Policy Update: Family Planning, ACA Lawsuit, Work Requirements and Assault Weapons

Summer & Fall Public Health Activities in AZ

Interested in finding out about the various public health conferences, meetings and events this Summer and Fall?  

Bookmark our AzPHA Upcoming Events webpage.  It’s as simple as that.  If I’ve missed something- let me know at [email protected]!

 

Proposed Title X Funding Changes Likely to be a PH Burden

The US Department of Health and Human Services has proposed changes to the rules for the federal family planning services program, known as Title X.  If the new rules are adopted as proposed, it’ll require Title X family planning services to be physically and financially separate from abortion services.

Many family planning clinics offer both family planning and abortion referral services, and if the changes are ultimately implemented many of the programs would likely decide not to take Title X funding, which would have a big impact on the network of available services and they’d have fewer resources available for STD screening, treatment and outreach.

BTW: Title X funds have never been allowed to be used for abortions. The proposed rule is available for public comment until the end of July.  You can read more about the proposed rule and comment by visiting the Federal Rulemaking Portal: http://www.regulations.gov. Just follow the instructions to submit.  Your comments might not influence the outcome, but at least you’ll have done your part. That and voting this Fall.

 

Federal Government Won’t Defend the Affordable Care Act in Court

So far, the Affordable Care Act has survived the 2 court challenges that made it to the US Supreme Court.  Back in 2012 the ACA was upheld by the Supreme Court for the first time (by a 5-4 margin) in the National Federation of Independent Business v. Sebelius case.   It was upheld again in 2015 when (in a 6-3 decision) the Supreme Court upheld ACA’s federal tax credits for eligible Americans living in all 50 states (not just the 34 states with federal marketplaces).

But, there are additional challenges out there that haven’t made it to the Supreme Court yet. One that’s progressing through the courts is a challenge filed by 20 states (including Arizona) arguing that the ACA’s individual mandate is unconstitutional and key parts of the act — including the provisions protecting those with pre-existing conditions — are invalid. 

This week Attorney General Jeff Sessions acknowledged that while “the Executive Branch has a longstanding tradition of defending the constitutionality of duly enacted statutes if reasonable arguments can be made in their defense,” the Attorney General will not defend the ACA from this challenge.  

The implications could be profound.  The ACA could potentially be completely overturned- or portions that require health plans to cover pre-existing conditions could be eliminated along with the mandate that persons have health insurance.

 

Medicaid Work/Community Engagement & Reporting Requirements

Any day now, the Centers for Medicare and Medicaid Services (CMS) will be approving Arizona’s request to include work requirements and/or community engagement and reporting requirements as a condition of Medicaid enrollment.  The request filed by AHCCCS is required by Senate Bill 1092 (from 2015) which requires them to ask CMS’ permission to implement new eligibility requirements for “able-bodied adults”.

AHCCCS initially proposed implementing the following requirements for able-bodied adults receiving Medicaid services including: 1) a requirement for all able-bodied adults to become employed or actively seeking employment or attend school or a job training program; 2) requiring able-bodied adults to verify monthly compliance with the work requirements and any changes in family income; 3) banning an eligible person from enrollment for one year if the eligible person knowingly failed to report a change in family income or made a false statement regarding compliance with the work requirements; and 4) limiting lifetime coverage for all able-bodied adults to five years except for certain circumstances.

Hundreds of comments were submitted (including comments from AzPHA) urging the agency to consider modifications to the initial waiver request.  AHCCCS later issued a final waiver request which includes exemptions for:

  • Those who are at least 55 years old;
  • American Indians;
  • Women up to the end of the month in which the 90th day of post-pregnancy occurs;
  • Former Arizona foster youths up to age 26;
  • People determined to have a serious mental illness (SMI);
  • People receiving temporary or permanent long-term disability benefits from a private insurer or from the government;
  • People determined to be medically frail;
  • Full-time high school students older than 18 years old;
  • Full-time college or graduate students;
  • Victims of domestic violence;
  • Individuals who are homeless;
  • People recently been directly impacted by a catastrophic event such as a natural disaster or the death of a family member living in the same household;
  • Parents, caretaker relatives, and foster parents; or
  • Caregivers of a family member who is enrolled in the Arizona Long Term Care System

A subsequent letter from the AHCCCS Administrator suggested that they (AHCCCS) are suspending their request for a 5-year limitation on lifetime benefits (for some members) for now.  Here’s our letter from back in February of 2017. 

 

Kaiser Family Foundation Issue Brief on Work Medicaid Requirements

Last month the Kaiser Family Foundation published an Issue Brief regarding CMS’ recent decisions to grant states the ability to experiment with their Medicaid programs that condition Medicaid eligibility on work or community engagement. The Issue Brief examines evidence of the effects of the Medicaid expansion and some changes being implemented through waivers.

Many of the findings on the effects of expansion are drawn from the 202 studies included in our comprehensive literature review that includes additional citations on coverage, access, and economic effects of the Medicaid expansion.

Regarding work requirements, the Brief concludes that “state-specific studies in Colorado, Kentucky, Michigan, Pennsylvania and most recently Montana and Louisiana have documented or predicted significant job growth resulting from expansion. No studies have found negative effects of expansion on employment or employee behavior. In an analysis of Medicaid expansion in Ohio, most expansion enrollees who were unemployed but looking for work reported that Medicaid enrollment made it easier to seek employment, and over half of expansion enrollees who were employed reported that Medicaid enrollment made it easier to continue working.  Another study found an association between Medicaid expansion and increased volunteer work in expansion states.

Furthermore, “work requirements have implications for all populations covered under these demonstrations. Those who are already working will need to successfully document and verify their compliance and those who qualify for an exemption also must successfully document and verify their exempt status, as often as monthly. States would incur costs to pay for the staff and systems to track work verification and exemptions.”

If you’re interested in the public health policy implications of our upcoming work/community engagement and reporting requirements, the KFF Issue Brief is a must-read.

 

Court Challenge to Kentucky’s Work Requirements being Heard this Week

Oral arguments are being heard this week in DC challenging Kentucky’s requirements that members work or participate in “community engagement” activities such as job training, school or volunteering. The case was filed in January by the National Health Law Program, the Kentucky Equal Justice Center and the Southern Poverty Law Center.  The outcome could have implications for AZ’s upcoming requirements.

Read National Health Law Program’s guide on what to expect from oral argument.

American Medical Association Endorses Assault Weapon Ban

The American Medical Association – Nation’s largest physician group – endorsed a ban on assault weapons as part of a package of measures aimed at combating the epidemic of gun violence in the US. The member driven initiative was endorsed at their annual policy conference. They also endorsed a ban on bump stocks, which basically turn semi-automatic rifles into automatic weapons. 

In a statement AMA Immediate Past President David O. Barbe, MD, MHA said: “People are dying of gun violence in our homes, churches, schools, on street corners and at public gatherings, and it’s important that lawmakers, policy leaders and advocates on all sides seek common ground to address this public health crisis, in emergency rooms across the country, the carnage of gun violence has become a too routine experience.”

 

AzPHA Public Health Policy Update

Save the date

90th annual azpha fall conference and annual meeting

Integrating Care to Improve Public Health Outcomes:

Primary Care | Behavioral Health | Public Health

October 3, 2018 

Desert Willow Conference Center

There’s widespread support for the goals of the Triple Aim: To deliver the highest quality care with an optimal care experience at the lowest appropriate cost. The key is developing systems of care that best achieve these goals. 

Our 90th Annual Fall Conference and Annual Meeting Integrating Care to Improve Public Health Outcomes: Primary Care | Behavioral Health | Public Health will explore efforts currently underway to integrate care and improve outcomes in Arizona as well as initiatives on the horizon to develop systems of care that best achieve the goals of the Triple Aim.

We’ll kick off our Conference with a presentation of the latest academic research that evaluates the outcomes of co-located and integrated models of behavioral care as part of primary care as well as evidence-based toolkits to assist practices including ways to measure progress. We’ll also be exploring how providers are implementing new strategies to integrate care via AHCCCS’ “Targeted Investment” program which provides financial incentives to eligible providers to develop systems for integrated care.

We’ll conduct a short AzPHA Annual Meeting over a delicious buffet lunch followed by our keynote address from the American Public Health Association President Joseph Telfair, DRPH, MSW, MPH.  In our afternoon sessions, we’ll learn about new initiatives to work with managed care in two key areas that impact health outcomes: tobacco use and housing and homelessness.

We’ll close with a panel discussion of key leaders among Arizona’s Managed Care Organizations as they discuss priorities and strategies for improving outcomes under the new integrated Medicaid contracts which will begin October 1, 2018.  The new contracts will require better coordination between providers which can mean better health outcomes for members.

After the conference we’ll have a hosted reception as we celebrate AzPHA’s 90th Anniversary!

I’m still working on the agenda, but I expect to have it fleshed out in a couple of weeks and have our registration site up and sponsorship packets out by the 3rd week in June. A summary of the conference is up on our homepage at www.azpha.org.

 

American Cancer Society Changes Colon Cancer Screening Recommendation

The American Cancer Society changed their recommendation for colon cancer screening by moving down the standard recommendation 5 years- suggesting that most people get screened at age 45. There are a couple of ways people can get screened, either using a sensitive test that looks for signs of cancer in a person’s stool or with an exam that looks at the colon and rectum (a colonoscopy).  The reason they changed the recommendation is because new data shows that cases of colorectal cancer for people under age 55 increased 50% between in the last 20 years (1994-2014).

