Feeling that old disconnect....

I am feeling that amazing old feeling of total disconnect between what our government is saying and what might well be somewhere close to the truth of the matter. Let me think. Oh yes, we need to take action in Syria because it is so dreadful that we need to show the world that chemical warfare is a no-no. We don't need to wait for the UN inspectors to make an inspection. Nope. After all they said very publicly that Iraq didn't have weapons of mass destruction but we needed to save the world and the Iraqis, so we went in against the UN's report.

We need to show the world that you can't kill civilians. People like Kissinger, Albright, H. Clinton, John Kerry can stand up with a straight face and serious outrage and say these words. Just amazing, really. So mind blowing that if it weren't so serious we would have to die laughing. A-Bombs, Agent Orange, depleted uranium cluster bombs, and drones aside, we have to take the high road on this issue.

Now I just assume that anyone and everyone in government is lying all the time. I sometimes read documents released by the Freedom of Information Act. I have read batches of Wikileaks documents. We have been overthrowing democracies for a long time, Guatemala, Chili, Iran, to name a few. Not that Syria is a democracy. Not that it matters.

What is the good in all of this? How can we ever imagine that in the big picture these arbitrary national borders and the small differences in racial or religious characteristics or financial worth make an ounce of difference in the long run. Who we are makes the difference. In the last few weeks I have talked with several people who were taking bold courageous stands for their truth. The reason these stands were bold and courageous is because they risked upsetting the status quo. In all cases the women gained so much by staying in their integrity that the old concerns no longer had any power or influence.

My truth is that I want peace in the world. My challenge is to hold that peace when the shit starts to fly. My challenge is to let go of the shame for our collective past mistakes and hold the peace. My job is to know that everyone from the powerful to the seemingly most insignificant person is equal in the eyes of god. "There is no path to peace. Peace is the path." Thick Nhat Hahn.

I awoke today disturbed by the thought that we are about to make another blunder and cause a great increase in suffering in the world. Now I am working on having compassion, real compassion for those who are causing suffering and experiencing it. I am trying to attune myself to the music of hope and beauty and love. It ain't easy, and it won't be easy later today or tomorrow.

"Forgiveness is for me. Forgiveness sets me free."

I just had an image of someone who, fairly recently, hurt me. I immediately felt a heavy constriction around my heart. I always jump to the worst diagnosis, so I decided that I was having a heart attack. Then I remembered (grace? miracle? good luck?) the words from Deepak Chopra, "Forgiveness is for me. Forgiveness sets me free." I muttered, "I forgive you." to my mental image of the offending party or rather the person I allowed to hurt me, and my physical body released the constriction instantly and even felt better than it had before the heart attack.

I claim no medical knowledge, but I had at least a metaphorical heart attack, and I was cured. At least for a moment. This kind of wisdom is one of the million things I think we should teach children. But to do that we would have to remember it ourselves. These lessons didn't come through to me in Catechism class. I remember the example of Christ on the cross saying "Father forgive them for they know not what they do." but that was Christ! I understood the word 'parable' but I didn't get it. Maybe we should have done some role playing or something. I have always suspected that I am sometimes a bit 'slow'.

My friend Susan Dodge said it well the other day. We were discussing how sick I had gotten with my parasites. I almost died. She reminded me that eight months before the great Dr. Blanco saved my life with his four little pills, (the four right pills at last!) I had told her that I thought I had cancer because I was loosing so much weight. She said, "Get to a doctor." I did not go. Her recent remark was something like, "It always amazes me how stupid really smart people can be sometimes." I appreciate that, Susan. It may be the sentence that saves my life next time, because sometimes really stupid smart people need to be hammered over the head for wonderful wisdom to get through.

My friend John Gardner used to say, "When God wants to talk to you, she first whispers, then shouts, then hits you over the head with a sledge hammer." So today with the forgiveness heart attack, I caught the whisper. Next time I am too scared or skeptical to go to a doctor, maybe I will hear God whisper through Susan's words. Amen.

Chelsea Manning lives her truth.

Lisa (www.satsangwithlisa.org) and I were talking this morning about how to be an activist in our current situation in the USA. We went all around the mulberry bush until we settled with a few thoughts. One was that if you are true to yourself, if you talk and live your truth, you are an activist.

One of my truths is that I strive to have love and compassion for all sentient beings. It is in this realm in politics that I fail most dramatically. In the moments when my snobbism about the Tea Party followers provokes me to make disparaging remarks and harbor elitist judgements that I move very far away from my core beliefs. Finding our truth is very hard and at the same time, very easy. It is always with us, inside, waiting to be recognized.

Acting from the precious love we have in our hearts is often harder. I know this. I am pretty blunt. I am very impatient. I can stand up for what I believe in. But, when I watch the life of someone like Chelsea Manning unfold, I am awestricken. This woman has walked in her truth regardless of the consequences. The consequences have been killer. Arrest, solitary confinement, long jail term, now being a woman in a men's prison. Already she is larger than life, just as Gandhi and Jesus Christ and MLKing were larger than life.

I watch these saints. I listen to these saints. And I pray for the courage to act my truth regardless of personal consequences. I still have nothing against signing petitions, supporting causes, doing projects and going to marches. These are feel-good activities and are energizing. Nothing is wrong with that. But having compassion and love for my enemies until I have no enemies, only loved ones, is hard inner work. Unless I get a miracle that is, and that is always possible.

I think we are all larger than life and we all can change the world, yes, even those I disagree with, if we could connect and stay connected with our personal truths.

Current Thoughts...Good and Bad Ways to Die...

When I hear that someone has died, I instantly, without forethought, judge whether I think it is a good or bad way to go. I am sure that those of you who have had different experiences and even are at different ages have other ways of evaluating.

GOOD WAYS TO GO:

1. Never wake up in the morning. Many friends would prefer this.

2. The big one, heart attack, anywhere, any time.

3. Chose to go lie on a mountain top when you know your time has come. Our First People had a cool tradition of this.

4. Quietly slip away surrounded by friends and family softly chanting Kumbya (sp?).

5. On the morphine cloud. (I am not so sure about this, never having had morphine) I am not a believer in suffering when it can be avoided.

