Tuesday, July 11, 2006

HIV Discrimination?

Here's another one of those stories that seems sort of reasonable at first:
A federal judge this week dismissed an HIV discrimination lawsuit brought last year by an AIDS activist against the former owner of a Schofield restaurant.

District Judge Barbara Crabb concluded that Korrin Krause Stewart failed to show that her HIV-positive status substantially limited a major life activity, a requirement to succeed in a disability suit.

Stewart, 21, was born with the disease. She sued Lee's Log Cabin Inc. after she failed to get an interview for a waitress job for which she had applied in March 2004. A few days after applying, Stewart returned to the restaurant to add dishwasher experience to her job application. She then noticed that Curtis Zastrow, a manager trainee, had written "HIV+" across the top of the application.

Crabb, however, ruled that Stewart's HIV status didn't meet the definition of disability because she didn't show any impairment due to her HIV status. Being impaired doesn't mean disabled under Americans With Disabilities Act case law, unless the plaintiff can show it limits her ability to eat, breathe, reproduce or other major life activity.

"In the present case, however, plaintiff has adduced no evidence regarding the impact of HIV on any of Stewart's major life activities. ... No reasonable jury could conclude from the evidence plaintiff has adduced that having HIV rendered Stewart disabled," Crabb wrote in the 10-page opinion.
Obviously, refusing to hire someone because they have HIV is a shitty thing to do regardless of whether or not their condition is disabling. Let's make that perfectly clear first. But given that a great many people with HIV are in perfect physical condition, it does make sense that HIV infection is not considered to be a priori evidence of disability, and therefore it makes a certain amount of sense to say that this woman's complaint didn't fall under ADA enforcement. Or, it seems to, anyway.

But guess again:
The EEOC filed suit, claiming unlawful refusal to hire on account of HIV status. In responding to the defendant’s motion to dismiss, EEOC provided information about how Stewart as a person with AIDS was physically limited in her major life activities, in order to establish her identity as an "individual with a disability" under the ADA.

Judge Crabb, asserting that there is a big difference between being HIV+ and having AIDS, found that the complaint only asserted discrimination based on HIV+ status, not AIDS, and therefore the evidence about how AIDS limits Stewart’s major life activities was not relevant to the question whether she had a disability under the ADA. [...] Crabbe would not credit any of the EEOC’s evidence about the impact of AIDS on Stewart’s abilities, because of the purported distinction Crabbe found between HIV and AIDS.
Abruptly, the story veers from "makes a certain amount of sense" to "batshit crazy." HIV is the virus that causes AIDS. A person infected with HIV becomes "AIDS-defined" when they develop one of the disease's characteristic opportunistic infections, or when their CD4+ (T-cell) count drops low enough to make them extremely vulnerable to such infections. In other words, by saying that Stewart had AIDS, the EEOC was simply saying "She's HIV-positive and it has made her sick" - the very thing the documentation was supposed to prove. Judge Crabb's "gotcha" claim that the EEOC shifted arguments midstream by bringing AIDS into it doesn't make the slightest bit of sense.

What on earth is going on? I don't think Crabb's been swayed by the claims of AIDS denialists. Is she just prejudiced, and looking for any justification, however specious, to ensure that someone with HIV won't be pouring her coffee? It's a possibility. But I also wonder about this:
Dean Lee, the restaurant's owner at the time, had said that Stewart wasn't hired because she put a 10-pound lifting restriction on her application. Since 1980, the job has required that waitresses be able to lift 20 to 25 pounds about 20 times per shift, he said.
Law professor Art Leonard comments, "after reading Crabb’s summary of the EEOC’s evidence of Stewart’s AIDS-related symptoms, one wonders how anybody so afflicted could possibly provide effective service as a waitress." I wonder that too, and I imagine that Crabb wondered it as well. It seems possible that Judge Crabb developed the conviction that Stewart didn't apply for the job in good faith, and then looked for reasons to reject the complaint. It's hard to imagine how a person might legitimately think that they could work a waitressing job without ever having to lift more than ten pounds. Was Stewart trying to provoke a confrontation?

