Israel getting serious about desalination

Buried in this item is some really good news. Israel is finally getting serious about securing its water supply: just yesterday a major new desalination plant came online.

The newest plant – in Hadera – was the scene of a dedication ceremony on Thursday, when it was connected to the National Water Carrier. It will produce 127 million cu.m. of water per year when it reaches full capacity sometime in 2010. At that point, there will be more water coming from desalination than being provided by Lake Kinneret [a.k.a. the Sea of Galilee, a.k.a. the Sea of Tiberias].

Good for them. Israel has been agonizing over the ever-dropping water level of the Kinneret for years, and the coastal aquifers have been overpumped to the brink of irreversible infiltration by salt water from the Mediterranean. Desalination plans were in part held up by the hare-brained idea that it would be good for Israel-Turkish relations to import water from Turkey by tanker. Presumably, as Turkey has been cozying up to Israel’s enemies recently, this economically senseless idea is now off the agenda altogether.

And make no mistake: drought and desertification are enemies of everybody in the Middle East, Jew and Arab alike.

Socialized Medicine. Part 2: Israel

In the previous installment in this series, we looked at the grandfather of all socialized medicine systems, Germany. Today we will consider Israel’s.

Israel has mandatory coverage through one of four authorized HMOs (historically named “kupot cholim”, i.e., “sick funds”): Clalit, Leumit, Maccabi, and Meuchedet. The first three go back to the pre-state period, while Meuchedet (“United”) was formed in 1974 by the merger of two pre-state HMOs (one funded by Hadassah, the other affiliated with the centrist General Zionist party — which later merged into the Likud).

The oldest and largest of them, Clalit (“General”), was founded in 1911 as a mutual aid organization of an agricultural collective, and in 1920 became the healthcare arm of the Histadrut (General Federation of Labor, the local AFL-CIO equivalent). Maccabi (“Maccabee”) was founded in 1941 by German-Jewish refugee doctors as a more market-oriented alternative to the socialist Clalit.  The small Leumit (“National[ist]”) fund, founded in 1931 by doctors who found themselves blackballed by Clalit for being followers of the right-wing Zionist leader Ze’ev Jabotinsky, has always been something of a niche player.

Historically, each of these organizations managed their own risk pool. However, as a result, Clalit (which had/has a disproportionately high percentage of high-liability insurees) nearly went bankrupt. As part of a thinly veiled bailout for Clalit, a joint health insurance tax and joint risk pool were established in 1995. (In fact, health insurance only became compulsory in 1995, but something like 95% of the population was already enrolled in one of the four HMOs anyhow.) Each HMO receives a share of health insurance tax revenue based on its relative membership numbers: this arrangement saved Clalit from bankruptcy but severely downgraded the finances of especially Maccabi (the HMO of choice for professionals etc.). As a result, quality differences between the four HMOs also narrowed.

Coverage and reimbursement rates are set by the government: any true competition between the HMOs is primarily defined in terms of quality of service and accessibility.

Israel’s medical system has solvency problems, but not as severe as the other systems covered in this series. The main reason for that is the “healthier” structure of the population pyramid: Israel still has by far the highest childbirth rate of all developed countries. There are also some unique local factors keeping costs down: for example, the Russian mass immigration included  a large number of medical doctors, many of whom failed to requalify as doctors in Israel. (Medical training in Israel is as demanding as in the USA or Germany.) Under an arrangement aimed at simultaneously providing jobs for new immigrants and improving primary care access in the HMOs, many such people work at low wages as glorified nurse-practitioners in HMO clinics, their official status being something like GP residents.

Access to primary care in Israel is quite good: seeing a GP (especially a GNP ;-)) at an HMO polyclinic on short notice is quite easy. Emergency medical care is available not just at hospital emergency wards, but at larger HMO polyclinics (e.g. regional head branches). Most (but not all) GPs in private practice enroll in the “network” of one or even two HMOs, and see patients of that HMO at least during part of their office hours. Specialists tend to work reduced hours for HMOs at government-set rates, and the remaining hours “sharap” (Hebrew acronym for sherut refu’i prati, i.e., “private medical service”) at market rates. An increased tendency of specialists to scale back their HMO hours in favor of more lucrative sharap hours leads to a situation where the same physician can see you with a 1-month wait on the HMO’s dime — or almost on the spot when paying privately.

As part of cost-containment efforts by the HMOs, the road to access to more and more advanced diagnostic procedures and outpatient treatments is becoming increasingly paved with red tape. In addition, the country is facing a shortage of doctors in certain critical clinical specialties (notably surgery), as — even in a culture where (supposedly) every mother dreams of her son/daughter becoming a doctor — medicine is becoming an ever less attractive career  path due to long working hours and low government reimbursement rates. (Some physicians attempt to build up practices consisting mainly and exclusively of “private rate” patients, or to move into specialties such as cosmetic surgery where HMO coverage is generally a nonfactor.)

