medicine

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On adequately filled places (Covid Diaries & Seneca)

Published by Anonymous (not verified) on Thu, 30/06/2022 - 9:55pm in

After nearly a month, it's time for another long covid update. (For my official "covid diaries," see hereherehereherehereherehereherehere; herehere; here; herehereherehere; here; here; herehereherehere; here; herehere; here; here; here, herehere;  here, here; here; and here). And, as usual, the situation is a mixed bag.

First, the good news. Thanks to non-steroidal anti-inflammatories (basically extra strength Aleve for those Stateside) I have managed to eliminate debilitating headaches. By 'debilitating' I mean: being in bed all day, and being incapable of reading or watching streaming online content. So, the amount of suffering has been reduced dramatically! In addition, if I take the meds before I socialize -- say a lunch in a quiet place -- I am capable of enjoying it without nuisance. So, I have some hope that I can reduce my relative social isolation. My body does notice I have socialized (I have a strange kind of fatigue then), so it's not without consequence, but it's better than it was. 

Unfortunately, some of life's simple pleasures remain out of reach due to my inability to engage in quite modest cognitive multitasking: even gentle walking while talking with others wipes me out cognitively. (I can do serious walking alone.) I am unable to enjoy music in the background while we're talking or even playing silently. I can't cycle in the city, I can't play basketball with my son, etc.

For example, recently, I had a lunch with a college friend in a quiet London club. The background music and noise of other lunch-guests were quite modest. I enjoyed it. (Hurrah!) I did have a vague sense that my capacity to eavesdrop on other conversations was much diminished. Once I walked out of the club into the air, I noticed how exhausted I was; and despite the lack of headache, and more meds, I was unable to concentrate again that day. It would not be wrong to call it 'brain fog', but the fatigue in my body is even worse: I walk slower then, and think slower. As I have mentioned before, I suspect a lot of symptoms commonly associated with aging are really the effects of post-viral syndromes. 

In Seneca's Letter 56, he notes that "words seem to be more distracting" to him "than noises; for words demand attention, but noises merely fill the ears and beat upon them." Seneca mentions that shouting is not as distracting as singing and an intermittent noise more troublesome [molestior] than a steady one, and I would agree. In fact, hearing other people talk or even just hum while I am engaged in some activity of my own drives me batty. (Well not as badly as a few months ago, but still.) I have mentioned, I think, that this makes family life with a teenager challenging. He hums when he is happy.

While Seneca repeatedly suggests in this letter and others that finding inner mental tranquility is fundamentally healing, he also recognizes that rousing ourselves to keeping busy with good works is healing, too [ad rerum actus excitandi ac tractatione bonarum artium occupandi sumus], and, if I read him alright, necessary for the non-sage (that is all of us). A Christian may well think this is a call to charity, but I read it somewhat self-servingly as keeping true to my vocation (as scholar and teacher). I don't want to claim Seneca invents the protestant work ethic, but I do think he is an important voice in its development.

In fact, Seneca notes that when he is in forced retirement (due to illness or political failure--the letter contains a rare admission or at least allusion to it) ambition is often revived [interdum recrudescit ambitio]. I recognize the truth of this because much to my own surprise, in my forced leave of absence, my disabilities have re-directed even expanded my vocational ambitions as a scholar (even if I have come to accept that some projects have to be let go), and (while more challenging) teacher.

Even though I had to withdraw from quite a few projects and also have given up on a number of papers, in some respects being a scholar has become easier because I have so many fewer social interactions and don't travel to conferences. I probably read more than I have ever. 

One unexpected effect -- I have mentioned it before -- of these covid diaries is that other scholars reveal their own enduring challenges with disability to me. I recognize that in my environment I have missed a lot of quiet suffering and almost heroic persistence. It's humbling to recognize what a bad observer of my umwelt I have been and, more importantly, to recognize that so many folk have achieved so much with chronic pain and cognitive instabilities. 

This experience makes me interpret Seneca's suggestion that a hidden disease is worse than one in the open (which is on the road to being cured) in a social way. Norms that internalize suffering, 'being Stoic' as they say, hidden from the world are, while convenient to the powerful, a social evil. In a famous passage, Adam Smith notes that people tend to refuse acknowledgment of poverty and disease and thereby make it worse. (Smith thinks our gaze and recognition naturally falls on the rich, famous, and beautiful/healthy.) Sometimes I wonder if I hear about other people's suffering now because other people sense greater receptivity on my part, or if they think it's only fair that after having read about my trials I ought to welcome learning of theirs, or if I have actually become more willing to discern other people's struggles. Despite my vocation as a teacher, I tend to be skeptical of narratives of growth. 

And after hinting at the need for regular cognitive-therapy -- good and solid thoughts [cogitationes bonas, solidas] -- as the road to wisdom, Seneca grudgingly admits that sometimes the best self-care is to seek out a quiet spot. I laugh, and admit that the reading room of the British Library is indeed my best friend. In fact, I now have my spot in the reading room that the other regulars leave alone -- and the librarians at circulation have started to recognize --; I love quietly reciting, in the spirit of cognitive-therapy, Newton's (early) definition of place being a part of space that a thing fills adequately just before I sit down at 'my' desk. 

This past month a co-authored paper was rejected by referees. And I had hoped to circulate the first seven chapters of my Foucault/liberal art of government book [I am soliciting catchy titles!], which covers his material on the physiocrats and the ordoliberals, to trusted friends. But the manuscript is still too much a mess, and so its circulation has been pushed back into the Summer. No professional life without ordinary professional disappointments, I tell myself. 

This is also my last digression of the academic year. On Saturday, we go on family holiday, and I don't expect resuming D&I until August. Thank you, my dear reader, for your continued interest in my (near) daily mumblings. 

Covid Diaries: A Half Full Glass and despite Minor irritants, maybe filling

Published by Anonymous (not verified) on Fri, 03/06/2022 - 1:29am in

It's been about a month since my last covid update. (For my official "covid diaries," see here; herehereherehereherehereherehere; hereherehere; hereherehereherehere; here; herehereherehere; here; herehere; here herehere, herehere; here, here; and here). And, as seems common in the most recent updates, the situation is mixed. But let me start with the non-trivial bits of good news.

First, if I take anti-inflammatory medicine before I have a social interaction (like a lunch or tea) I am capable of engaging in much longer social interactions than I was able to do during the past nine months. I am also capable of doing so in much more complex social environments. I have even been able to do so twice in a day (with a few hours apart). By this I mean that the usual symptoms of head fatigue and subsequent headache don't follow. So that's a big win, and at times I have felt euphoric about it. 