However, just because the recommendation from the ACS changed doesn’t necessarily mean that insurers will begin paying for it between 45 and 49 years old.  For that to happen, the United States Preventive Services Task Force would need to recommend the change and list it as a Category A or B preventive health service.

In recent years, a prevention model of health has woven its way into the fabric of traditional models of care. With the passage of the Affordable Care Act the role preventive services has expanded significantly in the US health care delivery system.  Preventive health care services prevent diseases and illnesses from happening in the first place rather than treating them after they happen.

Category A & B” preventive services recommended by the United States Preventive Services Task Force  are now included (at no cost to consumers) in all Qualified Health Plans offered on the Marketplace. In addition, many employer-based and government-sponsored health plans have included Category A & B preventive services in the health insurance plans they offer to their respective members.

Currently, the United States Preventive Services Task Force recommends 49 Category A & B Preventive Health Services that include screening tests, counseling, immunizations, and preventive medications for adults, adolescents, and children.  The Task Force consists of a panel of experts representing public health, primary care, family medicine, and academia.  They update the list of recommended services by reviewing best practices research conducted across a wide range of disciplines.

You can also browse the USPHS website and check out the preventive services that they have evaluated but don’t recommend. Most of the services are broken down by age, gender and other risk factors.

 

Medicaid Program Scorecard Released by Feds

The Centers for Medicare & Medicaid Services released a new Medicaid program scorecard this week.  It includes some quality metrics along with federally reported measures in a Scorecard format.

The data that’s built into the state by state scorecard only uses information that states voluntarily submit.  There are 3 main categories (state health system performance; state administrative accountability; and federal administrative accountability) and lots of subcategories.

The most interesting part of the Scorecard I think are the State Health System Performance Measures portion.  Some of the subcategories that are reported in that category on a state by state basis are things like well child visits, mental health conditions, children’s preventive dental services and vaccination rates, and other chronic health conditions.

It looks like a good and valuable tool that will (if they continue to populate the scorecard) provide more transparency into the effectiveness of state Medicaid programs over time. The data that are submitted are voluntary – not compulsory – so that hurts the number of measures that states turn in.  It might be something that you’ll want to bookmark for reference in the future.

 

Federal “Right to Try” Law Passed and Signed

Congress passed and the President signed a new law this week that gives people with a terminal illness new options for treatment by allowing those folks a way to independently seek drugs that are still experimental and not fully approved by the US Food and Drug Administration.

The new law basically gives terminally ill patients the right to seek drug treatments that remain in clinical trials and “have passed Phase 1 of the FDA’s but haven’t been fully approved by the FDA.  

Arizona voters have already approved a similar law (by a wide margin).  In 2014 AZ voters approved Proposition 303  (referred to the ballot by the Legislature) that makes investigational drugs, biological products or devices available to eligible terminally ill patients. The AZ law has uses the same definition of an “investigational” drug that the new federal law uses.

 

Western Region Public Health Training Center Grant Renewed

The Western Region Public Health Training Center was awarded a renewed grant as a center for the Regional Public Health Training Centers Program.  They’ll continue to be housed in the University of Arizona Mel and Enid Zuckerman College of Public Health and we will continue to assess the training needs and strengthen the skills of the public health workforce with their partners in Arizona, California, Hawaii, Nevada, and the Pacific Islands.

The training center has literally hundreds of trainings that focus on all sorts of health professionals and the public health workforce.  So no matter what your public health workforce training needs are – the thing to do first is to check the centers website to see if they have the course that you need.  Most likely they will.

________

I’m doing my best to populate the “upcoming events” part of our AzPHA website.  If you have an upcoming public health related event- please let me know and I’ll get it up on our website at: https://azpha.org/upcoming-events/

Travelogue #8 Travel Tips & Break-ins

Since I’m claiming this to be a “travelogue,” I thought I’d offer some actual travel tips that I’ve picked up along the way.
 
Pictures are great, but hang on to your phone/camera (see part 7).
 
Booking discount airfare is great, but you might make sure that the airline uses actual plane parts assembled by actual mechanics.  This is a photo of my exit-row window seat on our flight from Amsterdam to London.  A wiser man might have disembarked, but hey, the flight was cheap.

Don’t let your phone run out of battery.  When your traveling pack of old farts finally gives out due to feet or knees or backs or some other failing body part, it’s not a good thing to have no way to summon an Uber or call a cab.

Don’t trust the weather forecast.  Every few hours, the forecast for the next few hours here shifts.  In the morning, it says it will be dry and partly cloudy that afternoon.  By 2:00, it is pouring on you, exactly as predicted when they revised the forecast an hour earlier.  I have decided that Arizona meteorologists are far superior to their British counterparts.  Here, they are rarely accurate more than a day in advance.  Back home, you can confidently depend upon the 10 day forecast when they say, “110 and sunny, 110 and sunny, 110 and sunny…”
 
While living for an extended period abroad, have all the tools you’ll need.  While cooking one evening, a can of tomatoes required opening, but all we had was a dysfunctional can opener.  Our friend Denise decided to attack the can with the small ax that we used for firewood.  Failing in this effort, she approached a neighbor, whom she had not yet met, ax still in hand, gesturing her inability to whack the can open.
 
The approach of a wild-eyed stranger waving an ax caused some alarm.  Perhaps that assisted with the prompt production of a can opener for our use.  We’ll return it without bearing arms.
 
For those of you who may have considered the traveling RV lifestyle, here’s an alternative.  Canals are plentiful in this part of the world.  Not just in Amsterdam and Paris, but even here in the English countryside.  This pic is just a few miles from my house and canal boats are both moored and traveling all the way up and down.  The tow paths make for great walks, too.  Meanwhile, I haven’t seen a single RV, no doubt due to the impossibility of navigating British roads in one of those behemoths.
 
Speaking of walks, once you figure out routes, you can seemingly get anywhere around here on foot.  The only thing keeping me from getting all my steps in on a daily basis is the weather.  But walking has its hazards as well, including hungry horses, angry cows (I thought Mad Cow was over with), poop of various sources, and the frequent “fork in the road,” which everyone from Robert Frost to Yogi Berra urges us to take, yet can send you far afield when you have no idea where you are to begin with.  On the other hand, that’s how I’ve discovered some of my most cherished sights.
 
When traveling, try to not be an ugly American.  One hears plenty of American accents in London and elsewhere that we’ve been.  In a lovely restaurant in Paris, we sat next to a young American graduate student and his parents, who had come to visit him.  He was such a know-it-all jerk to them, dismissing everything that they had to say and taking every opportunity to show off his knowledge of… well, everything, that I just wanted to smack him.  At another sidewalk cafe in Paris we sat next to a guy in a LA Dodgers cap going off on how the French had barely discovered kale, and were still eating couscous, while of course the newest thing in California was spelt.

Be prepared to walk.

Nowhere I’ve been on this trip has heard of the ADA.  Few mass transit stops are accessible without the use of stairs.  One exception in London offers an elevator – with a long line waiting – and a sign that warns that the number of stairs are the equivalent of a 15 story building.

As we found in Paris, when you’ve finished hiking to your platform, there is at least ample seating while you await your train.
 
Another piece of travel advice:  If your instructions for an AirBnB rental seem odd, consider renting elsewhere.
 
Nancy and I rented a lovely apartment in Paris for our time there.  It was sweet, as our communication was with the young woman who owned it.  Yet this was the only such rental I’ve experienced where you never see anyone.  We were to obtain the keys from the cafe downstairs where they had been left for us in an envelope, and drop the keys back in the owners mailbox upon our departure.  It all went smoothly, and we even replenished the coffee supply and tidied up considerably before we left.
 
Several days later, we got an email from this young woman that she had finally returned to her apartment to find it ransacked, with all her valuables missing.  The keys were not in her inbox, she claimed, and because there had been no forced entry, her insurance would cover none of it.  (Really?)  A few email exchanges later, and she said that AirBnB had suggested their “arbitration” services to negotiate claims for damages against us.
 
I still don’t think we’re being scammed, exactly.  She seems genuine and we haven’t heard anything more for several days, but I’m hoping that this doesn’t end up becoming a legal issue.  And next time, I’m only renting when there’s someone there to receive the keys and check us out, as has been my previous experience.  Lesson learned.
 
While Bobbie and Jack were here, I discovered that I had never regaled them with one of my more infamous travel stories.  Of course, I was compelled to share it with them.  I’m sure that some of you have heard this one before, so with apologies I include it here because, well, it is travel-related.  And because I told it again while here.  And because I’ve never actually written it down.  So here goes.
 
By way of background, several years ago I had a chronic TMJ issue.  That’s “Temporomandibular Joint,” as in your jaw.  It’s a classic joint to have problems, sometimes requiring surgical intervention.
 
I never had much pain with it, but I developed a “click” in my left jaw when I sometimes tried to open my mouth, which progressed to greater and greater resistance over time.  Finally, I would occasionally find myself unable to open my mouth at all, my jaw clenched, until I managed to dislodge it.  At first, dislodging it required strenuously forcing my mouth open, culminating with a loud “pop” that could be heard across a room.  But as time went on, I found that I could only force it open by whacking the side of my jaw with my hand.  Hard.  Sometimes several times.  Hard.
 
Needless to say, when this occurred in a public place, others in my presence might be disturbed by the sight of the crazy man quite literally punching himself repeatedly in the face.  In general, they avoided eye contact and shuffled off.
 
