Physicians, Nurses, and the Future of Healthcare

The number of people scheduled to obtain some form of health insurance is in the millions. We also have a greater fraction of our population moving into the post-retirement phase of their lives when medical care needs increase. Some have interpreted this situation to mean that this will result in a shortage of doctors. That is the wrong interpretation. We already have too many doctors and our healthcare system is burdened by the need to provide the lofty fees necessary to cover their income demands and the overhead they create. We don’t need more doctors; we need to develop practices that make better use of their skills.

The traditional approach where the patient endures a sequence of 10 minute sessions with a personal physician in his office while the physician tries to figure out what is going on is no longer acceptable. A different form of care is required, particularly for the elderly and those with one or more chronic conditions. These are the people who generate the large medical bills. These patients need a more extended and intense interaction with caregivers than a doctor can provide.

The solution is for as many responsibilities of doctors to devolve to care givers who can spend more time with patients. Just having someone who will verify that patients are following their doctor’s orders would improve efficiency greatly and lower net costs. These workers would have an appropriate level of training for the activities they participate in and they would be paid at a lower level than physicians.

In 2010 the Institute of Medicine (IOM) issued a report studying how nurses might best be used in our evolving healthcare environment. It produced these recommendations:

"Nurses should practice to the full extent of their education and training."

"Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression."

"Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States."

This was clearly a call to allow nurses to assume a greater role. The IOM report also presented evidence of the efficacy of allocating more responsibility to nurses based on experience involving the Veterans Affairs Department (VA) when that agency was faced with a large influx of new enrollees. An article in Modern Healthcare provided this summary:

"In response, the VA moved away from a system of hospital-based acute care and toward community-based delivery emphasizing primary care and chronic-disease management—roles filled by registered nurses and skilled nurse practitioners, the IOM said."

"The result? Studies showed that higher proportions of veterans received appropriate care relative to comparable Medicare enrollees, and spending per beneficiary rose more slowly—30% cost growth for VA patients between 1999 and 2007, compared with 80% for Medicare beneficiaries over the same period, according to the Congressional Budget Office."

This is the path recommended above; it provides better healthcare outcomes at a lower cost.

Since the report was issued pressure has been placed upon nurses to upgrade their educational credentials, presumably in order to assume a more responsible role. Meanwhile, the doctors unions and their lobbyists have been out there trying to suppress competition by limiting the roles available to nurses in hopes of preserving the lofty incomes and privileged positions that doctors have been enjoying.

An article by Shannon Pettypiece in Bloomberg Businessweek, Nurse Practitioners, Doctors in Tug-of-War Over Patients, provides some context.

"Nurse practitioners must complete a master’s or doctoral program in nursing practice—which adds two years or more beyond the four years of school required to become a registered nurse and includes training in diagnosing acute and chronic illnesses, pharmacology, and health-care ethics. Depending on the course of study, they can provide basic primary care or specialize in such fields as pediatrics, women’s health, or cardiology. They do not typically perform surgery or invasive procedures such as colonoscopies or tumor biopsies."

Pettypiece builds the article around the experiences of Christy Blanco, a nurse practitioner who has invested in gaining a nursing doctorate and in setting up a clinic focused on low income women. She has been unable to begin practice because the physicians’ lobby has installed restrictions that require nurse practitioners to have doctor oversight.

"Christy Blanco’s health clinic is sitting empty. A nurse practitioner in El Paso, Tex., Blanco says she has all the necessary equipment and a doctorate in nursing practice that prepared her to perform routine physical exams and treat diabetes, asthma, high blood pressure, and many other common ailments. About 50 miles away in Las Cruces, N.M., dozens of nurse practitioners at clinics like Blanco’s are busy caring for patients. The only difference is that in Texas, nurse practitioners are required to contract with a doctor to sign off on medical charts; the physician must also spend 1 out of every 10 days at the clinic. In New Mexico, no doctor is necessary. "I just want to get started," says Blanco, who’s tried for nearly two years to recruit a physician for her clinic, which will specialize in care for low-income women. ‘I’m trying to work for the poor,’ she says. ‘I’ve spent thousands of dollars of my own money. I have a waiting list of patients, and I have to tell them I can’t practice’."

There are about 155,000 nurse practitioners caught in a battle with physicians over who has access the cash crop of patients.

The situation is made murky by a disparate collection of state laws and restrictions.

"States regulate how much oversight nurse practitioners must have. In 16, including Colorado, New Hampshire, and Washington, they can evaluate and diagnose patients, order diagnostic tests, and prescribe drugs. That means they can start a practice or work out of a clinic with no doctor on staff. The remaining states have a patchwork of regulations. In Florida and Alabama, nurses can’t prescribe certain drugs for pain, insomnia, or attention deficit disorder that are considered controlled substances. In New York, they need a written collaboration agreement with a doctor, and there’s a limit on how many each doctor can work with, effectively creating a cap on the number of nurse practitioners."

Doctors may have political clout, but they have little data to support their arguments.

"Elizabeth Dears, a senior vice president for the Medical Society of the State of New York, said in testimony to lawmakers that removing doctor oversight of nurse practitioners "would seriously endanger the patients for whom they care." This claim, echoed by lobbyists for doctors in other states, is contradicted by at least two high-profile studies. A 2009 report by Rand Corp. found no evidence that nurses provide lower-quality care. A 2010 study of nurse practitioners published by the Institute of Medicine, a division of the National Academy of Sciences, recommended an end to state laws requiring doctor supervision."

The states seem to recognize the lobbying for what it is: an attempt to preserve an unnecessarily high healthcare cost burden on them.

"New York Governor Andrew Cuomo intends to do away with doctor collaboration agreements for primary-care nurse practitioners. Lawmakers in at least 10 other states, including New Jersey and Massachusetts, are considering legislation that would allow them to operate independently."

This is serious business. Our nation is in danger of collapsing under the burden of unnecessarily high medical costs. To fix this, everyone has to do their share—including physicians.

Education and Affluence: Privilege and Burden

Paul Tough focused mainly on disadvantaged children in his book How Children Succeed: Grit, Curiosity, and the Hidden Power of Character. His thesis is that our educational system is narrowly focused on cognitive progress on things that can be measured with a test such as math proficiency or reading comprehension. To be successful in life a student must combine cognitive skills with certain non-cognitive attributes like self-control, conscientiousness, self-confidence, and optimism. No matter how intelligent a student might be, learning to the extent of one’s ability will always be difficult, time-consuming, and subject to failure. The same could be said about succeeding in later life. One requires the persistence and self-confidence to recover from disappointment and keep trying. Many students acquire these non-cognitive skills in their family environment and do well in school and later life. Children from impoverished backgrounds are much less likely to acquire them in their environments. If they are to succeed, these non-cognitive skills must be provided to them as part of their educational experience. Tough provides examples of how this can successfully be accomplished.