Interestingly enough, after some such activities later in the day I do register physically that I have had some such interactions. My body will feel unusually fatigued, and I need to take time to chill. (I am not allowed to nap because I need to keep day/night rhythm very distinct.) Some day, when I am fully recovered, I would like to team up with a (historical) epidemiologist and geriatric specialists because I am increasingly convinced that a lot of symptoms that in the past usually were treated as 'aging' really were the longue durée effects of (post-)viral infections.

Anyway, on the medical side, I am experimenting with the dosage of the anti-inflammatory meds. As they say in jargon: I am looking to find the minimally efficacious dosage. The month before I lost about six full days to random headaches. This past month, clearly 50% less. That's a lot of less suffering.

As an aside, it's fascinating that while the physicians can all tell you that there are increased risks associated with the use of my particular meds, nobody can tell you what the order of magnitude of the risk might be for a generic patient or for somebody that shares in some of my demographic or medical characteristics. So, while a lot of physicians practice a kind of pseudo medical autonomy -- telling me things like, 'it's your decision' or 'you need to weigh the trade-offs'  --, de facto there is a lot of ignorance being buck-passed onto a patient who is not being given even the minimal coarse-grained information to make autonomous decisions. (And regular readers know, I am no Bayesian--I am not asking for exact statistics, just very broad orders of magnitude.)

Be that as it may, I am quietly hoping that the anti-inflammatory meds also treat some underlying condition such that I can keep hoping for continued improvement over the medium term. The really interesting question for me is this: my symptoms have shifted around every few (two to three) months. And what I am wondering is whether that cycle can be broken. Stay tuned.:)

One thing I have learned about chronic disease or newly acquired disability: other ailments that in a different context would be barely noticed can be greatly destabilizing in the context of disability/chronic disease; think of things like a cold, modest hearing loss, swimmer's ear, blisters, etc. When you are learning to adjust to chronic disease such incredibly modest ailments sap energy. (Again see my comment above about aging as instances of post-viral symptoms.)

Second (back to the good news), next academic year, I'll have the kind of work-load I probably should have had this past year. I am only teaching my giant lecture course Winter 2023. To make this possible a lot of people showed me incredible amount of good-will: my immediate family, which is signing off on three months of research leave stateside (with two weeks of holiday for visits); the folks at Duke University's Center for the History of political Economy and the philosophy department; the folks at University of Arizona's Center for the Philosophy of Freedom. These allowed me to take  three months unpaid research leave this Fall. In addition, my department signed off on this. That, too, showed, good-will, but it did involve some negotiations.

Let me explain, one of the very strange features of the University of Amsterdam is that it works with a system of registered hours (for research, teaching, and some admin). Undoubtedly it was introduced for a mixture of fairness considerations (everyone pulling their fair share) and administrative control over the budget. But in practice, the 'hours' registered are by no means equal (and also model-based). And the obvious effect of the system is to turn academics into a bean-counter of sorts and, for some, also a chance to game the system. (I'll get to the really strange part in a second.)

Now, in practice these plan hours are bit like frequent flyer miles. You know what their official value is, but if you have been around for a while you also recognize you can never really cash them for their (ahh) labor value. This is especially so when there is a dire need for budget cuts; these hours are then easy prey. (That's how I 'lost' one batch of over-hours a few years ago.)

Anyway, despite my partial sick-leave, during the past few years, I actually accumulated more over-hours than I had when I started my partial sick-leave! So, to facilitate my leave and considerable teaching reduction I agreed to donate my (ca 900!) hours and start the next academic year back at level zero. I rationalized the deal to myself as a business class upgrade on a transatlantic/pacific flight.:) In addition, because of my medical leave I have been rather costly to the department and a lot of my rank-specific chores have been parceled out to others. While an apparent bad deal on paper, I felt this was very win-win, and also a chance for me to show my gratitude.

So, my underlying outlook is actually quite positive right now. Next year, I feel my work-load should allow me space to recover and do what I love work-wise (research, write, and lecture). It also allows me space to experiment, when I feel sufficiently recovered, with activities I have not dared to try yet (giving professional lectures, attending seminars, etc.) And while I will miss my family and my undergrad electives/seminars, it's good not to have to stress about their effect on my health. On the other hand, as I have hinted above, I am dealing with a bunch of minor ailments that prevent me from having unconditional optimism right now. The glass is half full, possibly filling.

 

 

 

Covid Diaries: Covid Induced Migraine

Published by Anonymous (not verified) on Sun, 01/05/2022 - 3:56am in

It's time for another Covid Diaries update. (For my official "covid diaries," see hereherehere; here; here; herehere; here; here; hereherehere; hereherehereherehere; here; hereherehere; here; here; herehere; here herehere, herehere; and here, and here).
 
It's been about a month since my last covid update. Unfortunately, the news is that it's been challenging. The last update coincided with the end of teaching and my return to London. And I figured that I would take ten days off, get back into a swimming routine, and then start working on some small projects before I would return to major research.
 
As you may recall I also saw the NHS long covid clinic neurologist, who diagnosed me with covid induced migraine. I have to admit that I was a bit surprised by her diagnosis because I thought my headaches were only triggered by social interactions beyond thirty minutes and i didn't have any other major characteristics of migraine. (In fact, the interactions first induce a weird fatigue and not always a headache.) On the other hand, she was optimistic I would continue to improve because on the whole I keep improving slowly.
 
But as it happened, my family left for a US trip and I was alone for a week without any social interactions at all (except very small talk at the swimming pool, supermarkt, and British Library). In their absence, I lost two days to debilitating headaches while they were away. Looking back over the month I have clocked six days of headaches--and my current best guess is that bad sleep and social interactions are possible triggers. I do find that days when I swim well and am well rested it's less likely to happen.
 
What's annoying about this is that in some respects the pattern of long covid has been that every two to three months the major symptoms shift. And this time is no different. Luckily on the non headache days I can swim, and do my reading and writing. But my social life is very limited, although my spouse has said I am in much better general mood than last year (which she takes as evidence that I am suffering much less). I still can't enjoy terraces, and even joint hiking. (There is a weird issue that walking and talking/coordinating with another while walking totally floors me--same with biking. It's as if cognitive load is too much.)
 