Stewart had already won one employment discrimination case locally - that's how the restaurant manager knew that she had HIV. The earlier case seems as clear an open-and-shut example of HIV discrimination as you'll ever see - she lost her job as a supermarket bagger because the management was afraid she'd infect customers or other employees. (They didn't specify how.) Now, I don't have a very hard time believing that Schofield, Wisconsin is particularly ignorant about HIV, or that a young HIV-positive woman living there might be discriminated against twice in three years. But I keep coming back to the fact that, on her job application for a waitressing position, she said that she couldn't lift more than ten pounds. That's when I stop being able to buy her as the innocent victim of discrimination. She might've been trying to be a provocateur, to raise awareness of HIV discrimination. She might've been out for settlement money. I haven't the slightest idea. But, no matter how much I strain to give her the benefit of the doubt, I just can't think that she was out to work as a waitress.

(Via The Gimp Parade.)

Saturday, July 08, 2006

Trauma is "Easy?"

This post is a collaboration between Respectful of Otters and Idealistic Pragmatist.

Think of the most terrified you've ever been. Heart pounding, mouth dry, sweat beading on your forehead, muscles locked rigid, violent or frightening images flooding your mind, screaming so loudly on the inside that you're barely aware of your surroundings. Now imagine being dropped randomly into that state a few times a day, every day, triggered by some innocuous thing or nothing at all.

This is Post-Traumatic Stress Disorder (PTSD), an anxiety disorder in which a person who has experienced or come into close contact with serious trauma later experiences crippling levels of anxiety, combined with vivid re-experiencing of the traumatic event and an intense desire to avoid anything that might bring the trauma to mind or trigger anxiety symptoms. PTSD is known to have a strong biological component; severe stress causes lasting alterations in brain neurochemistry. Trauma appears to damage specific receptors responsible for regulating catecholamines, which are hormones essential to the stress response. In people with PTSD, these stress hormones are elevated, leaving them constantly on the verge of a neurochemically-induced panic. "It's not fashionable," according to Canadian conservative columnist Margaret Wente, to be derisive of people going through that experience. But she courageously does her best all the same.

Wente's got a column up in The Globe and Mail, a Canadian national newspaper, that's been attracting favorable commentary even from bloggers who are ordinarily thoughtful and intelligent. (The column is behind a subscribers-only link, but you can currently access it through Google here). In the column, she suggests that PTSD in soldiers and veterans (and especially in the Canadian forces) is exaggerated and overdiagnosed, and insinuates that servicemembers diagnosed with PTSD are either whiners ("War is hell. But life can be pretty rough, too. You don't need battle trauma to cope badly with it.") or goldbrickers out for an easy life on disability benefits ("some people will abuse the system if it is financially attractive"). Her claims demonstrate little acquaintance with the scientific literature on PTSD; instead, they are heavily based on arguments by an American psychiatrist named Sally Satel, who is affiliated with and funded by the ultra-conservative American Enterprise Institute. Satel's - and, by extension, Wente's - claims about PTSD are baseless. Let's look at them one at a time.

Claim 1: PTSD rates among recent servicemembers are too high.

It's hard to know exactly what Wente means by this. We doubt she means that it's a terrible thing that so many servicemembers are suffering, although if she did, we would certainly agree. At times, she seems to mean that soldiers didn't used to suffer from PTSD, back in the high-moral-fibre days of World War II. She treats an elevation in rates over time as prima facie evidence that current diagnoses are overinflated. In fact, although PTSD has always been with us - previously it was called battle fatigue or shellshock - military strategists argue that aspects of the military and social context of modern wars increase the likelihood of PTSD. The increase in PTSD diagnoses is also due to changes in diagnostic criteria. Prior to the Vietnam era, psychiatric diagnosis was vague and tended to be based on Freudian theories rather than observable symptoms. Modern diagnostic systems, based in empirical research, have led to wider agreement about who has specific psychiatric illnesses, including PTSD.

Claim 1a: Therapists encourage veterans to blame everything that goes wrong in their lives on combat stress.

Wente implies that veterans who have moral or behavioral problems, such as a violent temper or an inability to hold a job, are encouraged by therapists to attribute their problems to PTSD rather than trying to fix them - thus, also, inflating PTSD diagnosis rates. But PTSD simply cannot be diagnosed without the presence of the three core symptoms listed in the second paragraph: intense anxiety, vivid and intrusive memories of trauma, and avoidance symptoms. You don't get to just go to a doctor and say "My life problems are caused by PTSD, now fork over a check."