6. The rapture. I don't know anyone who has been raptured up, but it sounds like a plan. (not the James Jones cool aid idea).


BAD WAYS to GO:

1. Painful, nasty, slow death.

2. Getting shot or stabbed or assaulted.

3. Drowning, getting eaten by a shark, caught in the rapids...the whole spectrum.

4. Fire. Too scary to think about. Was thinking about the Inquisition and the Salem Witch Trials and dear, brave Joan of Arc. All horrific.

5. OK, this is freaking me out.

I think I have to focus on living well. Most likely I won't have a choice in the matter of my demise. My friends who have worked for Hospice swear that stopping eating is pretty painless, but having experienced a severe degree of starvation when I had the evil parasites and a minor degree in the village I lived in in El Salvador, I don't think I am a fan of that method.

Sorry for this post, but I have been hearing almost daily about a friend or acquaintance dying and I found myself rating their manner of going against what I think I could bear. I know the mysteries of karma play into this. I also know that I think about aesthetics. They are important to me. Maybe in the end, none of our preferences matter at all.

Bold New Theory....the NRA...

OK, I can modestly say that I am almost 100% right about this kind of thing. I can immodestly say that being right has pretty much never helped change things in a good way.

Here goes. This morning I read a report or heard it on Democracy Now! that after very aggressively opposing the government on the same issue, the NRA has (is) compiling its own list of all gun owners in the USA.

Here is how this could come down. They are putting together a militia that they can call on when they decide it is righteous to do so. After hanging out with that bunch of Tea Party Texans in Nicaragua and hearing all their jabber about how much they HATE the government of the USA and HATE Obama and HATE anyone telling them what to do (as if their goal isn't to tell us all what to do right down to and including our vaginas), and how this and that person should be shot and how immigrants are ripping us off of all the wonderful jobs that we crave, and on and on, I am certain that there is a bigger plan. They are acting like dumb rednecks while making very significant moves.

I don't like it at all. We watch the killing of blacks by police, by watchdogs, and we have killing militias roaming around the Rio Grande killing people trying to come here. I suspect there is a bigger plan here. I think the collecting of this information while blocking the government from doing so is just one step towards some actions that could really bring drastic harm to us and to the world.

These are the same people who talk about "nuking the rag heads", who kill gays, who were lynching blacks a few years back. It is not a pretty picture.

I have no idea what can be done if what I fear is true. I only know that we can't sit back and think any of this is random or could be without consequence. I feel that if we think Manning and Snowden are treasonous, we should look very carefully at people who want to overthrow our government and talk about it publicly and are collecting the means.

I wasn't taking a vacation...

I was actually thinking. It didn't work out so very well this time. I missed writing this blog. I missed all of you. I have not heard from many of you, in fact, I have never heard from a single Latvian. You Latvians are among my strongest most dependable readers. Imagine that! Some days I have more Latvians reading this blog than people in my own country. It is hard to explain my feeling of missing you. I don't know you and I have no dialogue with you. But, you are there and I picture you sometimes when I am writing. Hi guys.

I really like telling stories. The stories I know are the things I see and experience. I like thinking about whatever and whomever comes into my orbit. I suppose that is pretty much how we form ourselves. I have met a lot of remarkable people lately. Come to think about it, we are all remarkable. On my walk today, Jane and I met up with a neighbor of hers. Somehow we got talking about where the edge is between "normal" people and really messed up people, the ones you would be smart to circle around giving them wide berth.

The thing that came to mind was the image of a 'cat lady'. My thinking went like this: If one person has twenty cats, say she rescues them and takes care of them, she is a saint. If another person has twenty cats and doesn't meet my bourgeois 21st century standards of a good cat husbandry, I think she is maybe off her rocker. Where is that line in my head? Dirty litter boxes? Bad smell? No shots? Who am I to judge?

And yet judge I do. I was visiting with my son. He has very high standards for himself and others. I admire that. But he pointed to several times when I, Saint Julie, was ignorantly making negative assumptions about people I didn't know. Moi? Made me think. I assume that we all have pretty much given up on any idea of normal these days. It is an archaic concept, proven to be of no use over and over. In fact, I sort of equate 'normal' with 'boring'. But, that is false also. No life is boring to me. All the billions of lives on this planet have great stories going down.

For now, I am going to do a little less thinking and go on telling you the stories I encounter. Life is better than any fiction I could create. Que viva la vida loca!

"I Cherish the Beauty of Myself and Others"

I am working on the 21 Day Meditation Challenge from Oprah and Deepak. "I cherish the beauty of myself and others." is the centering thought of day six. These simple focus thoughts can be a huge challenge. They are so obvious and nice and easy until I start to wonder why I don't see the beauty in a frightening dirty man who feels threatening to me. I don't see the beauty in racist red necks. I don't see the beauty in Rambo-type mercenaries. I could go on forever.

And the beauty in myself???? I see some beauty, yes, but I also see very many glaring faults. If I didn't see them on my own, after all my eye sight and hearing are dimmer, my kids and grand kids would let me know about them pretty quickly. My five year old grand daughter who loves me mightily, whispered to me one day, "Grandma, you have wrinkly skin." "No!" I said. "Yes you do." she sadly told me. Then I admitted to her that I knew this all along. Had to take the burden of this revelation off of her.

But, I suppose the beauty I am looking for has pretty much nothing to do with wrinkles. I assume it is what some would call "the Christ within" or the "Golden Heart". We are told by all teachers of all faiths that everyone has the spark of divinity. Even Lucifer was a fallen angel. I am good at looking at beauty in nature. Even the crumbling leaf as it dries up in Autumn and turns to dust has beauty. An old snake skin shed and left on the trail is a wonder. A broken robin's egg is a miracle. But people, man, that can get hard.