Unfortunately, the migraine meds I received have contraindications with pre-existing conditions/meds, so it's been a bit challenging to find the palliatives when the headaches hit. I know lots of people who manage migraines with varying degrees of success, so in a strange way I feel less alone with my condition. (It has made me wonder about the medical pathway from post-viral infection to migraine.)
 
Anyway, thanks to Federica Russo and Jean Wagemans, we finished one paper, and thanks to Nick Cowen we finished another. (Both under review.) And I wrote a book review. And then a week ago I did start my Foucault project, and while I lost one day through headaches, I have a nice writing rhythm and folks are even recognizing me again in the British Library. And I am really excited about the project--which started as a kind of therapy last year, but now feels like it might become a very neat book. I am lucky I have a work related passion that can be done in relative solitude for long chunks of time.
 
Before I left Amsterdam my occupational physician thought it was a good idea if I can figure out a research leave this Fall. So now I am in touch with various places which might sponsor a visit (you know who you are and I am very grateful for your help), so that I can take an unpaid leave. Hopefully I can sort something out that ticks various boxes and not be away from home too long.
 
That is it, I feel very grateful I have such supportive family, and the kind of job that is relatively secure and also so flexible now that teaching is done. I am still hoping that in six months i can attend workshops again and enjoy going out on dates with my better half, but I also thought that six months ago. So now I am mostly taking one day at a time.

Tremain on The Inductive Risks of Bioethics, Pt 1. (And *In the Shadow of Justice*, pt 4)

Published by Anonymous (not verified) on Wed, 13/04/2022 - 1:59am in

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medicine

My argument is that the academic discipline of bioethics relies on an epistemology of domination and is an institutionalized vehicle for the biopolitics of our time, that is, bioethics is a technology of government that provides intellectual resources designed to facilitate the “strengthening” (read: fitness) of a certain population and the elimination of others. I submit, furthermore, that the implicit and explicit governmental tenor of bioethical inquiries and discussions contributes substantially to the hostile environment that disabled philosophers confront in philosophy.--Shelley L. Tremain (2017) Foucault and Feminist Philosophy of Disability (University of Michigan), 160-161.

As the quoted passage suggests, Tremain diagnoses two kinds of inductive risks from the way bioethics is practiced: (i) it is eugenic in character: it promotes the "elimination" of populations with characteristics thought undesirable; (ii) it creates a hostile work environment for disabled philosophers within professional philosophy. Today's post is focused on (i). For on her view, it is constitutive of bioethics to "posit conceptions of the normal from which the possibility and probability of deviations are measured and classified in order to prevent and control their actualization." (169) Within the discipline, the normal is taken to be an objective feature of reality (often understood as something statistical or species functional), and the deviations -- in particular below the norm -- are treated as objective defects or harms (or costly). Following Foucault, Tremain treats the disciplinary articulation of this conceptualization a step in what she calls 'normalization.'

For the articulation of these conceptualizations and their understanding as objective (social) facts constitute a field of inquiry and creates a discursive power with normative authority in the university, the hospital, and in wider society. More subtly, Tremain argues that normalization shapes, by various looping effects (Hacking's terminology) the self-conception of ordinary agents in society and the possibilities available to them as they make, what they take to be, autonomous choices. Such normalization becomes eugenic once it becomes constitutive of (autonomous) reproductive choices by individual would-be-parents and by social (and sometimes legally mandated) technologies of risk-management and prevention to facilitate the creation of populations without characteristics thought abnormal (defective, costly, or not conducive to full participation/cooperation in society, etc.).

Before I offer some critical reflections on Tremain's position, I want to note two things: first, I agree with Tremain that until quite recently contemporary bioethics (both in its Rawlsian and Utilitarian guise) is eugenic in character and that it has badly theorized -- mostly by ignoring -- the inductive risk of its own activity. In fact, while it councils 'do-no-harm' to medicine and patient autonomy, it has been long reluctant to explore the possible harm that is the possible effect of social and institutional uptake of normative theorizing. For most of my adult life, analytic applied ethicists simply disparage those disciplines (Critical X) where inductive risk is taken seriously (recall my criticism of Heath). In so far as it is agreed that normative theory has possible bad social effects that's never due to the theory itself, but only due to bad people or bad social implementation. The character of the foreseeable uptake of a theory is not treated as a legitimate (professional) evaluative feature of the theory.

Second, and only a partial aside, while Tremain uses a Foucauldian framework (and linguistic register) to analyze these features, it converges with the decidedly non-Foucauldian treatment of the development of applied ethics offered by Katherine Forrester's In the Shadow of Justice: Postwar Liberalism and the Remaking of Political Philosophy (recall here; here; and here). In particular, I want to highlight a structural feature of applied ethics, the significance of which only became clear to me while reading Tremain. Forrester notes that:

Applied ethics soon also encompassed medicine, law, and business. But the fact that moral thinking about war, with all its extremities and appeals to necessity, was one of the first test cases for applied ethics had a wider impact on the development of moral and political philosophy. Its focus on dramatic and extra ordinary moral choices was soon imported into other realms of inquiry. Crucially, it was imported back into the realm of domestic politics, which was turned into a case of its own: public morality.--Forrester In the Shadow of Justice, pp. 74-75 (emphasis added)

Appeals to the necessity of choosing function as a mechanism to prevent the development of questions about the proper form of thought and its institutional embeddedness. The focus on existential social choice facilitates the rise of casuistry without thinking through what the structure of the demand for casuistry does to the supply of ethical theory (as the worth having). (An analogous problem shows up in normative decision theory.) To simplify greatly, we saw the after-effects of this in the most recent pandemic: bioethicists were primed to discuss the rationing of medical care and the justification of vaccine requirements, but had little guidance to offer on how to think about the integration of many different kinds of fast moving (and sometimes still immature) sciences and the complex trade-offs of major social policies.  