Paul Tough’s ideas have been discussed previously in Education: Success, Failure, and Character, and in Poverty and Stress: The Ability of Children to Learn.

Tough also described concerns on the part of some educators that the children of the most affluent might also be lacking in certain necessary non-cognitive skills due to deficiencies in their upbringing. Surprisingly, some of these deficiencies arise in ways remarkably similar to those experienced by the children of the very poor.

Tough describes extended interactions with the staff of Riverdale Country School located in a wealthy area on the fringe of New York City.

"When you visit the school today, what impresses you first is its campus, the largest of any school in the city, twenty-seven rolling acres adorned with stone buildings and carefully tended lacrosse fields....it is the kind of place members of the establishment send their kids so they can learn to be members of the establishment. Tuition starts at $38,500 a year, and that’s for prekindergarten."

It is clear to the staff at schools like Riverdale that they are working for the parents of the students, not for a publicly determined school board. This arrangement can have deleterious consequences.

"Although they would almost certainly not express it this way, wealthy parents choose a school like Riverdale for their children, at least in part, as a risk-management strategy....for a school that has been producing highly privileged graduates for 104 years, it boasts very few real world changers."

There seems to be more focus on producing children who will conform to expectations for the children of the wealthy rather than on producing children who will excel in any given way.

This is the way the meritocracy propagates itself. God help us!

"Traditionally, the purpose of a school like Riverdale is not to raise the ceiling on a child’s potential achievement in life but to raise the floor, to give him the kinds of connections and credentials that will make it very hard for him ever to fall out of the upper class. What Riverdale offers parents, above all else, is a high probability of nonfailure."

This affluent milieu places great pressure on the children to avoid failure, and great pressure on the school staff to help them avoid failure. But isn’t the best lesson a child can learn that failure is something one can recover from and be able to keep trying? Isn’t that the way life works?

These pressures experienced by the children of the affluent are not without effect. Tough reports on the research of Suniya Luthar, a psychology professor at Columbia University’s Teachers College.

Luthar performed a comparison of affluent, white tenth-graders with a cohort of mostly black, low income urban tenth-graders.

"To Luthar’s surprise, she found that the affluent teenagers used alcohol, cigarettes, marijuana, and harder illegal drugs more than the low income teens. Thirty five percent of the suburban girls had tried all four substances, compared with just 15 percent of the inner-city girls. The wealthy girls in Luthar’s survey also suffered from elevated rates of depression; 22 percent of them reported clinically significant symptoms."

In another study in which Luthar followed middle school students over a several year period she reported the following results.

"About a fifth of these high-income students, she found, had multiple persistent problems, including substance use, high levels of depression and anxiety, and chronic academic difficulties."

There seem to be some similarities in the parenting patterns of the very wealthy and the very poor.

"She found that parenting mattered at both economic extremes. For both rich and poor teenagers, certain family characteristics predicted children’s maladjustment, including low levels of maternal attachment, high levels of parental criticism, and minimal afterschool adult supervision. Among the affluent children, Luthar found, the main cause of distress was ‘excessive achievement pressures and isolation from parents—both physical and emotional’."

The issue of substance abuse has arisen in several contexts of late. The use of addictive amphetamines as study aids is said to be prevalent at elite high schools and colleges. The use of addictive prescription pain killers as a means of escaping the tensions and disappointments of real life is also becoming more common.

Poverty can certainly be devastating for a young child. It is somewhat startling to learn that affluence can also be devastating for a child.

Perhaps some good old fashioned income redistribution would deliver each from their demons.

Education: Testing and Conditional Intelligence

Our education systems place a place a great amount of trust in standardized tests of our children. Beginning in preschool, little three and four-year-olds are quizzed and graded. Based on those tests, educators make grand conclusions about the intelligence and life prospects of the child. In Education: The Danger in Testing Five-Year-Olds we discussed some extremes to which this trend could be taken. We quoted from an article by Stephanie Simon:
"A national push to make public schools more rigorous and hold teachers more accountable has led to a vast expansion of testing in kindergarten. And more exams are on the way, including a test meant to determine whether 5-year-olds are on track to succeed in college and career."

The idea that such a determination could be made for a young child on the basis of a test is rather disturbing considering that the SAT and ACT tests that graduating high school seniors take are not all that good at predicting college success. Could it be that we have mistakenly placed too much faith in the products of educational marketers? Could it also be that children are malleable, complex entities whose attributes cannot be assessed by merely inserting a dipstick?

Paul Tough, in his excellent book How Children Succeed, suggests that assessing a child’s capabilities is not a simple task.

The basis for most testing of children is the belief that cognitive capabilities have already been established and they are measurable. To address that issue, Tough reports on what is referred to as the M&M candy study. Back in the 1960s a researcher named Calvin Edlund collected a group children aged five to seven from mostly lower economic classes.

"The children were randomly divided into an experimental group and a control group. First, they all took a standard version of the Stanford-Binet IQ test. Seven weeks later, they took a similar test, but this time the kids in the experimental group were given one M&M for each correct answer. On the first test, the two groups were evenly matched on IQ. On the second test, the IQ of the M&M group went up an average of twelve points—a huge leap."

Should we be surprised that the test performance of children depends on some mixture of capability and motivation? Must we conclude that the intelligence test has an uncertainty of at least 12 points? Can we not tell the difference between above average and below average intelligence?

Tough also alerts us to another test-confounding phenomenon: stereotype threat.

"If you give a person a subtle psychological cue having to do with his group identity before a test of physical or intellectual ability....you can have a major effect on how well he performs."

If you tell a black student that a test is designed to measure intellectual capability and cause him to be reminded that some believe blacks are less intelligent than whites, he will tend to do less well on the test than the black student who was not so prompted. If a girl is reminded that girls are not expected to be as good at math as boys, then she will tend to do less well than if she had not been prompted it that manner.

The notion that prejudice can become prophecy is truly disturbing.

An article by Annie Murphy Paul in the New York Times elaborates on the notion that intelligence and social context are intertwined.

"Mr. Aronson, an associate professor at New York University, has been a leader in investigating the effects of social forces on academic achievement. Along with the psychologist Claude Steele, he identified the phenomenon known as "stereotype threat." Members of groups believed to be academically inferior — African-American and Latino students enrolled in college, or female students in math and science courses — score much lower on tests when reminded beforehand of their race or gender."

