Return to Zombie America

image from Umair Haque's article
on the American Collapse

Outstanding article "Why We are Underestimating American Collapse" by Umair Haque in Eudaimonia  looks at some of the human costs such as the epidemic of school shootings, the "opioid epidemic," the declining life expectancy of rural, white Americans.

This all fits in with what I've started calling  "zombie America." Zombies are variously referred to as the "undead" and the "walking dead," phrases that I think can be applied to American economy, politics and society at large. The nation is still lurching and weaving about, animated but no longer truly alive, dead (or dying) on the inside but because still animated, so that many observers still imagine it to have life.

Not like science fiction: the decline of America

 I began reading science fiction when I was nine, and it remains even today sixty-two years later still my favorite flavor of fiction, but science fiction has taught us all to expect the end of civilization to come abruptly, dramatically and unmistakably. This has made us collectively blind to the real world slow, drip-drip erosion of our society. 

A good example of what I'm talking about is the novel (and now HBO series) Station Eleven, a story of an apocalyptic pandemic and its aftermath. The novel published in 2014, shows the disease a deadly "flu" killing something like 90 percent of the people infected, and its impact in disrupting society occurs within days. People die in the streets, in their cars, everywhere all at once, and almost instantly modern society as we know it is gone.  Some time in the last month or so, I ran across someone (on Twitter or in an interview) using Station Eleven as the rubric against which our real world COVID pandemic should be marked as not very serious. I wish I'd written it down, saved the Tweet or bookmarked the interview because it epitomizes the way we've ingrained science fiction as the arbitrator of what is and what is not the end of the world.

Make no mistake about it, we are already in the midst of the fall and decline of the great American democratic, post-industrial society. It has been going on for some time now, at least two decades, but probably longer than that. Let me make it clear, I am NOT a MAGA, I am not talking about trying to recover some fake golden age of the past. I see as good and positive trends the exact things that MAGA people hate: increasing diversity, greater political, social and economic power for women and people of color, increasing openness to alternatives to rigid gender boundaries and the celebration of all kinds of sexual orientations. I applaud marriage equality and support the Black Lives Matter movement. 

However, even if the MAGA crowd is wrong about what ails our society and who or what is responsible, they are on to something when they express anxiety about the decline of America. Extreme inequality in wealth, political power, and social opportunities are fundamentally distorting and destroying our society. A very small class of people benefit hugely, others benefit slightly and the vast majority find themselves living on the edge with little voice and less influence. 

The COVID pandemic did not cause any of this, but it exacerbates all the existing problems, continues tiny piece by tiny piece to help tear away at the fabric of society. The pandemic which has killed less than one percent of our population has nonetheless shredded our health care system, scratches at our supply lines, and creates a huge new class of disabled persons, and is far from over in terms of its impacts, regardless of our intentions to just "live with it." 

How Can We Value Necessary Work?

A friend of mine posted a link to a very interesting blog post:  Being Blog - The Work We Value, The Intelligence We Ignore: Is the Work that Made America Great Valued Any Longer?  The focus of the post was on the testimony from Mike Rowe, the creator and host of Dirty Jobs, before the U.S. Senate Committee on Commerce, Science and Transportation about the current contradiction in the American labor force.  Today, while we have high unemployment, we also have thousands of skilled, blue-collar, manual labor jobs that are going unfilled. Here is Mr. Rowe's testimony in its entirety:

“Chairman Rockefeller, Ranking Member Hutchison and members of this committee, my name is Mike Rowe, and I want to thank you all very much for the opportunity to testify before you today.

I’m here today because of my grandfather.

His name was Carl Knobel, and he made his living in Baltimore as a master electrician. He was also a plumber, a mechanic, a mason, and a carpenter. Everyone knew him as a jack-of-all-trades. I knew him as a magician.

For most of his life, my grandfather woke up clean and came home dirty. In between, he accomplished things that were nothing short of miraculous. Some days he might re-shingle a roof. Or rebuild a motor. Or maybe run electricity out to our barn. He helped build the church I went to as a kid, and the farmhouse my brothers and I grew up in. He could fix or build anything, but to my knowledge he never once read the directions. He just knew how stuff worked.

I remember one Saturday morning when I was 12. I flushed the toilet in the same way I always had. The toilet however, responded in a way that was completely out of character. There was a rumbling sound, followed by a distant gurgle. Then, everything that had gone down reappeared in a rather violent and spectacular fashion.

Naturally, my grandfather was called in to investigate, and within the hour I was invited to join he and my dad in the front yard with picks and shovels.

By lunch, the lawn was littered with fragments of old pipe and mounds of dirt. There was welding and pipe-fitting, blisters and laughter, and maybe some questionable language. By sunset we were completely filthy. But a new pipe was installed, the dirt was back in the hole, and our toilet was back on its best behavior. It was one of my favorite days ever.