Now, let me return to Tremain's analysis; it is important to recognize that normalization (mediated by various social and governmental practices) produces "people with certain kinds of subjectivities, that is, these practices have constituted subjects whose actions are governed through the exercise of their own capacity to choose in accordance with the norm(al)." (190) And while the structure of Tremain's argument is akin to an ideology critique, she recognizes that there is no sense in which she can claim that these subjects have "been duped by the ideological forces of some distant and overarching external power," nor is she in a position (as she admits) to claim "these subjects make morally bad personal decisions." (190) 

Tremain is a very clear writer, and she puts her assumptions and commitments transparently on the table: she is a nominalist, a historicist, and a relativist. And she makes clear that the problem with ("epistemological and ontological assumptions" embedded in) disciplinary practices that are invested in normalization is that "the potentially detrimental effects for disabled people" is ignored. (192; this is also true of embryo research.) Part of these detrimental effects are the widespread uptake of the thought that the disabled have "diminished lives" and so nudge (and legally facilitate) abortion, infanticide, and euthanasia of them. (200)*

I hinted above that I would offer a criticism. The problem is that acknowledging, even internalizing detrimental effects in a (bioethical) theory is neither necessary nor sufficient to undermine such a theory. Again, I draw on Forrester and the implication of appealing to necessity. It is characteristic of applied ethics to use "abstract, personal, and interpersonal modes of justification to explore the most concrete of existential questions of life, death, and killing— questions that continued to remain at the core of applied ethics." (82) To put the point starkly: the 'heroisms' of applied ethics is precisely its willingness to face up to the existential nature of its questions.** That something is eugenic and has harmful externalities is certainly something that -- once pointed out -- has to be faced, but with theoretical equanimity. 

I'll put the dilemma facing Tremain and her partisans as follows: because she is unwilling to develop a normative theory of her own that can meet contemporary applied ethics on its own terms (I almost wrote 'ethical battlefield' there), merely stating and naming, even unmasking, an inductive risk is not sufficient to change a disciplinary practice. If anything, once it is domesticated as inductive risk her insights can feed into other technologies of biopower. (So she may well rightly object to this whole post.) And because such domestication is always a live risk, Tremain is probably prudential in avoiding the development of a normative theory of her own. But as her own analysis shows, society will confer authority on normative theory (and as Forrester shows it will create all kinds of rewards for those who develop it 'best'), so avoiding the contamination of normative theory seems to consign oneself to political and professional wilderness. But that conclusion would be victim blaming, and to understand that we need to look more closely at (ii), the marginalization of disabled philosophers in the profession. To be continued.

 

*The looping effect of this idea may also risk constituting the subjectivity of the disabled, and so contributing to depression, bad self-images, etc..

**Undoubtedly, there is a gendered element lurking here in how the field was thought 'manly' despite not being 'core.' 

Covid Diaries: Highs and Lows

Published by Anonymous (not verified) on Thu, 31/03/2022 - 5:00am in

It's time for another Covid Diaries update. (For my official "covid diaries," see hereherehereherehereherehereherehere; hereherehere; hereherehereherehere; here; herehereherehere; here; herehere; here herehere, here; here; and here). It's been a complex few weeks for me.
 
I want to start with a tremendous high. Last Tuesday I taught the last session of my intro lecture course to an overflowing auditorium. (I have over 600 students, and all the lectures are recorded and available with a thirty second delay.) At the end of my lecture I tagged on a few minutes of quasi-impromptu remarks. I thanked them from the heart for their encouragement and kindness during the semester; that they respected my boundaries and were unfailingly kind about my invisible/cognitive disability. This generated a tremendous applause. And I joined in the cheer, applauding them.
 
I then added a few remarks on the significance of political theory and the course, and closed with a kind of blessing wishing them wisdom (etc.) What happened next was surreal (like in a Hollywood movie you don't believe); I received a standing ovation. Eventually I joked -- which is what I do when I feel uncomfortable, I guess -- that I would hand out signatures at the end of class. That got the applause to stop. But I was mobbed by students who gave me flowers, thank you cards, chocolates, drawings, and -- never make this joke again -- a long line of kidz who wanted signatures. This lasted an hour! (Students had applauded after each lecture, so I knew there was appreciation.) During all of this, I knew I was going well beyond my cognitive limits and that I would have to deal with headaches and nausea. I walked home, got soup, and tried to sleep.
 

The next morning I woke up with a headache (the worst of the 7 weeks of lecturing), and decided to take it easy. I watched the end of the lecture on video a few times enjoying the moments again, and checking my memory of the event. By the end of the afternoon I was much improved, and could enjoy early Spring.
 

I also received news from HR that I won my battle with them about back-pay for holiday-pay that they had deducted in virtue of my disability. After consulting the union and jurisprudence, I had pointed out to them that according to European jurisprudence that holiday is a human right and that you can't lose it even if disabled or sick. (I learned from the union, that they generally obtain the pay out on behalf of people who are let go in virtue of their disability at the end of the contract. But that people like me who might return to work often end up losing a few days of holiday pay.) HR granted that they have no right to withhold it over 2021 (especially because they had already agreed to pay out in 2022!).

 
Later that week, I had a meeting with my department chair that I initiated. Under Dutch disability rules, in a few months my occupational physician, an outside expert, the department, and myself have to decide about my future. It's pretty clear now that I won't recover fully in the next two months The department has been very supportive (I have a few minor kvetches), but in all the communication to me it's always been about hoping for full recovery. So, I wanted to know how the department views a future with me if I don't fully recover. The meeting was encouraging and constructive. The real key for the department will be whether I can return to non-lecture format teaching or not. There is a lot more to say about this meeting, but I felt reassured that there won't be an effort to push me out.

 
After that, I decided to return to London. But not before my sister taught me some meditation tricks, and my mom  delivered some fantastic chocolate cookies.
 

Over the week-end I arrived in London exhausted. And the first 72hrs were both joyous and challenging catching up with the family after nearly 8 weeks away (with just one week-end visit). I had non-stop headaches and nausea for a few days. And I am reminded of my limits after two months of near self-isolation. Basically my symptoms are under control unless I interact socially with others for more than twenty-five minutes. 

 

Today, I had a meeting with the neurologist in the NHS long covid center at UCLH. She was a very kind and thoughtful physician. (I also learned that I was initially slotted to be seen by her in October -- she remembered my dossier -- but because they got overwhelmed with emergency care, I got pushed back. ) After taking my history and doing some cognitive testing, and discussing the situation with me, she decided to treat my symptoms like a kind of migraine. (A big contrast to My Dutch neurologist.) Her hope is to get the headaches under control first, and that I will get better and better in social environments over time. (She was also happy to hear that I had no teaching for four months.) I ran a number of the Dutch occupational therapy treatments by her, and that was instructive, too. She didn't promise miracles, but assured me that people with my symptoms do recover even after a year plus. Also, it's so nice to have a neurologist that takes my covid problems seriously. (Yes, I am pissed off at my Dutch neurologist.)
 

