Honoring our fallen heroes

Image by Beverly & Pack via Flickr

It was a poignant moment for me, if a bit flustering.  My grandfather and I were sitting at breakfast last Monday morning, Memorial Day, following a cousin's wedding over the weekend, and my grandfather asked me why the news never shows videos of flag-draped caskets returning our fallen soldiers from battle anymore?  His remark was a simple one, that those soldiers deserve to be honored for their sacrifices, and that it seems that everyone has forgotten that we're still at war these days.  I didn't have a good response for him, beyond my wholly unsatisfying initial reaction that most likely the news media didn't see any profits in devoting airtime to returning caskets from our wars overseas.  My grandfather asked me that I do some investigation into the matter, and that I post whatever I found on my blog, since he's a subscriber, and would be interested to see what I dug up.

First, a bit of background.

My grandfather, William G. Moir, or "Fahtie," as we grandchildren know him, is a Navy veteran who served in the Pacific theater in WWII.  Like many veterans, Fahtie has never spoken much about his experience in the war, or at least, he has never volunteered information about his service.  Since my childhood I have always felt as though he was a man who served his country proudly and bravely, but that when he returned to civilian life, he dedicated himself to providing a good life for his family (which later grew to 7 children) and never much sought to relive his experience through retelling it to his offspring.  More likely, Fahtie just never had the time nor inclination to turn his personal war story into a shared family story; working as a traveling salesman, raising many children, putting himself through night school for an MBA from the University of Chicago...it sounds like he had plenty else to do.

But nevertheless, the sheer lack of Fahtie's war story over the course of my childhood created a situation where even his glancing references to his experience, or to topics surrounding the military, elicit a feeling of import, of significance, for me.

And so it was this past Monday morning; Fahtie's seemingly simple question as to why we never see images of the fallen returning home from war struck me to the quick, and I felt...shame.  Shame for our consumerist modern culture that has neither the time nor the attention span to honor those who have sacrificed on our collective behalf; shame for the fact that a solemn event has been politicized in our hyper-partisan world.  I wanted to honor the fact that Fahtie had entrusted me with his feeling of outrage at the lack of honor accorded to our fallen heroes, to somehow find a way to redeem his faith in modern America, and thereby to redeem my own and future generations in his eyes as we collectively move further away from the historical and proper treatment of the war dead...but there was no way to do it.  Our world, our culture as it is constructed today, can never offer the kind of respect and dignity that is deserved by those who sacrificed all, and yet, I believe that we're doing slightly better these days.

__________________________________________________________________________________

Tonight I began searching around online to find out what exactly the story was behind President Obama's decision to allow the media to film returning caskets when they arrive at Dover Air Force Base in Delaware.  What began as a simple Google search has taken me far beyond what I initially had imagined.

First, CNN's initial report announcing President Obama's decision from February 2009:

The Pentagon will lift its ban on media coverage of the flag-draped coffins of war victims arriving at Dover Air Force Base in Delaware, Defense Secretary Robert Gates said Thursday.

But the families of the victims will have the final say on whether to allow the coverage, he said. President Obama asked Gates to review the policy, and Gates said he decided after consulting with the armed services and groups representing military families to apply the same policy that is used at Arlington National Cemetery.

"I have decided that the decision regarding media coverage of the dignified transfer process at Dover should be made by those most directly affected -- the families," he said at a news conference.

The report mentions the controversy surrounding the decision to lift the ban and covers both sides, but further searching revealed a nuanced article from the Columbus Dispatch:

The arrival of war dead at Dover has long pitted free-speech advocates against the government, which had been accused of using the ban to hide the horror of war from the public.

In 2004, Vice President Joe Biden, then a U.S. senator from Delaware, said, "The idea that they are essentially snuck back into the country under the cover of night so no one can see that their casket has arrived, I just think is wrong."

This year, the Obama administration sought a middle ground. Defense Secretary Robert Gates lifted the ban but said families should decide whether the media cover the homecomings of the fallen: "We ought not presume to make that decision in their place."

The fact that military families are now at least afforded a choice of whether they wish for media to be allowed to cover the arrival of their loved one appears to me to be a step in the right direction, however with the lifting of the ban, the expectations for media coverage appear to have left some families slightly surprised:

So Gloria Crothers of Edgewood, Md., was a little taken aback when just two news crews appeared for the arrival of the bodies of her son, Army Sgt. Michael Heede, and another soldier from Maryland. She wasn't so much disappointed as surprised, she said. "I was told there could be quite a few" news crews.

