisions, overboard yachtsmen, fish hooks in faces and a woman whose Jamaica vacation produced a hookworm called creeping eruption.

Video

But he sees many working-class people and foreign laborers: construction workers with sawed-off fingers or ears, commercial fishermen with chests crushed by winches. An equal opportunity malady is cobblestone rash — from falling (or stumbling drunk) on the island’s picturesquely uneven streets.

As Nantucket’s surgeon, medical examiner, school physician, football team doctor, Lyme disease expert, identifier of excavated Indian bones and occasional Dr. Doolittle, Dr. Lepore has pretty much seen it all.

“I treat the natives and the washashores,” Dr. Lepore said. “It can be a little like Lourdes on occasion, although usually I don’t have people on crutches outside.”

Compensation for Dr. Lepore’s services can be unconventional. One captain of industry thanked him for removing his daughter’s appendix by giving him a barbeque grill. Some people pay in lobsters, and one recently offered yard work for hernia surgery.

A Nepalese shaman on a book tour got his hernia fixed free — in exchange for an autographed picture and permission for Dr. Lepore to use an obsidian scalpel he carved himself. (“I like to flint knap,” he said about the ancient tool-making art — one of his idiosyncratic hobbies.)

To a South African restaurant worker unable to afford his appendectomy, “I said, ‘You work at a good cookie place,’ ” Dr. Lepore recalled. “ ‘Every week, bring me a couple of oatmeal raisin cookies.’ ”

Patients call or visit at all hours. Once, Dr. Lepore, a rabid runner, was tailed by a police car during a half-marathon and stopped at mile 10 for an emergency Caesarean section.

During a dinner party, “someone called and said they had an eagle who was hurt and they were bringing him by,” said Dr. Lepore’s wife, Cathy, a nurse. Tony Yates, 78, a diabetic who visited the office and got a doughnut to raise his blood sugar, said: “I come once or twice a month whether I need to or not. I just come to talk to him.”

David Aguiar, 53, a police sergeant, said, “He’s everywhere; he does everything.” Mr. Aguiar recently woke Dr. Lepore with an excruciating hernia.

“I don’t like to operate at night because the team is tired, and the team is me — but in good conscience, I couldn’t go back to sleep,” Dr. Lepore said.

His office decorations are not soothing seascapes or health tips, but instruments of, well, death. A revolver; pictures of muskets and ammunition; exam rooms named Smith and Wesson, Colt, and Winchester; a bathroom named P-Shooter.

Wearing a hunting vest, not a lab coat, Dr. Lepore sees no cognitive dissonance in being healer and firearm fanatic. He collects guns, makes bullets and carves arrows.

He hunts with Ajax, a red-tailed hawk he feeds with “bunnies who haven’t looked both ways,” road-killed rabbits he collects at dawn.

Fascinated with the island’s bugs that cause Lyme disease and other illnesses, he traps greenhead flies, and plucks ticks off deer that hunters shoot, shipping bottled bugs to mainland researchers. “Which,” he said, “is perhaps not going to get me a Nobel prize.”

Dr. Lepore, who moved from Providence in 1983, seldom leaves Nantucket. When he does, the 15-bed hospital brings in a surgeon and an obstetrician. (Two internists and three family practitioners work here year-round.)

He makes house calls, like one to Stanley Hollander, 78, after a heart attack Dr. Lepore detected when Mr. Hollander reported shortness of breath.

“We couldn’t live here without him,” said Mr. Hollander’s wife, Joan.

He does not make not yacht calls, fearing being unreachable for emergencies. Not violent emergencies — there have been only two murders in his time. (“Stockbrokers usually don’t go after lawyers,” he said.)

Sixteen years ago, Dr. Lepore was drinking gin and tonic with a friend when a boy crashed his moped. Dr. Lepore started the boy’s heart, removed his spleen — and decided never to drink again on Nantucket.

“I was fine, but if I’d had a second drink ...” he said. “You always have to be ready.”

Dr. Lepore insisted he and the boy be helicoptered to Boston in a thunderstorm. He said the Boston physician objected, saying the boy would die anyway. “I said ‘I agree with you, but he’s not going to die on Nantucket,’ ” Dr. Lepore said.

Although the boy died in Boston, he said, “A 14-year-old kid, you want to give him the benefit of everything that could be done.”

He often grapples with when to fly patients off-island and does so about 200 times a year. He said he could perform most surgeries, but the hospital cannot provide extensive postoperative care and has only six units of blood.

He often plays chicken with the weather. One recent Saturday night, he airlifted Kevin Mohler, a 34-year-old landscaper with a tick-borne illness, afraid he might get sicker later when fog would prevent flying.