What I came away from this morning's meditation thinking is that I have to change my eyes, my way of seeing. I have to push aside the knee jerk critical eyes and see beauty first, in myself and others. This is my intention. I have a mixed record of attaining my intentions. I still smoke and I had a minor orgy with my Solitaire game on the phone last night. I remember a vow a few months past to jettison that. Oh well, for now, for this moment, I am beautiful and so are you. It really feels good to see the world this way.

Remembering a peak experience.

It was food. So, I was born in 1944, in the USA. I had an Irish mother who tried hard but was not a good cook. My first memory of food was when my mother let me mix the yellow coloring with the little bag of lard(?) to make "butter". I also remember the god awful blue color of powdered skim milk. There were a few years after the war when we still suffered slight shortages due to the war. Then, in my memory came Betty Crocker and the amazing everything came in a package times. I had a friend , Karlene Goode, who's mother made real things like pastries. I couldn't believe them.

Because Mom's ethnic background was least famous for cooking, because Mom was modern, because it was those times, coffee was instant, bread was supermarket, whipped cream was in a spray can. You get the picture. It was the fifties in middle America. I used to dream of being Italian or French and of what
their food would taste like.

Then, when I was 20, I went to Europe on a Grand Tour. I can still remember my first cup of Cappuccino in Italy. 'Oh my god! This is what coffee tastes like'. Swoon. Then tasting butter in France. "This is the best thing I have ever eaten." Butter is still one of my major food groups. Then the veggies! The fruit! So much different from canned veggies. You can't imagine. And how about sausage in Germany. I had only had hot dogs before that. And real whipped cream!!! Fresh octopus in Greece, yeee gods, frozen fish sticks didn't even compare. You get my drift. Every bite, every common food in Europe was a treat beyond treats.

The thing that brought on these memories today was going into a lovely food store in Seattle and seeing every possible great food from every country everywhere just available right now, right here. I know there are still parts of the world where this is not possible. I know that even in Betty Crocker cake mix world time you could find an ethnic neighborhood in a big city and buy the real thing. I know that there were even in those times there were wonderful cooks out on the farm making their own sausages from real meat. But I also know that it ws more than twenty years later in the ordinary parts of this country when real coffee and real ice cream and fifty varieties of salt (imagine that) started showing  up everywhere. (Häagen-Dazs was bought by Pillsbury in 1983. General Mills bought Pillsbury in 2001. However, in the United States and Canada, Häagen-Dazs products are produced by Nestlé subsidiary Dreyer's, which acquired the rights as part of the General Mills Pillsbury deal. The brand name is still owned by General Mills but is licensed to Nestlé in the US and Canada.)

I wondered today why it took so long. Didn't everyone who tasted the really good stuff want more of it? I did. From that little bit of info about Haagen-Dazs, it looks like it wasn't until the big players got into the picture that the good stuff came to us. I hope the trend continues, although deciding among fifty kinds of olives can be taxing. But it is far better than just having pale green olives stuffed with pimientos as a choice of one. Although, truth be told, I sometimes get nostalgic for ice burg lettuce. Don't you?

I have this idea. Anyone want to be my co-worker?

I guess it would have to be online. It doesn't make sense to do this on paper because who would buy it? The idea is to have people take pictures and send them to me of the most expensive house(s) in their town, city, rural area and also take a picture of the worst, poorest home(s) in the same area. I think the 99% /1% divide would be very powerful in pictures. Both ends of our economic spectrum live in ghettos, mas o menos, in the USA and we don't often set eyes on each other. And we all know that the middle class is disappearing.

I am open to ideas about how this might be accomplished and where I might put it. Thanks, Jules

I can't get this article out of my mind.

Paying Till It Hurts

This article doesn't even require a rant from me. It is such an ridiculous indictment  of our current idiocy about health care in our country. The article does, however, open my mind to a new concept. If a person seeking affordable care doesn't dare go to a third world country for medical stuff, they can go to a developed country and pay a bit more. This is nothing to do with Obamacare. The new program will do nothing to cure this overpricing. 

I am still ashamed to tell other people from other countries that we sign a statement in the doctor's office  saying we will pay the uninsured part of our bills when we don't have any idea until after the service what the bill will be nor do we have any notion how much the insurer will pay. Medical care is the only thing I buy without knowing the cost. It feels very reckless and idiotic to me while I am doing it. Every time.

What do we value here? I guess we value the right of the greediest companies to get more over rational solutions to our problems. I can't come to any other conclusion. We don't need a revolution, we need common sense. And we need to get over the false notion that paying more gets us better care. It ain't necessarily so.

These are Gandhi's super-famous Seven Blunders of the World. Gandhi gave the list to his grandson on the day of his assassination. He said that they were the root causes of violence. 

 God, I could spend a month thinking about each of these seven root causes. Probably each and every one of them could be applied in thinking about the implications of the following article. Test them out. Are we doing the best we can with what we have?

A Trip Abroad

Part 3: Joint Replacement

In Need of a New Hip, but Priced Out of the U.S.

By ELISABETH ROSENTHAL | Published: August 3, 2013

Josh Haner/The New York Times

Michael Shopenn, who has an artificial hip, on Copper Mountain in Colorado.

WARSAW, Ind. — Michael Shopenn’s artificial hip was made by a company based in this remote town, a global center of joint manufacturing. But he had to fly to Europe to have it installed.

Mr. Shopenn, 67, an architectural photographer and avid snowboarder, had been in such pain from arthritis that he could not stand long enough to make coffee, let alone work. He had health insurance, but it would not cover a joint replacement because his degenerative disease was related to an old sports injury, thus considered a pre-existing condition.

Desperate to find an affordable solution, he reached out to a sailing buddy with friends at a medical device manufacturer, which arranged to provide his local hospital with an implant at what was described as the “list price” of $13,000, with no markup. But when the hospital’s finance office estimated that the hospital charges would run another $65,000, not including the surgeon’s fee, he knew he had to think outside the box, and outside the country.

“That was a third of my savings at the time,” Mr. Shopenn said recently from the living room of his condo in Boulder, Colo. “It wasn’t happening.”