Throughout all of this progression, I practiced the tried-and-true medical strategy of ignoring the problem.  I mean, it didn’t really hurt, and it only happened once every few weeks or so.  I only occasionally freaked out passersby.  And I really didn’t want to hear what course of treatment might be recommended.
 
Once during this same period, I also had the misfortune to scratch a cornea.  If you’ve never had that happen, think OWIE.  Big OWIE.  It hurts in a unique way.
 
To allow the cornea to heal, you need to minimize the amount of rubbing of the inside of the eyelid against the eye.  In years past, they would try patching the eye, until that was shown to be pretty worthless.  Now they just instruct the patient to keep that eye closed, and to try to not move your eye around.  Look left and right by moving your neck, not your eyeball.  The pain encountered by moving your eye provides instant feedback to help remind you.
 
A couple of days after scratching that cornea, I had to take a flight for a meeting.  I passed through the airport and boarded the plane keeping my one eye closed, hoping not to look too weird, and settled into my aisle seat, with an empty middle seat between me and and a passenger in the window.  As I often do on flights, I quickly fell asleep.
 
Sometime later I was awakened by the conversation between a flight attendant and my aforementioned fellow passenger.  As I stirred, I realized that in my slumber, I had leaned upon my arm so that it was now completely asleep.  Numb and flaccid.  My face had also been firmly planted in such a way that I could tell it was a droopy, wrinkled mess.  And to my chagrin, as I regained consciousness, I also realized that my TMJ had kicked in and my jaw was locked.
 
There I sat, one eye closed, one side of my face drooped, with a totally flaccid arm and a clenched jaw.  I was a textbook picture of someone who had just had a stroke.  The flight attendant eyed me with alarm.  “Sir,” she inquired, “are you alright?”
 
“Arrrawagggh,” I replied, unable to open my mouth to speak.
 
The flight attendant spun on her heels and hurtled up through the aisle.  I glanced at my seat mate to my right just long enough to see that she had pushed herself up against the wall of the plane, recoiling in horror.  Probably not a good time to begin socking myself in the jaw to relieve my condition, I thought.  In no time I spied the flight attendant rushing back in my direction with her flight attendant buddy in tow.  And I had a sickening premonition that I was about to hear that dreaded overhead page, “Is there a doctor on board?” In response to which, of course, I would be ethically obliged to raise my one remaining good arm and shout, “ARRRAWAGGGH!”
 
And one final piece of travel advice:  take all your keys with you when you leave your rental property.
 
We took our buddy Denise into London on a day that we knew a realtor was going to be showing the cottage to future potential renters.  It was Denise’s last day here, as she was flying out the next morning.  We had a good time.  We ate lunch at our favorite place (the best seafood restaurant on earth, I’m convinced).  We caught a show (“Everyone’s Talking About Jamie”).  We ate dinner at a fav pub.  We took a train, taxi, and another train on our return.  We didn’t arrive home until nearly 11 pm.  It was just starting to rain.
 
Nancy stuck her key into the door lock and turned it, but the door didn’t budge.  It was being held shut, as if by a separate deadbolt.  It took a moment to realize that the second lock on the door, which had an old-fashioned skeleton keyhole and which we had always ignored, was locked tight.  Previously, I hadn’t even thought it was functional.  It seemed so antiquated, so merely decorative, and I didn’t think there was even a key to it, as we didn’t have one.  (It turns out that, unbeknownst to me, there actually was a set of keys inside.)
 
Obviously, the realtor did have a copy of that key.  And had used it.
 
We checked the back door.  It was locked, but we knew it was a flimsy latch that we could kick if we had to.  I tried both of the ground floor windows.  Shut tight.
 
Lots of options sprung to mind.  There was an open window on the second floor, but no easy way to reach it without depending upon a rickety-appearing overhang for support.  I searched for a ladder behind a neighbor’s home that I had seen days earlier, but couldn’t find it.  Might a neighbor have a spare key?  All their lights were off, save those in the elderly lady’s house whom I knew by reputation would call the police for any suspicious activity.  Nancy had the landlady’s number in her phone, but her phone had earlier run out of juice (see above advice), so we found ourselves back sitting in the running car to charge her battery.  But that wasn’t the solution, as we needed our home WiFi to call anyone, because we’re out of cell range out here in the sticks.
 
At this point, with Nancy seriously suggesting kicking the back door in, the better part of valor might have been to seek out a hotel in some nearby town.   But Denise needed to depart for the airport in the morning, all her stuff was inside, and there were no better prospects of getting the landlady or the realtor out early the next day – the Sunday of a three-day weekend – than there was of doing so that night.
 
In desperation, as Nancy sent texts from the car, I went to the pub, which was just in the process of closing up, but had plenty of folk still gathered on this Saturday night.
 
Did they know our landlady well enough to have a spare key?  No.  Did anyone have a ladder that could reach our second-floor window?  No.  I borrowed their phone, but didn’t get through to our landlady and couldn’t leave a message.
 
One young patron with whom we’d shared some prior lively conversation perked up.  “Let me have a look,” he said, and followed me home to investigate the possibilities.  As he staggered around our property, I discouraged him from his thoughts of trying to climb the wall to the open window.
 
I returned to the pub intending to try calling again.  A few young, inebriated lads passed me on their way toward our cottage, insisting that they’d “broken into plenty of houses before.”  Meanwhile, in my brief absence from the pub, our landlady had returned the missed call from the pub’s phone, spoke to others there, so now had an inkling of an idea of the drama that was consuming her property.  I finally got through and spoke to her and she said she’d try calling the property agent, as they refer to realtors here, although she wasn’t sure whether they even had an emergency contact number.
 
I rushed back to the scene of the crime that was now our cottage to find our inebriated young friend quite literally shoving another inebriated young man up off his shoulders towards the second floor window.  The would-be burglar was grasping for whatever toe-hold he might find along the brick wall below the open window which, I was pretty sure, would not support much weight.  And of course, all of this was in the rain.
 
I severely protested, humbly suggesting that they not break their necks in this endeavor.  Every injury prevention synapse I possessed was firing warnings as I watched in alarm this wobbling tower of amused determination.  One foot was perched upon a shoulder, the other upon the palm of an outstretched arm, straining to push upwards toward the promise of a flimsy window pane just beyond reach.

“They’ll be fine” insisted an onlooking third inebriant, as legs and arms flailed about the brick wall.  I flashed on Will’s old blog describing his sudden descent from a tree.

 
It worked.  In no time, he scooted through our window, descended the stairs, and opened our door.
 
I owe these guys so much beer the next time I see them in the pub.  And the time after that.  And perhaps the time after that.  And I believe them that they’ve broken into plenty of houses before.
 

 

Travelogue #7: “The Number You Have Called is No Longer in Service”

Nancy and I went to Paris for a few days.  A great experience full of interesting sights and spectacular food.  And it had an interesting start.

The first night we were there, we hooked up with a friend (who is house sitting for us) and her boyfriend.  To protect the innocent, they shall remain nameless.  We were to meet for dinner at a restaurant that had been recommended to them.

We arrived at the arranged spot, and found them already in line at the crowded, obviously popular establishment, only to then be told that there were no tables for four all night.  Hmmm.  The place doesn’t accept reservations.  There were perhaps four hours to go before it closed.  It was enormous.  No tables for the duration?  Perhaps they had seen me coming.

In any case, a quick search found a restaurant just next door with a table immediately available.  We settled in without any idea where we were, until we were presented menus that made it clear.  Burgers, tacos.
 
We were in one of the few restaurants in Paris with an exclusively, to the point of being mocking, American menu.

So my first ever night in Paris, perhaps the culinary capital of the world, I had fish tacos.  Battered, fried fish.  With mayo.  Yum.  But the company was great, we had a great time, and all was well.

It was the only bad meal I had there.  It appears that the key to delicious cooking is butter.  Lots of it.  I don’t understand how it is that the entire population of France doesn’t die of coronaries at the age of 40, but they don’t.  I must consult my former nutritionist staff upon my return. 

We saw amazing things there.  For example, there was this enormous movie set that apparently was built for the movie, “Hugo.”  It was in the design of a large railway station.  After the filming of the movie, they apparently didn’t know what to do with the set, so they filled it full of old stuff like pieces of canvas with paint on them.  My favorites were those signed by Vincent somebody.  But the best part was the food in the cafe.  Now THAT is art!

While we were there in Paris, we hopped on a giant Ferris wheel on the Allee Centrale, near the Louvre.  Another photo opportunity from aloft on a day already packed with photos.  Nancy and I both whipped out our phones to snap pics.  I duly cautioned her to hang onto her phone as she sat next to the door which had an open space around it.

Now, you know that when you’re taking pictures through glass, it often helps to press your phone up against the glass to reduce glare.  I swiveled in my seat and pressed my phone against the glass behind me as we gracefully rose high into the sky.

And yes, of course I let it slip.  Rats, I thought to myself, now I’ll have to fish it out from behind the back of the seat.  I twisted, peered, and realized that there was no “back of the seat.”  I was looking at open air, with steel beams supporting our carriage some 30-50 feet directly below, and pavement an equal distance below that.  No phone in sight.

If you’ve ever been in a traffic accident, you know the feeling “no, this isn’t happening,” immediately followed by “no, this didn’t just happen.”  Suddenly, the beautiful view was lost on me, as we slowly circled around and around, and all I found myself doing was peering straight down for any sign of splattered electronics, to no avail.