"It’s just one example of the powerful influence that social factors can have on intelligence. As parents, teachers and students settle into the school year, this work should prompt us to think about intelligence not as a ‘lump of something that’s in our heads,’ as the psychologist Joshua Aronson puts it, but as ‘a transaction among people’."

"The evolving literature on stereotype threat shows that performance is always social in nature. Even alone in an exam room, we hear a chorus of voices appraising, evaluating, passing judgment. And as social creatures, humans are strongly affected by what these voices say."

Fear of confirming a stereotype is not the only social issue that can affect test performance.

"In a 2002 study led by Roy F. Baumeister, a psychologist now at Florida State University, participants were given an I.Q. test and then a personality inventory. Some of the participants were randomly selected to receive false feedback from the personality inventory, informing them that they were ‘the sort of people who would end up alone in life’."

"The participants then took another test. Those who had been told they would be loveless and friendless in the future answered significantly fewer questions correctly than on the earlier test."

If concern about social exclusion can render one less "intelligent," what about the physical fear that children living in high crime areas or in dysfunctional families experience?

"If the threat of social exclusion can decrease the expression of intelligence, so can a perceived threat to physical safety. It’s common to blame disadvantaged children’s poor academic performance on their ‘environment.’ By this we usually mean longstanding characteristics of their homes and neighborhoods. But research on the social aspects of intelligence suggests that much more immediate aspects of kids’ surroundings can also affect their I.Q.’s."

"In a study conducted on the troubled South Side of Chicago, for example, students whose neighborhoods had been the site of a homicide within the previous two weeks scored half a standard deviation lower on a test of intelligence."

Paul concludes with some advice for how we should treat our children in our schools.

"This research has important implications for the way we educate our children. For one thing, we should replace high-stakes, one-shot tests with the kind of unobtrusive and ongoing assessments that give teachers and parents a more accurate sense of children’s true abilities. We should also put in place techniques for reducing anxiety and building self-confidence that take advantage of our social natures. And we should ensure that the social climate at our children’s schools is one of warmth and trust, not competition and exclusion."

This advice from Paul may seem a bit extreme given that what she suggests is counter to all current practices that have taken root in our education system. However, we do have an example of a school system that follows exactly the path Paul recommends. It is an important example because it is a school system that the United States recognizes as providing more successful educational outcomes.

Whenever comparison tests of math and science proficiency between students from a variety of countries are taken, Finland’s students perform among the best, while the United States’ students end up in the middle of the pack.

Finland’s children receive education in non-cognitive skills such as curiosity, self-control, self-confidence, and conscientiousness while learning how to socialize with other children. This process goes on until age seven. It is only at that age that they begin to introduce academic subjects such as math and reading. Their children are never given standardized tests before they reach an age equivalent to our high school. And their children are never separated into groups labeled fast learners and slow learners.

There appear to be a number of ways to produce good academic results. Perhaps we should try one.

The current dependence on testing to justify all things is foolish and dangerous. The notion that all learning depends on the quality of the teacher, and the teacher’s competence can be measured by student test results, ignores the role of the student in the process. Teachers can teach, but students must do the learning. As Paul Tough recommends, we should focus more on providing the students with both the cognitive and non-cognitive skills they need to succeed rather playing a blame game with teachers and focusing entirely on cognitive skills.

Poverty and Stress: The Ability of Children to Learn

Those who study the data on the academic attainment of our children must inevitably conclude that poverty is a factor in determining whether an individual child is likely to be successful. Given that knowledge, what does one do about it? How can one provide better educational outcomes for children who live in poverty? Most often the response is to provide more of what seems to be successful with advantaged children, but the results have been disappointing. Could there be an association with poverty that is deeper, more fundamental, and more complex than we have imagined? That is the thesis Paul Tough presents in his book How Children Succeed: Grit, Curiosity, and the Hidden Power of Character.

Tough’s story begins with a remarkable study performed by Kaiser Permanente in the 1990s. This health maintenance organization began surveying members with a focus on gathering information on traumatic childhood experiences. The information collected could then be correlated with the organization’s medical records for the survey participants. The results were tabulated for a large group that was representative of the middle class rather than having any particular association with issues of poverty. The results were published in a paper written by Vincent Felitti and Robert Anda under the title The Relationship of Adverse Childhood Experiences to Adult Health: Turning Gold into Lead. This work is commonly referred to as the ACE study with the acronym representing "adverse childhood experiences."

The first revelation from the study was the frequency of childhood trauma.

"More than a quarter of the patients said they had grown up in a household with an alcoholic or a drug user; about the same fraction had been beaten as children. When the doctors used the data to assign each patient an ACE score, giving them one point for each category of trauma they had experienced, they found that two-thirds of the patients had experienced at least one ACE, and one in eight had an ACE score of 4 or more."

When correlations were made between the results of the survey and the health outcomes of the patients, startling results were obtained.

"The correlations between adverse childhood experiences and negative adult outcomes were so powerful that they ‘stunned us,’ Anda later wrote. What’s more, those correlations seemed to follow a surprisingly linear dose-response model: the higher the ACE score, the worse the outcome on almost every measure from addictive behavior to chronic disease."

We are used to thinking that social and emotional problems can lead to unhealthy lifestyles that can cause enhanced probability for disease, but there is more going on than that.

"When they looked at patients with high ACE scores (7 or more) who didn’t smoke. didn’t drink to excess, and weren’t overweight, they found that their risk of ischemic heart disease (the single most common cause of death in the United States) was still 360 percent higher than those with an ACE score of 0."

The conclusion that was reached by the authors and subsequent researchers was:

"The adversity these patients had experienced in childhood was making them sick through a pathway that had nothing to do with behavior."

Researchers have since concluded that the villain in this story, the one that causes physical and mental damage to bodies, is the response to stress that evolution has developed in our bodies. For most of our evolution stress was associated with life or death situations. The appropriate response in that case is to max out all possible reactions to a threatening situation. Unfortunately for modern humans, stress has become frequent, often long and drawn out, and sometimes chronic. A response system designed to be life saving, can be life threatening if over used.

"Our bodies regulate stress using a system called the HPA axis. HPA stands for ‘hypothalamic-pituitary-adrenal’....when a potential danger appears, the first line of defense is the hypothalamus, the region of the brain that controls unconscious biological processes....The hypothalamus emits a chemical that triggers receptors in the pituitary gland; the pituitary releases signaling hormones that stimulate the adrenal glands; and the adrenal glands then send out stress hormones called glucocorticoids that switch on a host of specific defense responses."

Some of these responses are apparent to us such as higher blood pressure and a faster heart rate. Others are less observable to us:

"....neurotransmitters activate, glucose levels rise, the cardiovascular system sends blood to the muscles, and inflammatory proteins surge through the bloodstream."