Thirty years later in San Francisco when my toilet blew up again. This time, I didn't participate in the repair process. I just called my landlord, left a check on the kitchen counter, and went to work. When I got home, the mess was cleaned up and the problem was solved. As for the actual plumber who did the work, I never even met him.

It occurred to me that I had become disconnected from a lot of things that used to fascinate me. I no longer thought about where my food came from, or how my electricity worked, or who fixed my pipes, or who made my clothes. There was no reason to. I had become less interested in how things got made, and more interested in how things got bought.

At this point my grandfather was well into his 80s, and after a long visit with him one weekend, I decided to do a TV show in his honor. Today, Dirty Jobs is still on the air, and I am here before this committee, hoping to say something useful. So, here it is.

I believe we need a national PR Campaign for Skilled Labor. A big one. Something that addresses the widening skills gap head on, and reconnects the country with the most important part of our workforce.

Right now, American manufacturing is struggling to fill 200,000 vacant positions. There are 450,000 openings in trades, transportation and utilities. The skills gap is real, and it’s getting wider. In Alabama, a third of all skilled tradesmen are over 55. They’re retiring fast, and no one is there to replace them.

Alabama’s not alone. A few months ago in Atlanta I ran into Tom Vilsack, our Secretary of Agriculture. Tom told me about a governor who was unable to move forward on the construction of a power plant. The reason was telling. It wasn't a lack of funds. It wasn't a lack of support. It was a lack of qualified welders.

In general, we’re surprised that high unemployment can exist at the same time as a skilled labor shortage. We shouldn't be. We’ve pretty much guaranteed it.

In high schools, the vocational arts have all but vanished. We’ve elevated the importance of “higher education” to such a lofty perch that all other forms of knowledge are now labeled “alternative.” Millions of parents and kids see apprenticeships and on-the-job-training opportunities as “vocational consolation prizes,” best suited for those not cut out for a four-year degree. And still, we talk about millions of “shovel ready” jobs for a society that doesn’t encourage people to pick up a shovel.

In a hundred different ways, we have slowly marginalized an entire category of critical professions, reshaping our expectations of a “good job” into something that no longer looks like work. A few years from now, an hour with a good plumber — if you can find one — is going to cost more than an hour with a good psychiatrist. At which point we’ll all be in need of both.

I came here today because guys like my grandfather are no less important to civilized life than they were 50 years ago. Maybe they’re in short supply because we don’t acknowledge them they way we used to. We leave our check on the kitchen counter, and hope the work gets done. That needs to change.

My written testimony includes the details of several initiatives designed to close the skills gap, all of which I've had the privilege to participate in. Go Build Alabama, I Make America, and my own modest efforts through Dirty Jobs and mikeroweWORKS. I’m especially proud to announce “Discover Your Skills,” a broad-based initiative from Discovery Communications that I believe can change perceptions in a meaningful way.

I encourage you to support these efforts, because closing the skills gap doesn't just benefit future tradesmen and the companies desperate to hire them. It benefits people like me, and anyone else who shares my addiction to paved roads, reliable bridges, heating, air conditioning, and indoor plumbing.
The skills gap is a reflection of what we value. To close the gap, we need to change the way the country feels about work.”

The gap that Mr. Rowe speaks about is entirely real. There are many fields of skilled, blue-collar, manual labor where jobs go unfilled, and workers are desperately needed. But his analysis of why we have this problem is woefully simplistic and lacking. This is no simple matter of attitudes and values, but the result of a complexity of forces that have reshaped our economy and the choices of individuals within that economy.

Which means that it is an issue too complex to be dealt with in one little blog post. However, let's look at two issues briefly: 1) the physical demands of the jobs, opportunities for advancement and retirement, and 2) the issue of health care.

While it is true that most young people think only about the job they will get when they graduate, how much it pays and what its like, their parents and teachers often encourage them to think about longer term issues, such as opportunities for advancement, and how the job will fit them as they age. The skilled manual labor jobs that are going unfilled in our economy are jobs for younger people, with flexibility and strength. The majority of people are unable to continue with physically demanding jobs past their fifties.

Unlike Mr. Rowe (who puts the check on the counter and comes back to work completed), I've been present and actively observing all the plumbing, septic, electrical and construction work done to install my new double wide. What I've noticed is that all the men (no women) who have been using shovels to dig, climbing in ditches, crawling under houses, and climbing ladders have been under 45, and all the men who have been yelling instructions, checking paper work, assigning tasks, and supervising have been over 55. Now the problem is that for each over 55 year old doing supervisory work, there are three to five young men carrying out the physical labor, meaning that not every young man who goes into manual labor will have an opportunity to become a supervisory worker or construction business owner. So what does that person do when they hit 50 and their knees no longer bend easily, and their back spasms every time they try to crawl under a house, or pick up a load of bricks, or climb a ladder to install wiring?