When they let us out, I instantly bolted for the area into which it would have fallen — nothing.  I sprinted from one worker to another to another, each responding with, “You did what?”  I was referred elsewhere and then elsewhere until at my last chance someone stepped from behind the befuddled employee who didn’t quite understand me, and held out my phone.

It was intact.  I mean, the glass wasn’t even cracked.  An obvious yet minor scratch on one corner of the protective case, covered by a small bloodstain and a tuft of hair wedged between the case and the phone.

OK, so I’m kidding about that last part.  But I’m fortunate that I hadn’t actually beaned a stray passerby or I’d be writing instead about the workings of the French criminal justice system.

Despite the intact appearance, the phone was well and truly dead.  My attempts at CPR were useless.  I had killed it.

Days later, back in the UK, I trekked to the closest Apple store where they confirmed the irreparable demise.  We’ve paid for coverage that includes clumsy klutz damage, although we shall soon see whether that includes tossing the phone from hundreds of feet.  Perhaps those of my colleagues who work on the 14th floor of my former office will benefit from the results of my inquiry, as I’m sure I wasn’t the only one tempted from time to time to pitch my phone out the window.

So the same day that the “Genius Bar” staff pronounced my phone DOA, I went to the giant Tesco supermarket nearby and got a cheap, temporary replacement, so that my same phone number could be used by transferring the British SIM card we had previously bought, and importantly, to make it possible to connect with others whom I had ditched earlier that day and needed to travel home with. 

I proudly took my new phone and began texting.  None went through.  So I began calling.  None went through.  No problem, I thought, I had brought my tablet as a backup, and I knew that texts and at least email went through with that.  Halfway through typing my first message, it stopped working.  I mean, it would no longer respond to anything I did.  I couldn’t even turn the thing off because it wouldn’t respond to my touching the screen where it said, “swipe to turn off.”

Sheepishly, I walked back to the Apple store.  As I presented my tablet to a young man whom I swear I hadn’t seen earlier in the day, he greeted me with, “Oh, you’re the guy who dropped his phone from a Ferris wheel!”

I have achieved infamy on both sides of the Atlantic.

As I scribble this, sitting in a coffee shop in Watford (a city with which I am becoming much more familiar as I walk back and forth repeatedly between the same shops), I have no idea how on earth I’m reconnecting with anyone today, nor exactly how I’ll get home.  If you receive this, you’ll know that I survived… somehow… yet again.

 -Bob

Travelogue #6 The Traveling Old Farts

The traveling old farts:

Our buds Bobbie and Jack came for a visit.  We all went to Amsterdam, taking the train from London.  It boggles my mind that one can take a train under the English Channel, zip along at ~200 mph and arrive in Amsterdam a few hours later.  We traveled late, and found our way to our AirBnB rental near midnight.  Having not eaten dinner, and being totally unfamiliar with local eateries, we sought sustenance from the bar immediately beneath our apartment.

There were still a few patrons, and a lovely young French woman served us.  Unfortunately, she spoke little English, and interestingly, little Dutch as she attempted to communicate our questions to the bartender/cook.  Thankfully, our confusion was minimized by the fact that there was almost nothing left to eat.  Yes, there was still food, it turned out, but only “snacks.”  We perused the appetizer menu until we were later informed that by “snacks,” they meant only nachos.

So in desperation, we ordered the nachos.  We were presented with tortilla chips covered with some sort of melted Dutch cheese — so far, so good — but with a “salsa” consisting of three large, round slices of tomato on top and scattered green cocktail olives.  Hmmm.

We devoured them.

As you may recall, I had earlier complained about the configuration of the stairs in our English cottage.  No more.  Not after having lived through climbing two flights of “stairs” to our apartment in Amsterdam.  Think: even narrower, even higher angle of elevation, and perhaps 4 inches in depth in places.  A rope ladder would have felt as secure, especially with luggage in tow.

he Netherlands is, however, incredibly lovely, both physically and in spirit.  Bikes are everywhere, actually outnumbering cars it seems, with their own lanes and traffic lights.  Being a pedestrian is rendered a bit more hazardous by this, although having a cheery bicycle chime alert one to the fact that you’ve just errantly stepped into their path is considerably less disconcerting than having a car horn blast away at you in New York.

Just a few blocks from where we stayed was a magnificent granite gateway, soaring several stories high in the air, with an inscription in Latin which, I at first presumed, carried some profound or historic message. 

Then I read it.

“HOMO SAPIENS NON URINAT IN VENTUM” it proclaimed majestically.  OK, I thought to myself, “Homo sapiens” I know.  “Non” seems obvious.  “Urinat?” Um… I think I understand, although I’ve never seen it so dramatically written.  “In” seems universally to mean, “in.”  “Ventum” I had to look up.  It means, “wind.”

Really?  A monumental structure devoted to warning all who may pass, “People, don’t piss into the wind!”  Really?  There’s a story there that I might look up, but it’s probably better to not.

Just outside of Amsterdam, we went to the Keukenhof tulip festival.  It was beautiful, but reinforced a fear in me that I may spend the rest of my life merely gazing at lovely things, if not my navel (which is, I assure you, not so lovely). 

You see, I confess that this retirement thing still hasn’t sunk in.  Max told me before I left that it would take me a month just to decompress.  Well it’s been a few, and I’m still discombobulated. 

It took that first month for my usual dreams to switch from the work-themed panic-stricken variety (forgetting to pack for a trip, forgetting a to give a talk, etc) into those less stressful. Now, I even occasionally wake from a dream in which I miss being part of the action.  I also do so occasionally when awake.  Occasionally, I stress.  🙂

Speaking of stress, there are other ways to achieve it, such as watching news from an international perspective.  There is every imaginable channel here.  Want news from India?  China?  There’s even “local” channels in other languages, such as Welsh, where you can watch football matches and such with a commentary understood only by people just a little to the west of us, and nowhere else. 

There are also truly disturbing outlets available.  Salisbury, where the former Russian spy and his daughter were poisoned with an unimaginably potent nerve agent, isn’t very far from here.  As you might imagine, that evolving story and the saber rattling that resulted was even more prevalent on the news here than I imagine it was back home.  But a channel I can watch here that I never could at home is something called “RT,” which is “Russian TV.”  It’s actual English language Russian government-sponsored news. 

OK, at home we may decry the ideological bias in Fox News or MSNBC, but nothing compares to real, true government propaganda.  It is amazing to watch.

The poisoning never happened.  Then it did, but it was obviously the Brits who did it, then it wasn’t the same poison after all, on and on.  But then, in the midst of this, when the US missile attack on Syria was looming over another alleged (but RT-denied) use of chemical weapons, I watched as show after show declared, “If Trump gets his way and there is World War III…,” or ended their broadcasts with, “We only hope we’re all still here for next week’s show.” 

AAAUGH!
 
This channel with Russian government-approved news was actually preparing their surviving viewers for who to blame when the inevitable Armageddon occurred within a few days.  Like anyone would care whose fault it was.  Like anyone would care that anyone else would care.

I grew up in the “duck and cover” generation.  If you’re too young to know what I’m talking about, you’ve avoided a lifetime haunted by memories of a childhood spent practicing for nuclear annihilation as casually as practicing fire drills.  Hear the recess bell sound repeated short bursts?  Line up single file to walk calmly to the playground to await the fire trucks.  Hear the recess bell in one, long tone?  Crawl under your desk, turn your little butt to the glass windows, and await either instant vaporization or a blast that will send thousands of glass shards into those little butts.  Only much later did it occur to us that radiation poisoning would take us before those little butts ever had a chance to heal.

To watch a state-sponsored media outlet broadcast messages seemingly in anticipation of the real thing felt just a wee bit disconcerting. 

I have stopped watching RT.

We also spent time with Bobbie and Jack in London, of course.  On one such trip, we bit off more than we could chew, and after walking more than a few miles, we resembled the walking dead.  Between the four of us, we included two asthmatics, one diabetic, and four old farts.  With aching backs, sore feet, asthma, failing knees, blood sugar swings, and general poopiness, we were quite the sight as we staggered through ancient London streets and dodged young joggers who were oblivious to their surroundings.

I must say, if you plan on walking in London, be prepared to dodge joggers at least every minute or so.  They are plentiful and despite the risk they pose to mere pedestrians, it is a beautiful thing to see so many Brits committed to taking care of themselves. 

Update on the remainder of our schedule:

Denise is here visiting us until May 27.
We may be gone from ~June 1 until ~June 12, seeing a friend of Nan’s in Germany, visiting Vjollca in Kosovo (yea!), and perhaps another friend in Romania, if it all works out.

Ron is here June 14 until June 26.
We travel to Finland to meet Dawn and Anthony at his conference June 26 until July 1.
July 1 until July 8 we are at Lake Como in Italy with family.
For a few days after that, hopefully in other places in Italy.
By July 13 at the latest, back in the cottage in Belsize, England.
July 18-29 Dawn and Anthony are back here, and we all close up the house.
Departure on July 29 either home or to one last fling somewhere before heading home to the US.

Can we time it or what?  Returning to Phoenix in late July or early August.  We will know we’re home the moment we step off the plane!

It seems like a lot, but changes may occur, and please let us know if anyone thinks they might be heading to this part of the world before we return.  We’re having a great time hosting, and you can’t beat free rent in Europe.

‘See y’all soon.

-Bob

Travelogue #5 Interlude (the wedding)

Interlude:

This part of the travelogue is out of order, because I simply must tell y’all about the wondrous experience that was the Royal wedding.  I’ll get back to the regular stuff, on which I’m oh-so behind, shortly.  I promise.  Maybe.

