The Rest of the Story

I told myself that I was going to write about science today, perhaps this or this; but I got sidetracked.

You may recall that Halliburton announced, in January 2005, that it would be pulling out of Iran, citing "a poor business climate."  We learned later that this was not really true.  

Business As Usual?
Halliburton’s CEO says his company is pulling out of Iran. But a corporate subsidiary is still going ahead with a deal to develop Tehran’s natural gas fields

By Michael Isikoff and Mark Hosenball
Newsweek
Updated: 6:10 p.m. ET Feb. 16, 2005

Feb. 16 - Only weeks before Halliburton made headlines by announcing it was pulling out of Iran—a nation George W. Bush has labeled part of the “axis of evil”—the Texas-based oil services firm quietly signed a major new business deal to help develop Tehran’s natural gas fields.

Halliburton’s new Iran contract, moreover, appears to suggest a far closer connection with the country’s hard-line government than the firm has ever acknowledged. [...]

But in March, Halliburton reiterated its pledge, under pressure from the New York City Comptroller, who was troubled by the fact that the City invested a large sum, via its pension plans, in a company that did business with the Axis of Evil.  As reported in the Washington Post:

Halliburton Won't Seek Iran Work
Company Makes Vow in Response to Shareholder Pressure

By Henry Goldman
Bloomberg News
Friday, March 25, 2005; Page E02

Halliburton Co., the world's largest oil-field services company, has pledged not to seek new work in Iran, a country accused by the State Department of state-sponsored terrorism, said New York City Comptroller William C. Thompson, a steward of pension funds holding company stock worth about $42 million.

Halliburton's vice president and corporate counsel, Margaret E. Carriere, wrote in a letter faxed to Thompson's office from the company's Houston headquarters yesterday, "Halliburton will take appropriate corporate action to cause its subsidiaries to not bid for any new work in Iran," while continuing on work previously undertaken. [...]

Now it turns out that things are not going so well for Halliburton: Agenzia Gournalistica Italia has a news section, News for Arab Countries, which it describes as a "Special service by AGI on behalf of the Italian Prime Minister's office."  They are reporting something about Halliburton that American news agencies are not, but that American voters, as well as certain investors, might like to know:

News for Arab Countries
Special service by AGI on behalf of the Italian Prime Minister's office

---

HALLIBURTON: LOSES IRAN CONTRACT DUE TO CORRUPTION CHARGES

(AGI) - Tehran, Iran, Aug 23 - US multinational Halliburton lost a 310 million dollar contract for natural gas extraction in the Iranian site of South Pars. According to Tehran authorities, Oriental Oil Kish, a subsidiary of Halliburton operating in the Middle East, won the contract last January thanks to bribes. The activities of the company in South Pars have been suspended and the contract annulled. Halliburton, once led by US Vice President Dick Chaney, is under investigation for the same contract in the US as well, on the basis of a 1996 law that punishes companies, both American and foreign, which invest more than 40 million dollars in Iran. The contract should now be passed on to the National Iranian Drilling Company, the Iranian state-owned energy company. (AGI) -
231946 AGO 05 COPYRIGHTS 2002-2005 AGI S.p.A.

(Beret tip to PA Liberal, who starts college tomorrow; congratulations, Samantha!)

Readers may want to know how Halliburton is able to do business in Iran, given that it is illegal for American firms to do so.  Halliburton spokeswoman Wendy Hall has the answer:

Halliburton Set to Begin Work in Iran

DALLAS (CBS) -- Halliburton, under investigation for its operations in Iran, is set to begin oilfield services work in that country as a subcontractor for Oriental Kish, a spokeswoman said.

Halliburton shares closed at $38.19, up 35 cents. Halliburton spokeswoman Wendy Hall said that she did not know the value of the contract and noted that Oriental had won the contract, not Halliburton. Halliburton's products-and-services division is to help Oriental Kish, which is based in Iran, develop the South Pars natural-gas field.

"Halliburton's business is clearly permissible under applicable US laws and regulations," Hall said. "Also, we are in the service business, not the foreign-policy business. We have followed and will continue to follow applicable laws."