The burden this stress response places on the body is referred to as alostatic load. Too high an alostatic load:

"....especially in infancy and childhood, produces all kinds of serious and long-lasting negative effects—physical, psychological, and neurological."

How does this specifically relate to poverty and learning? Being poor is not detrimental in itself, but poverty makes it likely that children will experience more frequent and more intense stressful situations. Physical, sexual, and emotional abuse become more likely. Physical security and emotional security are often at risk. Not knowing where your next meal will come from can definitely be stressful.

Those who study the physiology of stress have learned that the prefrontal cortex is the part of the brain most susceptible to damage in children subjected to abnormal amounts of stress.

"The part of the brain most affected by early stress is the prefrontal cortex, which is critical in self-regulatory activities of all kinds, both emotional and cognitive. As a result, children who grow up in stressful environments generally find it harder to concentrate, harder to sit still, harder to rebound from disappointments, and harder to follow directions. And that has a direct effect on their performance in school."

Tough refers to these "self-regulatory activities" controlled by the prefrontal cortex as "executive functions." He does not view the fact that these processes have been compromised in many poor children as the end of the story.

"The reason that researchers who care about the gap between the rich and the poor are so excited about executive functions is that these skills are not only highly predictive of success; they are also quite malleable, much more so than other cognitive skills. The prefrontal cortex is more responsive to intervention than other parts of the brain, and it stays flexible well into adolescence and early adulthood. So if we can improve a child’s environment in the specific ways that lead to better executive functioning, we can increase his prospects for success in a particularly efficient way."

Tough provides examples where disadvantaged children with poor early educational experiences were converted into productive students with potentially bright futures. He emphasizes that the rehabilitation of these children’s educations requires not just better approaches to subjects like math and reading comprehension, but it also requires a conscious effort to help students attain greater control of these executive functions.

What matters most in a child’s development....is not how much information we can stuff into her brain in the first few years. What matters, instead, is whether we are able to help her develop a very different set of qualities, a list that includes persistence, self-control, curiosity, conscientiousness, grit, and self-confidence. Economists refer to these as noncognitive skills, psychologists call them personality traits, and the rest of us sometimes think of them as character."

Further discussion of Tough’s book and the subject of enhancing the performance of disadvantaged children can be found in Education: Success, Failure, and Character.

Education: Success, Failure, and Character

Paul Tough has written a book that should cause all those arguing the rights and wrongs of school reform to stop and reconsider. The focus of most advocates of reform has been on the development and measurement of cognitive skills that are quantifiable, such as reading comprehension and mathematics. The goal seems to be to take children as early as possible and begin drilling them on these topics. It is assumed that with good teachers, students will have a satisfactory learning experience. However, Tough reminds us that teachers can only teach. It is the students who must learn, and we cannot assume they are blank slates just waiting to be written upon.

Paul Tough’s book is titled How Children Succeed: Grit, Curiosity, and the Hidden Power of Character. He discusses a growing body of evidence that suggests the path to educational attainment is much more complex a process than merely cramming facts and figures into developing young minds.

"....in the past decade, and especially in the past few years, a disparate congregation of economists, educators, psychologists, and neuroscientists have begun to produce evidence....What matters most in a child’s development, they say, is not how much information we can stuff into her brain in the first few years. What matters, instead, is whether we are able to help her develop a very different set of qualities, a list that includes persistence, self-control, curiosity, conscientiousness, grit, and self-confidence. Economists refer to these as noncognitive skills, psychologists call them personality traits, and the rest of us sometimes think of them as character."

Tough argues that learning is a difficult process for all children, no matter how fundamentally intelligent they might be. If they are to perform up to their potential, it will be necessary that they possess the characteristics he has listed above.

He makes his point in a number of ways. For example, he points out that the SAT and ACT tests were devised in order to allow colleges to assess the probability of student success no matter where the student was educated. Prior to these standardized tests being available, the only data generally available on students were GPA (grade point average) and teacher recommendations. The colleges worried that they would be unable to compare students from affluent urban areas with those from poor rural areas, for example. The SAT and ACT tests measured cognitive qualities: intelligence and prior education. Presumably, they do a good job of that. But do these tests determine who is best suited to perform well in college?

Tough reports on a study described in Crossing the Finish Line: Completing College at America’s Public Universities by William G. Bowen, Michael S. McPherson, and Matthew Chingos.

"The authors....discovered that the most accurate predictor of whether a student would successfully complete college was not his or her score on the SAT or the ACT, the two standardized college admissions tests. In fact, it turned out that, except at the most highly selective public universities, ACT scores revealed very little about whether or not a student would graduate from college. The far better predictor of college completion was a student’s high school GPA."

The conclusion to be drawn is that it is easy for a bright student to score well on an isolated test, but in order to generate a high GPA, he/she must be willing and able to apply themselves diligently over a long period of time while negotiating the depressing setbacks, delightful distractions, and complex social interactions of adolescence. In order to attain a lofty GPA a student must exhibit the attributes that Tough refers to as character. And that seems to be quite important in college performance.

Tough also delves into the experiences of the KIPP (Knowledge is Power Program) schools in trying to produce students who are able to perform well on standardized tests and also able to succeed in later life after they have left the KIPP environment. The KIPP charter schools accept middle school students from disadvantaged backgrounds via a lottery system. The purpose of the lottery is to avoid selecting only the most promising of the potential students. The KIPP approach was very successful at producing children that performed well academically.

"....[KIPP’s] formula seemed to have worked, and remarkably quickly: in the eighth-grade citywide achievement test in 1999, the students of KIPP academy earned the highest scores of any school in the Bronx and the fifth highest in all of New York City. Those scores—unheard of at the time for an open-admission school in a poor neighborhood....."

What the KIPP leaders learned over time is that the academic lessons and training they were providing their students was insufficient to enable them to attain their academic potential. The students who excelled in graduating to high school were referred to as the Class of 2003 for the year they would be entering college.

"Almost every member of the Class of 2003 did make it through high school, and most of them enrolled in college. But then the mountain grew steeper. Six years after their high school graduation, just 21 percent of the cohort....had completed a four-year college degree."

This performance was unacceptable, and inconsistent with the early achievements of the students. After much soul searching, the KIPP people concluded that the students they were training were being sent out into the world with only a fraction of the tools they would need to succeed. They had been focusing on cognitive results, but the results indicated that once the students left the KIPP support system they did not necessarily possess the noncognitive tools they needed to succeed.

The traits that KIPP believed it needed to focus on were:

grit
self-control
zest
social intelligence
gratitude
optimism
curiosity

The schools and the teachers set out in enhance these characteristics in their students. They went so far as to begin issuing two report cards to students: one for academics, and one for "character."