Part of the problem of getting young people to go into skilled manual labor fields of work, is the problem of what happens to them when they hit middle age and can no longer handle the physical demands of that job. We have to think seriously and realistically about how to provide work for older blue collar workers, that doesn't treat them as surplus labor to be thrown on the heap of long term unemployment and disability. As a society we are not currently doing well for our 45 to 65 year old blue collar workers. Young people know these workers as their parents and grandparents, and seeing what has happened to them is part of what deters them from going into those fields.

Related to this, of course, is the issue of retirement. A person going into manual labor has to have a realistic expectation that they will be able to retire while they still have some strength and vitality (early to mid-60's at least) and have adequate income to live comfortably. As a society we are not doing a good job of providing young people with any kind of assurance that social security, much less private pensions, will be there for them.

The second issue is health care. When I graduated from college in 1973, during a recession, I took a secretarial position paying minimum wage ($1.80 an hour). With that income I paid for rent, food, transportation and clothing, and I was also able to afford to buy my own, individual health insurance policy from Blue Cross/Blue Shield. The skilled manual workers at the businesses where I was employed made considerably more money than I did, and could afford health care not only for themselves but for their families as well.

Although young people are more cavalier about their needs for health insurance than older people, health insurance coverage is one of the incentives that a occupational choice may offer someone. Physical labor, puts greater demands on workers, and although actual accidents are usually (but not always) covered under workman's compensation, the general wear and tear on the body's joints and systems is not.

A truly universal health care system that seriously attacks the costs of medical care and medication would go a long way towards allowing young people to consider a wider range of occupational choices. If health care stops being tied to jobs, than jobs can be chosen for reasons other than health care coverage.

These are only two of the dozens of complex issues that affect occupational choices of young people in this country, and must be addressed as part of a multi-faceted approach to develop the workforce we actually need to move this nation forward.

college students today....

College professors have always complained about college students. The complaints usually starts with the phrase "the trouble with college students today..." and usually also contains the phrase "when I was a student..."

The fact is that college students today are different from the past, in a whole host of ways. Let's look at the demographics: in 1966 the total number of undergraduate college students of all ages was 6,085,000 which represented 3% of the total U.S. population, in 2008 the total number of undergraduate college students of all ages was 14,955,000, which represented 5% of the total U.S. population ; in 1966 39% of college students were 18-19 years old, 15% were age 25 or older, 94% were white and 5 percent were black, 38% were women and 62% were male; in 2008 22% were 18-19 years old, 37% were age 25 or older, 77% were white and 13 percent were black, 55% were women and 45% were male. In the year 1970 (first year for which the government collected data on this) the percent of all undergraduate students attending community colleges was 27%, in 2008 that had risen to 36%.

As discussed this past week in the Chronicle of Higher Education most of the increasing numbers of college students in the last couple of decades have gone into the community colleges, and to a lesser extent into less selective four year colleges (public and private). More selective colleges and universities have used the increased numbers of students applying to become more selective, more choosy.

Family income which impacts college choices due to rising costs, also has a strong positive correlation with standardized test scores and to a more moderate correlation with high school grade point average. Other aspects of social class, such as parental educational levels influence students' selection of or assignment to courses of study in high school. [The college educated parent is more likely to know that taking algebra in summer school before high school can put their child on a fast track to advance math classes in high school making him or her more attractive to selective colleges and universities.]

As a result of the confluence of increased selectiveness and rising costs, social class and income stratification between colleges has increased steadily over the past twenty years. Students from poor and working class families are becoming a smaller and smaller percentage of elite, selective colleges and universities, while community colleges become the primary educational institutions for poor, working class, and even lower middle class families.

The flood of new college students into community colleges and less selective four year colleges, is made up primarily of poorer, working class and lower middle class students who are the first in their family to go to college. Educational pundits have pointed out the impact of this on the level of college preparation -- a large percentage of these new students were shunted by their high school advisers into non-college preparatory tracks or classes. They did not take the mathematics, science or even English, history, etc. usually taken by college bound secondary students. Pundits have also made much about the lack of monetary resources of these students, and the high percentage of them that have jobs (all of these things have been discussed extensively in The Chronicle of Higher Education in recent weeks and over the last few years).

One thing that has not been discussed at all, that is painfully obvious among our poorer and working class student body at my Kentucky community college, is the impact of poor health and health care problems on students. Our students themselves have a very high level of health problems, including diabetes and its complications, heart disease, other obesity related conditions, back problems, rheumatoid arthritis, lupus, and a frighteningly high level of cancer for a relatively young population. As many health problems as my students have, their families -- spouses, parents, grandparents, mothers- and fathers-in-law, siblings, aunts and uncles, have even more. Because in lower income communities, people are highly dependent on family and kin for aid during crises, students often are primary care-takers for ill family members, providing emotional support, transportation, and nursing care at home or in the hospital. [These days with nursing staffs stretched so thinly -- especially in poor rural areas like this -- some one needs to be present in the hospital with a patient to insure proper nursing care.]