But a few is the norm, said Maj. Carl Grusnick, an Air Force spokesman. Often the only professional journalist is a lone AP photographer. 

"The feeling is that somewhere there is a hometown, a family, a newspaper for whom the homecoming of the soldier is very important news," said Paul Colford, an AP spokesman. "So we have made the commitment to covering each and every one of those at Dover."

The AP is doing an honorable thing, covering each and every arrival (that they are allowed to) which is as much of a public service as anything else.  Further searching turned up the AP's online archives of all of their images of caskets returning from overseas - they refer to them as "casualty returns." The images are there for commercial purchase and use, but as a rough guide to the procedures and ceremonies around the casualty returns, they are quite poignant.

Continuing from there, the Columbus Dispatch ends its article on a far more upbeat note that I believe sums up exactly why we ought to film the casualty returns in the first place:

Since the media ban was lifted, the military also started paying for families to travel to Dover to welcome their loved ones home. More than 70 percent of families have made the trip.

That's what mattered to Shane Wilhelm of Plymouth, Ohio: being there for the quiet, white-gloved military rite. Wilhelm said it made him feel proud of his 19-year-old son, Army Pvt. Keiffer Wilhelm, and of his country.

"It was representative of the United States, that's the way I viewed it," he said. "It shook me to the bone, but it made me feel proud instead of having all that grief. All these people are here all because of my son."

The ritual, the honor afforded to the dead is presumably a key element in a family's grieving process, and if it helped Mr. Wilhelm to be able to attend his son's arrival in person, then that would appear to be a great addition to the military's services to surviving family members.

But all that aside, why aren't we seeing more coverage on TV, as Fahtie asked me to investigate?  A CNN article ominously entitled "Interest in photographing return of war dead to U.S. wanes" gives some insight:

Of those 472 (casualty returns), about 260 -- or 55 percent -- have been open to media coverage, according to statistics from the Mortuary Affairs office. And over the past year, the media attendance has dropped off to a trickle.

"Those numbers reflect that the interest in covering the story diminishes as the story becomes repetitive," said Ralph Begleiter, a former network correspondent and now professor of communications at the University of Delaware....

...Many major news organizations rely on the fact that The Associated Press is covering these events, and will keep the images as they are brought in, but often they are still not used.

"Just because things are covered does not mean the public sees it. Lots and lots of things are covered [by news organizations] but then never actually end up on the air," Begleiter said.

So we see that the majority of families are opting to have their loved ones' arrivals open to media coverage, yet the media isn't covering the arrivals beyond perhaps buying the AP's photos of the event.  My hunch, borne out by the facts over the last 9 years of war, is that there is not a shared sense of loss among the public because there is not a shared burden from the wars we are fighting among the public.  In the days of an all-volunteer military, with the prospects of a draft being negligible (barring catastrophe,) the vast majority of the suffering and the hardships of war will fall on those families whose loved ones chose to serve.  And yet, there are striking reminders of the private tolls endured by families out there in the world if one looks for them.

__________________________________________________________________________________

If it's not apparent, all throughout this article I've been interspersing links to various other websites, photo archives, and news reports, and those various resources out there led me to the conclusion I've finally come to: while our society may be too stratified, too hectic, too narcissistic in the aggregate to honor our returning war dead in the unified way we used to when there were only three major news networks, the sheer volume of information and resources out there far exceed what was possible in the Vietnam era.  Beyond that, there are amazing communities of people who gather online (and in person, naturally) to share stories, remembrances, and to honor the dead, far more than I have represented here.

And just to show that the world is full of "surprises," I would like to make note that at the infamous liberal website DailyKos.com (itself founded by Markos Moulitsas, a military veteran) there is an ongoing series of diary posts entitled "IGTNT" meaning "I got the news today," which honor those who have died serving in our armed forces.  The description of the IGTNT series follows below (note that there are a number of online avatars/usernames sprinkled throughout, which makes for awkward sentences if you're not familiar with the use of avatars):

I Got the News Today is a diary series intended to honor, respect and remind. This series, which was begun by i dunno, is currently maintained by Sandy on Signal, noweasels, monkeybiz, silvercedes, MsWings, greenies, blue jersey mom, Chacounne, Wee Mama, twilight falling, labwitchy, moneysmith, joyful, roses, SisTwo, Avila,a girl in MI and me, SpamNunn.