First off, there are Royalists and anti-Royalists here.  The Royalists are fans of the more than thousand-year history of succession, albeit with the usual palace intrigue of wars, torture, murders, overnight flip-flops in the mandatory national religion, and even the offing of little children who happened to be heirs to the throne.  The history of what family members did to each other over governing this place puts to shame our pathetic claims to political infighting back home, although I note that the US seems to be working on catching up to medieval standards.

In particular, Royalists are fans of the House of Windsor, the current family in line to a monarchy that seems to be nearly purely symbolic.  (There remains some real power in some matters that is a little surprising to me, given that no one seems any longer to support the divine right of kings to actually govern — at least no one I’ve found who will admit to it).

Then there are the anti-Royalists, whose ideology descends from some guy named Oliver Cromwell, whose antics in overthrowing the King (briefly) had a thing or two to do with the eventual philosophy that sometime later led a bunch of guys in Boston to throw a party.  But that’s another story.  Cromwell’s ideology, in turn, descended from what some king had said, allegedly under duress, that was later renegotiated in a church, which was part of a school for lawyers, which had been founded by the Knights Templar.  Yes, those guys from the Crusades who were formed in large part to inspire conspiracy theories about the Holy Grail and to further Tom Hanks’ career.  This pronouncement was eventually confirmed, however, by a later king, and became a really big deal.  They call that thing the Magna Carta, which I think must mean “Big Deal,” and you can see an actual original copy of the document, upon which all civil liberty for all of us is based, at the British Library
 

If all of this sounds like “drunk history,” please know that I’m not currently drunk, but I think this country is today.  Because today, the entire nation (and I understand much of the world called the “Commonwealth”) dropped everything to be engrossed by the Royal wedding.

It was quite the show.  I’m sure some of you saw parts, although given the time difference I doubt many of you watched it live.  But it was everywhere here.  For several days it led the newscasts…  “Welcome to BBC News.  Nuclear Armageddon threatened, but first, let’s go to Reginald for the latest on whether Meghan’s dad will attend the wedding.”

People were seriously talking about this thing for weeks.  When the show finally happened, it didn’t disappoint.  It really was sweet, with very human touches like Meghan’s mom holding back tears and adorable kids and such.  And the symbolism of a British Prince marrying not just an American, but an African American, with something of an activist bent, is just outstanding.  Maybe useful stuff will actually come from this.

And the culture shock!  The Black American Bishop Michael Curry’s riffs and the looks on the faces of many of the Royals, who all seemed either stunned or bemused by the deviation from protocol, was a treat.  One of the news broadcasts later showed a gathering of finely dressed British women gathered for a group showing of the wedding all belting out “Stand by Me” along with the gospel choir.  It was great!

In case you were watching, you may have noted the several minute gap during which the principles and a few important family members disappeared.  The time was filled by a cellist, who was extraordinary both for his music and his socks.  This not being our first rodeo, having attended a certain wedding of a Brit and American not long ago, Nancy and I instantly knew what was happening.  Those folks had to disappear to sign the register, required by British law to take place immediately and out of the view of any camera.  So even the Royals, even when the ceremony is watched live by hundreds of millions around the world, have to follow those rules. 

That’s a nice concept.  Even the powerful have to follow the rules.  Hmmm.

Afterward, our local pub hosted a celebration in their garden.  Blissfully, this was by far the nicest day since we’ve been here — blue skies and shirtsleeves.  Woo hoo! 

Nancy and two of our friends here wore “fascinators,” those silly fancy “hats” that British ladies wear askew to the finest of functions.  They were alone in their millinery festivity, as it turns out.  Several people were chuckling about Bishop Curry’s effect on the Royals, evident on their faces when the camera caught them.  People brought finger food — cheddar and onion on white bread, anyone?  Nan made killer wings with a Parmesan-herb coating.  Score one for the Americans.

At any rate, in this cradle of modern democracy, albeit with touches of archaic, medieval tradition well intact, politics took a holiday.  All you need is love.  Someone from here once said that. 

Well, love and a $43 Million wedding. 

(OK, OK, so $40 Million of that was for security…  who says our Super Bowl has the lock on the most over-the-top security costs?)  So all you need is love, and an army to back you up.

Travelogue #4 Hoof Beats

Part 4
 
I often wake up here to the sound of hoof beats, as horse riders amble past our door.  This is horse country, with regular riders as well as new learners in abundance.  It doesn’t just add to the ambiance.  It has confused the heck out of me a couple of times when, following a night of burning coal in this converted carriage house, waking to hoof beats in my morning dreamlike state leaves me wondering which century this is.  Eventually I remember, and decide to crawl back under the covers seeking the past. 
 
As I write this, it is 40 degrees and raining.  Thus, comparatively, it is gorgeous!  Spring has sprung.  The signs are everywhere… flowers blooming, inevitably doomed by the coming freeze later this week.  It wasn’t even raining yesterday, so Nancy and I went for a walk and she actually spotted my long-lost glove, lost amid the stampede that accompanied me on a prior outing.  A few weeks buried in snow and muck, yet the biggest risk to the glove’s survival may yet be the wash it needs.  When I washed my oh-so-comfy fuzzy-lined leather slippers to remove the dog poop a few weeks ago, my size 13s curled into what most closely resemble a pair of baseballs, with roughly the same consistency.  Maybe I can soak them and stretch them enough to eventually fit Nancy’s size 4½ feet.  
 
Meanwhile, I have been doubling up on socks.   
 
Of course, living in small quarters where it is nearly or literally freezing and raining 6 days a week – oh, excuse me, Nancy insists that I am exaggerating.  It has not actually rained here 6 days a week.  Some of those days, it was snowing. 
 
As I was saying, being cooped up in this joint has led to some degree of cabin fever.  One tends to notice small things.  Like the creaking floorboards that respond to nearly every late night or early morning step with a raucous chorus that might as well be a car alarm in its effect on a slumbering spouse.  One day, Nancy postulated a classically American solution to anything that squeaks:  WD-40. 
 
The squeak wasn’t actually due to the century-plus old boards, she explained.  It must be due to the boards rubbing against the nails that held them down.  My scientific skepticism to this theory was disregarded, and the next thing I knew, we were spraying WD-40 onto every nail head of every squeaky board, right over the paint that covered them.  Yes, applying a lubricant to historic (at least by American standards) wooden floor boards.   It worked.  I cannot quite believe it, but it worked.  It did not leave a stain, and it almost completely eliminated the noise.  I can now sneak to the bathroom (or sneak into bed ridiculously late) without alerting my beloved.  Well, sometimes at least. 
 
The dogs are gone – off to Dubai.  Yea!  Unfortunately, so is our daughter.     It really was wonderful to spend so much time with her, albeit a busy period, with her mostly working and with various preparations for everyone’s emigration to the UAE.  Juniper has for the last time imprinted good English mud prints upon every article of clothing I own.  Ahh, the greetings left by jumping up upon my shoulders, leaving paw prints all over my shirt.  Following one such occasion, I ventured out to scoop the myriad loose poops in the yard, and found several with paw prints squarely in the blobs of poop.  I looked down again at the “muddy” paw prints on my shirt, and back at the paw prints in the poop.  Then back at the paw prints upon my shirt. 
 
But I digress.  The dogs are gone, but so are Anthony and Dawn.  The happy family is adjusting well to their new home, while Nancy and I are now adjusting to figuring out what to do with ourselves. 
 
We’ve been taking in more of our local environs as well as the occasional trip into London.  We have delightful next door neighbors.  We went to see our neighbor play bass with his buddies at an open mic night.  This involved Nancy driving at night for some 20 miles to reach our destination 5 miles away – thanks to my expert navigational assistance.  During this hour-long adventure, we were within blocks of our destination probably a half-dozen times.   
 
But we arrived intact.  Physically, at least.  And still married for the moment. 
 
Open mic night was a hoot.  The “theater” was a roomful of folding chairs behind a small bar, with tickets sold at a table in the back.  We were welcomed by an acapella version of Strawberry Fields, then a Leonard Cohen tune, “sung” in part spoken-word, part hum by a septuagenarian.  We were then treated to original tunes from a young Bob Dylan wannabe folksinger, but without even Bob’s vocal range, accompanied here and there by an occasional, random few bars of harmonica practice from the ticket seller in the back of the room.  All of this was absorbed by an audience, exclusive of the various musicians waiting for their turn, of perhaps 8 of us. 
 
But our friend’s group was actually really good, as were some others, including a first-timer, a shy but bluesy Dobro player.  And a room full of mostly aging hippies still clinging to their music gives me hope. 
 
England is incredibly cosmopolitan.  Oh sure, more so in London than outside it, but even out in the ‘burbs and elsewhere.  On a recent trip to Brighton, we were chatted up by a traveling electrical engineer, an old computer programmer from the early days back in the ‘70s, half Afghani, half Irish, raised in London and married to an Indian.  A recent trip to a large supermarket found me passing the large Passover display being studied by a single discriminating customer, a young woman wearing a hijab.  I love it. 
 
London itself is incredibly diverse.  The US hardly has a claim to be the world’s melting pot compared to here.  Every possible shade of color, every imaginable ethnicity, and multiple languages on nearly every block.  And that doesn’t even count the language spoken here that the locals insist is English.  Sitting on a train or in a pub and eve’s dropping is very different from listening to the locals indulge us as they speak… slowly… and… carefully… to their American cousins.  The various dialects of English spoken here are sometimes as mysterious as any of the other languages one may hear.    But just as I was feeling smug about American English, a shopkeeper inquired as to where in the States I was from.  Upon hearing “Arizona,” she remarked that she thought I was from the West due to my “lovely” accent.  My accent?  What accent?? 
 
