Applica Consulting Group

Recently I interviewed a new patient for a mental health rehabilitation program where I am the attending psychiatrist. “David,” a 20 year-old man, attended an Ivy-league college and achieved a 3.5 grade-point average during his first year. At the end of the otherwise-successful first year, he had a psychotic break. After going without sleep for one week, he was arrested for pursuing a grocery clerk relentlessly around the store and babbling nonsense. Subsequently, David sank into a depression so severe that for many months he could barely shower, dress or even leave his bed. Concentration was difficult and his thoughts were rambling and disconnected. Struggling with distinguishing reality from fantasy, David believed he would never function normally again and consequently made three suicide attempts. Psychiatrists tried multiple different medications in a myriad of combinations, but nothing seemed to help. Finally doctors suggested Electroconvulsive Therapy (ECT), also known as shock therapy.

Unlike many patients who receive ECT, David did not have fast relief from his depression. In the end, he had 29 ECT treatments which he feels had little positive impact on his mood. His assessment of the treatment’s lack of success was substantiated when he made yet another suicide attempt near the end of his ECT treatments.

One of the unfortunate possible side-effects of ECT treatments is memory loss. Usually this loss is limited to the period of time while patients are receiving ECT, but in rare cases it can include events preceding the illness. For most, memory deficits with ECT generally improve over time, but even several months after the procedures, David describes reading his high school journals and feeling as though he is reading about someone else. He feels “really misled” about the severity of memory loss that could occur with the procedure.

There is virtually no other treatment in mental health that raises such fear and passion as ECT, or about which such mythology continues to circulate. Hollywood depictions, such as the ECT treatment Russell Crowe’s character underwent in the film A Beautiful Mind, often include sinister music, painful-appearing seizures in unanaesthetized patients and lobotomy-like after-effects. The few studies of patients’ subjective experiences with ECT indicate that patients have many fears, including personality change or brain damage. The majority, however, describe ECT as an overall positive and sometimes life-saving experience, even in cases like David’s, where side effects occur.

What is ECT, how does it work and why does it remain so important in the armamentarium of psychiatric treatments? Electroconvulsive therapy was first used as a psychiatric treatment in the 1930s, in an age before psychiatric medications were developed and at a time when prognosis for those with mental illness was extremely bleak. In the early 1930s, a European physician named Ladislaus von Maduna noticed that patients with both psychosis and epilepsy had fewer psychotic symptoms after their seizures. Von Maduna used injections of camphor to induce seizures in 26 non-epileptic psychotic patients and was able to show either a reduction or complete remission of their psychosis. Later that decade, the physicians Luigi Bini and Ugo Cerletti began using electric current to initiate the seizures, which caused fewer side effects than the camphor injections. The seizures themselves were physically traumatic, sometimes resulting in broken bones. In the 1940s, the medication curare entered use as a muscle relaxant to stop the muscle contractions so that the brain experienced the electrical events of a seizure, but the body lay peacefully calm. Advances in ECT and anesthesia technique have further minimized side effects and risks.

An ECT procedure is short, taking about 15 to 20 minutes including preparation time. Patients receive IV sedation with an anesthetic agent so they are not awake for the actual procedure. Two electrodes are then attached to the scalp in positions determined by the type of therapy received: unilateral therapy, with both electrodes on the non-dominant–usually right-sided–half of the head generally produces fewer side effects, while bilateral therapy, with electrodes on either side of the head, is more effective for more severe depression. The actual shock lasts little more than one second. Brain wave monitoring allows the doctor to observe the seizure that occurs, and anesthesiologists watch the patient’s blood pressure, breathing and heart rate. A normal course is six to twelve treatments, which may be given as frequently as 48 hours apart. Often patients begin to feel improvement as early as the second or third treatment.

ECT is the most rapid and effective known treatment for mood disorders, both depression and mania. Antidepressant medications relieve symptoms of depression 45 to 60 percent of the time, whereas ECT is effective in 80 percent of depressions. While antidepressant medications may take weeks to start working, ECT can show dramatic effects within days. In highly dangerous mood episodes, those accompanied by psychotic symptoms (hallucinations, delusions, thought disorganization), agitation, refusal to eat or high suicidality, the immediate effects of ECT can be life-saving.