Tomorrow, my students take their final exam, so I am hoping that this time next week, I can close the door on course related stuff for the academic year. (It's astonishing  how many logistical and other curve balls come your way when class size is this huge.) I have returned to my daily swim, and next week I return to my research. I also look forward to my regular blogging. I am still withdrawing from conferences and other events, but I am growing hopeful I can return to these later in the year.

Where Hunger Fell When Covid Hit

Published by Anonymous (not verified) on Wed, 30/03/2022 - 7:00pm in

Tags 

farms, Food, medicine

Three great stories we found on the internet this week.

The way we were

The pandemic has changed the way we live — in some cases, by reverting it back to how it once was. Hakai reports on how some Pacific Islands, faced with market closures, have re-embraced traditional systems in which food is grown locally and used for sustenance rather than sale. These shifts have had an unexpected effect: hunger has fallen as communities have gone back to growing and sharing their own food, making sure there is plenty to go around.

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A new study found that islands that remained reliant on imported food were nearly twice as likely to report food insecurity as islands that produced most of their own, such as Fiji and Micronesia. Bartering increased as well, with some communities giving the traditional practice a modern twist with digital tools. “The point is not to change too much,” said one of the co-authors of the study. “There’s a lot of management for resilience that’s been going on in villages for generations. So when the government comes in, it’s important to remember that things are already working in a certain way — and working pretty well.”

Read more at Hakai

Time’s up, doc

How will the medical community respond to the effects of climate change? A growing number of med schools are incorporating climate-related health impacts into their curriculums.

Grist takes a look at one of the latest schools to jump on board: Emory Medical School in Atlanta, which is revising parts of its curriculum to take into account the changing climate’s effect on human health. The revisions have broad reach, accounting for changes such as increases in strokes, asthma, mosquito-borne diseases, dehydration and preterm births caused by extreme heat. The curriculum revisions were pushed for by students themselves: the young generation of doctors and nurses who will confront the worst of climate change in the coming decades.

heatFirst responders treat a cyclist for possible heat stroke in New York. Credit: Brecht Bug / Flickr

In 2019, the American Medical Association endorsed the teaching of climate change’s health impacts in “undergraduate, graduate and continuing medical education.” Schools seem to be taking note. As of today, some 47 medical schools in the U.S. have incorporated best practices and educational trainings for teaching climate change developed by Columbia University. “Progress has previously felt a little slow and ad hoc,” said the faculty advisor for Emory’s new climate effort. “Now, there is momentum that seems to reflect a shared recognition that climate change matters for the health of our patients, for clinical care delivery, now.”

Read more at Grist

Wild at heartland

The concept of rewilding, in which land altered by humans is allowed to return to its natural state, is growing in popularity. But can it work in Iowa, one of America’s most altered landscapes, where 85 percent of the land is actively farmed and 97 percent privately owned?

iowaAn Iowa corn field. Credit: Rich Herrmann / Flickr

A group called BeWild ReWild believes it can. The organization’s ultimate goal is a wilderness corridor that follows the Mississippi and Missouri Rivers from Canada to the Gulf of Mexico. To achieve this, BeWild ReWild uses a mix of town hall events, workshops and op-eds in local papers to convince private landowners to voluntarily rewild parts of their land, creating a natural patchwork that can eventually connect as a whole. “Forty-six acres at a time is a drop in the bucket compared to what needs to be done,” said organizer Leland Searles, but “restoration in strategic locations can advance what we’d like to see as far as rewilding.”

The group’s ultimate goal is to reintroduce native species like wolves and bison to a state that was once 80 percent wild prairie. There’s a long way to go, but in a place like Iowa, where farming is life, even getting the conversation started is seen as a victory. “The solutions exist,” said Searles. “It’s a matter of allowing the solutions to happen.” 

Read more at Civil Eats

The post Where Hunger Fell When Covid Hit appeared first on Reasons to be Cheerful.

Cartoon: Newly diagnosed ailments

Published by Anonymous (not verified) on Sat, 19/03/2022 - 8:50am in

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Long Covid Diaries: On Victim Blaming

Published by Anonymous (not verified) on Sat, 12/03/2022 - 10:56pm in

Tags 

medicine

This past week, I started two new treatments: on the advice of the UCLH long haul clinic (in London), I started a nightly round of Famotidine. It's mostly used to treat acid indigestion (and related ailments). And when my Dutch pharmacist dispensed to me, she started to explain its use to that end. She was surprised I was prescribed it to treat my long covid. (For my official "covid diaries," see herehereherehereherehereherehere; here; here; here; here; hereherehereherehere; here; herehereherehere; here; herehere; here herehere, here; and here). My Dutch GP, who is kept abreast of my treatment plans at UCLH long haul clinic by me thanks to a wonderful patient centered app the UCLH hospital used, commented that she thought the evidence was rather thin for the effectiveness of Famotidine in long haul. Since I had presumably looked at the very same studies as she had, I had to agree. When the physician at UCLH had suggested Famotidine to me, she said they were doing new trials -- I had been excluded from these because of a too recent booster -- and claimed they were finding that Famotidine was improving cognitive functioning by 20% or so. While a part of me was supremely curious about the measurement of that number, at over fourteen months of illness, I took a modest amount of hope over no hope of improvement. The underlying idea was that my immune system was generating some kind of inflammation.  I wondered whether the anti-histamine of Famotidine might help control the effects of my chronic sinusitis. 

In response to my very kind Dutch GP, I pointed out that the referral she had just written at behest of my occupational physician to start treatment with a 'neuro-psychologist' specializing in long covid, was for a treatment that had no known clinical efficacy for long covid. For, I was under the impression I was being referred for cognitive behavior therapy (CBT). My view was this was unlikely to help my particular symptoms, but I decided it was worth a try since (i) it might benefit me in other ways, and (ii) it was a good idea to be a cooperative patient of my occupational physician (who so far had been a reliable ally). After my intake meeting with the 'neuro-psychologist' a few weeks ago, I was a bit puzzled because she warned me that my treatment might last for one or two years; I always assumed CBT was favored by society because it was relatively brief (and so cheap). But this past week, I realized that CBT would be a minor part of my treatment--one might call it a façade for insurance purposes, but to do so would get someone in trouble. 