“Very leery” of going to a developing country like India or Thailand, which both draw so-called medical tourists, he ultimately chose to have his hip replaced in 2007 at a private hospital outside Brussels for $13,660. That price included not only a hip joint, made by Warsaw-based Zimmer Holdings, but also all doctors’ fees, operating room charges, crutches, medicine, a hospital room for five days, a week in rehab and a round-trip ticket from America.

“We have the most expensive health care in the world, but it doesn’t necessarily mean it’s the best,” Mr. Shopenn said. “I’m kind of the poster child for that.”

As the United States struggles to rein in its growing $2.7 trillion health care bill, the cost of medical devices like joint implants, pacemakers and artificial urinary valves offers a cautionary tale. Like many medical products or procedures, they cost far more in the United States than in many other developed countries.

Makers of artificial implants — the biggest single cost of most joint replacement surgeries — have proved particularly adept at commanding inflated prices, according to health economists. Multiple intermediaries then mark up the charges. While Mr. Shopenn was offered an implant in the United States for $13,000, many privately insured patients are billed two to nearly three times that amount.

An artificial hip, however, costs only about $350 to manufacture in the United States, according to Dr. Blair Rhode, an orthopedist and entrepreneur whose company is developing generic implants. In Asia, it costs about $150, though some quality control issues could arise there, he said.

So why are implant list prices so high, and rising by more than 5 percent a year? In the United States, nearly all hip and knee implants — sterilized pieces of tooled metal, plastic or ceramics — are made by five companies, which some economists describe as a cartel. Manufacturers tweak old models and patent the changes as new products, with ever-bigger price tags.

Generic or foreign-made joint implants have been kept out of the United States by trade policy, patents and an expensive Food and Drug Administration approval process that deters start-ups from entering the market. The “companies defend this turf ferociously,” said Dr. Peter M. Cram, a physician at the University of Iowa medical school who studies the costs of health care.

Though the five companies make similar models, each cultivates intense brand loyalty through financial ties to surgeons and the use of a different tool kit and operating system for the installation of its products; orthopedists typically stay with the system they learned on. The thousands of hospitals and clinics that purchase implants try to bargain for deep discounts from manufacturers, but they have limited leverage since each buys a relatively small quantity from any one company.

In addition, device makers typically require doctors’ groups and hospitals to sign nondisclosure agreements about prices, which means institutions do not know what their competitors are paying. This secrecy erodes bargaining power and has allowed a small industry of profit-taking middlemen to flourish: joint implant purchasing consultants, implant billing companies, joint brokers. There are as many as 13 layers of vendors between the physician and the patient for a hip replacement, according to Kate Willhite, a former executive director of the Manitowoc Surgery Center in Wisconsin.

Hospitals and orthopedic clinics typically pay $4,500 to $7,500 for an artificial hip, according to MD Buyline and Orthopedic Network News, which track device pricing. But those numbers balloon with the cost of installation equipment and all the intermediaries’ fees, including an often hefty hospital markup.

That is why the hip implant for Joe Catugno, a patient at the Hospital for Joint Diseases in New York, accounted for nearly $37,000 of his approximately $100,000 hospital bill; Cigna, his insurer, paid close to $70,000 of the charges. At Mills-Peninsula Health Services in San Mateo, Calif., Susan Foley’s artificial knee, which costs about the same as a hip joint, was billed at $26,000 in a total hospital tally of $112,317. The components of Sonja Nelson’s hip at Sacred Heart Hospital in Pensacola, Fla., accounted for $30,581 of her $50,935 hospital bill. Insurers negotiate discounts on those charges, and patients have limited responsibility for the differences.

The basic design of artificial joints has not changed for decades. But increased volume — about one million knee and hip replacements are performed in the United States annually — and competition have not lowered prices, as would typically happen with products like clothes or cars. “There are a bunch of implants that are reasonably similar,” said James C. Robinson, a health economist at the University of California, Berkeley. “That should be great for the consumer, but it isn’t.”

Comparing Two Operations

‘Sticky Pricing’

The American health care market is plagued by such “sticky pricing,” in which prices of products remain high or even increase over time instead of dropping. The list price of a total hip implant increased nearly 300 percent from 1998 to 2011, according to Orthopedic Network News, a newsletter about the industry. That is a result, economists say, of how American medicine generally sets charges: without government regulation or genuine marketplace competition.

“Manufacturers will tell you it’s R&D and liability that makes implants so expensive and that they have the only one like it,” said Dr. Rory Wright, an orthopedist at the Orthopedic Hospital of Wisconsin, a top specialty clinic. “They price this way because they can.”

Zimmer Holdings declined to comment on pricing. But Sheryl Conley, a longtime Zimmer manager who is now the chief executive of OrthoWorx, a local trade group in Warsaw, said that high prices reflected the increasing complexity of the joint implant business, including more advanced materials, new regulatory requirements and the logistics of providing a now huge array of devices. “When I started, there weren’t even left and right knee components,” she said. “It was one size fits all.”

Mr. Shopenn’s Zimmer hip has transformed his life, as did the replacement joint for Mr. Catugno, a TV director; Ms. Foley, a lawyer; and Ms. Nelson, a software development executive. Mr. Shopenn, an exuberant man who maintains a busy work schedule, recently hosted his son’s wedding and spent 26 days last winter teaching snowboarding to disabled people.

His joint implant and surgery in Belgium were priced according to a different logic. Like many other countries, Belgium oversees major medical purchases, approving dozens of different types of implants from a selection of manufacturers, and determining the allowed wholesale price for each of them, for example. That price, which is published, currently averages about $3,000, depending on the model, and can be marked up by about $180 per implant. (The Belgian hospital paid about $4,000 for Mr. Shopenn’s high-end Zimmer implant at a time when American hospitals were paying an average of over $8,000 for the same model.)

“The manufacturers do not have the right to sell an implant at a higher rate,” said Philip Boussauw, director of human resources and administration at St. Rembert’s, the hospital where Mr. Shopenn had his surgery. Nonetheless, he said, there was “a lot of competition” among American joint manufacturers to work with Belgian hospitals. “I’m sure they are making money,” he added.