Claim 1b: Servicemembers and veterans are just faking PTSD to get disability benefits.

Wente cites no evidence for this, which is probably because there is none. The Dart Center for Journalism & Trauma demolishes this claim completely:
Matthew J. Friedman, M.D., is the executive director of the National Center for PTSD, a division of the Department of Veteran's Affairs. In an e-mail to the Dart Center, Friedman said that Satel's argument was based on a "misreading or inability to appreciate the meticulous process by which personal reports of combat exposure were verified by military records" in the 1990 National Vietnam Veterans Readjustment Study. Friedman noted that the vast majority of veterans surveyed had not applied for medical disability because of their PTSD.

The notion of veterans falsely claiming to have PTSD is also contradicted by statistics published by the U.S. Department of Veteran's Affairs. In 2002, 65,154 Vietnam veterans claimed 100 percent disability for "Psychiatric and Neurological Diseases" (about 2.1 percent of the 3.14 million soldiers who served in Vietnam). A total of 202,183 Vietnam veterans claimed a partial level mental-health disability (about 6.4 percent of all Vietnam veterans).
The National Vietnam Veterans Readjustment Study found that 31% of Vietnam vets met full diagnostic criteria for PTSD. Given the low percentages of vets actually receiving benefits for psychiatric disability, there can hardly be an epidemic of false claims. And if And if Wente is going to claim that things are different in Canada, it is incumbent on her to provide proof. She hasn't. She can't.

Claim 2: Therapists are brainwashing PTSD patients into believing that they'll be disabled for life.

The vast majority of cases of PTSD either resolve on their own or are responsive to treatment. According to the Diagnostic and Statistical Manual of Mental Disorders - the very manual used by the mental health establishment that Wente denigrates - half of all cases of PTSD resolve within a few months. Another 20% of cases resolve within the first year after the trauma. Even among chronic cases that last for years or decades, treatment is often effective in reducing the severity of symptoms and allowing people to return to normal social functioning even if symptoms of anxiety continue. (A good overview of treatment options can be found here.)

But early identification and intervention are critical. According to the Veterans Administration:
Extensive research indicates that early distress and symptoms of PTSD are not very good predictors of a long-term prognosis. Thus, while Hoge et al. (2004) reported that 18% of soldiers newly redeployed from Iraq have PTSD - a rate that is alarmingly high, it is likely that this rate will decrease over time. Studies suggest that in the face of severe military service demands, including combat, most men and women do remarkably well across the lifespan. [...]

For those soldiers who don't recover, the most troubling aspect of military-related PTSD is its chronic course. There is evidence that once veterans develop military-related PTSD their symptoms remain chronic across the lifespan and are resistant to treatments that have been shown to work with other forms of chronic PTSD. Thus, it is vitally important to provide early intervention to reduce the risk of chronic impairment in veterans.
Unfortunately, the prejudice and derisive attitudes of Wente and her American counterparts stand in the way of these servicemembers getting the early intervention they need.

Claim 3: PTSD is just like normal worries and stresses, an sufficiently "resilient" people get over their worries and stresses without help.

Conservatives never seem to get tired of belittling severe traumas by pointing out their superficial similarities to minor traumas. (Remember the "fraternity hazing" analogies about Abu Ghraib?) There is no excuse for this kind of unconscionable dishonesty. It's as if Wente were to dismiss and minimize the consequences of blindness based on the argument that sometimes everyone has to strain their eyes to see in dim light. Even if you're heartless enough to doubt the testimony of people with PTSD, the altered neurochemistry is undeniable.

None of this information is hard to find, even without the resources of one of Canada's largest newspapers. The entire first page of Google hits for "Satel PTSD" are either articles by Satel (Wente's only "scientific" source), or articles debunking her claims about overinflated PTSD diagnoses. Wente really had to work hard to avoid evidence that Satel is not credible. Either she's so incompetent that she can't manage a Google search, or she has a serious agenda. We vote for the latter.