This semester I had one student providing physical, household, medical/nursing, and emotional support for her mother with cancer and her mother-in-law with congestive heart failure (the mother-in-law died just before the end of term). An other student spent weeks in the nearest research hospital (3 hours away from her home) providing support for her long term partner who was dying, and then came home to her own diagnosis of heart disease and need for heart surgery. At least a dozen other students in my classes (I only teach about 75 students a semester) had serious health issues for themselves or family members this term, and this was not an unusual semester.

All these forms of illness have a higher incidence among lower income and working class populations. On top of that, are the burdens imposed by lack of good health coverage. Many of them have the additional struggle of having to worry about mounting medical bills that they may never be able to pay off. If they have assistance from Medicaid or from the local public health department, they often have very little control over the times of appointments and have to invest more time than some one with insurance would have to invest.

Just this week as I was getting my mammogram I overheard the following situation -- a woman with a suspicious lump had been referred by the public health department to a private physician to order a diagnostic mammogram and had authorized payment for that mammogram. The physician however, had decided that an ultrasound would provide him with more information and wrote an order for an ultrasound. The woman showed up at the radiography department for her appointment, only to be told that she would have to return to the public health department, so that they could write a new authorization for payment for the ultrasound, and then go back to the physicians office for a new order to go with it, and have to reschedule the mammogram for a day later in the week. It was obvious from the conversation that her husband who accompanied her, had taken off from work and was losing pay, and would have to take off yet another day later in the week to accompany her for the second go-round.

Poor health and poor health care are huge obstacles to successful college completion for lower income and working class students.

The pharmaceutical industry and American health care

Today I sat in our family doctor's waiting room for three hours while my husband was seen for broken ribs. While we were there (and waiting for three hours), a total of eight different drug company representatives were allowed welcomed in to speak to our family doctor. Eight.

The numbers today may have been a little unusual, but the presence of drug representatives is not. I have yet to come to see my physician with out spotting at least one and more often two or three drug representatives during the time of my visit.

Why be concerned? Well first, why with people waiting for hours in the lobby, should drug reps be given the fast track to doctors time? But far more importantly, how much pressure is being brought to bear on family physicians and internists to prescribe new, more costly, patented medicines instead of older, less expensive, generic medicines?

More than a decade ago, after some type of injury my physician prescribed a generic muscle relaxant for me. It worked well, was helpful, and cost me (with health insurance) $5. A year or so later, after another injury, she prescribed a new brand new, name brand muscle relaxant, that when I got to the pharmacy turned out to cost $45 (with insurance -- imagine what it would have cost without insurance). Well it didn't work as well for me as the generic. Some time later, another injury, another visit, and time for another prescription. This time I specifically told her that I wanted the generic, that I found it worked better than the name brand and was 1/9th the cost. She mumbled a bit and said, oh, well I was told that this new medicine would be better, and wouldn't upset people's stomachs. While this may be true, it never once occurred to my doctor to 1) ask if I'd had any problems with the generic drug and needed a substitution or 2) think about the huge difference in cost. This kind of blind acceptance of drug company sales pitches is part of the current problem with health care.

social issues: obesity and air conditioning

Obesity may have once been an individual trouble (to use C. Wright Mills' terminology), that was the consequence of individual decision-making and behavior, but today it is a complex social issue that is the result of patterns of modern economic and social life. Mills distinguished between troubles (which were purely individual or interpersonal in origin) and social issues which were created by the structure of society.

The media (as well as the government) has recognized obesity as a social "problem" largely because the many of the costs of obesity in medical expenses and lost work days are born by society. There has also been some recognition of social factors contributing to obesity -- such as the pervasiveness of candy and soda machines in schools. However, for the most part, while recognizing the social consequences, government decision-makers and the media are blind to the social causes of obesity, focusing perversely on individual behavior and individual decisions about food and exercise.

Each semester I use the topic of obesity as a way to engage students in SOC 101 in the sociological imagination (C. Wright Mills); getting them to move beyond individualistic thinking to sociological thinking. Asking them to explore questions about how work, school, transportation, community design, and many other aspects of social life contribute to the problem of obesity. We talk about things such as how the occupational structure of society has changed (away from active blue collar to sedentary white collar work), how the cost of living has changed (from the family wage earned by men, to the dual pay-check family), how the layout of communities have changed(from walking friendly to car-essential designs), and so forth.

This summer term (today in fact) one of my students mentioned something, that caused a proverbial light bulb to go on in my mind. She said that kids today don't want to go out in the heat during the summer. She didn't realize that she was bringing up something that represented a change. Indeed she pronounced this as if it were an unchanging element in American life: indoors was always cooler than outdoors during the summer. I immediately recognized that the relative comfort of indoors and outdoors during the summer months is something that has changed drastically in the past 50 years, and could be an important missing piece of the puzzle for understanding the development of the obesity epidemic during that time.