He once had to airlift his own son, T. J., paralyzed by a stroke at 7. T. J., 27, recovered and is in medical school. Dr. Lepore’s daughter is a nurse joining his practice. Another son works for a malpractice lawyer, although “I prefer that he play piano in a whorehouse,” Dr. Lepore said.

Dr. Lepore can be a gadfly, arguing for more deer hunting to control ticks and for help for nurses buying houses. He does not always win, but knows his leverage: “I suggest that perhaps I’m going to take a couple months off.”

WASHINGTON, Aug. 11 — Despite promises by Congress to end the secrecy of earmarks and other pet projects, the House of Representatives has quietly funneled hundreds of millions of dollars to specific hospitals and health care providers under a bill passed this month to help low-income children.

Instead of naming the hospitals, the bill describes them in cryptic terms, so that identifying a beneficiary is like solving a riddle. Most of the provisions were added to the bill at the request of Democratic lawmakers.

One hospital, Bay Area Medical Center, sits on Green Bay, straddling the border between Wisconsin and the Upper Peninsula of Michigan, more than 200 miles north of Chicago. The bill would increase Medicare payments to the hospital by instructing federal officials to assume that it was in Chicago, where Medicare rates are set to cover substantially higher wages for hospital workers.

Lawmakers did not identify the hospital by name. For the purpose of Medicare, the bill said, “any hospital that is co-located in Marinette, Wis., and Menominee, Mich., is deemed to be located in Chicago.” Bay Area Medical Center is the only hospital fitting that description.

The primary purpose of the bill is to expand the Children’s Health Insurance Program while enhancing benefits for older people in traditional Medicare. But a review of the bill by The New York Times found that it would also direct millions of dollars a year to about 40 favored hospitals, by increasing their Medicare payments.

The bill, for example, would give special treatment to two hospitals in Kingston, N.Y., stipulating that Medicare should pay them as if they were in New York City, 80 miles away. Representative Maurice D. Hinchey, Democrat of New York, who worked to get this provision into the bill, said it would allow the hospitals to pay competitive wages so they could keep top health care professionals.

John E. Finch Jr., a vice president of Benedictine Hospital, one of the two in Kingston, said the bill would “make a significant difference to us financially,” increasing the payment for a typical Medicare case by $1,000.

Some Republicans have complained about what they call “hospital pork.” Representative Pete Sessions, Republican of Texas, said the bill was “littered with earmarks for hospital-specific projects.”

Republicans sometimes did the same thing when they controlled Congress. Under a 1999 law, for example, a small hospital in rural Dixon, Ill., was deemed to be in the Chicago area — 95 miles away — at the behest of its congressman, J. Dennis Hastert, who was then speaker.

When Democrats took control of Congress, they promised to be more open and accountable, saying they would disclose the purpose of each earmark, the name of the lawmaker requesting it and the name and address of the intended recipient.

But Democrats said they had no list of the projects in the recently passed bill and no explicit criteria or standards for judging which hospitals should be reassigned to an area with higher Medicare payments.

Nadeam Elshami, a spokesman for Speaker Nancy Pelosi, Democrat of California, said people should keep the big picture in mind.

“It’s easy to criticize individual provisions of large, complex bills,” Mr. Elshami said, but “the focus should be on the huge number of uninsured children who will be eligible for life-saving health care under our bill.”

Representative Bart Stupak, Democrat of Michigan, who championed the provision for Bay Area Medical Center, lives in Menominee. Alex Haurek, a spokesman for Mr. Stupak, said, “The congressman will not be available for comment.”

The formula for paying hospitals under Medicare is complicated, but the basic idea is to adjust payments for differences in wage rates in different geographic areas. For each Medicare beneficiary admitted to a hospital, the government typically pays a fixed amount, depending on the person’s illness. About 70 percent of the payment is meant to cover labor costs, which vary widely. The standard payment ranges from $4,100 a case in low-wage areas to more than $6,500 in some high-wage counties.

Nancy A. Douglas, executive director of Bay Area Medical Center Foundation, a fund-raiser for the hospital, defended the change. “We compete nationwide and have to offer competitive salaries for nurses, pharmacists and other health care professionals,” Ms. Douglas said.

But Representative Dave Camp of Michigan, the senior Republican on the Ways and Means Subcommittee on Health, said treating the hospital as if it were in Chicago was “absurd on its face.”

“Every hospital in America would like to be reclassified” into a labor market with higher wages because it would then receive more money from Medicare, Mr. Camp said in an interview.