She added that Halliburton has no ownership in Oriental Kish and had played no role in its creation.

Because of Iran's suspected links to terrorism, US companies are severely restricted in their dealings with the country. The 1996 Iran-Libya Sanctions Act limits companies to an investment of $20 million or less a year in Iran's oil and gas sectors, according to the US Energy Information Administration.

However, "separately incorporated foreign subsidiaries are not included in the definition of US persons under the current Iranian executive order," a US Treasury official said. "If a US person is involved, that person may be in violation of the sanctions."

The Halliburton unit is registered in the Cayman Islands as Halliburton Products and Services.

"These entities and activities are staffed and managed by non-US personnel," Hall said.

In July, the company said in a regulatory filing that a federal grand jury was investigating Halliburton operations in Iran. [...]

Is there reason to think that a "US person" might be involved?  CC reports, you decide:

60 Minutes decided to ask Halliburton's subsidiary about its work in Iran. But we weren't allowed to enter the building with a camera. So we went in with a hidden camera, and were introduced to David Walker, manager of the local Calidonian [sic] Bank, where the subsidiary is registered.

60 Minutes was expecting to find a bustling business, but, to our surprise, Walker told us that while Halliburton Products and Services was registered at this address, it was in name only. There is no actual office here or anywhere else in the Caymans. And there are no employees on site.

We were told that if mail for the Halliburton subsidiary comes to this address, they re-route it to Halliburton headquarters in Houston. [...]

It actually was the Caledonian Bank.  Oddly, www.caledonian.com is not responding.  Maybe it's the hurricane.

Maybe the Flying Spaghetti Monster is punishing them for doing business with a bunch of crooks.

Via a rather loose concatenation of links, I began reading the first page of the book, Zero: The Biography of a Dangerous Idea by Charles Seife:

An Eastern concept, born in the Fertile Crescent a few centuries before the birth of Christ, zero evoked images of a primal void, it also had dangerous mathematical properties.  Within zero there is the power to shatter the framework of knowledge.

It is not so strange that I would read this eventually, although it is a bit strange that I would be reading it now.  Last night, I was reading The Golden Ratio : The Story of PHI, the World's Most Astonishing Number, by Mario Livio.  What is strange is the confluence of ideas thus provoked.  I went from the mathematics of Zero, to the amount of postwar planning for Iraq.


In an earlier post, I quoted a snippet of lyrics from a Patti Smith song, Radio Baghdad.  Here is the entire thing.  Unfortunately, the lyrics do not convey the message.  (You really have to hear Patti work this one over, in her own special way.)

Suffer not Your neighbor's affliction
Suffer not Your neighbor's paralysis
But extend your hand Extend your hand
Lest you vanish in the city And be but a trace
Just a vanished ghost And your legacy
All the things you knew Science, mathematics, thought
Severely weakened Like irrigation systems
In the tired veins forming From the Tigris and Euphrates
In the realm of peace All the world revolved
All the world revolved Around a perfect circle
City of Baghdad City of scholars
Empirical humble Center of the world
City in ashes City of Baghdad
City of Baghdad Abrasive aloof

Oh, in Mesopotamia Aloofness ran deep
Deep in the veins of the great rivers
That form the base Of Eden
And the tree The tree of knowledge
Held up its arms To the sky
All the branches of knowledge All the branches of knowledge
Cradling Cradling
Civilization In the realm of peace
All the world revolved Around a perfect circle
Oh Baghdad Center of the world
City of ashes With its great mosques
Erupting from the mouth of god Rising from the ashes like
a speckled bird Splayed against the mosaic sky
Oh, clouds around We created the zero
But we mean nothing to you You would believe
That we are just some mystical tale We are just a swollen belly
That gave birth to Sinbad, Scheherazade We gave birth
Oh, oh, to the zero The perfect number
We invented the zero And we mean nothing to you
Our children run through the streets
And you sent your flames Your shooting stars
Shock and awe Shock and awe
Like some, some Imagined warrior production
Twenty-first century No chivalry involved
No Bushido