Practical home air conditioners were developed in the late 1920's, but until forty ago, air conditioning was extraordinarily rare in homes. It wasn't until the early 1970's that air conditioning reached more than fifty percent of American homes (by 1978, only 45 percent of American homes did not have air conditioning). In the 1950's only the most affluent had air conditioning. Even fans, which were made of metal and relatively more expensive were not within the reach of many people.

The need for air conditioning of course varies geographically, but in much of the U.S., sweltering summer heat and humidity forced people, and especially children, out of doors, to seek summer breezes and shade and cooling sources of water. I spent part of many childhood summers in Virginia and a vivid part of those childhood memories is smothering damp heat, and the various ways we attempted to stay cool, with cool drinks and splashing in water (lawn sprinklers, wading pools, creeks and streams). Riding bicycles, roller skating, even running around in the shade of the back yard was cooler than sitting still inside.

The heat and humidity affected how we cooked and ate. Few people wanted to heat up the house even more by using their ovens for extended periods. One also felt less like eating a heavy meal on the hottest days. Of course, in addition to air conditioning, the microwave has changed how we view summer cooking.

Air conditioning has made the indoors far more attractive than the outdoors during the summer for scores of Americans. Coupled with an explosion in fun things to do indoors (computers, video games, Tivo, DVD's) and with the ability to easily microwave highly processed meals and snacks, it is not surprising that there has been a dramatic increase in the prevalence of obesity in America.

smoking up the joint - in Kentucky

One day during this past fall term, I stepped into the elevator at work, and was nearly overcome by the stench of cigarette smoke. Since smoking is prohibited in all state buildings, including college buildings, I wondered if someone had been smoking in the parking garage (also not allowed, but not enforced on our campus), next to the elevator access door.

I mentioned the smell to one of our staff. He explained the source of the problem. The majority of the students in our respiratory care program smoke, and when they get their short breaks, they rush, en mass, from their third floor classroom, to the elevator and step outside the building, where they fire up their smokes for 10 minutes, and then at the last minute cram themselves back in the elevator carrying the putrid smell with them.

I have always found it disturbing that such a high percentage of our students smoke, and that every break between classes is a cigarette break. But as an asthma sufferer, I find it obscene that the majority of our respiratory care students are smokers. These are the people who hope to be entrusted with the care of people who suffer from breathing disorders.

Kentucky ranks number 1 in the percentage of adults who are smokers. More than 28 percent of Kentuckians smoke (2007 CDC report) . A study done in 1999-2000 found that 23 percent of pregnant women in Kentucky smoked. Though I have no hard data, I'm certain that both figures are higher in eastern Kentucky than in the urban portions of the state.

The political power of tobacco interests and smokers in Kentucky shows in the low cigarette taxes; only 30 cents per twenty-pack in 2008, lower by at least half compared to all but one of the state surrounding Kentucky. Other evidence of political power: the state of Kentucky has declared smokers a "protected class," and it is illegal to discriminate against smokers in employment and education (Cincinnati Enquirer October 22,2008), despite the well documented fact that smokers are more expensive employees than non-smokers. They are more likely to be absent, their medical costs are higher on average, and they always seem to be out taking a smoking break when you need them.

It seems more than reasonable to me that being a non-smoker should be a requirement for entry into certain fields of employment -- respiratory therapy being one of those. If nothing else, allied health programs (nursing, respiratory care, radiography, physical therapy assistant, and so forth) ought to put a high priority on developing "quit smoking" programs for their students. Many medical facilities, even in Kentucky, are creating smoke free campuses; that is they are eliminating smoking not only in all their buildings, but in all the outside areas between the buildings. Imagine being some one who smokes a pack or more a day, and discovering that in your job at a hospital or medical complex that you have to walk a block or more, and then stand on a busy public street in order to smoke. The Appalachian Regional Hospital (ARH) chain that serves eastern Kentucky has not yet moved in the direction of smokeless campuses, but not all graduates of allied health programs in eastern Kentucky will remain in the region.

Kentucky needs to consider raising cigarette taxes as well. It makes good health policy and would provided needed revenue.

Open Letter to Barack Obama

Please do not write off eastern Kentucky and the rest of central Appalachia. There have been two excellent pieces in the last few days, by West Virginian dawnt on the daily kos and by Dee Davis of Whitesburg, KY on Salon.com about the need for Obama to include central Appalachia in any campaign for the presidency. Both writers explain why it is a huge mistake to write off this region of the nation. Appalachians can be won over. We just have to be asked -- in person -- for our support.

Appalachians are the last American ethnic group that it is socially acceptable to negatively stereotype. While I'm not suggesting that no basis exists for some of the stereotypes, the stereotypes blind people (inside and outside the region) to the reality of the rich human tapestry here.