The underlying idea of Dutch occupational physicians is that long covid is primarily the effect of a stress system that is out of control. And this, in turn, is an effect of pre-existing conditions or life-style of those hit by long covid. (Since the Dutch university system is chronically underfunded and burn out a systemic problem in it, we should be hit by massive wave of long covid!) So, it's best tackled by a range of low key interventions like teaching patients how to medidate (via an app offered for free by a Dutch medical insurance company) and to re-acclimatize the brain to filtering out various noises. While undoubtedly earnestly felt by those who propagate it -- and a nice cover for complete unwillingness to research long covid by Dutch medical researchers --, it often comes across as victim blaming. (I first learned about it from a fellow long hauler, a high school friend, who is one of the most successful people in the Dutch art scene now, who was not amused.) My neuro-psychologist makes a great show not to blame me -- in fact she repeatedly praises me for life-style changes made during the first year of the pandemic --, but points out my problem is the effect of the accumulated stress of many years showing. I have decided that the best thing about learning mindfulness is to be steeled against this kind of talk, and that after all the British won WWI with a terrible theory of airplane flight (go read David Bloor's classic).

Anyway, my treatment is fairly straightforward: I have to meditate three times a day. One of these times should be after a ten minute period in which I try to work/read with some kind of noise or music in the background. This is to start getting my brain used to filtering out noises. In addition, I am not allowed to wear my noise canceling head-sets while walking about town. (We compromised that before my three remaining lectures I can do it.) I am also trying to reduce cortisol production, so I should avoid exercise that leaves me drained. (Luckily my kind of mellow lap swimming is permitted.) At my own initiative -- surely successful entrepreneurism improves well-being --, I have started to drink black teas, especially Lapsang Souchong, which has the best name and odor in Tea-land. Daily, I thank the heavens that my sense of smell is fine.

In reflecting on existing sources of stress, it occurred to me that that the possibility of an accidental nuclear war and, more prosaically, my uncertainty over my job future might not be trivial. But after meditating on it, I was also reminded of the hard work I had to put in to get some medical reimbursements -- the blood tests I discussed in my last covid diary still hasn't been paid yet --  and to get my university to pay up in various ways. At some point someone in HR decided that given European jurisprudence, the university was required to pay my vacation days in full. (Since I went on partial disability, they had been paying me in pro-rated fashion.) But unaccountably they decided they only had to do so in 2022 and not in 2021. Some correspondence with my chair and various people in HR ensued. I decided to consult my union and read up on the European and Dutch jurisprudence. Somewhat fascinatingly, vacation is treated as a human right in European labor law now, and so employers have to pay out vacation days in full. The union lawyer told me that Dutch jurisprudence had been settled on this quite a while now, and that their practice is to demand full pay-out once an employee can't continue in their job. I wrote a fine letter to HR, and eventually my chair informed that my asking for reasons had apparently caused a change in policy. (I should expect some modest back-pay in a month or two.)

Because I strictly control how many bureaucratic battles I fight per week, I have left the insurance claim for next week. I also have another bone to pick with the university because they refused to commit to paying any balance between what my insurer will cover for the neuro-psychologist and what she will charge. (They cover 100%, but that's 100% of the rate they want to cover.) I was surprised the university was unwilling to do so because the money involved would be modest, and we often pay for all kinds of coaching, mediation, and training (including stress management). And since the neuro-psychologist was prescribed by their own occupational physician, I thought my case would be strong. But I decided to wait with a new letter to HR until it's clear to me how much extra money we're talking about.

That's a let of set-up for the main business of this 'diary.' I have taught ten sessions now of my huge lecture course. I still have trouble falling asleep and sleeping after the lecture, but out of ten sessions, I have had real headaches only four times the next day. Most of the weirdness in my head is gone by the next afternoon. Since all restrictions have been lifted, the auditorium is now filled with students. They kindly wear masks on my behalf on the first three rows, and they send me super sweet messages of encouraged and gratitude. In turn, I adore performing my act for them, and while a part of me is horrified that I have become a figure of entertainment, I soak up the applause after each lecture. I'll be curious to see the evals, but I think it's probably the best cycle of the lecture course I have taught; because I don't try to entertain myself (and so avoid most of the improv shtick that confuses students), I follow the outline of my slides carefully--I have never received so much recurring feedback on how clear I am. If I wrote a private diary, I would have had an entry by now on how I became an analytic philosopher through long covid. Anyway, the good news is I am clearly much better than a few months ago, and I can imagine teaching more even with my current limitations.

I decided to go to London last week-end and visit my family who I had not seen for a month. Nobody had told my teenage son (who is decidedly taller than his mom now and only an inch smaller than I am), and the surprise and joy on his face when I opened the door was followed by a fantastic bear hug. While it was a sweet visit, I  learned that I am still fairly easily drained by non-stop interactions. By 'drained,' I mean I get my characteristic head-fatigue (from the nose up) and the start of a headache. So, I withdrew a few times into the bedroom and simply laid on the bed.  That helped.  At night I slept deeply and calmly alongside my better half.

Yesterday, I started the experiment with ten minutes of concentration alongside background noise. I went to my favorite espresso bar, and decided to read a book outside. Next to me was a guy talking loudly through his earbuds while I was trying to read a paper I was supposed to referee. I have to admit the guy's talk drove me batty. I lasted about eight minutes, and the nausea only dissipated after a half hour amble in the part. Even there the city's noises are never distant. With my noise canceling headsets therapeutically left at home, I already miss the quiet.

On Irresponsible Science Journalism: No, those studies do not show that a market in Wuhan was the source of the Coronavirus

Published by Anonymous (not verified) on Mon, 28/02/2022 - 6:14pm in

Tags 

medicine, Politics

International scientists on Saturday released two major studies which one participant said made it “extraordinarily clear” a market in Wuhan, China was the source of the coronavirus which fueled the Covid-19 pandemic – and not a Chinese government laboratory, a theory championed in the US by rightwing campaigners, columnists and politicians.

The question of where Covid-19 came from and how it spread has proved divisive...

In August last year, a US intelligence review of the issue proved inconclusive.

The New York Times first reported the new studies, which it said had not been published in any journal.--"Coronavirus came from Wuhan market and not Chinese lab, twin studies say"--The Guardian, 26 February, 2022. 