Oh, the code of the West Long gone
Never been Where does it lie?
You came, you came Through the west
Annihilated a people And you come to us
But we are older than you You come you wanna
You wanna come and rob the cradle
Of civilization And you read yet you read
You read Genesis You read of the tree
You read of the tree Beget by god
That raised its branches into the sky Every branch of knowledge
Of the cradle of civilization

Of the banks of the Tigris and the Euphrates
Oh, in Mesopotamia Aloofness ran deep
The face of Eve turning What sky did she see
What garden beneath her feet The one you drill
You drill Pulling the blood of the earth
Little droplets of oil for bracelets Little jewels
Sapphires You make bracelets
Round your own world We are weeping tears
Rubies We offer them to you
We are just Your Arabian nightmare
We invented the zero But we mean nothing to you
Your Arabian nightmare

City of stars City of scholarship
Science City of ideas
City of light City
City of ashes That the great Caliph
Walked through His naked feet formed a circle
And they built a city A perfect city of Baghdad
In the realm of peace And all the world revolved
And they invented And they mean nothing to you
Nothing to you Nothing

Go to sleep Go to sleep my child
Go to sleep And I'll sing you a lullaby
A lullaby for our city A lullaby of Baghdad
Go to sleep Sleep my child
Sleep Sleep...
Run Run...

You sent your lights Your bombs
You sent them down on our city Shock and awe
Like some crazy t.v. show

They're robbing the cradle of civilization
They're robbing the cradle of civilization
They're robbing the cradle of civilization

Suffer not The paralysis of your neighbor
Suffer not But extend your hand

-- Patti Smith, Oliver Ray

The Iraq war is like some crazy TV show.  Crazy in that we don't know who to believe.  A fork in my link-skipping took me to this:

Secrets of the morgue: Baghdad's body count

By Robert Fisk
The Independent
17 August 2005

Bodies of 1,100 civilians brought to mortuary in July
Pre-invasion, July figure was typically less than 200
Last Sunday alone, the mortuary received 36 bodies
Up to 20 per cent of the bodies are never identified
Many of the dead have been tortured or disfigured [...]

they're robbing the cradle...

The Independent have placed most of the story into their archive, but the full version can be viewed at Information Clearinghouse.  It includes this:

While Saddam's regime visited death by official execution upon its opponents, the scale of anarchy now existing in Baghdad, Mosul, Basra and other cities is unprecedented. "The July figures are the largest ever recorded in the history of the Baghdad Medical Institute," a senior member of the management told The Independent.

Fisk mentions that there are no official reports on the subject of Iraqi mortality, so it is not possible to confirm his report independently.  Regardless, there is some supporting evidence.

In October 2004, the leading medical journal in Britain, The Lancet, published a controversial study (free registration) in which it was estimated that there had been 100,000 (note the large number of zeros) excess deaths in Iraq since the start of the war.  By "excess," they mean that the death toll was above that which would have been expected in prior years, even under Saddam's brutal regime.  Fisk's article in The Independent is consistent with the results of the Lancet report.  According to Fisk, in July 2005, in Baghdad alone, there were about 900 excess deaths.

The Lancet article was released early, leading to claims that it was a politically-motivated effort to influence the results of the Presidential election in the USA.  That may have been.  Unfortunately, if that was the intent, it did not produce the desired result.  Various people attempted to discredit the report by criticizing the methodology.  Incidentally, a statistician, Tim Lambert, posting at Deltoid, took an interest in this.  In my view, he successfully defended the methodology of the report.  

Many of the critics of the Lancet report cited a UN report,  Iraq Living Conditions Survey 2004, which estimated the number of excess deaths to be much lower (about 23,000).  Note, however, that even the more favorable report is not even faint praise for the US-led effort:

• 12% of the Iraqi children in the age group 6 months – 5 years suffer from general malnutrition.
• 8% of children suffer from acute malnutrition.
• 23% of children suffer from chronic malnutrition.

[...]

In the two weeks prior to the survey it was found that 14% of children had had a cough or cold, 14% had had fever, and 9% had had diarrhea. Two percent had had other illnesses, and 1% had experienced an accident.

they're robbing the cradle...

According to the Washington Post, the incidence of child malnutrition was increased, compared to pre-war levels.  Recall that, before the war, the general population was suffering from the effects of economic sanctions.  So the fact, that child malnutrition has been worse after the war, is really, really disturbing.  