Representative Pete Stark, the California Democrat who is chairman of the subcommittee, acknowledged that “it’s hard to decipher” the cryptic language used in the bill to identify specific hospitals. “It’s always been thus,” Mr. Stark said in an interview. “I am at a loss to explain why.”

Granting relief to particular hospitals is sometimes a way for Congress to improve “the equity and fairness” of Medicare payments, Mr. Stark said. Under Medicare, he added, “you are basically setting prices, and the system is clumsy.”

The two hospitals in Kingston, N.Y., that are beneficiaries of the bill, Benedictine Hospital and the nearby Kingston Hospital, recently announced an agreement that would bring them together under a single parent corporation.

Neither hospital is named in the bill, but they are the only ones that could qualify. The bill guarantees higher Medicare payments for New York hospitals with a “single unified governance structure,” located less than three-fourths of a mile apart in a city with a population of 20,000 to 30,000.

Kingston has a population of 22,828, according to Census Bureau data issued this week.

Under the bill, hospitals in three counties of upstate New York — Albany, Schenectady and Rensselaer — are deemed to be in “the large urban area of Hartford, Conn.” Representative Michael R. McNulty, Democrat of New York, said this provision would bring $28 million to “underpaid hospitals” in his district.

Under another provision, an unnamed hospital in Burlington County, N.J., would be reassigned to the New York City metropolitan area, where wages are significantly higher.

This provision was written for the benefit of Deborah Heart and Lung Center, in Pemberton Township, N.J., more than 60 miles from the bustle of New York City. Donna H. McArdle, a spokeswoman for the hospital, said it was “located in bucolic countryside, surrounded by farms and pine forests.”

Richard A. Rifenburg, the reimbursement manager for Deborah hospital, said the House bill would increase its Medicare payments by $3 million to $5 million a year, or about 10 percent.

This is one of the few provisions added to the bill at the request of a Republican, Representative H. James Saxton of New Jersey.

Representative Artur Davis, a Democrat, secured special treatment for a hospital that may soon be built in his district in rural Alabama. Small rural hospitals can obtain many benefits, including higher Medicare payments, if they are designated “critical access hospitals.”

Under federal law, the proposed Alabama hospital could not qualify because it would be too close to another hospital, in Meridian, Miss. The House bill would waive that restriction “in the case of a hospital that is located in the county seat of Butler, Ala.” That is where Rush Health Systems proposes to build a hospital.

“This is a very narrow, very limited provision in a very big bill,” Mr. Davis said in an interview. “If I can help a rural community in my district get a hospital, I’m glad to do it.”

Urban hospitals would also receive some federal largess.

Representative Marcy Kaptur, Democrat of Ohio, won extra money for St. Vincent Mercy Medical Center in Toledo. Under the House bill, the hospital would be “treated as located in the same urban area as Ann Arbor, Mich.,” more than 40 miles away.

Lawmakers did not identify St. Vincent by name, but referred to a hospital with Medicare provider number 360112. That is the identification number for St. Vincent.

Scott E. Shook, senior vice president of St. Vincent, said this provision would bring $6 million a year in additional revenue to the hospital.

“Ann Arbor has a higher Medicare payment rate that reflects the higher wages there,” Mr. Shook said.

Steven D. Fought, a spokesman for Ms. Kaptur, said the congresswoman was happy to help because “St. Vincent is a major employer, a source of good jobs in a community that has been hard hit by globalization and grievously hurt by the loss of manufacturing jobs.”

CINCINNATI, Aug. 11 — The Ohio Civil Rights Commission is pushing for a broad expansion of benefits for pregnant workers.

If its proposals are adopted, Ohio would join 18 states that require employers to offer maternity leaves that exceed those mandated by the federal Family and Medical Leave Act. That law offers workers at businesses with 50 or more employees 12 weeks of unpaid leave for infant care.

Expectant mothers must have worked for a business for a year, or 1,250 hours, to be eligible.

The Ohio commission has proposed that businesses with four or more employees offer 12 weeks of unpaid maternity leave to pregnant employees, regardless of how long they have worked for the businesses.

Workers not eligible under the federal law would need a doctor’s orders to qualify.

The commission is revising its proposal after business groups said the rules would hurt small businesses and the state’s economy. The revisions are expected to go next month to a State Senate and House committee that could approve the rules without further action by the Legislature.

Jeanine P. Donaldson, who this year became the first woman to lead the commission, said the law on maternity leave needed to ensure that more women were protected against discrimination.

Ms. Donaldson said she was willing to bend on the number of weeks of guaranteed leave but hoped to preserve the stipulation that length of service would not affect eligibility.