For those who may read my blog for the first time, I am not a rightwing campaigner.  I have been a critic of former President Trump since 2015. I am also not a virologist or epidemiologist, however, I am a philosopher of science and my original interest in the field is evidential arguments. I will suggest below that the claims in The Guardian and in The New York Times are examples of irresponsible and sloppy science journalism. Before I get to explaining why I think that, here is a flavor of The New York Times reporting:

The studies, which together span 150 pages, are a significant salvo in the debate over the beginnings of a pandemic that has killed nearly six million people across the world. The question of whether the outbreak began with a spillover from wildlife sold at the market, a leak from a Wuhan virology lab or some other event has given rise to pitched debates over how best to stop the next pandemic.

“When you look at all of the evidence together, it’s an extraordinarily clear picture that the pandemic started at the Huanan market,” said Michael Worobey, an evolutionary biologist at the University of Arizona and a co-author of both new studies.

Several independent scientists said that the studies, which have not yet been published in a scientific journal, presented a compelling and rigorous new analysis of available data. "New Research Points to Wuhan Market as Pandemic Origin" The New York Time, updated 27 February, 2022

One of the papers with the suggestive title "The Huanan market was the epicenter of SARS-CoV-2 emergence," is the main source of the claims reported by the The Guardian and The New York Times that I will argue are examples of irresponsible and sloppy science journalism. The paper, which I downloaded on February 27, and that I will be discussing can be found here. I heard about the paper through a tweet by Marion Koopmans shared by my colleague John Grin (since unshared after learning of my concerns below). Dr. Koopmans is a leading virologist and public health scientist in the Netherlands. Professor John Grin and I both work in a political science department; he is a former physicist, who works in public policy on issues related to transition economy. I consider both high quality sources of science related material. And so when I decided to read the paper, I assumed I would be convinced by the findings.

Michael Worobey (the lead author of the paper) and his colleagues have dome some impressive modeling and statistical analysis to argue that the source of the spread of the pandemic is probably to be found in the Wuhan market. The paper has, however, a peculiar step, which deserves some scrutiny, and which weakens the claims by the media that this article rules out a lab leak.

As is clear from the suggestive title of the paper and the media reporting I have quoted above, the political significance of this paper is it that it is presented as ruling out that the virus leaked out of the lab of the Wuhan CDC. Since outside access to it has been denied (here is the Guardian's reporting; here's the New York Times), this has generated concerns over a cover up.

What the media reporting fails to remark is that this possibility is addressed in only one sentence shown in a picture below.* 

So, naturally, I was curious to see what source (9) is. It's the Chinese CDC! (See the other picture.)

Now, clearly the authors of the report treat the Chinese CDC as a reliable source, and they may well have good reasons to do so. Both papers rely heavily on data from it, it seems.

But, if the point is to rule out a lab leak (and, hence, a cover up), this line of reasoning will not do at all. For, rather than testing whether the data they do rely on can distinguish empirically between the evidence for the Wuhan market and against a lab leak, the paper rules out a lab leak by fiat on the authority of those whose impartiality is questioned by critics of China. So this paper does not settle the matter at all.

Notice that I am not claiming this is poor science. The paper uses what it calls "spatial analyses" to "show that the earliest known COVID-19 cases diagnosed in December 2019 were geographically distributed near to, and centered on, this market." And this it undeniably does compellingly and with interesting techniques. And so the paper may well be published after proper peer review.

But in the media Michael Worobey's paper is presented as settling the politically salient issue (lab leak vs market). And his own comments seem to contribute to this perception in the context in which they are presented. I assume he consented to this because in my experience science journalists tend to be careful with their scientific sources in checking how they are presented. Yet, for the purposes of the controversy (lab leak vs market), the underlying logic of the paper  is something like this, "given that we assume on authority of an interested party that the lab cannot be the origin, we will study how data on the initial spread relates to the Wuhan market." 

I really hope I have missed something and that I am wrong about this because I do not want to contribute to the undermining of trust in science reporting of quality media. But even leaving aside the part of the story that has made it a central issue in our contemporary culture wars, there are many public health reasons to get clear on what the source of the original problem is. And it is a mistake to consider and irresponsible to claim that it is settled based on these studies. 

 

 

*The sentence occurs on p. 19 of my downloaded copy of the paper. Somewhat unusually the document does not have page-numbers. Reference 9 can be found on p. 65 in the "Supplementary references."

Even in a Welfare State Being Sick Is Expensive and Trying to get Care draining (Covid Diaries)

Published by Anonymous (not verified) on Fri, 25/02/2022 - 10:00pm in

In January 2021 (recall), after I tested positive for covid-19 in London, I contacted my GP in Amsterdam. She was gracious in acknowledging that her initial diagnosis (stress) of my symptoms was mistaken. (For my official "covid diaries," see hereherehereherehereherehereherehere; here; here; here; hereherehereherehere; here; herehereherehere; here; herehere; here here; here, and here). On the phone she urged me to get a blood-test to establish some base-lines for my disease (amongst other reasons). Because I was not part of the NHS (yet), I found a private provider who came to my home. Much to my amazement there were numerous providers of blood tests in London who cater to the very large ex-pat community. Within 24hrs, in the middle of a lockdown and stories of long lines of ambulances waiting to deliver urgent care patients, I had my test results and a hefty bill. I paid the bill. After consulting with my travel and health insurance companies, I decided to submit (via a nice app) to my Dutch medical insurance. The insurance company specializes in medical care workers (since my better half is a surgeon), and I have always been very happy with them. When a few weeks later, I checked on its status, I noticed it was declined. I contact the insurance company which informed me that I needed a proper referral from my GP. 

I contacted my Dutch GP -- where the practice was, of course, also groaning under Covid restrictions and added volume of care --, and explained the situation. Thankfully my GP had good notes, and it was agreed to provide with a referral for the insurance company. I was then introduced to the secured email system they use to communicate sensitive information to patients, and I was reminded that I could use the (less secure) web portal for communications with the GPs while I was in London. In the year since, I have become very familiar with the quirks of both software systems (but about that some other time), but they have also made life much much easier (especially as my brain fog developed).* So, a few weeks after submitting the initial declaration, I resubmitted it. 

I think most regular readers realize that my family lives in London, whereas I work and have a place in Amsterdam. (I eventually joined the family GP in London, and so entered the NHS system.) In fact, I bought my 1BR in the Fall of 2019. This was, in fact, the first bit of property that I owned in my life. And as 2020 developed, travel between London and Amsterdam became increasingly cumbersome. And just before it became nearly impossible, my Chair suggested I head to London as we were transitioning to remote teaching. (Subsequently, I negotiated a teaching leave during the Fall because I accumulated a lot of extra hours.) So, for most of 2020 and 2021, the final book boxes remained unemptied in my living room. That Fall (2020), because I didn't have a home office space, and the British Library was closed, I subscribed to one of those office companies so that I could get some research done and have a quiet please for contact with my colleagues and PhDs.