These diaries are heartbreaking to write, but, we believe, an important service to those Americans who have died, and to our community’s respect for and remembrance of them. If you would like to volunteer, even once a month, please contact Sandy on Signal, monkeybiz, or noweasels.

As you read this diary, please consider that the families and friends of those profiled here also may read it and that many members of our community have served in the Armed Services of the United States of America.  I hope that our comments tonight will demonstrate our respect for the sacrifices of our fallen military and our compassion for their families, whatever our personal or political feelings about the current war or any war happen to be.

While the vast majority of DailyKos users oppose the wars in Iraq and Afghanistan, this just goes to show that even peaceniks can rally around our troops and honor their sacrifices.  A particularly touching diary post is here, about the recently-identified remains of two WWII pilots who were lost over Germany.

__________________________________________________________________________________

So ultimately, Fahtie, I don't have a good answer for you.  I've spent quite a few hours working on this blog posting now, and I suppose the topic of how we honor our war dead, and why it is different than before, will be one I will have to investigate further and return to in the future.

UPDATED: Health care statistics, undermining health care debate?

Peter Orszag
Image via Wikipedia

UPDATE: I had originally written this post based mainly off of the NY Times piece linked to below, coupled with my own knowledge of health care policy, but it seems that this article has sparked a vigorous debate in the blogosphere regarding just how accurate it's claims about the Dartmouth Health Atlas are.  I have edited parts of my post below to take into account new information, but for more, see Kevin Drum at Mother Jones, David Leonhardt at the NY Times, or the Dartmouth Health Atlas authors' response.  Needless to say, the situation is far more complex than the Times writers acknowledge, involving statistical analysis and the extrapolation of data.  More info below my blog posting.

____________________________________________________________

There's a fascinating article out today in the New York Times about a Dartmouth study on health care spending and the resultant health outcomes across hospitals, states, and regions of the U.S.  The study was used by the Obama Administration and Congressional Democrats to make the case for the efficacy of cutting health care spending while actually improving patients' health outcomes.  The article paints a picture of the Administration's efforts to sell their plan via the study:

Mr. Orszag even displayed maps produced by Dartmouth researchers that appeared to show where the waste in the system could be found. Beige meant hospitals and regions that offered good, efficient care; chocolate meant bad and inefficient.

The maps made reform seem relatively easy to many in Congress, some of whom demanded the administration simply trim the money Medicare pays to hospitals and doctors in the brown zones. The administration promised to seriously consider doing just that. (emphasis added)

Mr. Orszag is Peter Orszag, Budget Director of the Office of Management and Budget at the White House, and one of the primary cheerleaders for health care reform within the Administration.  Color-coded maps are like catnip to legislators eager to provide pseudo-intellectual cover for their legislative aims, as they can simply point to the maps to make their overly simplistic arguments to their constituents.  The idea that politicians would ever think that health care reform is easy is truly scary.  We really need more economists and statisticians in Congress.

But while the research compiled in the Dartmouth Atlas of Health Care has been widely interpreted as showing the country’s best and worst care, the Dartmouth researchers themselves acknowledged in interviews that in fact it mainly shows the varying costs of care in the government’s Medicare program. Measures of the quality of care are not part of the formula. (emphasis added)

Did you catch that?  The Dartmouth study solely looks at the cost of care, not the quality of care, yet somehow or another the link between lower spending and better care was made by policymakers in Washington.  How did that happen?

In addition to their hospital rankings, the Dartmouth researchers have also done separate studies of how Medicare spending affects patient care regionally. A 2003 study found that patients who lived in places most expensive for the Medicare program received no better care than those who lived in cheaper areas.

Because some regions spent nearly a third more than other regions without any apparent benefit, the Dartmouth team concluded that at least one dollar in three was wasted by Medicare. When applied generally to the nation’s health care system, that meant about $700 billion could be saved.

But as it began publicly discussing its research, the Dartmouth team often extrapolated beyond this basic finding. Not only do high-spending regions fail to provide better care, the Dartmouth team began to argue, but those regions actually offer worse care. 