Afterdowningstreet.org and various members of the BBA have reported that planning for the post-war period began in 2001.  But the documents uncovered so far indicate only planning for military affairs and oilfield development.  But it appears that the amount of planning for the welfare of the Iraqi people was a big, fat Zero.

Used worldwide, The Empathy Belly  has proven itself to be an extremely beneficial teaching tool resource for medical students, obstetrical physicians and allied professionals in the fields of Maternity Health Care and Education. By wearing The Empathy Belly they significantly increase their understanding and sensitivity about the pregnant condition. Consequently they are better trained, more effective, and more likely to establish genuine rapport with the pregnant women in their care. For obvious reasons, this is especially true for service providers who are male, or women who have never experienced a full-term pregnancy.

No thanks.  But seriously, we all know that many doctors need to be more empathic.  A Google search on the string, "empathy in medical training" gets about 745,000 hits (including the one above).  Many medical schools have incorporated empathy training into their curricula.  Even so, the problem persists.  We see articles in the NYT such as Awash in Information, Patients Face a Lonely, Uncertain Road, which I was going to post about, until I saw that Shrinkette already did.

From NYT:

Ms. Gaines, bald, tumor-ridden and exhausted from chemotherapy, was reeling. "I'm not a doctor!" she shouted. "I'm a criminal defense lawyer! How am I supposed to know?"

This is the blessing and the burden of being a modern patient. A generation ago, patients argued for more information, more choice and more say about treatment. To a great extent, that is exactly what they have received: a superabundance of information, often several treatment options and the right to choose among them.

As this new responsibility dawns on patients, some embrace it with a sense of pride and furious determination. But many find the job of being a modern patient, with its slog through medical uncertainty, to be lonely, frightening and overwhelming.

From Shrinkette:

Hasn't serious illness almost always been a lonely, uncertain road? The best doctors make that road easier to bear. But this article says that many patients feel abandoned by their doctors, and adrift in the system. It's hard to imagine a satisfying solution.

Also see the NYT article, Sick and Scared, and Waiting, Waiting, Waiting, for an additional perspective on the problem.  

Later, I encountered a physician's essay on the topic of empathy: Empathy: Lost or Found in Medical Education? (Medscape: free registration required) by Sonal Singh, MD; that inspired me to write this post.

What can be done about the lack of empathy among physicians?  To answer that, one first must learn what already has been done.  Recently, the Josiah Macy Foundation funded a study, the Macy Initiative in Health Communication.  According to a report in Academic Medicine:

Sixty-five percent of medical schools teach communication skills, usually in the preclinical years; however, communication skills learned in the preclinical years may decline by graduation. [...]

The three schools use a variety of methods to teach third-year students in each school a set of effective clinical communication skills.

Moving some of the instruction to the third year is a good idea, because it is impossible to learn the skills properly, outside of a clinical context.  (The first two years are spent mainly in classroom instruction.)  Also, of course, communication skills are only a part of being empathic.  Plus, communication is, by definition, a two-way process; you can't solve the problem by having only one person learn the skills.  The solution has to involve medical training centers, medical practice settings, the physician's ongoing efforts at self-education and self-improvement, and the the patients.

First, in regard to medical training programs: the points learned in the Macy study are important.  The instruction tends to loose effect shortly after it is taught, and it is more effective when taught in a clinical -- as opposed to a classroom -- context. It would make sense, then, to incorporate the instruction into residency training programs, as well as continuing medical education programs.  It would not take a lot at any one time, to be effective.  What would make it effective would be to give the subject at least some attention at every opportunity.  

In addition, for such instruction to be effective, it would have to be pertinent.  How to make it seem pertinent?  Try this, from Archives of Internal Medicine (Vol. 154 No. 12, June 27, 1994):

The doctor-patient relationship and malpractice. Lessons from plaintiff depositions

H. B. Beckman, K. M. Markakis, A. L. Suchman and R. M. Frankel
Department of Medicine, Highland Hospital, Rochester, NY 14620.