Dr. Cram, the Iowa health cost expert, points out that joint manufacturers are businesses, operating within the constraints of varying laws and markets.

“Imagine you’re the C.E.O. of Zimmer,” he said. “Why charge $1,000 for the implant in the U.S. when you can charge $14,000? How would you answer to your shareholders?” Expecting device makers “to do otherwise is like asking, ‘Couldn’t Apple just charge $50 for an iPhone?’ because that’s what it costs to make them.”

But do Americans want medical devices priced like smartphones? “That,” Dr. Cram said, “is a different question.”

A Miracle for Many

When joint replacement surgery first became widely used in the 1970s, it was reserved for older patients with crippling pain from arthritis, to offer relief and restore some mobility. But as technology and techniques improved, its use broadened to include younger, less debilitated patients who wanted to maintain an active lifestyle, including vigorous sports or exercise.

Narayan Mahon for The New York Times

Dr. Rory Wright at the Orthopedic Hospital of Wisconsin with two modern hip joint options.

In the first few decades, implants were typically cemented into place. But since the 1980s, many surgeons have used implants made of more sophisticated materials that allow the patient’s own bone to grow in to hold the device in place. For most patients, implants have proved miraculous in improving quality of life, which is why socialized medical systems tend to cover them. Per capita, more hip replacements are done in Britain, Sweden and the Netherlands, for example, than in the United States.

Motivated in part by science and in part by the need to create new markets, joint makers churn out new designs that are patented, priced higher and introduced with free training courses for surgeons. Some use more durable materials so that a patient requiring a hip implant at age 40 or 50 might rely on it longer than the standard 20 years, while other models are streamlined and require smaller incisions.

Zimmer got a big sales bump a few years ago when it began promoting its new “female knee,” a slightly slimmer version of its standard design, in an advertising campaign directed at patients. Hospitals on average pay about $800 more to buy the gender-specific knee implants, according to MD Buyline.

Many doctors say that for most patients, older, standard implants with a successful track record are appropriate. Expensive modifications make no difference for the typical patient, but they drive up prices for all models and have sometimes proved to be deeply flawed, they say.

In the last few years, joint manufacturers have faced lawsuits and have settled claims with patients after new, all-metal implants, which were meant to be more durable than the standard version, had unusually high failure rates. As for those “female knees,” a study featured at the meeting of the American College of Orthopedic Surgeons this year concluded, “While we certainly use the female components frequently in surgery, we don’t detect any objective improvement in clinical outcomes.”

That is why Dr. Scott S. Kelley, an orthopedist affiliated with Duke University Medical Center, generally tries to dissuade patients who request “new, improved” joints. “I tell them: ‘That’s taking a big risk for the potential of a few percentage points of improvement. You wouldn’t invest your retirement account this way.’ ”

A Town’s Lifeblood

The power and profits of the medical device industry are on display here in Warsaw, which has trademarked itself the Orthopedic Capital of the World. Four of the big five joint manufacturers in the world are based in the United States; the other is in Britain. Three of these giants — Zimmer, Biomet and DePuy, a division of Johnson & Johnson — have their headquarters here, a town of 14,000.

An industry that began as a splint-making shop in 1895 has made Warsaw the center of a global multibillion-dollar business. The companies based here produce about 60 percent of the hip and knee devices used in the United States and one-third of the world’s orthopedic sales volume, local officials said. Nearly half the jobs in Kosciusko County, where Warsaw is, are tied to the industry. Residents joke that a mixed marriage is when one spouse works for Zimmer and the other for DePuy.

The industry’s benefits are evident. The county has the lowest unemployment rate in Northern Indiana, and the median family income of $50,000 puts it significantly above the state average. The town boasts lush golf courses and streets lined with spacious homes. The lobby of the elegant City Hall, which is in a restored 1912 bank, features plaques about device manufacturers.

“We eat, sleep and breathe orthopedics,” said Ms. Conley of OrthoWorx, which she said was set up to “plan for the future of the orthopedic industry here.” OrthoWorx’s board of directors includes executives from Biomet and DePuy.

With a high-tech industry as its lifeblood, Ms. Conley said, Warsaw needed to attract engineers and doctors from afar and train local youths for “the business.” It has upgraded the public schools and helped create programs at local colleges in orthopedic regulation and advanced machinist techniques.

Officials at OrthoWorx say the device makers do not discuss “competitive issues” among themselves, including the prices of implants, even as employees stand together watching their children play baseball. Still, it is in everyone’s interest not to undercut the competition. In 2011, all three manufacturers had joint implant sales exceeding $1 billion and spent about only 5 percent of revenues on research and development, compared with 20 percent in the pharmaceutical industry, said Stan Mendenhall, the editor of Orthopedic Network News. They each paid their chief executives over $8 million.

“It’s amazing to think there is $5 billion to $6 billion going through this little place in Northern Indiana,” said Mr. Mendenhall, adding that the recession has meant only single-digit annual revenue growth rather than the double-digit growth of the past.

Device makers have used some of their profits to lobby Congress and to buy brand loyalty. In 2007, joint makers paid $311 million to settle Justice Department accusations that they were paying kickbacks to surgeons who used their devices; Zimmer paid the biggest fine, $169.5 million. That year, nearly 1,000 orthopedists in the United States received a total of about $200 million in payments from joint manufacturers for consulting, royalties and other activities, according to data released as part of the settlement.

Despite that penalty, payments continued, according to a paper published in The Archives of Internal Medicine in 2011. While some of the orthopedists are doing research for the companies, the roles of others is unclear, said Dr. Cram, one of the study’s authors.

Although only a tiny percentage of orthopedists receive payments directly from manufacturers, the web of connections is nonetheless tangled.