The diversity here doesn’t mean that there isn’t the same strife over immigration that seems to be the human condition absolutely everywhere.  Witness Brexit.  Shortly after arriving, another neighbor noticed my accent and inquired as to my home.  Apparently, “Arizona” has a reputation even here, as this seemed to assure her that I must be a kindred soul.  She launched into espousing, within a 10 minute span, every conspiracy theory known to man, so as to answer every question I may have ever had.  Donald Trump actually won more than 80% of the popular vote, but for the massive voter fraud that nearly stole the election from him.  The Gulf War was a plot of Tony Blair’s to create an excuse for mass migration many years later, all pretending to be refugees, which of course none of them actually are.  This, in turn, is part of the one-world global conspiracy to remove all people’s autonomy and to subject us all to slavery.  To which of course, we are more susceptible given the mind control from chem-trails and the globally controlled media.  On and on.  Even Pizza-gate.  Yes, Pizza-gate.  Despite my voiced skepticism, I was reassured that it is all “absolutely true.”  
 
Next time, I may say I’m from Massachusetts.  Unfortunately, my lovely accent may give me away. 
 
We had Easter dinner with our son-in-law’s family.  Andy, Steph and family are lovely people, and I can’t wait to introduce them to our buds who come visit, if for no other reason than to help them try to understand their weird, new American family.  So far, our schedule is: 
 
Bobbie & Jack will be here April 13 – May 3 (and we’ll all be in Amsterdam April 15-18). Laura (Nan’s bud from Carson City) will be here May 10-20. Denise (our bud from Denver) is still figuring out dates, but will be here, we certainly hope. At the end of June, June 26-29 plus a day or a few before or after, we’ll be in Finland.  The first week of July we’ll be in Italy with Nan’s sister Martha and our bro-in-law Fred. The last week of July we’ll for sure be back here in Belsize, as Dawn and Anthony will be back here and we’ll all be closing up the house. 
 
More are welcome to fill the gaps.  Or even to overlap and join the party!  We have two bedrooms, a sleeper sofa in the living room, and we can come up with a bedroll and a chamber pot for the back “summer house.”  I even swept it up the other day. 
 
We have to leave for home by August 7, plus the sum of the number of days we can show that we’ve been out of the country in the meantime, or we’ll have overstayed our time as tourists without a visa.  Hmmm… there’s an idea.  Overstay our welcome and become undocumented immigrants.   
 
‘Tell y’all what…  Fix everything at home while we’re gone, and let me know when it’s safe to return

Travelogue #3 Nutrition

Part 3
 
Many of the place names here have a very familiar ring.  They are identical to many of those I came to know well in Connecticut and Massachusetts.  I often shake my head at just how many names the British appear to have stolen from New England.  While in London the other day, we visited Covent Garden, which is not a garden at all but a quaint old shopping center, the very design of which was blatantly stolen from Quincy Market in Boston.  The nerve of these people! 
 
Immediately across a plaza from Covent Garden lies St Paul’s Church (not to be confused with the enormous St Paul’s Cathedral).  St Paul’s Church was first completed in 1633.  Its modestsized burial ground is said to have seen so many burials that they must be somehow ingeniously stacked.  In 1665, the first known victim of the great plague outbreak was buried there, the first of more than 100,000 lives (15-25% of the entire population) consumed by a bacteria that is still an occasional risk in part of Arizona.  The church was spared in the great London fire of 1666, which of course is how the epidemic is thought to have ended — a novel solution to problems that perhaps bears greater consideration in Arizona. 
 
While we were at the church, Nancy saw an email from a dear friend that his mother had passed away.  Without skipping a beat, Nancy replied that we were currently in St Paul’s, “So we are in a good place to put in a word for an accelerated journey into the afterlife.”  Pausing to consider our friend’s lack of fervent religiosity, Nancy added, “Like TSA pre-check.” 
 
🙂 
 
Many of you familiar with London will know the phrase, “Mind the Gap.”  It adorns cups and stickers and all manner of tourist schlock.  It’s actually a polite reminder to watch your step as you exit or enter a train and traverse the often significant gap between the rail car and the platform. 
 
Well, on one trip into London, we were at last treated to a demonstration of just what happens when one does not “mind the gap,” when a young woman in front of us did a face-plant into the car, legs dangling out the door as the doors began to close.  One of her friends forcibly shoved her legs under her to clear the doorway.  As I hovered over her momentarily, it became quite clear that it was not merely her inattention that caused her tumble, but also what must have been an impressive blood alcohol content.  Judging the only real injury to be to pride, Nancy and I took up seats toward the center of the car, with these three hapless friends at one end. 
 
This woman struggled mightily, and loudly, for the next three stops, to somehow pry her legs out from under her prostrate torso, her friends’ assistance to no avail.  Her high heels having
somehow swiveled into reverse position no doubt didn’t help.  At the third stop, a half dozen young men entered the other end of the car. 
 
Now, football here is a big thing.  But not that football.  Soccer is appropriately enough called football nearly everywhere but the US, and somehow this spectator sport which may see a single point scored in an entire game inspires passions like I’ve never seen.  Upon entering the train, these 6 young men immediately began belting out some anthem for a team whose game they no doubt had just witnessed. 
 
Immediately, our prostrate inebriant summoned the strength to spring to her feet, and answered with a roaring chorus of her own, no doubt representing a different team.  The young men wasted no time bellowing out a few lines more, in harmony, to which she responded heartily with lines of her own, not so melodically, while being restrained by her friends as she endeavored to stagger towards her opponents.  Back and forth they went.  It was amusing, but we were thankful that our tube stop was next, as we exited toward the National Rail station. 
 
To our dismay, both groups of carolers exited with us, but we were able to meld with the crowd and leave them to entertain other patrons behind us.  Or so we thought. 
 
As we stood with the crowd in the main room at Euston Station, gazing up with hundreds of others at the “split-flap display” (the train departure schedule board), I noticed a familiar person slide in right beside me.  Almost immediately, she began belting out another tune, while a friend tried to shush her.  “Focus… focus…,” her friend implored while struggling to hold her up.  Both groups of balladeers soon left for another track, and for a few minutes I wondered whether they got off without further incident, until we saw a group of four of London’s finest sprinting in that direction. 
 
The Beast from the East (see Part 2) departed as suddenly as it arrived, and freezing temperatures were replaced by the “big thaw.”  This saw water mains all over the country burst, and a real calamity ensued as emergency supplies of water were needed by many for days on end, although not in our area.  The temperature here, even for the low, never dipped below 20 degrees Fahrenheit.  It was colder further north, but I don’t think by much more than another 10 degrees or so.  That the infrastructure (roads, railroads, schools, water supplies, fuel supplies) were so challenged by this surprises me.  Weather resilience is something they really should have stolen from New Englanders. 
 
So it’s a balmy upper 40s now, which means more walks, and more mud.  I’ve noticed several signs along the footpaths, such as these:  
 
 

 
 
 
 
 
We made another, final trip to the vet for the dogs’ imminent immigration to the UAE.  These supposedly house-trained dogs proceeded to pee, poop, and puke all over the pet store that houses the vet’s office.  Chalk it up to “white coat syndrome,” I suppose. 
 
There have been a couple of public health items in the news here in recent weeks, both nutrition-related, and the level of attention, I must confess, took me by surprise.  The first was a report from the Office of National Statistics that “one third of Britons underestimate the number of calories they consume.”  It said that on average, among this third of the population, men claim to eat 2000 calories per day while consuming more than 3000, and that women claim to eat 1500 per day while actually consuming nearly 2500. 
 
Duh. 
 
The second story was a challenge from Public Health England, their version of the CDC, for the food industry to cut calories that they typically offer as a meal by 20%. 

 Both of these are good stories, of course, but I was struck by how much attention they got.  Over and over they played in the news for days, with panel discussions, and industry representatives responding, as if this was some sort of revelation.  The coverage rivaled that of the poisoning in England of that former Russian spy.  And all this attention appears to have been generated merely by a couple of press releases.  Wow, I wish the media paid so much attention to what Public Health says in Arizona.  Maybe we can learn their secrets. 
 
Speaking of British food, it is a curious combination.  They have lots of international influences, yet render them in their own style.  Lasagna, for example, always seems to consist of lasagna noodles with béchamel sauce, ground beef, and good, British cheddar cheese.  A favorite snack is a “chip butty,” which consists of two pieces of buttered white bread, with chips (read: French fries) in between.  Yes, I’m talkin’ a French fry sandwich.  Of course, additional toppings range from mayo or ketchup to malt vinegar.  Yum!   
 
While in our neighboring pub one night, Nancy spied the above-mentioned snack being consumed by locals she had just met, and behaved in a most un-British manner by approaching them, asking whether that was, indeed, what she thought it was, and then asking whether she could take their picture: 
 
 
The 4 basic food groups: 
 
Ketchup
 
Mayo
 
Buttered bread
 
Chips
There is a really great pub and restaurant, the Paddock, perhaps a mile and a half from here.  It’s run by an Israeli immigrant, with all sorts of international influences, and the food is really spectacularly flavorful.  Therefore, few of the locals like it.  Typically, home-made dishes are prepared leaving out, for example, garlic or onions that a menu may call for, as these would impart “too much flavor.”  Suggestions to the contrary are likely to be met by a bemused, “What are we, French?”  So there is a mixture of a few foodies and a lot of people who prefer comfort food as they know it, which is to say a lot of meat and potatoes with very little spice.  Thankfully, I live with Chef Nancy! 
 