Problems with memory and confusion immediately following the procedure are the major side effects that can accompany ECT. Confusion can be frightening for patients and their families, but is short-lived. During this time patients may not be aware of where they are or may not recognize people familiar to them. Confusion generally resolves over a period between 30 minutes to a few hours. Memory loss is generally limited to events in the weeks immediately surrounding the procedures, but can be more extensive in some individuals. Memory effects can be either loss of memory for events preceding the procedure (retrograde amnesia), or difficulty storing new information (anterograde amnesia). Changes in ECT technique over the past one or two decades have reduced the severity of memory loss. Memory effects usually improve with distance from the ECT procedures, resolving six to eight weeks after treatment in many cases. Because of anterograde amnesia during the treatment process, it is not uncommon for patients to retain some gaps in memory for the period of active ECT treatment. Factors that are associated with more severe memory effects are bilateral ECT treatment, a larger number of treatments and high-dose ECT (as opposed to a titration method, where the patient receives the lowest dose needed to produce a seizure). Studies have shown that the extent of memory loss is unrelated to the benefits of ECT, and improvement in mood is not due to forgetting one’s problems.

Many patients considering ECT also fear they will suffer irreversible brain damage. More vocal opponents of ECT have compared it to minor head trauma and have claimed that ECT causes brain atrophy, cerebral bleeding, edema (brain swelling) and neuron death similar to prolonged epileptic seizures. In general, these claims are based on early, uncontrolled and methodologically flawed studies. We now know that major depression itself is associated with structural brain abnormalities on MRI scans. Newer studies that have examined brain structure both before and after ECT have shown no changes or brain swelling from the procedure. Reliable studies from both humans and primates have identified that neuron death in epilepsy occurs only with prolonged uninterrupted seizures (more than 20 minutes) and is mainly a result of low oxygen. In contrast, seizures during ECT treatment last less than three minutes, and the patient is well-oxygenated by mask the entire time. ECT does not raise levels in the bloodstream of chemicals that are markers for brain trauma. The preponderance of evidence from a large number of well-designed studies with modern research techniques has found no evidence of structural brain damage from ECT.

Despite the many theories and observations, the exact mechanisms for how ECT works are not precisely understood. Some of the brain effects recently noted with ECT are similar to the effects found over longer periods of time with antidepressant medications and even with non-medication treatments such as psychotherapy. For instance, recent research has shown that ECT increases a growth factor called brain-derived neurotrophic factor (BDNF), a chemical that is responsible for maintaining cell growth in the hippocampus–a brain area involved in mood and memory. Studies have shown that in depression, levels of BDNF decrease and the cells lining the hippocampus begin to thin out. There is also evidence that as individuals begin to respond to antidepressant therapies–whether pharmacological, psychotherapeutic, or perhaps just exercise–BDNF increases and hippocampal cells return to their pre-depression state.

While ECT is currently the most effective known treatment for an episode of depression, particularly depression with psychotic symptoms, its effects are temporary. After a successful course of ECT treatment, individuals can often maintain their remission from depression with medication, even if medication was not successful in bringing them out of the depression originally. Others find that no alternative treatment works for them except ECT. For these individuals ECT can be continued in less frequent “maintenance” sessions (given, for example, once a month), often with concurrent use of medication. Some critics have equated ECT’s lack of permanence with lack of effectiveness, but this criticism misses the point. Depression is a chronic illness, in the same way diabetes and heart disease are chronic illnesses. When one stops treatment for any chronic illness the symptoms will return.

For those who fail to respond to medications alone, new treatments for severe depression may soon be available as alternatives to ECT. A procedure called repetitive transcranial magnetic stimulation (rTMS) uses magnetic pulses applied to the scalp to stimulate underlying brain structures. Intermediate research results of rTMS are showing similar results to ECT for non-psychotic depression. Advantages of rTMS are that is does not produce seizures or cognitive side effects and does not require anesthesia. Studies are underway to determine the best locations and intensities for the magnetic pulses, and if rTMS is effective for other conditions treated with ECT, such as mania.

Depression is the leading cause of days missed from employment. It is also one of the major risk factors for suicide (studies show that one in six patients with depression commits suicide). When an illness itself is debilitating, evaluation of any treatment must consider the risks of not treating the illness as well as the risks of treatment. Unfortunately, depression often interferes with individuals’ ability to absorb, understand and remember the information presented to them, so weighing alternatives can be difficult. Those considering ECT should request written information about the risks and benefits. If possible, a friend or family member should be present to hear the explanations and help weigh the alternatives.