Folks living here in Appalachian include affluent business owners, educated professionals, solid middle class white collar workers, technical and health care workers, hard working skilled blue collar workers, dedicated factory workers, minimum wage workers who scramble to make ends meet for their families, retired folks on social security, and poor folks on SSI and temporarily on welfare. Yes, the percentage of elderly, disabled, and poor are higher here than suburban America, but they are not the majority.

We may live in "hollers," and the red-lining practices of banks may make manufactured housing ("trailers") easier to obtain than "built" houses, but folks here lavish care on their homes as much (or maybe more) than folks anywhere. [All photos are of homes in my "holler" in Hemphill].

People in Appalachia care about the same issues as other Americans: Health care, the economy (jobs and prices), the war in Iraq, the environment. In fact, I would argue that each of these issues is even more important to us here, since there are fewer jobs that provide health insurance, lower median incomes mean that economic uncertainties hit harder, a higher percentage of our young people are likely to enlist, and the nasty consequences of strip mining have immediate impacts on us here.

One of the most damaging stereotypes that has been brought up in this election is of Appalachians as racist. Sure there are racist folks here, as there are in Chicago, Philadelphia, New York, Washington, D.C., Eugene, Oregon, etc. But there are also African Americans who live and work peacefully along side whites in Appalachia. There may not be many African Americans in eastern Kentucky, but there also aren't any ghettos in eastern Kentucky. In Letcher County, there are black teachers, administrators, sanitation workers, surgeons, ministers, housewives, coal miners, secretaries, and many other occupations.

Moreover, being a lower income region, a very higher percentage of the physicians in this region are from the middle east and the Indian subcontinent (and many of whom are Muslim and Hindu). A brief perusal of the physicians listed in this region includes names like Ahmed, Alam, Alchureiqi, Ali, Ambalavanan, Appakondu, Bajwa, Chandarana, Chandrasheker, Chaturvedi, Garimella, Guindi, Gutti, Ghazal, Khater, Khouzam, Mehrpouyan, Mohmand, Narola, Pampati, Paliwal, Podapati, Quddus-Roopani, Rahman, Sahay, Singh, Abubakar Tidal, Valavalkar, Yalamanchi. These are highly respected members of the professional community. For example, folks around these parts swear by Dr. Tidal. I can't even begin to count the number of times in the past 12 years, that one of my students has said started a sentence with "Dr. Tidal says..." Until I did this little search for this post, I had no idea that Dr. Tidal wasn't an native born American of European descent.

I believe that most folks in Appalachia would welcome Barack Obama if he'd just take the time and come and visit with us face-to-face. We like to judge people as individuals, on their character, but we're folks who want to make those judgments in person. We need to see and talk to folks to decide whether or not we trust them. We don't like to depend on media images or stereotypes.

The calvary is coming...

...so declares a new sign by the outpost of the striking Kentucky Nurses Association (KNA) in front of the Whitesburg hospital of Appalachian Regional Healthcare system .

I didn't get to stop and ask who the calvary might be, but this week's article in the Lexington Herald-Leader suggests that the calvary might be "a federal mediator and state officials" who have been instrumental in restarting negotiations between ARH and the KNA.

Six weeks ago when the strike began, ARH took a hardline stand, refusing to continue negotiations and announcing that they would begin immediately to hire permanent replacements for the striking nurses.

This week's article provides another hint about why ARH might be willing to temper their hardline stand and resume the negotiations. The precise numbers are in dispute (depending upon whether you are reading the KNA site, the ARH site, or the Herald-Leader), but approximately 750 registered nurses are involved in the dispute, of which about 600 have refused to cross the picket line. Some 150 to 175 union nurses have violated the picket line and continued to work. ARH has permanently replaced another 125 striking nurse positions.

It's not hard to see that this leaves ARH with at least 450 registered nurse positions that are unfilled. One wonders how ARH ever imagined that they could replace the striking nurses in today's employment market. They acted as if they had not heard there was a nursing shortage. Or perhaps they merely hoped that time, cold, lack of income, and the threat of replacement would soften the KNA resolve.

The real jobs for the twenty-first century!

On Monday this week, my Kentucky Community and Technical College System newsletter carried a story from Inside Higher Education entitled "University Training in the Skilled Trades" by Elizabeth Redden.

West Virginia University recognizing from their own difficulties in hiring skill trades workers (including carpenters, electricians, heating, ventilation and air conditioning mechanics, and plumbers) decided to create their own four year "apprenticeship program [that] pairs each apprentice with a mentor, and includes 1,600 hours of on-the-job training per-year and 145 annual hours of classroom training (to be conducted through a combination of classes at a local technical college, distance education and instruction from West Virginia staff)." Redden points out that West Virginia is hardly alone in this, "the University of Virginia...just celebrated its 25th anniversary for its apprenticeship program in July [2007]."