Companies “build a personal relationship with the doctor,” said Professor Robinson, the Berkeley economist. “The companies hire sales reps who are good at engineering and good at golf. They bring suitcases into the operating room,” advising which tools might work best among the hundreds they carry, he said. And some studies have shown that operations attended by a company representative are more likely to use more and costlier medical equipment. While some hospitals have banned manufacturers’ representatives from the operating room, or have at least blocked salesmanship there, most have not.

No Gift Shop

There are, of course, a number of factors that explain why Mr. Shopenn’s surgery in Belgium would cost many times more in the United States. In America, fees for hospitals, scans, physical therapy and surgeons are generally far higher. And in Belgium, even private hospitals are more spartan.

When Mr. Shopenn arrived at the hospital, he was taken aback by the contrast with NewYork-Presbyterian Hospital, where his father had been a patient a year before. The New York facility had “comfortable waiting rooms, an elegant lobby and newsstands,” Mr. Shopenn remembered.

But in Belgium, he said, “I was immediately scared because at first I thought, this is really old. The chairs in the waiting rooms were metal, the walls were painted a pale green, there was no gift shop. But then I realized everything was new. It was just functional. There wasn’t much of a nod to comfort because they were there to provide health care.”

St. Rembert's, the private hospital in Belgium where Mr. Shopenn had his hip replaced for $13,660. Thomas Vanden Driessche for The New York Times

The pricing system in Belgium does not encourage amenities, though the country has among the lowest surgical infection rates in the world — lower than in the United States — and is known for good doctors. While most Belgian physicians and hospitals are in business for themselves, the government sets pricing and limits profits. Hospitals get a fixed daily rate and surgeons receive a fee for each surgery, which are negotiated each year between national medical groups and the state.

While doctors may charge more than the rate, few do so because most patients would refuse to pay it, said Mr. Boussauw, the hospital administrator. Doctors and hospitals must provide estimates. European orthopedists tend to make about half the income of their American counterparts, whose annual income averaged $442,450 in 2011, according to a survey by the Commonwealth Fund, a foundation that studies health policy.

Belgium pays for health care through a mandatory national insurance plan, which requires contributions from employers and workers and pays for 80 percent of each treatment. Except for the poor, patients are generally responsible for the remaining 20 percent of charges, and many get private insurance to cover that portion.

Mr. Shopenn’s surgery, which was uneventful, took place on a Tuesday. On Friday he was transferred for a week to the hospital’s rehabilitation unit, where he was taught exercises to perform once he got home.

Twelve days after his arrival, he paid the hospital’s standard price for hip replacements for foreign patients. Six weeks later he saw an orthopedist in Seattle, where he was living at the time, to remove stitches and take a postoperative X-ray. “He said there was no need for further visits, that the hip looked great, to go out and enjoy myself,” Mr. Shopenn said.

Staying Active

The number of hip replacements has risen sharply in recent years, with much of the growth coming from people younger than 65.

Source: Agency for Healthcare Research and Quality

With baby boomers determined to continue skiing, biking and running into their 60s and beyond, economists predict a surge in joint replacement surgeries, and more procedures for younger patients. The number of hip and knee replacements is expected to roughly double between 2010 and 2020, according to Exponent, a scientific consulting firm, and perhaps quadruple by 2030. If insurers paid $36,000 for each surgery, a fairly typical price in the commercial sector, the total cost would be $144 billion, about a sixth of the nation’s military budget last year.

So far, attempts to bring down the price of medical devices have been undercut by the industry.

When Dr. Daniel S. Elliott of the Mayo Clinic decided to continue using an older, cheaper valve to cure incontinence because studies showed that it was just as good as a newer, more expensive model, the manufacturer raised its price.

“If there was a generic, I’d be there tomorrow,” he said.

With artificial joints, cost-trimming efforts have been similarly ineffective. Medicare does not negotiate directly with manufacturers, but offers all-inclusive payments for surgery to hospitals to prompt them to bargain harder for better implant prices. Instead, hospitals complain that acquiring the implant consumes 50 percent to 70 percent of Medicare’s reimbursement, which now averages $12,099, up 25 percent from $9,645 in 1993. Meanwhile, surgeons’ fees have dropped by nearly half.

With the federal government unwilling to intervene directly, some doctors and insurance plans are themselves trying to reduce the costs by mandating preset prices or forcing more competition and transparency.

After concluding that hip replacements billed at $100,000 yielded no better results than less expensive ones, the California Public Employees’ Retirement System, or Calpers, told members that it would pay hospitals $30,000 for a hip or knee replacement, and dozens of hospitals have met that number.

Dr. Wright’s orthopedic hospital near Milwaukee has driven down payments for joints by more than 30 percent by resolving to use only two types of hip implants and requiring blind bids directly from the manufacturers; part of the savings is passed on to patients.

The Affordable Care Act tries to recoup some of the medical device manufacturers’ profits by imposing a 2.3 percent tax on their revenues, effective this year. But Brad Bishop, the executive director of OrthoWorx and a former Zimmer executive, said that the approach would harm an innovative American industry, and that the cost would ultimately be borne by joint replacement patients “whose average age is 67.” He argued that the best way to reduce the cost of joint replacement surgery was to rescind the tax and decrease government interference.

The medical device industry spent nearly $30 million last year on lobbying, according to the Center for Responsive Politics. The Senate moved to repeal the tax, and the House is expected to take it up this fall. The bill’s supporters included both senators from Indiana.

Mr. Shopenn’s new hip worked so well that a few months after returning from Belgium he needed a hernia operation — a result of too much working out at the gym. He was home by 4 p.m. the day of the outpatient surgery, but the bill came to $16,500. Though his insurance company covered the procedure, he called the hospital’s finance department for an explanation.

He remembers in particular a “surreal” discussion with a “very nice” administrator about a $750 bill for a surgical drain, which he called “a piece of plastic in a sealed bag.”

“It was mind-boggling to me that the surgery could possibly cost this much,” he said, “after what I’d just done in Belgium.”

When to offer a bribe ....sometimes a tough question.