But in the city, you can find every spectacularly created style of food you want.  We have found our share already, much of it reasonably priced.  We’ve twice been to a restaurant with handsdown the best seafood I’ve ever had.  So come on over!  We’ll share. 
 
 

Travelogue #1 Getting Settled

Travelogue, Part 1

A week-and-a-half into this retirement thing, I felt it was high time to give an update to my buds left behind, especially those of you still working for a living.  How tiresome.  

So greetings from somewhere in the UK!  Actually, if you want to know where I am, you could try searching on a map for Belsize, which is in Chipperfield, which is in Rickmansworth, near London.  I say “near” London, because it appears so on a map, but feels a world apart. My daughter’s daily commute, starting from here on the northwest side of London, to a university also on the west side of London, is 2 hours each way!

When Dawn described “village life,” I had imagined an actual village, with shops and eateries and pleasant strolls among the villagers and such.  But no, this is an area of homes and farms and fields.  The only establishment of any sort that is walkable from here is the pub that lies almost immediately next door.  It goes without saying that we shall become well acquainted.

It is not that civilization is all that far — it is a mere 2 miles to a lovely area just as I had    imagined above, but you cannot walk there from here without trekking much of that distance on the pavement of the local “main drag,” which is a non-starter for reasons I shall soon explain.

My daughter rises to catch a cab precisely at 6 a.m. each day, takes it to a metro station some 4 miles away, and transfers her way to her destination, reversing the process and getting home after 6:00 each night.  This, despite the fact that she has a car, left here by her husband when he took his new job in Dubai.  She no longer drives, having learned that doing so is illegal, which she was originally given to believe was a technicality of sorts, having exceeded the year’s period during which her Arizona driver’s license could be used.  

This car, which was to have been our ticket to seeing the local environs, was itself left by a friend of Dawn’s at the aforementioned metro station, a mere 4 miles from here in Croxley Green.  After Dawn paid a few days’ extra parking fare, Nancy and I ventured via cab to the station on our third day here to retrieve the car.  We choose the middle of the day, far from any heavy traffic period, and set Nancy’s “maps” function.  I volunteered to drive.

Now, the roads in this part of the world are ancient, and have been modernized simply by having been paved at some point during the previous century.  Originally laid out for pedestrians, livestock, and the occasional cart, they are amply broad enough at all points for two bicycles to comfortably pass each other, with thick hedges, solid trees, or the random stone wall penning you in on each side. Down these paths hurtle mostly compact vehicles, careening around curves with obscured visibility, encountering each other head-on.  

Of course, I exaggerate.  There is at every point at least 2-to-3 inches between side-view mirrors, so long as at least one of the vehicles is literally scraping the hedges or polishing the granite curbs.  There is obviously an elaborate dance and sophisticated rules by which these vehicles alternate slowing or embedding themselves into the hedges to allow the other car to pass.  These rules are, however, beyond comprehension.

When in more civilized stretches through villages, rather than widen these suddenly busier streets, the locals compensate by allowing parking virtually anywhere, typically with one wheel over the curb, and the dance now includes indecipherable rules by which one lane of traffic or the other stops, far in advance of these blocks-long stretches of parked cars, to allow a caravan of opposing traffic to proceed.  Notification regarding whose turn it is to proceed is communicated via telepathy.

Every other intersection or so one finds a roundabout, a remarkably efficient mechanism by which to move traffic. This efficiency, of course, depends upon knowing what on earth one is doing.  One might think that being greeted by the “yield to traffic in the circle” sign would mean that one should yield.  That was certainly the assumption I made, to the consternation of the line of drivers behind me.  What it actually means is:  don’t enter the circle until you have enough room that the oncoming traffic has just enough space to brake so as not to crash into you.  

Doing all of this while on the wrong side of the road, sitting on the wrong side of the car, crossing traffic to make right-hand turns, and shifting our manual transmission with the wrong hand, provided me with an exciting new challenge on that 4 mile drive home.  

Admirably enough, I only ate the hedges 10 or 12 times during that initial drive home, whacked my left side mirror nearly off against a tree, and helpfully assisted in filling potholes with excess available rubber from our tires.  The best thing was the enlightenment that I inspired in Nancy, as I’ve never before heard her exclaim with such enthusiasm her appreciation for life in this world.

It’s good that I’ve retired early, as that brief drive took two years off my life.  Needless to say, Nancy has driven since, yet still infrequently, as each of those adventures takes another single year off what’s left.  Thus, we have been limited in our excursions, such as obtaining our SIM cards only a couple of days ago.  These provide us with new UK phone numbers, which I’ll list at the end of this communication, but which will do many of you no good whatsoever as there is no cell service here at all.  With WiFi, however, those of you with iPhones may FaceTime us, although please, unlike my mom, do remember that we are 7 hours later than Arizona time (and it will be 8 hours once every other part of the civilized world goes to daylight savings).

Wait, why again, you may ask, is my daughter, who is well-accustomed to driving here, no longer driving?  It is illegal to drive in the UK longer than a year unless you have a UK license.  At 500 pounds cost and with only a month to go, it’s not worth it.  She might still risk it and just drive anyway, but for an experience she and her husband had.  

Minding their own business driving one day, Anthony had to eat the hedges not to avoid an oncoming vehicle, but one that was literally flying through the air over their car, on a missile trajectory to collide with others.  Naturally curious about the outcome, they learned that the driver had been arrested for driving without a UK license after having lived here for more than a year.  Not planning on using her car to fly, yet wishing to avoid imprisonment, Dawn has chosen to pass.

We forayed out again today out of necessity, given our 6 pillowcases stuffed with laundry that we had to schlep to the laundromat.  “Wait,” you may say, “you’ve been gone barely a week.  How did you accumulate so much dirty laundry?”

Ah, that leads to the next part of the story.

Especially for those of you hoping to join us here at some point, I should describe our abode.  This is a quaint little row house type of cottage, converted from an 1850s carriage house.  It totals 700 square feet, I presume inclusive of the expansive 6-inch by 2-foot closet. Downstairs is a tiny but cute art-deco fireplace, which we are required to fire up at least every other night, reportedly to help control dampness.  And to light this fire we use? Why, good British coal.  I’m not kidding.  I’m making a fire with coal.  

Excuse me, I believe that’s Charles Dickens who has come calling at my door.

Upstairs are two bedrooms.  We have the larger one — the one with the expansive closet and a good foot or so space to circumnavigate the bed.  When we were planning our trip, Dawn messaged us that when we arrived we would have to make the bed.  “No problem,” we thought, until we arrived to find the bed in pieces leaning up against the wall. We had to “make the bed,” as in, follow the IKEA instructions to construct the thing.  But I find I can follow directions better when there are no words, but merely hieroglyphics to instruct me, along with the helpful corrections from Nancy.

The other bedroom neatly frames the other bed wall-to-wall, but it contains the sole bathroom.  That’s right, my midnight pee trips involve tiptoeing past my sleeping adult daughter, rendered more acceptable by the absence of her husband in her bed, at least until he comes for a weekend next month.

These bedrooms are accessed by the narrow, and I swear 60 degree elevation staircase.  This is no problem except for the fact that the first step down is immediately outside of both bedroom doors, rendering waking my daughter the least of my concerns during my slumbering pee trips.  On the bright side, I may not need a repeat bone scan to test the progress of my osteoporosis.  If, by the bottom of the stairs, I am still intact, I should be good to go.

It really is a sweet little cottage, but for the beast.  

As some of you may know, Dawn has for years had Belvedere, a well-behaved little Schnoodle.  For a year, Belvis became the office dog at Nancy’s workplace in Nevada.  But now that Belvis is a Brit, he no longer has the run of the place to himself.

You are no doubt familiar with the British obsession with royalty, and royal bloodlines that extend back as far as can be discovered.  Well, the same extends to pure bred dogs. Apparently, it’s not just the offspring of cross-breeding that have discounted value, but the parents themselves, having violated protocol by succumbing to the pleasures of the fur with a breed other than their own, lose value themselves. So when attempting to breed pure-breds, and two dogs with eyes for each other stray outside of their own kind, it is best to cover-up the transgression, and hustle off the newborns as quickly as possible.

Dawn and Anthony adopted such a puppy to add to their family.  Juniper is the product of an English Spaniel and, wait for it… a Weimaraner.  This 7 month-old puppy weighs some 40 pounds so far and feels like she outweighs me whenever she chooses to throw her weight around, which occurs roughly every 5 or 6 seconds.

First greeting me with her front paws seeming to reach my shoulders and a “kiss” not so much a lick as a nose plant into my face, she quickly presented me with the gift of my shoe, and we progressed from there.  Given the chance, every cushion on the couch will be sent flying, and the stuffing joins the toys scattered across everything.  I am treated to endless displays of WWE Wrestling matches between the dogs, and often am compelled to participate. This is basically non-stop unless Juniper gets hours of vigorous romping across nearby farmland, rain or shine (who am I kidding?  It is always raining, unless it’s sleeting). This serves to expend her energy nearly as much as mine.

Recognizing the advanced age of her father, Dawn has thoughtfully spared us from as much of this as possible, often walking the dogs alone, boarding both dogs during the day (a continuance of what she had been doing during the work day while she was alone), and enclosing them in a cage-like kennel for sleeping at night.