BACKGROUND: The current literature does not provide an answer to the question, "What prompts patients to sue doctors or hospitals?" Not all adverse outcomes result in suits, and threatened suits do not always involve adverse outcomes. The exploration of other factors has been hampered by the lack of a methodology to contact plaintiffs and elicit their views about their experience in delivered health care. This study employed the transcripts of discovery depositions of plaintiffs as a source of insight into the issues that prompted individuals to file a malpractice claim. [...]

CONCLUSIONS: In our sample, the decision to litigate was often associated with a perceived lack of caring and/or collaboration in the delivery of health care. The issues identified included perceived unavailability, discounting patient and/or family concerns, poor delivery of information, and lack of understanding the patient and/or family perspective. Particular attention should be paid to the postadverse-event consultant-patient interaction. [emphasis added]

If that does not impress trainees with the pertinence of the subject, perhaps this would: collect evaluations, from patients, of the performance of medical students and residents.  Just knowing that people are paying attention often results in improved behavior.  

Second, with regard to medical practice settings, it is important for the institution to have a culture that is self-correcting.  If a practitioner sees an instance of poor empathy, she or he should feel free to point it out; furthermore, the person who made the error should be receptive to corrective feedback.  It turns out that there is already a good article on the subject, in an AMA Virtual Mentor Vignette, here.  

Each institution has its own culture, and that culture determines what behaviors are acceptable, and what topics are acceptable topics for conversation.  Physicians need to take a leadership role in encouraging others to give corrective feedback.  Perhaps more importantly, they need to model the graceful receipt of such feedback.  "Thank you for pointing that out," is always good.   Remember the principle of Ostler's  Aequinimitas.  

Cultivate, then, gentlemen, such a judicious measure of obtuseness as will enable you to meet the exigencies of practice with firmness and courage, without, at the same time, hardening "the human heart by which we live."

In an essay (Medscape link), Dr. James Dykes elaborated:

Now I teach Duke medical students. I tell them that although "objectivity" is important in the practice of medicine, it is often misunderstood. When the great physician Sir William Osler (1849-1919) wrote his treatise on the importance of "objectivity," he used the Latin term "aequanimitas," which can be translated as equanimity. To practice with equanimity, we must cultivate inner peace.

Also remember: the giving and receiving of such feedback actually helps build a sense of teamwork and camaraderie.  This may seem counterintuitive; at first glance, it may seem that one member of the team criticizing another would be destructive.  But done properly, in the context of a healthy institutional culture, it actually is constructive.

Third, in regard to physicians' ongoing self-education and self-improvement: this is a personal thing.  As physicians, we all worry about missing the next retroperitoneal abscess, or the next case of idiopathic hemochromatosis.  That's why we rush home from the clinic, ignore our spouses and children, and breathlessly page through the latest copy of Archives of Medical Obscuranta, groaning every time the pager goes off.  

Next time, try this: pay attention to you spouse and kids.  They know more about empathy than you ever will.  They will even teach you, if you would just pay attention every once in a while.  Like everything else in medicine, the best way to learn it, is to watch an expert do it.

Fourth, perhaps the most difficult: just as communication is a two-way process, so is empathy.  We don't have an empathy training belly that patients can wear, to learn what it is like to be a doctor.  

I think what would help, would be for patients and physicians to have a shared model of what their interactions are about.  I find that it helps to look at it this way:  Suppose you own an auto body shop.  You are an expert on auto body repair.  You want to advertise your business, so you go meet with an advertising specialist.  The two of you sit down.  Each of you is an expert on something.  Together, you combine your expertise to figure out what to do.

In a medical setting, the doctor is an expert on the subject of medicine; the patient is an expert on the subject of the patient.  The patient will always know more, about himself or herself, than the doctor will.  They both are experts in their respective fields, and they should interact as two experts do:  each listening to the other, each respecting the other, each appreciating that the other knows more about the other's area of expertise, and each deferring to the other when appropriate.  

The nice thing about empathy, is that if we all learn to do it better, we all will benefit.  If it is true in medical settings, it also is true in other settings.  

As Dr. Dykes said in the essay that inspired this post, "we must cultivate inner peace."  It is a lifelong process.