My first blush with bribery happened on Nantucket Island the summer after my freshman year of college. On a whim I had gone to Nantucket after the eighth or so day after Dana Hall graduation. Our graduation party had traveled from Wellesley, MA to Greenwich, CT to New York City and then run out of steam. It was a hot day and a few of us decided to go to Nantucket to the beach. At that time, my memory is that the flight from New York cost about $12, which is about how much money I had left from my $50 graduation present.

There were, however, a few Dana girls on the Island and one was a year-rounder. We went to Sydney's house and her father offered me a job at his diner (Allan's Lobster Bar and Grill). I found a girl's boarding house to live in. This turned out to to one of the most fun places I have ever landed in. Wally and Anne owned this house by inheritance and they were grad students, so they rented rooms to pay the taxes and keep the house. In a way it was pretty much the lunatics running the asylum. A great time was had by all.

That was a magic summer. The diner was an insanely popular place with terrific food. It was on the wharf  where all the tourist boats landed. It was one of a few places open all year round so the locals all came. Everyone came. I made a ton of money working breakfast and lunch. The rest of the day was for beach, tennis, parties and more of the same. I bought a Vespa scooter for $50 and sold it at the end of the summer for $50. I went home missing the first few days of college because it was hard to leave the Island.

The next summer, the one in which I saw my first bribe pass hands, had a bit more edge to it. We were heavier drinking. A bunch of friends had come along with me. Some of them had a harder time getting jobs. We ended up in an illegal room in the basement of a laundry in the middle of town. The owner was an unpleasant man, but he gave work to my friends, folding laundry and delivering it to mostly renters around the Island.

It was a pretty horrible room, but we were outside at the beach or sailing pretty much all the time. We didn't care one way or another. That is until we had a rainy spell and we had colds and suddenly we were lying around talking about what a dump it was and what a rip off it was. So, we decided to decorate it. We bought a huge array of oil paints and painted pictures (real art) all over the walls and the doors and pretty much every surface. We thought two things. 1. At least it was clean. 2. It was really quite beautiful. The nasty landlord had no objections until one of my room mates started a little side business doing laundry for his customers cheaper. She started earning real money and he started losing business. "This is capitalism at its best", we thought.

It was almost Labor Day when he figured this out. He kind of freaked on us and called the police. We had an amusing chase over some rooftops and were finally brought in. He couldn't charge us with being better businessmen than he was so he charged 4 of us with "Willful and malicious destruction of property." (Our beautiful art) This charge was unfortunately a fellony charge.

A good/bad thing was that my parents were coming for Labor Day weekend to celebrate their 25th wedding anniversary. Their honeymoon had been in Nantucket. Good-my parents were coming. Bad-I hadn't confirmed their room because we were in jail. Good- I needed my Dad. Bad-He was pretty pissed and I felt really bad about their weekend being ruined.

So, it was a holiday weekend. No court. Somehow, Dad managed to have a little talk with the judge. He was smoking a cigar dressed in a tee shirt and baggy pants with suspenders. He listened to my father and had us brought in the room...not a courtroom...this was all outside of the process. He listened carefully and said to my Dad, "I have been the judge here for a long time and in my recollection, no off-islander has ever won a case here."

My father, as straight a man as has ever lived, listened and then asked, "How much?" The judge answered as clear as day, "I would ordinarily ask a thousand dollars each, but I am feeling generous $2,500." I thought Dad would drop dead. That was a lot of money in 1963. He paid. He gave us all 'the look.' and over the next 5 months we all paid him back.

Now really, the only lessons we learned were that my Dad was a good guy, that no off-islander had a chance if they went to court and that this judge at least was up front about being bribed. (This was not a fine). Later in my life I would find it much more confusing deciding when to bribe and when not to. Also, I never again was told how much.  More on this subject anon.

"The only reason I Live in the USA Is so I'm not a victim of US foreign policy."

I can't even remember who uttered this amazingly resonating line. Was it Dick Gregory or Abbie Hoffman? Memory blank here. But, I think of this quote often because things have changed a lot in the past years. Now, it is abundantly clear to anyone with half a brain that we in the homeland are increasingly victims of US foreign policy. We have many political prisoners here. We have unbelievable surveillance. NSA and all that. We are subjected to tons of propaganda. Drones are fast becoming ubiquitous. We order assassinations of US citizens, unabashedly.We buy and sell democracy. We allow and encourage companies to poison our citizens (think Monsanto, think fracking, think coal fired power plants).

We have had a lot of practice in other countries. How could we not expect it to come home to visit itself upon us? The other day a facebook friend, Julie DiPaulis, re-posted an anti-Muslim racist rant on her page. It was filled with hate and ignorance and drum beating for further violence. It was couched in shallow verbiage about protecting America and supporting our troops. Many of her friends 'liked' this post. I was horrified and filled with hurt. Hatred and violence are hatred and violence no matter what side you are on. It is no-where stuff. Nothing good can be born from hearts filled with hate. Think about it.

“In war, good guys always become bad guys.” 
― Howard Zinn

I can get pretty mixed up about my tendency to condemn ignorance. If, as I postulate, these attitudes come from ignorance ( It is still hard for me to believe that many people still think that "Iraq bombed the World Trade Center.") then they can be forgiven as such. But we are not talking here about illiterate peasants in the middle of nowhere. These people actually have education and some minor evidence that, for instance, the damage to the Trade Center came mostly from airplanes, not bombings. Does that make the ignorance not ignorance? If a person has a choice about whether to be ignorant or not, do we need a new word here?

If I believe that all good change begins at home, then I must put aside my righteous indignation and love the writers of this crap. I can only go so far, but I'll give it my best shot. "We are all poor suffering schmucks bumbling our way through life. Help us all to manifest true brotherhood and support all living beings in their quest for happiness and peace. Amen."

The Cake That Turned the Tide

I was just visiting my friend Heather. She is 34 and an absolute beauty. Our families have known each other for a long time. Over the years, my kids lived with her family and hers with mine. Heather is a Douala in a hospital midwife group in Portland, Oregon. I can't get enough of her birthing stories. They are so different from the days when I attended home births in New Hampshire. Epidurals and fetal monitors have changed the process so much. I used to watch the birth channel on cable TV until it got so boring watching the women lie around bored while laboring with little or no feeling from the waist down.