“I don’t think a woman can decide when to get pregnant,” Ms. Donaldson said. “To choose motherhood over livelihood, I don’t think that is what the legislators had in mind.”

Business groups say the expanded leave would damage the economy. “There’s really no reason to change the current law,” said Tony Fiore, director of labor and human resources policy for the Ohio Chamber of Commerce.

Requiring small businesses to hold open positions would be a hardship, he said, as would the immediate eligibility for new workers at large corporations.

Ty Pine, legislative director for the Ohio branch of the National Federation of Independent Businesses, said the market was doing a good job of establishing reasonable maternity leaves for workers and businesses.

“We would like to maintain the current practice of reasonable time off without mandating specifically,” Mr. Pine said.

Among the many odd moments on the House floor in the tumultuous week before the start of the August recess, this may have been the oddest: Republicans waving goodbye to Democrats after they pushed through an expansion of a popular federal health care program for children.

While Democrats celebrated passing what they considered a can’t-miss piece of legislation, Republicans thought Democrats had just made a boneheaded blunder that would cost them control of the House next year: including in the bill a cut in a popular Medicare program.

“It was one of those rare times on the House floor when both sides thought the other side had just done something really dumb,” said Representative Roy Blunt of Missouri, the second-ranking Republican.

Time will tell, of course, as to which side was right. But the fight over the State Children’s Health Insurance Program (SCHIP) provides a glimpse into the emerging 2008 campaign strategies of Republicans and Democrats. It also illustrates some of the problems House Republicans face in their first election cycle as the minority party in 14 years.

To Democrats, extending and expanding the children’s health care program, which is set to expire Sept. 30, is a no-brainer. They believe they can easily paint Republican opponents of the measure -- abetted by President Bush - as being against helping poor sick kids.

“Health care is really the biggest issue outside of the war,” said Speaker Nancy Pelosi, the California Democrat who has made the health proposal a personal crusade.

With support from the nation’s governors and the medical community, House Democrats approved a $50 billion increase in spending on the program over the next five years, an amount that would provide new health insurance to millions of children whose families do not qualify for Medicaid but have trouble paying for private coverage.

The money would come from a boost in the tobacco tax and, most importantly from a political perspective, from reducing payments to private insurance companies that offer comprehensive health plans to Medicare beneficiaries.

To Republicans, that provides an irresistible opening to go after Democrats for cutting subsidies for the private Medicare plans that have grown increasingly popular in rural America.

“When seniors find out what is really going to happen, they are not going to be happy,” predicted Representative J. Dennis Hastert, the former Republican speaker, who said tens of thousands of older Americans in his district in northern Illinois rely on the private plans.

But analysts and others suggest this could be a tough sell for Republicans. First, Democrats have accumulated decades of credibility on Medicare while Republicans, until recent years, were identified more as foes of the program. They are still haunted by former Speaker Newt Gingrich’s remark that Republicans would be content to let Medicare “wither on the vine.”

In addition, Democrats are getting important political cover from AARP, the influential senior organization that is backing the expansion of the children’s health program. The advocacy group’s position so infuriated House Republicans that Representative John A. Boehner of Ohio, the Republican leader, demanded AARP withdraw support. That seems unlikely.

And Republicans, who as the majority party have been flush with campaign cash during recent election years, now find themselves trailing Democrats in fund-raising. That could hinder their efforts to make a complex health care issue reverberate.

“When Republicans were at the top of their game, they could stick Democrats with this issue and turn it into something,” said Charlie Cook, a nonpartisan political handicapper. “I am not sure they have the credibility to make it happen now.”

Lastly, Democrats built a little political insurance of their own into the bill. While they reduced what they see as excessive subsidies for private Medicare insurers, they turned a planned reduction in doctor payments into a slight increase, a proposal that soothed the American Medical Association. They would also increase aid to poor Medicare beneficiaries and eliminate co-payments for preventative health care covered by Medicare, putting more money in the pockets of seniors.

Those elements have Democrats preparing to go on offense. Instead of sitting back waiting for Republican attacks, Democratic campaign strategists are preparing a radio advertising campaign against selected Republicans, accusing them of opposing new Medicare benefits with their votes against the children’s health program. The idea is define the bill before Republicans define it for them.

It makes an interesting case study for 2008. Can Republicans persuade voters that Democrats are gutting Medicare, and will the Republicans have the resources to do so? Or will Democrats succeed in portraying Republicans as cold-hearted opponents of new health coverage for both kids and older folks?

“We will see what the repercussions are,” said Mr. Hastert.