Each morning, perhaps half an hour after my daughter’s ‪6 a.m. departure, I am woken by Juniper’s “OMG I’ve got to poop right now!” whine.  Stumbling my way downstairs I generally get to the front door just in time for her to step a foot or two outside before depositing copious puppy diarrhea on the front walk, but alas, not always in time. Even if outside, my choice is then to ignore the deposits and have them ultimately tracked back in, or do my best to scrape it up.  

Both pooches then scamper upstairs, Belvis hoping to escape the madness and sleep with Nancy, Juniper hoping to touch every square inch of mattress around her before absconding with some article of clothing.  I can usually manage to calm the beast down for a few moments of dozing on the couch during the morning, but otherwise wrestle for a few hours until both dogs are off to doggie day care.

I am repeatedly and endlessly covered in dog slobber, tracked in mud, and who knows what those other fluids are. I thus have soiled more laundry than usual, leading to our aforementioned trip to the laundromat, which of course required another life-expending drive, parking the car on the sidewalk and moving it three times, and a host of laundromat cultural lessons.

So just to pique my early retirement experience, we combined both driving and Juniper into a single adventure this week when we drove the dogs to the vet.  Having just endured endless vaccines and other requirements to become British, Belvedere is required to repeat the process for the UAE.  Of course, Juniper has to do it, too.

Despite the white-knuckle life-shortening aspect of riding in the passenger seat while Nancy drives (much, much better than I do), I at least have been able to assist in navigation between bouts of loss of sphincter control.  But I could not do so while desperately wrestling the beast in the back seat to keep her from attempting to drive.  

Thankfully, on the drive over to the vet, Dawn’s father-in-law chauffeured us.  I was especially grateful upon our transmigration of the “magic roundabout,” which consists of a single large roundabout fed on all sides by 7 separate roundabouts, some of them one-way, some two-way, lanes of traffic crossing, and no stoplights involved.  Roundabouts here go clockwise, unless others are feeding a central roundabout, which must then travel counter-clockwise, whose outer ring of traffic travels in the opposite direction.  It’s indescribable, especially at rush hour.

At one point during the vet visit, I was left for 20 minutes or so to constrain Juniper in the car while Belvis was with the vet.  I mistakenly settled in for the usual wrestling match, until she caught me with a right hook that sent my glasses flying and myself wondering whether I still possessed lips.

Convinced I was now involved in MMA, I soon realized that Juniper could not abide even those rules as she landed several kicks which, as the British might describe it, were received “down low and full square.”

Nancy then drove home admirably through rush hour.  I am learning to just not look.

I remain alive, but not for long.  So those of you who want to join us here may need to hurry!

Dawn is leaving us ‪on March 12.  The only firm dates we have for others being here are for Bobbie and Jack, here ‪April 12 – May 5.  We can handle more than one at a time as we have a sleeper futon sofa, and there is a “summer house” in the back with electricity and heat, but no plumbing.  Thus, your late night pees may need to involve slogging through the mud before climbing the stairs and stepping past others sleeping.  Either that, or chamber pots.  😛  Or perhaps taking a cue from the dogs and watering the yard.

The easiest way to reach me is still through email:  [email protected] .

CHW Rulemaking, Opioid Epidemic Ends and Various CEU Opportunities

Community Health Worker Certification Rulemaking

The new law that authorizes the voluntary certification of community health workers will officially take effect on August 3 (HB 2324 Voluntary Certification for Community Health Workers). Voluntary certification can’t begin until the ADHS completes their Administrative Rulemaking (regulations) that’ll flesh out the details of the certification program including defining the core competencies, the criteria for establishing those competencies, continuing education requirements, the fee and other certification details. 

The first step in the Rulemaking process is for the ADHS to populate the 9 member advisory council to help inform the Rulemaking (the ADHS Director makes those appointments based on the criteria in the Session Law – the language at the end of the bill here).  After that, the agency needs to open the docket for the rulemaking and put draft rules out for public comment in what’s called the Arizona Administrative Register.

The public will then have a chance to comment on those initial draft regulations.  The ADHS will then consider those comments and file the final proposed rules with the AZ Secretary of State (here’s a summary of the rulemaking process on the SOS website).

Before the rules become effective- the agency needs to get final approval of the regulations by the Governor’s Regulatory Review Council (GRRC).  If GRRC approves the rules- they’d become effective and voluntary certification could begin.

Realistically- even if the ADHS starts right away and appoints the advisory council and they begin meeting this Summer and began writing the initial draft rules later this year, it could easily take a couple of years before they’d become effective- so it’s important to begin the process soon with initial advisory council meetings. 

You might be familiar with other agency rulemaking that have gone a lot faster than this.  That’s likely because those were probably “exempt” rulemakings, which provides several rulemaking short cuts including an exemption from the GRRC requirements.  Sadly, the CHW Rulemaking isn’t “exempt”.

The Rulemaking will be among the topics we’ll all be talking about at the AZCHOW Conference on June 21st and 22nd in Tucson.  Hopefully many of you will be able to make it.  AzPHA will be exhibiting at the conference.

 

Opioid Public Health Emergency Executive Order Ends

This week the Governor officially ended the emergency public health declaration that was signed via an Executive Order about a year ago.  Much has been accomplished over the last year including implementing legislation that improves prescribing practices and enhances emergency responses and increases access to treatment.  Of course- the work will go on.  The epidemic didn’t start overnight, and it surely won’t end overnight.  You can read the official end of the emergency declaration here.

Rep. McSally (R) is hosting a House of Representatives Border and Maritime Subcommittee hearing today (May 30) at 9:30 am at the UA College of Medicine Phoenix (Building 2) entitled: “An Unsecure Border and the Opioid Crisis: The Urgent Need for Action to Save Lives” featuring the Governor, various federal officials from the DEA, CBP, and DHS as well as Dr. Christ, Debbie Moak, and some people from faith-based organizations. You can see the panel line up here.  It looks like it’s an open meeting.

 

Aligning Health and Early Childhood Learning

Evidence shows how important early childhood education is in protecting people from disease and disability as an adult–  and that a child’s health impacts his or her ability to learn and succeed in school and later in life. Even with these known positive connections between early learning and wellness- health and education systems sometimes fail to align and provide opportunities to maximize health and early learning outcomes for children.

To address the disconnect between health and education, the HHS & US Department of Education outlined a set of recommendations for states and communities to align health and early learning systems. The recommendations emphasize the need for a comprehensive, seamless, and coordinated set of systems to support children, parents, and families.

 

Legislative Session Webinar Posted

The UA has posted my webinar from a couple of weeks ago that summarizes the legislative session from a public health perspective.  The whole thing is about an hour long.  You can check out the webinar on the UA Telemedicine Website.  Here’s the PowerPoint that I used.

 

CDC’s Learning Connection

The CDC has what they call a “Learning Connection” which connects public health professionals, including healthcare workers, to training opportunities and educational tools developed by CDC. Their Learning Connection also engages public health professionals around the world via social media messaging and a monthly e-newsletter.

The CDC Learning Connection: 1) features quality learning opportunities from CDC, other federal agencies, and federally funded partners; 2) keeps you up-to-date on the latest training through a free monthly e-newsletter; 3) offers access to thousands of training opportunities through CDC TRAIN — CDC’s online learning system; 4) connects you to information about CDC internships and fellowships; and 5) makes it easy to locate courses that offer continuing education. There are literally hundreds of courses one can take- mostly on-line and self-paced.

 

Free Continuing Education from MMWR and Medscape:

CDC MMWR and Medscape introduced a new FREE continuing education (CE) activity that describe trends and demographic differences in health outcomes and healthcare use for childhood asthma, based on a CDC analysis of asthma data from the 2001-2016 National Health Interview Survey for children 17 years and younger.

This activity is intended for pediatricians, pulmonologists, public health officials, nurses, and other clinicians caring for patients with childhood asthma. To access this FREE MMWR / Medscape CE activity visit https://www.cdc.gov/mmwr/cme/medscape_cme.html. If you’re not a registered user on Medscape, you may register for free or login without a password and get unlimited access to all continuing education activities and other Medscape features.

 

Free Continuing Education Training for Opioid Prescribers offered by UA

With the requirement of Arizona prescribers to complete 3 hours of opioid, substance use disorder, or addiction-related CME, the University if Arizona’s Center for Rural Health we offer Arizona based materials and continuing education opportunities including:

Free online CME vouchers worth $150: order vouchers by responding to this email. We can mail them to you in batches of 100 to 500. Please feel free to forward the listserv blast below and attached documents for your attendees.

Free Arizona Opioid Prescribing Guidelines printed copies: order at http://www.azdhs.gov/audiences/clinicians/index.php#clinical-guidelines-and-rx-guidelines-order

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I’m doing my best to populate the “upcoming events” part of our AzPHA website.  If you have an upcoming public health related event- please let me know and I’ll get it up on our website at: https://azpha.org/upcoming-events/

 

Dr. Bob’s Travelogue

I’ve gotten a couple more Travelogues from Dr. Bob in the last couple of weeks.  He’s been living for the last couple of months just outside of London. He’s writing some entertaining travelogues- with a splash of public health of course. Take a few minutes when you’re on a comfortable couch and enjoy Travelogue 1 & 2: Getting Settled and Travelogue 3: Nutrition. Here’s Interlude from last week and this new one Hoof Beats.