I am not against feeling no pain, my working theory of exercise is "No pain, no pain." as opposed to "No pain, no gain." I guess I just can't relate that much. However,I think the birthing women are very lucky to have knowledgeable, attentive care throughout their labor. And each and ever threshold story is still magical to me.

A friend of Heathers dropped by and asked how we got to know each other. Heather thought a while. Her memory went to a pivotal moment in our lives. I had owned a New Age Bookstore, Christine Masters New Age Bookstore, named after a character I had written about a few years previously. Heather's mom, Shelley wandered into the store. We became friends. Shelley was a macrobiotic cook as well as a follower of Guru Maharji and a single mother of three gorgeous kids. We walked around Marblehead Neck almost daily.

Shelley was not feeling well, but she was working very diligently to get healthy. Heather and I can't remember when it was that she found out that she had a malignant tumor inside her spinal column. I am not certain that I knew about this at the time. Shelly was losing weight  and it was no wonder. As she got sicker, she was purifying her diet until it basically consisted of brown rice and miso soup. (That's my memory.) We were walking a lot because that felt good to her. Sometime during that process, Shelley connected with Catherine Sears in a neighboring town.

Catherine was a healer who used crystals and energy for her work as well as her own psychic powers. She was very expensive for our budgets. Very. But she was a strong, clear woman and Shelley put her faith in her. She told Shelley that she had cancer because of old anger and resentments and had to work to clear this and she would be healed.

Soon, I had to drive Shelley to these appointments. She was getting weaker and thinner and the tumor was making her less able to walk or move. It was cutting off the nerves to the bottom half of her body. Catherine kept telling her that the tumor was shrinking and things were better. I got so I was totally angry at Catherine because in her weakened state, Shelley was in her thrall. Our lives were getting pretty sketchy. I had three kids and a small business to run and Shelley's kids needed attention.

One bad day, (pain, not able to eat) I called the kids together and said I needed to call Shelley's parents. She weighed about 84 pounds and looked like death to me. I asked the kids if they knew the names of the grandparents and their faces brightened up and when they replied "Mopsey and Papa." Oh shit, that wasn't much help. I finally found Peter, the kid's dad, and he knew the contact info. Of course, the parents were cruising in the Bahamas on their sailboat. Through a series of miracles, we contacted them, they were able to charter a plane or helicopter or something and got to Marblehead late that night. Shelley was too out of it to protest. The next morning she was having a nine hour operation with the amazing Dr. Fang at Mass General. He was able to get the entire tumor out without releasing any cells and I had the care of the kids.

When Shell got home from the hospital, she was skinny and weak, but cured of cancer. She still would not eat anything that wasn't macrobiotic and then only tiny bits. Anyone could see that she needed more. Heather told me that Shelley used to love carrot cake. We went up to her room and asked her whether she would eat some carrot cake if we made one. She said that she would if it was vegan. I said I had the perfect recipe.

Heather and I made a plan. We made a carrot cake as rich and nourishing and loaded with calories as humanly possible. We used a dozen eggs, a half of a pound of butter, tons of walnuts, piles of carrots, two cups of maple syrup, whole wheat flour, cream cheese frosting with honey and the juice of many lemons. The thing weighed about 8 pounds. Heather was so afraid that her mother would find out that she took the egg shells to a neighbors house to get ride of them. I took the cream cheese packaging home.

Shelley ate the whole thing over the next few days. It was the starting point of her regaining her strength and her appetite. For years she talked about the cake and wanted the recipe. She bragged about how the tofu frosting tasted just like cream cheese and the cake was as rich as if it were loaded with eggs and butter. I never blabbed. Heather told Shell the truth about the amazing cake about 8 years later.

I taught the child the dubious lesson that sometimes you have to twist the truth a little bit for righteous outcomes. It really was the most amazing cake ever and I am so not famous for my cooking.

The Other Side of Ride Share, fill up that SUV of yours.

If you are going somewhere and have the nice car and the money for gas, why don't you offer a ride share on Craig's List or somewhere. If you don't need the money, give it to some nice humanitarian project. (I'll be happy to give you suggestions if you need them.)

We liberals moan and groan about how the conservatives don't believe in global warming, and yet sometimes we skip some simple steps we can take to lesson our own carbon footprint. Like filling up our cars with other people so that there are fewer cars going the same places.

I have lived through the nightmare of car pooling. It is really hard. But ride share can be so simple. "I am driving from Boston to Scranton, PA Wednesday. Leaving at 10 AM. $25 gas donation. Room for 2." Done.

I used to be a great fan of hitching. Having been a high school and college kid in New England, it was the thing we all did. First we would start asking around our friends and if that didn't work out, then we'd just go on the road and stick out our thumbs. With 80 colleges and universities in Boston and tons more in the surrounding area, this was easy stuff. Somehow I don't think it is as easy, safe or popular anymore. Is this because half the kids arrive at college with their new Saab convertible? Maybe it is much less safe these days. Maybe ride share is the new hitch hiking. I don't know. I do know that out here in the wild west, distances are so great from city to city, that a little planning is necessary. I also know that public transportation (between cities) out here in the wild west couldn't be more inconvenient, expensive, and down right stupid.

Many of my friends who are recovering hippies were very happy with the ride share story because our memories of the early hippie days were memories of great innocent crazy fun and Charlotte and Wisconsin reminded us of the days of wonder and innocence when it was all mind blowing "Oh Wow, Far Out, Blew My Mind" dawning of the Days of Aquarius. Yup. Those were our good old days. My younger friends considered my story and came to the conclusion "mushrooms." They could be right. Mellower picture than meth or coke or heroin.

Becoming childlike once in a while is really fun. Watch a little kid watching you blow a bubble some day and see her eyes getting big and her utter fascination and her hands opening up. We all can experience this with or without the mushrooms, don't ya think?