Interestingly, this column isn't the first time Wente has written about PTSD in the Canadian military. Back in May of 2005, the Globe and Mail published a different column of hers that could have been the current column's more inflammatory cousin. The arguments were identical, although the tone was even more openly derisive: there are so many cases of PTSD these days that they must all be faking it, many of those cases sound absurd on paper (especially when the paper is the Globe and Mail and the columnist describing the cases is Margaret Wente), isn't it obvious that they're all just in it for the cold hard cash. Her closing line was even "But resilence is out of fashion. Besides, it won't get you a cheque." One underresearched, ideology-laden column might be a passing fancy, but two certainly smacks of an agenda, or even an obsession. We can't help but wonder what might drive Wente to write what amounts to the same column twice--could it be that she didn't manage to convince anyone a year ago, so she decided to tone down the rhetoric and recycle her original words once the casualties in Afghanistan had started mounting and the polls had started indicating a dip in support for the mission?

Although Wente is quick to declare that doubting the validity of PTSD is "unfashionable," in fact, with her commentary, she joins a whole framework of American conservatives with close ties to the Bush Administration, who are currently engaged in an effort to discredit the entire concept of PTSD - particularly the notions that it is common and frequently disabling.

Why do so many conservatives in both countries want to deny the reality of PTSD? On the American side, many are motivated by a reflexive disapproval of federal spending, and a corresponding desire to decrease spending on psychiatric treatment and disability benefits for servicemembers and veterans. Others fear that honesty about the prevalence of PTSD will hurt the war effort:
Dr. Susan Mather, a former top VA official who retired in January as its chief public health officer [says that] "They already have a recruitment problem...the parents of these youth, if they think their children will come back from the military experience changed forever - which they undoubtedly will be; not only changed but disabled by the experience, mentally as well as physically - they are going to be a lot less anxious to have these kids join up. And there’s a feeling that if this gets too much publicity and appears to be too widespread, it will hurt recruitment."
But neither of those pragmatic reasons explains the fervor of their attacks on PTSD-disabled vets, or the contempt that drips from Wente's words as she writes about young soldiers in trouble. It seems that there are deeper ideological factors at work. Generally speaking, any argument that individuals may be helpless to escape their life circumstances is threatening to the conservative ideology of personal responsibility. Social psychology research demonstrates that conservatives are more likely to hold the implicit worldview that bad things don't happen to good people, or, conversely, that the troubles people suffer are generally deserved. Finally, conservative discomfort with PTSD is also motivated by the perceived need for aggressive support of the war effort. It's as if they believe that negative effects of war must never be acknowledged, or the case for military action will collapse. In Canada, this is currently being expressed as denial that Canadians are even engaged in war in Afghanistan - the preferred conservative terminology is "peacemaking." (Hello, Orwell!) Clearly, that case collapses if large numbers of Canadian troops engaged in such a mild, inoffensive activity are found to be suffering from major psychiatric trauma as a result.

But the hysterical denial of war's negative effects is most common among conservatives who are far removed from the actual work of combat. Lieutenant Colonel Dave Grossman, a retired Army Ranger and a professor at West Point, paints a very different picture:
It is essential to acknowledge that good ends have been and will continue to be accomplished through combat. Many democracies owe their very existence to successful combat. Few individuals will deny the need for combat against Nazi Germany and Imperial Japan in World War II. And around the world the price of civilization is paid every day by military units on peacekeeping operations and domestic police forces who are forced to engage in close combat. There have been and will continue to be times and places where combat is unavoidable, but when a society requires its police and armed forces to participate in combat it is essential to fully comprehend the magnitude of the inevitable psychological toll.
Exactly so. If you believe that war is sometimes necessary, then it is your special obligation to be aware of the human cost of what you are asking your soldiers to do, and to mitigate the damage - with early treatment, when possible, and a supportive safety net for those who don't respond to treatment - to the greatest possible extent. More and more, the military recognizes that. Why don't the conservative hawks?

Friday, July 07, 2006

Friday Baby Blogging

Alex in the garden

I like this picture because it conveys a rare hint of her inner life. Mostly, at 15 months, everything is right there on the surface.

She's had a rough week with her Papa away. I thought she might cry for him or search for him a lot, given that before he left she was in a very papacentric mood. She'll talk about him when we look at his picture, but she doesn't bring him up. Instead, the stress of his absence is manifesting as extreme clinginess to me. I had to leave work early today because she spent the entire morning crying for me. It's as if she has figured out that if he could leave, I could leave - and then she'd be alone.

(Fortunately, the Significant Otter returns tomorrow.)