While I haven't seen the exact data the Dartmouth team examined in making these claims, the argument that one-third of Medicare spending is wasteful seems like a rather large extrapolation to make.  The blunt instrument of health care spending statistics does not lend itself to nuanced analyses of the quality of doctors or nurses at a hospital or of their clinical judgments in deciding what treatments to order for patients.

Last year, New Yorker writer (and practicing doctor) Atul Gawande wrote a major article about McAllen, Texas, the city with the highest per-capita Medicare spending in the country after Miami, a city with a much higher cost-of-living and more elderly population.  Gawande describes a meeting he has with a group of McAllen doctors, one of whom responds to Gawande's inquiry about the high spending thusly:

“Come on,” the general surgeon finally said. “We all know these arguments are bullshit. There is overutilization here, pure and simple.” Doctors, he said, were racking up charges with extra tests, services, and procedures. 

The surgeon came to McAllen in the mid-nineties, and since then, he said, “the way to practice medicine has changed completely. Before, it was about how to do a good job. Now it is about ‘How much will you benefit?’ ”

Naturally, when the incentives for doctors are to over-prescribe treatments so that they are compensated, they will tend to run more tests than necessary, and to focus on moving their patients into the more expensive treatment programs, rather than lower-cost preventive medicine treatments, which may be more effective.  So when the Dartmouth researchers make the arguments that higher cost equates to worse outcomes, that may indeed be true, as more health care does not always mean better health care, but it cannot be the case universally across the country.  If a doctor correctly diagnoses a serious ailment, and prescribes a necessarily expensive treatment regimen for it, then simply looking at the spending figures will not be able to take into account the correct diagnosis of that ailment.

In interviews, Dr. Fisher and Mr. Skinner acknowledged that there was no proven link between greater spending and worse health outcomes. And Dr. Fisher acknowledged the apparent inconsistency between his statements in interviews with The New York Times and those made elsewhere, saying that he was sometimes less careful in discussing his team’s research than he should be.

In any case, the more-is-worse message has resonated with insurers, whose foundations now help to finance the Dartmouth Atlas. Dartmouth researchers also created a company, Health Dialog, to consult for insurers and others on Dartmouth’s findings. Valued at nearly $800 million, the company was sold to a British insurer in 2007 and still helps to finance the Dartmouth work.

It appears that, surprise, if as a researcher you make arguments that resonate with insurance companies, they will take a financial interest in your research.

Ultimately, the problem here is twofold: 1) high per capita Medicare spending in an area may signify the overutilization of care by doctors, but to make the conclusion that higher spending is always wasteful goes too far; 2) researchers and academics who create studies that fit neatly into the narrative that the powers-that-be seek to promulgate (in this case the Obama Administration and the health insurers) will have their conclusions amplified, despite arguments to the contrary.  This resulted in the further muddying of the already opaque health care reform discourse in which nothing is quite as cut-and-dry as we might wish.  While I still believe the reform bill was a good step towards a healthier America, it's unfortunate that the system has been gamed by so many parties.

UPDATE, cont...Further muddying of the waters:

3. Some research has shown that even the most glaring cost
differences noted in the Dartmouth research are associated with
improved outcomes for those conditions where something close to random
assignment of patients to alternative patient regimes occurs. The guy
who is doing this work is Joseph Doyle at MIT. If the Times article
had described some of his work, readers would have learned something.
For example, you can be pretty sure that people who suffer coronaries
while on vacation do not choose in which county to have the heart
attack. Doyle studied such patients. He found that they did better
in Florida counties that spent most, the very counties that the
Dartmouth folks have held up for their poor average outcomes. He also
found that preemies who were a couple of grams under the threshold at
which they are described as in need of intensive care did materially
better than did preemies a couple of grams over that threshold and,
hence, treated as normal births. The weight difference was too small
to matter medically and went in the wrong direction; the intensity of
care mattered.

Doyle's reasearch and the finding on the inverse relationship between
Medicare spending and private spending, together with the fact that we
can't predict worth crap who will and who will not benefits from many
procedures means not that the Dartmouth people are wrong, but that any
savings will be very hard to achieve without doing more harm than good
and will be very slow in coming. The Administration, and Orszag in
particular, were wrong in neglecting the warning to forecasters of
Scottish economist, Alec Cairncross, 'Give a number. Or a date.
Never both.'