KIPP has a goal of a six-year graduation rate of 75%. Since this new focus was established the college graduation number has improved.

"....the six-year graduation rate had gone up from 21 percent for the Class of 2003....to 46 percent for the class of 2005."

The personality traits that KIPP is trying to generate are usually developed in early childhood. Research indicates that the quality of that experience for the child is important in determining the characteristics of the child. In particular, it appears to be critical that the child grow up in a relatively stress-free environment where it can feel secure and have at least one person to which it can form a strong and comforting attachment. This is precisely the type of environment that is difficult to attain for children who emerge from endemic poverty. Perversely, it seems that this type environment might also be difficult to attain for the children of the very affluent.

KIPP, and others who have come to the same realization, seem to be on the right track now. Sadly, decades have been wasted following the wrong approaches. The most important thing to take from this discussion is that these traits that are necessary for success can be developed and improved even into adolescence.

Teachers can only teach; students must do the learning. Let us focus on helping the students directly and stop blaming everything on the teachers.

Nuclear Warheads: How Low Can We Go?

If there is a positive side to the insanity known as sequestration, it will be the forced reductions in defense spending. It is long past time to perform a thorough reevaluation of priorities given the changed fiscal situation and changed world in which our military finds itself. Nowhere is such a reevaluation more needed than in our nuclear weapons posture. We are now well into the third decade since the justification for our nuclear policies became null and void, yet we persist in proceeding as if little has changed.

President Obama is on record as wishing to leave office with the world placed on a path towards a zero nuclear weapon future. There is no better time than right now to initiate some movement in that direction. An article by David E. Sanger in the New York Times suggests that such a move is being contemplated by the president.

"....White House officials are looking at a cut that would take the arsenal of deployed weapons to just above 1,000. Currently there are about 1,700, and the new strategic arms reduction treaty with Russia that passed the Senate at the end of 2009 calls for a limit of roughly 1,550 by 2018."

"But Mr. Obama, according to an official who was involved in the deliberations, ‘believes that we can make pretty radical reductions — and save a lot of money — without compromising American security in the second term. And the Joint Chiefs have signed off on that concept’."
 "Among the most outspoken advocates of a deep cut has been a former vice chairman of the Joint Chiefs of Staff, Gen. James E. Cartwright, whom Mr. Obama continues to turn to on strategic issues. General Cartwright has argued that a reduction to 900 warheads would still guarantee American safety, even if only half of them were deployed at any one time."

If the dual goal of saving money and making the world a safer and saner place is to be reached, then the civilian components as well as the military components of the nuclear weapons industry must be addressed.

"Mr. Obama is already moving quietly, officials acknowledge, to explore whether he can scale back a 10-year, $80 billion program to modernize the country’s weapons laboratories. "

"The White House agreed to the spending on the weapons labs as the price of winning Republican votes on the new Start three years ago, but one senior defense official said late last year that ‘the environment of looking for cuts in the national security budget makes this an obvious target’."

The question of how many nuclear warheads we can get rid of is inseparably intertwined with the history of the nuclear weapons program. While the generals tried mightily to conjure up a nuclear war-fighting posture, tactical weapons have always been an expensive and unloved component of their arsenal. It was the standoff with the Soviet Union over strategic forces known by the chillingly appropriate term MAD (mutual assured destruction) that preoccupied our military planners decades ago, and still does to this day.

The logic behind MAD was that each side would have sufficient nuclear weapons, even after a first strike by the other side, to annihilate the enemy in a counterattack. This strategy was unconditionally unstable as each side was encouraged to produce more weapons and more difficult-to-kill weapon systems. If long range bombers were the original weapon of choice, greater survivability was gained by adding long range, and increasingly more accurate intercontinental ballistic missiles (ICBMs). Perhaps the greatest technical achievement was the addition of a third arm, the sea launched ballistic missile. Each improvement in capability was matched by the other side. Each new technical development could be viewed by the opponent as an attempt to upset the equilibrium and attain a viable first strike capability. The burden of this arms race eventually convinced both sides of the need to limit the number of warheads and delivery systems to what was needed to maintain the equilibrium provided by MAD. This occurred in the SALT (Strategic Arms Limitation Talks) agreements (see chart below). With the demise of the Soviet Union both sides agreed on the necessity to continue to wind down their arsenals.

The next level of capability under MAD logic would be the development of an anti-ballistic missile (ABM ) defense system. Ronald Regan wasted a lot of money on systems doomed to fail under his presidency, but war fighting planners have long wished for such a system. Given the state of cooperation between Russia and the US, the implementation of such a scheme could easily be taken as an attempt to game the system and threaten the other with a potential first strike that could not be effectively countered. Such a system was forbidden under earlier negotiations, but George Bush decided to abrogate the treaty and pushed for the implementation of a broad version. This explains why Russia is so sensitive to the installation of ABM systems no matter what justification is announced by Washington.

An article in The Economist provides a chart that nicely summarizes the growth and decline in nuclear warheads as this scenario unfolded over time.

Given this history, what level of nuclear capability might make sense, and can we ever get to zero warheads? An article in Foreign Affairs by Bruce Blair, Victor Esin, Matthew McKinzie, Valery Yarynich, and Pavel Zolotarev, Smaller and Safer: A New Plan for Nuclear Postures, provides a useful discussion of these issues.

While the latest drawdown of warheads negotiated by Obama and approved by congress was useful, there are serious issues that were not addressed. Of particular importance is the need to negotiate a stand down from the instant war readiness of the weapons systems that have been maintained. The issue of tactical warheads must also be addressed.

"The New START agreement did not reduce the amount of "overkill" in either country's arsenal. Nor did it alter another important characteristic of the U.S. and Russian nuclear arsenals: their launch-ready alert postures. The two countries' nuclear command, control, and communication systems, and sizable portions of their weapon systems, will still be poised for "launch on warning" -- ready to execute a mass firing of missiles before the quickest of potential enemy attacks could be carried out. This rapid-fire posture carries with it the risk of a launch in response to a false alarm resulting from human or technical error or even a malicious, unauthorized launch. Thus, under the New START treaty, the United States and Russia remain ready to inflict apocalyptic devastation in a nuclear exchange that would cause millions of casualties and wreak unfathomable environmental ruin."

The authors argue that the concept of what constitutes a viable response to a first strike is what ultimately defines the number of warheads required to be maintained.

"The planners assumed that in order for deterrence to be stable and predictable, a country had to be able to retaliate against 150 to 300 urban targets. These judgments played a key role in setting the warhead limit of 1,550 for each side in the New START treaty."