Several of the HMOs have since long sold supplementary insurance policies that offer some additional options (e.g., physician choice, semiprivate or private hospital room,…) As quality of HMO-based care deteriorates (and/or people just become choosier), a minority of the better-to-do professionals are opting for private supplemental insurance. For those unable or unwilling to purchase private (super)insurance, protektziya (connections) or lack thereof often determine whether one has access to the best specialists or surgeons in a given field. (This is a general pattern in countries where “money doesn’t determine access to medical care”: access to scarce resources, such as a particularly skilled surgeon, often becomes determined by personal connections. And guess which socio-economic class — who just happen to be the most vocal advocates of socialized medicine — generally has the best such connections?)

Finally, on the margins, medical tourism to Israel by foreigners is bringing in some money. (There is even some medical tourism from countries that have no diplomatic relations with Israel ;-)) The combination of high-quality (in some fields cutting-edge) medicine and comparatively low cost (even at private rates) is quite attractive to some: bypass surgery will cost you a quarter of what it costs in the USA, and in-vitro fertilization one-sixth.

Israel’s system of socialized medicine is often held up as an example of “it can work”. However, one should consider the conditions are uniquely favorable (sound population pyramid, high social prestige enjoyed by doctors, basic absence of a tort litigation/malpractice insurance cost spiral,…) — yet still the system is showing cracks. If it isn’t sustainable in Israel, it probably isn’t gonna work anywhere.

Socialized Medicine. Part 1: Germany

In this series of blog posts, we will look at socialized medicine systems in a number of countries that are usually held up as “models” to the USA. To kick off the series, we will start off with the granddaddy of all socialized medicine systems: Germany’s.

The German word  itself, “Krankenkasse” (sick fund), reveals the historical origins of German health insurance organizations in the mutual aid-based sick funds maintained by members of guilds and professional associations.

As summarized well here (caveat lector always applies with Wikipedia), Germany’s universal healthcare system started with the Health Insurance Bill of 1883, Accident Insurance Bill of 1884, and Old Age and Disability Insurance Bill of 1889, all pushed through by Wilhelm I’s “Iron Chancellor”, Otto von Bismarck. Originally only certain low-income groups were covered, but the income threshold kept being raised. According to several expat websites (here, there, and yet elsewhere), everybody with an income below the Versicherungspflichtgrenze (mandatory insurance threshold, which seems to sit somewhere between the 85th and 90th income percentile) has statutory public coverage: everybody above may opt for either public or private insurance. [Update: the self-employed, people in the “liberal professions” (as medicine, law,… are known in continental Europe), and civil servants may opt for private insurance regardless of income.]

As explained here, post-WW II, East Germany had full-bore state-run medicine, while West Germany had a system that was state-supervised and state-regulated, but not state-run. The latter system prevailed after reunification. Deductibles and mandatory coverage are set by the government: the over 200 Krankenkasse primarily compete on the basis of service quality.

Since a recent reform, all health insurance taxes collected are pooled in a single “risk pool”. As much bad blood as the concept of forcing otherwise healthy people to buy health insurance has caused in the USA, the fact of the matter is that systems like the German one can only be solvent (or approaching solvency) at all thanks to many young and healthy people paying much more into the system than they take out of it.

Somewhere between 8 and 15 percent of the population (depending on the source) opt for private insurance through one of about forty for-profit insurers: broadly speaking, about one in ten Germans has primary coverage of this type, while another percentage has private supplemental insurance that covers treatments and amenities over and above those covered by the statutory insurance. These include private or semi-private rooms (rather than “sickbays”), treatment by doctors and surgeons of one’s choice,…

In recent years, financial pressures, and especially an aging population, have led to various cost-cutting measures, with no end in sight. Expect the “statutory” care to become ever more bare-bones, and the gap between public and private care quality to widen.

In two future installments, we will cover the systems of Israel and Belgium. Some general observations will be offered in a fourth installment.

Dr. Sanity on “Therapeutic psychobabble”

Psychiatrist and retired NASA flight surgeon Pat Santy (who blogs as “Dr. Sanity”) is probably the one blogger that made me think seriously about the role of psychology in setting the discourse of society. (The one psychiatrist I read more religiously is Charles Krauthammer — but he, unlike her, quit the profession decades ago to become one of America’s most incisive opinion journalists.)

In today’s post she laments that “therapeutic psychobabble” is not only destroying the credibility of psychiatry as a discipline, but having an invidious effect on society at large. “This is a particular American madness, as far as I can tell, the invocation of ludicrous pop psychology to explain acts that can only properly be described as evil.” she quotes John Podhoretz. (However, I can testify that this sort of thinking, perhaps in slightly less mediatized and saccharine ways, is very much alive in Europe as well. Do not forget that the old saw: “to understand all is to forgive all” is a direct translation of a French proverb: “comprendre tout, c’est pardonner tout”. As Robert Heinlein wrily noted: ‘some things, the more you understand the more you loathe them’.)