Many colleges across the country are facing difficulties in recruiting and hiring skilled trades workers, a situation, likely to increase as large numbers of skill workers move into retirement in the next decade.

The key element of the programs that Redden discusses is the apprenticeship. The lack of apprenticeship opportunities is one of the major stumbling bottlenecks in the development of a new generation of skilled workers, as there must be employers willing to employ apprentices and provide appropriate supervision for them over a period of several years.

While most Kentucky Community and Technical Colleges provide training for electricians, plumbers, carpenters, and HVAC workers, only one college in the system -- Jefferson CTC -- has apprenticeship programs and only in carpentry and millwright work. Other KCTCS programs appear to stop short of apprenticeship, providing at most preparation for the journeyman examinations such as in plumbing.

Skilled trades jobs will never be outsourced to India or China. They require workers to be physically present. There will always be a need for carpenters, millwrights, plumbers, electricians, masons and bricklayers, gardeners and landscape specialists, and auto repair workers in the American economy. Yet Kentucky community and technical colleges seem to be more interested in producing exactly the kind of worker whose job will be outsourced -- the digital worker. Certainly every 21st century worker, including or even perhaps especially those in the skilled trades, needs to be technologically savvy and have strong computer skills. But it is a serious mistake to focus on the kinds of technology (e.g., programming) and office (e.g., medical transcript) jobs that are already being outsourced to India.

The allied health professions are a focus of Kentucky community and technical colleges, and appropriately so. Nursing, radiography (unlike radiology), and respiratory therapy cannot be outsourced. These health care workers have to be physically present with the patient, wherever that patient may be.

The skilled trades do not hold the allure and status of allied health professions, but they do promise as good or better job opportunities, and should not be overlooked. More energy needs to be invested in developing business partnerships and apprenticeship opportunities in the skilled trades. Why let universities (like West Virginia and Virginia) take over the historical mission of community and technical colleges? Community colleges in other states (such as Michigan and Wisconsin) have far more extensive apprenticeship programs. KCTCS wants to be the very best community college system in the nation, here's an opportunity!

Treatment of Nurses Supports Social Conflict Theory

I have a deep rooted respect for nurses. Three of my father's sisters were nurses. They provided frontier (horseback) nursing services in Appalachia, served as military nurses in World War II, and in civilian hospitals for decades after the war. In my generation on my father's side both of my female cousins became nurses.

Nurses form the first line of defense in our health care system. When we visit the doctor's office a nurse is the first health care practitioner we meet, and often the one that interacts with us the most. When we enter the hospital the majority of our care comes from nurses.

The training for nurses is challenging and demanding. I know because I observe it happening in my own college. Not everyone has the intellectual ability or the emotional stamina to become a nurse.

There is a documented shortage of nurses in this country. One that gets worse with each passing year.

So we have an occupation that provides an extremely important, valuable service (function) for society, which also requires extensive training that not just anyone can do, and there is a demonstrable shortage in this valued occupation. Structural-functional theory in sociology (Davis and Moore "Some Principles of Stratification") would suggest that nursing should be a highly rewarded (both in monetary terms and in a wide range of benefits), and highly regarded occupation. If structural-functional theory were correct, nurses should be able to write their own ticket when it came to pay and working conditions.

Not being a big fan of structural-functional theory, it doesn't surprise me that the theory fails to accurately reflect the real world treatment of nurses.

This week, in the Appalachian region, more than 650 registered nurses in the Appalachian Regional Healthcare System are on strike when their contract ended and negotiations failed to produce a new contract. While pay is an issue in the contract dispute (the offered 2% raise would be entirely swallowed up by increased cost of health insurance and decreases in holiday pay), the nurses greater focus is on the issues of benefits and staffing/work schedules.

The new contract ARH put forward, offered the nurses "flexible" scheduling -- it offered the the choice (!!??) of 10 hour shifts or 12 hour shifts. ARH nurses are required to work overtime, every week. Overtime is a mandatory condition of all ARH nursing positions.

The practical result makes it common for the actual nurses shift to be 15 hours, and 24 hour shifts happen all too often. Not only are nurses stretched thin in overly long shifts, but they are covering greater numbers of patients during those shifts. These conditions are not only draining the nurses, but they compromise the levels of care that are provided. A Lexington Herald-Leader article on the strike provided comments from a number of the striking nurses such as:

Lynn Hall, who has been a nurse at McDowell for 16 years, said she is the only person who works in the hospital's four-bed intensive-care unit.
"I don't even have someone to help answer the phone," she said. "It's just the opposite of the way it should be. A hospital should strive to have nurses with high morale, instead of walking out with tears in your eyes because you couldn't do it all."

The ARH response to all this? They aren't even trying to negotiate. They have already started looking for permanent replacements, while in the short run they bus in nurses from temp agencies. Nothing could make it clearer that the occupational realm is one governed by conflict and power, with the hospital administration holding most of the cards. The nurses recognize, but regret the struggle.