Putting The Pieces Together

Steven Green, the former U.S. soldier arrested yesterday for the rape of a young Iraqi woman and the murder of her entire family, received a medical discharge from the service based on a diagnosis of Antisocial Personality Disorder.

ASPD is defined as "a pervasive pattern of disregard for and violation of the rights of others," including failure to obey rules or laws, excessive temper or aggression, poor planning, impulsive behavior, an inability to meet basic social demands, and - probably most importantly - a lack of remorse. The diagnosis subsumes, but is not synonymous with, the much more serious diagnosis of psychopathy - true consciencelessness, the inability to empathize with others, and a consistent, remorseless tendency to manipulate, use, and hurt other people to meet one's desired ends.

All cracks about the inability to distinguish ASPD from proper soldierly behavior aside (and please keep them aside, because I don't want to hear them), soldiers with ASPD or psychopathy are a disaster for any military organization. To meet criteria for the diagnosis, these characteristics have to be general, inflexible, and persistent across contexts and situations. In other words, it's not possible to aim the person's psychopathy at the enemy and yet be able to trust them at home. They don't adhere to discipline or obey military regulations. They exploit and fight with their comrades as well as the enemy. No officer or NCO wants to be responsible for them. Many police forces screen candidates for psychopathy; they make terrible cops for many of the same reasons that they make terrible soldiers.

So, on the one hand, this analyst's comment is totally plausible:
Loren Thompson, a military analyst at the Washington-based Lexington Institute, said it is standard practice to discharge soldiers whose profiles suggest they are incapable of maintaining military discipline.

"Despite all the stories about the military having trouble recruiting, it is considered anathema to retain somebody like that," said Thompson.
And yet. Something about this story just doesn't pass the smell test for me.

ASPD is not something one suddenly develops at Green's age. To qualify for the diagnosis, significant symptoms have to have been present prior to age 15, and the person has to have a substantial track record of failure to meet basic social standards in a variety of settings. It's true that the Army has historically been a common destination for young men like that - families, and judges, have often reasoned that a heavy dose of military discipline will straighten them out. Green's family seems to have thought so as well. But the pattern of behavior that constitutes ASPD, or psychopathy, has to have been in place at the time that he entered into military service, by diagnostic definition. If he was constitutionally incapable of conforming to military discipline, that should have been evident to his commanders by the end of boot camp, at the latest.

Plenty of guys with ASPD-like symptoms enlist. Some of them are kicked out early for "failure to adjust to military service." Some of them are "administratively separated" for problems like drug use, or receive bad conduct discharges. Not many of them get a medical discharge for being antisocial. This table demonstrates that even for servicemembers who have personality disorders bad enough to require hospitalization, only 40% wind up being discharged for that disorder. (That's all personality disorders considered together - not just ASPD. And some of the other disorders, like Borderline PD, which often involves suicide attempts, seem likely to account for more of the medical, as opposed to punitive, discharges.) And that was in 1998, well before the current desperate drive to hold onto soldiers.

I asked the Respectful of Otters Military Advisory Board, who seemed to have a pretty clear mental picture of what kind of soldier Green would have been. "Why a medical discharge, and not some kind of bad conduct discharge?" "Probably because they wanted to get him out of there as fast as possible, and a medical discharge was the quickest option."

So here we have a guy who, by diagnostic definition, had a pattern of disregarding the rights of others and failing to conform to authority or social expectations for years. And nonetheless he was retained in military service for a year. In March, in the company of other soldiers, he raped and murdered a young woman and killed her entire family. In April, he was pulled out of Iraq, and in May - apparently without any kind of court martial charges or major disciplinary action - he was officially declared to be so antisocial that he was no longer suitable for service. And yet, supposedly, the military didn't learn of the rape and murder until last month.

If no one was aware of his crimes, what happened to precipitate his discharge, by the quickest and quietest means possible? Something doesn't add up.

Edited to add: Just to clarify, I think there are three possibilities.

1. The Army just got tired of his general disregard for rules and discipline and sent him for a psych eval, thus landing him the ASPD diagnosis. By sheer coincidence, this happened just after he had committed a horrific war crime, unbeknownst to them.

2. On some level, his superiors were aware that he had committed a horrific war crime. That was the precipitating factor for the ASPD diagnosis. He was medically discharged rather than investigated and prosecuted.