But let’s yield the stage to Dr. Sanity:

“The therapeutic sensibility”, or what I call “therapeutic psychobabble”, is not actually therapeutic (i.e., it does not lead to healing) in the least.

In fact, this sensibility often becomes the major impediment that prevents patients with serious emotional problems from taking control over their lives. And, for individuals who aren’t patients (but soon will be, most likely) it reflects a passive world view, where a person is the helpless victim of forces outside their control.

“The key aspects of this psychobabble include an overemphasis on “self-esteem” at the expense of self-control and personal responsibility; an attitude that practically worships “feelings” at the expense of reason and truth; a fundamental misunderstanding about stress and the role of stress in life (i.e., that “all stress is bad”, for example; and failing to appreciate that stress, when it is acknowledged and dealt with in healthy ways can enhance maturity and psychological health); and finally the glorification of victimhood and the celebration of unhealthy narcissism and the narcissists who exhibit it.”

Read the whole thing, as they say.

PS: let’s leave the last word to Jonah Goldberg: “We have a real problem when much of the political and journalistic establishment is eager to jump to the conclusion that peaceful political opponents are in league with violent extremists, but is terrified to consider the possibility that violent extremists really are violent extremists if doing so means calling attention to the fact that they are Muslims.”

Hillary may run in 2012?!

A guest commentary piece by Tony Blankley for the  Rasmussen Reports opinion polling website, Hillary in 2012?, looks at the possibility that Hillary Clinton might consider running for the White House in 2012.

Update: While we’re on the subject of Rasmussen, some breaking polls: 60% Want Fort Hood Shooting Investigated as Terrorist Act and 81% View U.S. Military Favorably This Veteran’s Day.

Veterans Day / Armistice Day

In memory of all who fell in foreign fields, and particularly those who fell “In Flanders Fields”.

This chilling song is about the WW I Battle of Paschendale, a.k.a. Battle of Passchendaele (correct Dutch spelling), a.k.a.Third Battle of Ypres. Perhaps the bloodiest battle ever fought on Belgian soil, it became a byword for trench warfare among all who witnessed it.

Iron Maiden: Paschendale (Smith/Harris)

In a foreign field he lay
lonely soldier, unknown grave
on his dying words he prays
tell the world of Paschendale

Relive all that he’s been through
last communion of his soul
rust your bullets with his tears
let me tell you ’bout his years

Laying low in a blood filled trench
killing time ’til my very own death
on my face I can feel the falling rain
never see my friends again
in the smoke in the mud and lead
the smell of fear and the feeling of dread
soon be time to go over the wall
rapid fire and the end of us all

Whistles, shouts and more gun-fire
lifeless bodies hang on barbed wire
battlefield nothing but a bloody tomb
be reunited with my dead friends soon
many soldiers, eighteen years
drowned in mud, no more tears
surely a war no one can win
killing time about to begin

See my spirit on the wind
across the lines beyond the hill
friend and foe will meet again
those who died at Paschendale

Home, far away. From the war, a chance to live again
Home, far away. But the war, no chance to live again

The bodies of ours and our foes
the sea of death it overflows
in no-man’s land G-d only knows
into jaws of death we go…

Crucified as if on a cross
allied troops, they mourn their loss
German war propaganda machine
such before has never been seen
swear I heard the angels cry
pray to G-d no more may die
so that people know the truth
tell the tale of Paschendale

Cruelty has a human heart
every man does play his part
terror of the men we kill
the human heart is hungry still

I stand my ground for the very last time
gun is ready as I stand in line
nervous wait for the whistle to blow
rush of blood and over we go…

Blood is falling like the rain
its crimson cloak unveils again
the sound of guns can’t hide their shame
and so we die in Paschendale

Dodging shrapnel and barbed wire
running straight at canon fire
running blind as I hold my breath
say a prayer symphony of death
as we charge the enemy lines
a burst of fire and we go down
I choke I cry but no one hears
feel the blood go down my throat

Home, far away. From the war, a chance to live again
Home, far away. But the war, no chance to live again
Home, far away. From the war, a chance to live again
Home, far away. But the war, no chance to live again

See my spirit on the wind
across the lines beyond the hill
friend and foe will meet again
those who died at Paschendale…

Hello world!


Herewith, thanks to, a new blog is seeing the light of day: “Spin, strangeness, and charm”. Derived from the names of the three quantum numbers of elementary particles in the “Standard Model”, the name also refers to media spin, to the increasingly bizarre world we live in, and to the charming things that sometimes are what make life worth living.