"Still, Hall and the other nurses said they would rather be working than striking.
"We don't want to be here," Tanner said. "We tried not to be here. We just want to negotiate the rest of our contract."

The only hope the nurses have is support from the general public. Unfortunately most people in eastern Kentucky have few choices. For those who do, consider taking your medical business else where, to hospitals and clinics where the nursing staff is treated more fairly and with the respect they deserve.

Shortage of Rheumatologists

In December 2006, just before New Years, my primary care physician ordered up some blood tests for me. I seemed to be in pain all the time, all my joints hurt, and I was exhausted everyday. I'd get home from work at 6:00 PM and just sit in the car for another twenty minutes trying to summon up the energy to walk into the house. Right after New Years she called me with the results. The tests indicated the possibility of rheumatoid arthritis. Since the blood tests for RA are not definitive, I would need to see a rheumatologist for a history and physical exam. That's when I learned that the closest rheumatologist was a 1 hour drive away (the closest!!) and that no matter how far I was willing to drive it would take at least three months before I could get an appointment. In fact, it turned out to be four months. Whenever I talked to anyone about it, I would joke that there must be a shortage of rheumatologists, and that if they knew anyone in medical school they ought to pass on the word.

I finally got my appointment -- in April -- and was diagnosed as being in the early stages of rheumatoid arthritis, and began medication. This past week I had my second follow-up visit, and while I was waiting in the waiting room (so aptly named), I picked up a copy of Arthritis Today Magazine put out by the Arthritis Foundation. The issue was only a few months old, and the cover story was "The Rheumatologist Shortage". It was one of those "ah-ha!" moments when I find the data to support one of my gut feelings or pet theories.

The story of the rheumatologist shortage, places in bold relief some of the problems inherent in our patchwork private/public/profit/non-profit medical care system in the United States.

Rheumatology is a specialty whose number of practicianers are steadily declining, and whose number of patients are steadily increasing. According to the article: "Currently, 46 million people have had a doctor tell them they have a form of arthritis, such as osteoarthritis (OA) or RA, or a related condition, such as lupus, gout or fibromyalgia. Within 25 years, as the over-60 population peaks, that number is expected to reach 67 million." On the supply side, the article states: "The ACR [American College of Rheumatology] Workforce Study estimates about half of practicing rheumatologists will retire within just eight years, and that by 2025 there will be a shortage of 2,600 rheumatologists in the U.S."

There have been enormous strides in the development of new medicines for rheumatoid arthritis -- you've probably seen the ads on television for Humira or Enebrel or Remicade. The problem, there are not enough rheumatologists available to get these drugs to the people who need them. It doesn't matter how wonderful the treatments are, if there is no one available qualified to prescribe the treatment.

So why is there this shortage? You'd think with such high demand, there'd be people clamouring to go into the field. There are several interacting causes, discussed in "The Rheumatologist Shortage". After completing medical school, the physician aspiring to the field of rheumatology must spend three years as an internal medicine resident and then another two or three years completing a fellowship in the sub specialty of rheumatology. This is a some what longer period of training that some other specialties, although there are others that are more popular that take more years. The biggest catch is the fellowship requirement. First there has to be a full-time faculty member in that specialty to supervise the fellowship, and with declining numbers of rheumatologists these are harder to find. Second, there has to be funding for the fellowship, funding that pays for the salary and benefits of the fellow -- who after all has to have something to live on while he or she is working. There's a shortage of funding for rheumatology fellowships. Arthritis after all does not have the cachet of some other diseases, and has not attracted as much attention or fund raising.

"According to the 2005-2006 ACR study, 395 fellowships were available, but only 366 were filled." Some of the unfilled fellowship slots remained unfilled because there was no money to pay the fellows. Some remained unfilled for the lack of a qualified supervising faculty member. And some remained unfilled because rheumatology, despite its slightly longer training period, is lower paying that other internal medicine specialties. Annual salaries for rheumatologists are about 60 percent of the salaries of specialists in such fields as gastroenterology and general cardiology. When the average physician is burdened with more than $150,000 of debt for his/her education, significant salary differences can be influential in choosing specialties.

In our current medical care system long-term chronic conditions (which require careful monitoring by a physician, but no surgical procedures or other types of treatments other than medication) receive much lower reimbursements from private insurance companies and federal government programs. When the course of rheumatoid arthritis does require surgical intervention (as it often does) a surgeon (not the rheumatologist) reaps the reward of the higher insurance payout. The perversity of this system is that a good job by a rheumatologists in early diagnosis, careful monitoring and supervised drug therapy can make surgery (and its high cost to insurance companies and government) unnecessary.

The shortage of rheumatologists is merely an inconvenience today, it is likely to become a crisis within twenty years, unless something changes in the funding and availability of fellowships and the relative pay for rheumatology practitioners.