3. His superiors didn't know about his horrific war crime. However, he did something else that was awful - not necessarily another war crime, but some notable breach of discipline or crime against a fellow soldier - and that was the precipitating factor for the ASPD diagnosis.

Wednesday, July 05, 2006

State Of The Otter

I realize that my posting volume has dropped again, and I'm sure it's making some of you twitchy - wondering if I'll claim to be running out for a pack of otter pops and then disappear for another nine months. That doesn't seem likely to me; even though I haven't had time to post, I've still had post ideas crowding my head, and they're not likely to leave me alone until they're written. But first there were some health issues, and now my Significant Otter's long annual business trip has combined with our nanny's illness to make me, temporarily, a stay-at-home single mother. So I've been busy.

Given that I am back, though, I badly need to update my blogroll. Some blogs have died, and some have moved; that much I can fix on my own. What I don't know is who I ought to be reading these days. The blogosphere changes a lot in nine months. Okay, obviously Firedoglake and Glenn Greenwald - but who else? Suggestions, please.

Sunday, July 02, 2006

Dying From Red Tape

Millions of poor Americans may lose their health benefits:
A Medicaid rule takes effect tomorrow that will require more than 50 million poor Americans to prove their citizenship or lose their medical benefits or long-term care.

Under the rule, intended to curb fraud by illegal immigrants, such proof as a passport or a birth certificate must be offered at the time a person applies for Medicaid benefits or during annual reenrollment in the state-federal program for the poor and disabled.

Critics fear that the provision will have the unintended consequence of harming several million U.S. citizens who, for a variety of reasons, will not be able to produce the necessary paperwork.
Unlike many Republican policies towards the poor, which read as though they were written by someone who was cackling and twirling his mustache, this one seems reasonable on the face of it. Citizenship (or, in some cases, permanent residency) has always been required for enrollment into Medicaid, and this new rule simply establishes a documentation requirement. Probably most of the people reading this post could produce the necessary documents without much effort - a phone call to Mom to ask for the birth certificate, perhaps, or, at worst, a letter and a check sent to the registrar of the county where they were born. A reasonable amount of effort to ask people to put forth, if the payoff is reducing fraud and saving health care dollars.

But it only seems reasonable if you haven't had much contact with people living on the margins of American society. This rule affects homeless people who have only a garbage bag full of posessions to their names, and no idea where any of their relatives might be. People institutionalized because of mental illness or mental retardation. Elderly people born before all births were recorded - particularly elderly black Southerners, who were likely to be born at home due to Jim Crow hospital policies, and the rural elderly poor. People who are no longer able to communicate clearly due to disability. They don't have passports. They may not know where they were born, or be able to communicate it to their caregivers.

Look at some of the plaintiffs in lawsuits challenging the new rule:
Ruby Bell, 95, born in an Arkansas county that did not issue birth certificates until 1914, and George Crawford, 80, who is so incapacitated from strokes that he cannot speak. According to attorneys, the church members who care for Crawford in Illinois don't even know where to start looking for documents that would pass muster. [...]

Alphonso DeShields, who was born in his parents' home in Spartanburg, S.C., a few months after World War I began. For five years, he has lived in a nursing home in Northwest Washington. He has a severe heart condition, cancer and other ailments.
Do these sound like they must be just a few odd, isolated cases? I've worked in health care for the desperately poor for six years now, and I can tell you that they sound pretty typical to me.

Even if most of these people are eventually able to document their citizenship, they are likely to experience gaps in medical treatment. Probably the ones dependent on institutional care won't be kicked out, but others will go without their insulin or HIV drugs or blood pressure pills. They'll wind up in the ER as indigents, suffering from preventable complications of chronic illness. And beyond the human cost, the financial cost of all of this documentation will be appalling. Social service agencies, nursing homes, and institutions will spend money that could be spent on direct services, tracking down their clients' birth certificates in cases where citizenship is not in the slightest doubt.

We all know that the Bush Administration and their allies in Congress have never signed on to the maxim, "better that ten guilty men go free than one innocent man be punished" - their Guantanamo policies make it clear that they believe the reverse, many times over. On the domestic side, it's clear that they also believe that it's better for ten deserving people to go unhelped than for one "undeserving" person to receive benefits to which they are not entitled. And yet they, the majority of them, call themselves Christians.