Okay, back to that insurance claim. Early last year I forgot about it because I had more important things on my mind: like not burning down the house accidentally while making lunch, figuring out how to coordinate the exams for a massive lecture course from my sick-bed in another country, and, say, my inability to walk more than fifteen minutes with my family. But 300€ is a lot of money even in good times, so eventually I remembered, especially when, under ordinary social security rules my salary started to be cut after nine months of illness (at the start of October 2021). This amounted to a 15% salary cut. Not huge, but noticeable in a two-household single family with a school-going kid. At that point, I took a sober look at my expenses, and made some non-trivial cuts: I gave up my US phone-number (after thirty years or so), paused my habit of collecting antique books, didn't renew a whole bunch of subscriptions to learned journals and magazines, and stopped my habit of ordering out when alone and took up cooking again (at which time I was less likely to burn down the house). During the early phase of my illness I also eventually remembered to halt my office subscription. None of these decisions felt like hardship, and whatever stress I had about my illness, I am blessed that I am not especially worried about my financial future. 

So, in the Fall of 2021 I contacted my insurance company which suddenly became much harder to reach due to their service agents working from home, the heavy volume increase in claims (by folk like me), and, I assume, increased sick leave (some of this information comes from the message they repeatedly provide you with while whiting for an agent). And because I was not feeling so well during this period, I invariably gave up after waiting after endless periods on hold.  I return to the claim below.

Now, the insurance claim is not the only such extra expense I have encountered. And I will spare you the many examples. Unlike in the American system where these kind of things can be catastrophic, the extra expenses per occasion amount to 10-20€ at a time. In the Dutch context this is primarily due to the fact that many individual, specialist care providers in the Dutch system are opting out of direct contracts with insurance companies, so that they can charge slightly higher rates. (The rates have a mandated ceiling to them, but they like to charge near the ceiling.) And at the urging of my occupational physician I have tried out some of these care providers (some of which providing highly experimental care). In most cases, I have simply swallowed the cost, but I have also tried to get my university to pay for some of the additional costs (the margin between what my insurer will pay and the amount I will pay), and much to my frustration the university declined to do so (even though the care is being undertaken at the urging of the occupational physician). Don't get me wrong I don't feel arm-twisted by the occupational physician; I am happy she is on the look-out for care that might help.

As an aside, you may wonder why I bother with the Dutch health care system, if I am now part of the NHS (where nearly everything is free except for some modest co-payments for prescription drugs). The simple answer is that the wait-periods for non-urgent care -- and long haul is not considered urgent -- is really extraordinarily long in the NHS. (There is a lot of quiet suffering in the UK!) Obviously, this is partially the effect of switching resources and people to treat urgent Covid-19 care, but it is also function of structural underfunding of NHS, and the way its referral procedures and prescriptions function. It's quite amazing really that a few weeks delay in the Dutch lead to modest apology, and it would be treated as a miracle of efficiency in the NHS. (In a nearby possible world, I would do comparative health care spending research by now.) So, I keep my Dutch GP informed of my treatment and consultations with the long haul clinic at UCLH, and she helps coordinate my Dutch care. So, I try to get the best of both worlds, but it is exhausting to get care for myself.  (I will ignore in this post the many things that make it infuriating including the fact that many Dutch specialists treat long covid as a life style burn out or as primarily a lung disease.)

Last week, I needed to call my insurer again to figure out reimbursement on a new health care provider and in particular how to make the insurance codes match on her bills to me and my claim submissions. The wait was short, and I got a wonderful agent on the phone. And after we solved that problem (it would cost me, I guess, 10-20€/visit), I decided to ask her about the blood test claim of January 2021. Thanks to the app, it was easy to hunt down all the information in her system, and after, putting me on hold, and looking through the claims, she admitted it was unclear to her why I was not paid out. But she couldn't make the decision, the claims department had to do it. And then she informed that she did not get priority with the claims department, but that she would also be put on hold and that the wait would be long. Would it be okay if she called me back next week? I noted and wrote down her name, and happily agreed to these terms. I also noticed I had gone well beyond the 30 minutes I can handle phone-conversations. And so went to bed to give my head a rest.

Fast forward to the present. I just got off the phone with another kind insurance agent who had no record of my conversation ever happening last week. He never doubted that it did happen. He and I went through the case again, and he agreed with his colleague's evaluation that it was odd I was not paid yet, but formally this was a decision of the claims department. This time, I asked if he could send me an email or a letter that we had had this conversation. He agreed. And he also suggested that the company would only contact me if they declined to pay. If the claims people sign off, I would get the usual notice on my app, and the money. I happily agreed to those terms. When we hung up I noticed the conversation I had lasted 27 minutes and 5 seconds. It was time to make another espresso.

Now, to reiterate, none of this is catastrophic American style. I don't have the risk of collecting agency breathing down my neck, eviction, etc. But it has given me a glimpse of the ordinary struggles that poor people with chronic diseases have even in reasonably well functioning welfare states. (And, of course, Dutch recent history -- google 'toeslagenaffaire' or 'Dutch childcare benefits scandal' -- suggests it does not work so well for poor people who have a migration background.) Expenses accumulate in open-ended fashion just as the source of income is reduced. It eats up energy to keep track of these, and to try to get claims paid out. This is alongside the emotionally draining aspect of trying to get oneself (or loved ones) the care they need, and navigating complex bureaucratic systems and the not infrequent passive aggressiveness of overworked care workers who may not be able to help you at all. (The ones that clearly think they may be able to help you tend to be much nicer!) As a male professor, I have a lot of social capital, and I have non-trivial number of connections in medicine. My rule of thumb is, if the whole process is difficult for me, it must be agonizing for folk with much fewer social and financial resources.

So, if your underlying disease makes it difficult for you to concentrate and have modestly long conversations, trying to get care (while partially working and being a dad/husband/son/brother/uncle, etc.) actually undermines one's heath and sanity. And it's a peculiar social fact that when your expenses increase due to need, your income gets cut. Meanwhile, that blood test remains un-reimbursed.

 

 

*The NHS, by contrast, uses a standardized portal for GPS that is cumbersome and time-consuming, and actually likely to lead more errors.    

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