The scale of this counterstrike needs to be rethought. The authors believe the ability to hit 10 targets would be sufficient.

"Many planners still contend that deterrence also requires the ability to retaliate against an opponent's leadership bunkers and nuclear installations, even empty missile silos. But this Cold War doctrine is out of date. Deterrence today would remain stable even if retaliation against only ten cities were assured."

The strategy then would be to maintain the MAD logic but ramp down the number of warheads as the concept of unacceptable nuclear damage is redefined.
"Our modeling found that the United States and Russia could limit their strategic nuclear arsenals to a total level of 1,000 warheads each on no more than 500 deployed launchers without weakening their respective security. De-alerting these forces actually helped stabilize deterrence at these and lower levels. And the modeling showed that fairly extensive missile defense deployments would not upset this stability."

Going to lower numbers would be possible if only the US and Russia were involved. Going much lower than 1,000 would necessitate negotiations and treaties that involved other countries. This table taken from data provided by Wikipedia lists what is believed to be known about the nuclear stockpiles of other countries.

While the US and Russia might be able to maintain their standoff with even further reductions in weapons, how much farther would one go knowing that China has about 240 warheads and may be building more? Further progress probably requires the world to reach a state in which all nuclear states feel comfortable in reducing their stockpiles in unison.

At this point the issues become as much political as military. Obama has stated that he doesn’t expect to see a world with zero nuclear weapons in his lifetime. That is a wise assessment. Such a goal is attainable, but it will take a very long time, and it will require a world that is much different than the one we live in now.

But does that mean it is futile to begin the process now? It can only begin with the US and Russia taking the first step. So let’s get started!

　
"BRUCE BLAIR is President of the World Security Institute and Co-coordinator of Global Zero. VICTOR ESIN is a retired Colonel General and former Chief of Staff of the Russian Strategic Rocket Forces. He is a Professor of Military Science at the Institute of the United States and Canada of the Russian Academy of Sciences. MATTHEW MCKINZIE is a Senior Scientist at the Natural Resources Defense Council. VALERY YARYNICH is a retired Colonel and served at the Center for Operational and Strategic Studies of the Russian General Staff. He is a Fellow at the Institute of the United States and Canada of the Russian Academy of Sciences. PAVEL ZOLOTAREV is a retired Major General and former Section Head of the Defense Council of the Russian Federation. He is Deputy Director of the Institute of the United States and Canada of the Russian Academy of Sciences."

Social Impact Bonds: Making Money from the Misfortune of Others?

The term "social impact bond" (SIB) is synonymous with "pay for success bond" and "social benefit bond." It refers to an agreement between a group of investors and a government agency that does not actually possess the characteristics of a bond. It is more of a proposal to perform a specific task with the agreement that if the task is performed successfully, the investors will be compensated for expenses and provided a profit of a certain level. The logic behind the arrangement assumes that the government will have been saved sufficient funds via the deeds of the proposal that the expenses can be paid and both parties come out ahead. The peculiar part of the agreement is that if the performance target is not met, the investors receive no compensation and the return on investment is zero. The first such project was initiated in Britain in 2010 with a program aimed at lowering recidivism among prisoners at Peterborough Prison. 

An article in The Economist discusses the issue of SIBs as an investment vehicle. Under the terms of the Peterborough agreement the investment appears rather risky.

"The Peterborough SIB dangles an annualised return of up to 13% if reoffending rates go down by enough; but investors lose everything if recidivism does not fall by at least 7.5%."

In spite of the potential for zero return, a number of such proposals are in place or being planned. The bulk of the article describes a project aimed lowering the cost of providing services to the homeless.

"The cash will fund a three-year programme, the success of which is measured by everything from the number of nights that the rough sleepers spend on the streets to their visits to hospital. As targets are met, payments will flow to investors from the Greater London Authority (GLA), the SIB’s commissioning body."

"The arrangement suits all parties. The rough sleepers are frequent users of government services, including accident-and-emergency wards. Cutting their number should save the GLA enough money to fund payments to investors if goals are met. At a time when public spending is under pressure, the taxpayer stumps up only if results are achieved. Investors have the prospect of a return to entice them, of up to 6.5% if targets are met."

It would seem unlikely that your average investor would be interested in such a vehicle. The nature of the activities proposed suggests that a fraction of the funds, perhaps the largest fraction, comes from philanthropic sources.

An article in the New York Times by Caroline Preston, Getting Back more Than a Warm Feeling, describes a similar program in the US aimed at limiting recidivism at New York City’s Rikers Island jail. This project is being organized and funded through Goldman Sachs.

"In New York City’s case, Goldman is lending $9.6 million to MDRC, a nonprofit group that oversees the work of two charities running the jail program. A fourth nonprofit evaluates the results of the four-year program."

"If recidivism rates drop by 10 percent, Goldman gets its money back. The bank could make up to $2.1 million if the rates fall further. (Bloomberg Philanthropies is guaranteeing $7.4 million of the loan, leading some to say the New York City deal is not a true test of the bonds’ appeal to commercial investors.)"

Whether or not SIBs are enticing investment opportunities is perhaps a trivial question compared to the need to ask if this approach is in any way a good idea for government and society.

Proponents of SIBs suggest that this is a way for governments to get work done without actually having to go through the usually futile exercise of trying to fund the effort directly. Implicit in the process is the notion that the private investors somehow have come up with a better approach than the government currently utilizes, and if successful, this approach will be incorporated in government efforts.

That sounds good, but it is reminiscent of the entrance of philanthropy and finance into the education system. Every billionaire seemed to have a better way to educate our children, and all have been wrong thus far. Charter schools were intended to be trials of new learning approaches that, if deemed successful, would be incorporated into public school systems. Charter schools turned out to be no better than the public schools, and, on average, worse. That has not stopped moneyed interests from using charters to launch an all-out assault on public education in this country.

Introducing the profit motive into education was supposed to solve a variety of shortcomings. For-profit schools have mainly become a means of imposing heavy debts on unsuspecting students and raiding the public treasury for income.

Complicated issues like childhood learning require long-term investments in efforts by dedicated professionals. It is the natural domain of the government to nurture and oversee such activities. People who swoop in and claim that in one, two, or three years they will have impacted a critical social problem are deceiving themselves and their potential sponsors.

Of greatest concern is that this is just another means transferring responsibility from the public sector to the private and thereby diminishing the sense of community between citizens that government is supposed to reflect. What kind of society do we have if every public interaction becomes one defined by price and return on investment?

We probably can’t stop these SIBs, but we should be very careful in dealing with them.

Climate Change, Food Security, and Revolution

Lester R. Brown was written a troubling account of the future we face as we enter an era when our food requirements are beginning to outstrip our capacity to produce food: Full Planet, Empty Plates: The New Geopolitics of Food Scarcity. Brown is President of the Earth Policy Institute.

Brown begins his book with this statement:

"On the demand side of the food equation, population growth, rising affluence, and the conversion of food into fuel for cars are combining to raise consumption by record amounts. On the supply side, extreme soil erosion, growing water shortages, and the earth’s rising temperature are making it more difficult to expand production. Unless we can reverse such trends, food prices will continue to rise and hunger will continue to spread, eventually bringing down our social system."

The emphasis is mine. Brown suggests that the sequence of revolutions in the Middle East that we refer to as The Arab Spring were partially fueled by high food prices. Could it be that Brown’s prediction has already seen its first instantiation in the Middle East? Could this be the first in a sequence of social upheavals caused by climate change and failures of countries to provide food security for their populations?

A collection of essays assembled by Caitlin E. Werrell, Francesco Femia, and Anne-Marie Slaughter provide a more explicit connection between food supply issues and the political events: The Arab Spring and Climate Change. Thomas L. Friedman provides a tidy summary of the report in his column in the New York Times.

"Jointly produced by the Center for American Progress, the Stimson Center and the Center for Climate and Security, this collection of essays opens with the Oxford University geographer Troy Sternberg, who demonstrates how in 2010-11, in tandem with the Arab awakenings, ‘a once-in-a-century winter drought in China’ — combined, at the same time, with record-breaking heat waves or floods in other key wheat-growing countries (Ukraine, Russia, Canada and Australia) — ‘contributed to global wheat shortages and skyrocketing bread prices’ in wheat-importing states, most of which are in the Arab world."

"The numbers tell the story: "Bread provides one-third of the caloric intake in Egypt, a country where 38 percent of income is spent on food," notes Sternberg. ‘The doubling of global wheat prices — from $157/metric ton in June 2010 to $326/metric ton in February 2011 — thus significantly impacted the country’s food supply and availability.’ Global food prices peaked at an all-time high in March 2011, shortly after President Hosni Mubarak was toppled in Egypt."

While neither source indicates food price was the prime driver for social upheaval, it certainly helped feed the unrest. Unless the food supply issue can be resolved it is also likely to contribute to continued unrest as the newly formed governments struggle to attain stability.

The entire Middle East region seems to be beset by problems associated with climate and food supplies.

"Consider this: The world’s top nine wheat-importers are in the Middle East: ‘Seven had political protests resulting in civilian deaths in 2011,’ said Sternberg. ‘Households in the countries that experience political unrest spend, on average, more than 35 percent of their income on food supplies,’ compared with less than 10 percent in developed countries."

Brown’s book provides more insight into the problems that have developed throughout this region. He describes a situation where ever-growing populations have been confronted with climate change, overuse of water supplies, and increased soil erosion.

Brown lists eighteen countries that were drawing down their water aquifers more quickly that they could be refreshed in 2012. The list includes the United States, China, and India. More pertinent to this discussion, the list also includes Iran, Iraq, Israel, Jordan, Lebanon, Morocco, Saudi Arabia, Syria, Tunisia, and Yemen.

The entire region is arid and most crops must be produced using irrigation. In many countries, the only sources of water for irrigation are underground aquifers that are essentially trapped water supplies (fossilized) that do not get replenished.

"...after more than 20 years of wheat self-sufficiency, the Saudis announced in January 2008 that their aquifers were largely depleted and they would be phasing out wheat production. Between 2007 and 2011, the wheat harvest of just under 3 million tons dropped by nearly half. At this rate the Saudis likely will harvest their last wheat crop by 2016, as planned, and will then be totally dependent on imported grain to feed nearly 30 million people."

Brown relates how the grain market is becoming an unreliable source for highly-dependent countries. Traditional grain producers have nearly topped out their production capabilities, and they are also subject to changing weather conditions, including drought and rising temperatures. Brown quotes studies that indicate crop productivity is strongly temperature dependent, with each degree centigrade of temperature rise causing between 10% and 18% lower crop yields.

Rich countries such as Saudi Arabia are buying up or leasing land in Africa in hopes of being able to utilize the one remaining significant source of underutilized land to feed their own people.

Some countries have few options.

"Yemen, where population growth is spiraling out of control, is fast becoming a hydrological basket case. With water tables falling, the grain harvest has shrunk by one half over the last 40 years, while demand has continued its steady rise. As a result, the Yemenis now import more than 80 percent of their grain. With its meager oil exports falling, with no industry to speak of, and with nearly 60 percent of its children physically stunted and chronically undernourished, this poorest of the Middle East Arab countries is facing a bleak and turbulent future."

Surface water is also becoming scarcer and causing serious problems.

"Iraq, suffering from nearly a decade of war and recent drought and chronic overgrazing and overplowing, is now losing irrigation water to its upstream riparian neighbor—Turkey. The reduced river flow—combined with the deterioration of irrigation infrastructure, the depletion of aquifers, the shrinking irrigated area, and the drying up of marshlands—is drying out Iraq. The Fertile Crescent, the cradle of civilization, may be turning into a dust bowl."

Improper use of the land leads to soil erosion, a growing problem in some areas.

"Dust storms are forming with increasing frequency in western Syria and northern Iraq. In July 2009 a dust storm raged for several days in what was described as the worst such storm in Iraq’s history. As it traveled eastward into Iran, the authorities in Tehran closed government offices, private offices, schools, and factories. Although this new dust bowl is small compared with those centered in northwest China and across central Africa, it is nonetheless an unsettling new development in this region."

Iran has its own soil problems caused by overgrazing.

"Mohammad Jarian, who heads Iran’s Anti-Desertification Organization, reported in 2002 that sandstorms had buried 124 villages in the southeastern province of Sistan-Balochistan, forcing their abandonment. Drifting sands had covered grazing areas, starving livestock and depriving villagers of their livelihoods."

It would seem that the peoples of the Middle East have more to contend with than just poor leaders and weak or tyrannical governments. Their political troubles may, one day soon, be the least of their problems.

Lead Poisoning: The Ignored Scandal

Some time ago we provided a post titled Why We Need the EPA: Lead Poisoning, Intelligence, and Crime Rates. The article was a celebration of all the beneficial effects of banning the introduction of lead into the environment via commercial products such as gasoline and paint. The elimination of lead was found to have diminished lead poisoning incidents greatly, increased the IQ of the next generation by several points, and was associated with a fall in the crime rate. Studies have shown that childhood exposure to lead can lead to aggressive and antisocial behavior in later life. No better explanation for the fall in crime in the subsequent years has yet been put forward. However, we now learn more about the history of our nation and its approach to lead poisoning and realize that while there was cause for celebration, there is also cause for national shame.

Helen Epstein discusses the history of lead pollution in our country in an article in the New York Review of Books: Lead Poisoning: The Ignored Scandal. Epstein’s comments are focused on reviewing a book by Gerald Markowitz and David Rosner: Lead Wars: The Politics of Science and the Fate of America’s Children.

The danger of lead poisoning was well known.

"The problem began in the early twentieth century when a spate of lead-poisoning cases in children occurred across the United States. The symptoms—vomiting, convulsions, bleeding gums, palsied limbs, and muscle pain so severe ‘as not to permit of the weight of bed-clothing,’ as one doctor described it—were recognizable at once because they resembled the symptoms of factory workers poisoned in the course of enameling bathtubs or preparing paint and gasoline additives. One Dupont factory was even nicknamed ‘the House of the Butterflies’ because so many workers had hallucinations of insects flying around. Many victims had to be taken away in straitjackets; some died."

The use of lead in paint was particularly insidious.

"By the 1920s, it was known that one common cause of childhood lead poisoning was the consumption of lead paint chips. Lead paint was popular in American homes because its brightness appealed to the national passion for hygiene and modernism, but the chips taste sweet, and it could be difficult to keep small children away from them."

While it was a good thing to ban lead from paint in the latter half of the century, it is less well-known that our country was about 50 years behind most of the world.

"Because of its well-known dangers, many other countries banned interior lead paint during the 1920s and 1930s, including Belgium, France, Austria, Tunisia, Greece, Czechoslovakia, Poland, Sweden, Spain, and Yugoslavia."

"In 1922, the League of Nations proposed a worldwide lead paint ban, but at the time, the US was the largest lead producer in the world, and consumed 170,000 tons of white lead paint each year."

Thus begins a tale reminiscent of the tobacco fiasco.

"The Lead Industries Association had grown into a powerful political force, and the pro-business, America-first Harding administration vetoed the ban. Products containing lead continued to be marketed to American families well into the 1970s, and by midcentury lead was everywhere: in plumbing and lighting fixtures, painted toys and cribs, the foil on candy wrappers, and even cake decorations. Because most cars ran on leaded gasoline, its concentration in the air was also increasing, especially in cities."

When the dangers of lead in paints came under public scrutiny, the lead industry responded in a now familiar manner. Advertising campaigns were mounted to improve the image of their products, public relations experts were brought in to plant friendly articles in conservative media outlets, and scientists were hired to produce false data to counter the scientific evidence.

"When University of Pittsburgh professor Herbert Needleman first showed that even children with relatively modest lead levels tended to have lower intelligence and more behavioral problems than their lead-free peers, some of these industry-backed researchers claimed that his methods were sloppy and accused him of scientific misconduct (he has since been exonerated)."

"The companies also hired a public relations firm to influence stories in The Wall Street Journal and other conservative news outlets, which characterized Needleman as part of a leftist plot to increase government spending on housing and other social programs."

"....the lead industry....lied to Americans for decades, and the government did nothing to stop it."

How severe was the problem of lead poisoning in children?

"According to the Centers for Disease Control, parents should be concerned if their children’s blood lead concentration exceeds five micrograms per deciliter, but studies have found that even infinitesimally low levels—down to one or two micrograms per deciliter—can reduce a child’s IQ and impair her self-control and ability to organize thoughts."

Epstein puts these amounts in perspective for us.

"....Dutch Boy paint—which contained enough lead in one coat of a two-by-two-inch square to kill a child...."

Epstein estimates that the number of children harmed was in the millions.

"There is no way of knowing how many children were harmed over the past century by America’s decision not to ban lead from consumer products early on, but the number is somewhere in the millions. The most accurate national survey of lead poisoning was probably the 1976–1980 National Health and Nutrition Examination Survey, which found that 4 percent of all children under six—roughly 780,000—had blood lead concentrations exceeding thirty micrograms per deciliter, which was then thought to be the limit of safety."

"Black children, the survey found, were six times more likely to have elevated lead than whites. The number of children with lead levels over five micrograms per deciliter—or for that matter over one or two—was obviously much higher, but there’s no way of knowing how high it was."

Incredibly, when the dangers from lead exposure became widely recognized and lead was forbidden in most domestic products, almost nothing was done to eliminate the exposure dangers that already existed.

"During the 1980s, government officials finally agreed that the lead paint crisis was real, but they were conflicted about how to deal with it. In 1990, the Department of Health and Human Services developed a plan to remove lead from the nation’s homes over fifteen years at a cost of $33 billion—a large sum, but half the estimated cost of doing nothing, which would incur a greater need for special education programs, Medicaid and welfare payments for brain-damaged and disabled lead-poisoning victims, and other expenses."

Then politics as usual entered the picture.

"But the plan was opposed by the lead industry, realtors, landlords, insurance companies, and even some private pediatricians who objected to the extra bother of screening children."

Epstein tells us the US government has spent less than $2 billion on lead abatement.

"This money has supported a number of exemplary state and nonprofit programs that work in inner cities, but it’s a tiny fraction of what’s needed, and about twenty times less than US spending on the global AIDS crisis since 2004 alone."

Our government allowed a known health problem to persist for another quarter century even though it knew children were continuing to be poisoned. Consider this information currently found on the website of the National Institute of Environmental Health Sciences.

"Even minor exposures to lead can cause nervous system disorders, lowered IQ’s, impaired memory and reaction times, and shortened attention spans. So it is very important to clean up areas where lead paint was once used and dust frequently to avoid the lead particles that accumulate in household dust."

"Lead poisoning is a serious problem! Childhood lead poisoning is still one of the most important health issues in the United States today. According to recent CDC estimates, 890,000 U.S. children age 1-5 have elevated blood lead levels, and more than one-fifth of African-American children living in housing built before 1946 have elevated blood lead levels. These figures reflect the major sources of lead exposure: deteriorated paint in older housing, and dust and soil that are contaminated with lead from old paint and from past emissions of leaded gasoline. And to complicate things, lead poisoning can be so subtle that the affected child may not show any clear physical signs."

Epstein finishes on an appropriately depressing note by reminding us that politicians reply to pressure. Who was there to speak up for the children of the poor for whom this continues to be a threat? There was no one organized to counter the lead industry, realtors, landlords, insurance companies, and lazy pediatricians. The children of the poor did not rate the sort of advocacy campaigns that have inspired other political actions.

"If lead poisoning had been seen as a problem affecting middle-class children, this might well have happened."