In David’s situation, he has noticed other improvements from the ECT that have allowed him to return to normal functioning. ECT eliminated his psychosis (his disorganization and delusions) when medication was unable to do so. Also, while he subjectively remained depressed during ECT, his functioning in terms of being able to take care of himself (get out of bed, remember the day and date, attend some activities, etc.) did improve. Furthermore, since his ECT treatments, David has been able to respond to antidepressant medication.
When asked recently, David indicated he did not regret having ECT, despite the serious side effects he has experienced. “You would have to see my journals from back then,” David says. “I don’t think people knew how crazy I was. If I hadn’t had the ECT, I would still be psychotic. I wouldn’t be on medication that worked and I wouldn’t be going back to school.”

TORONTO–Everybody knows about Regina-Lumsden-Lake Centre Alliance MP Larry Spencer’s (in)famous interview with the Vancouver Sun and the predictable fall-out from it. Spencer — who quickly apologized — said it was a “mistake” to legalize homosexual acts and talked about a “conspiracy” of homosexual activists recruiting school children to push their agenda. As he must have known would happen, the earth suddenly came crashing to a halt, and all the forces of righteousness — as they would see themselves — went into attack mode. Furrowed brows and wringing hands became the order of the day. Spencer was dismissed as a bigot, a crackpot, and more. Worse, the entire social conservative movement — and indeed, the Canadian Alliance itself — was tarred. Even the National Post, usually more sensible about these things than, oh, The Toronto Star or The Globe and Mail, resurrected the usual suspects — i.e. Betty Granger’s “Asian invasion” comments and Bob Ringma’s remarks about moving minorities “to the back of the shop” — to illustrate how pervasive these unacceptable views are among Reform/Alliance supporters. Never mind that both Granger and Ringma’s comments, like so many of the standard examples of “intolerance” used to marginalize so-cons, are wildly out of context in the retelling. Everybody knows that while not all Alliance members are crackpots, if you are a crackpot, where better to feel at home than in the Alliance? Before you think I support Spencer’s suggestion to criminalize homosexuality or tie it to pedophilia, I don’t. I do think, however, some of his remarks are valid, e.g., his concerns about a sharply lower life expectancy among homosexual men, which should be a legitimate subject of public health debate, but can’t be because of the tyranny of the media and others brought to bear against anybody who dares raise them. Spencer’s mistake — and it was stupid of him to make it — is that by being so extreme in part, he ruled out the possibility of reasonable debate over his legitimate concerns, providing a convenient target for all those who do not wish to discuss any of the negative side of homosexuality. Lest you think we so-cons are a tad paranoid, perhaps you care to explain why Liberal David Kilgour, who uttered similar (although not quite as extreme) concerns about the homosexual lifestyle, has been virtually ignored by most media. Nobody argues that because Kilgour, a Liberal, said such things that all Liberals must be extreme, any more than they would define all New Democrats as extremists because of some of the decidedly immoderate comments and actions by such stalwarts as Svend Robinson over the years. That one-size-fits-all-formula, it seems, only applies when the extreme view comes from the Alliance. To read most reactions to Spencer, and to others who have been roasted for far less offensive remarks on the subject, you’d think that concerns about homosexual lifestyles was restricted to a tiny minority of Canadians. Yet everybody knows this is not true. The Wednesday Post, for example, ran as its main story a public opinion poll showing a mere 31 per cent of Canadians polled supported same-sex marriage, down dramatically from earlier polls showing roughly a 50-50 split. The COMPAS poll found 31 per cent said marriage should include heterosexuals only, and another 37 per cent said the traditional definition of marriage should remain intact, but a new category could be created to allow for same-sex unions. So does this make the 67 per cent who do not favour same-sex “marriage” all bigots, crackpots, kooks or homophobes? Apparently. On the issue of health, lost in the avalanche of vitriol directed at Spencer, even the ultra-liberal Star reported on its front page this week that HIV/AIDS cases are up 17 per cent in Canada, with the largest group by far still homosexual men. Surely this is a serious, and tragic, health issue. But the danger of muzzling anybody who questions the homosexual lifestyle on any level is that it cannot even be addressed for fear of provoking charges of “homophobia” or worse. Social conservatives, in theory, have as much right as social liberals to be heard. When they say something really stupid, as Spencer did, they also should expect to be criticized. After all, free speech does not protect you from other people’s rights to exercise their free speech right back at you.

Chicagoans have praised the city for its handling of a bacterial meningitis outbreak among its gay residents in October. City officials quickly set up emergency clinics, distributed fliers and fact sheets, and vaccinated 14,267 people in eight days. The city’s action limited the casualties of the crisis to three gay men dead and three seriously ill.
“The city moved so quickly and so smoothly because it just put into effect the plans it made for fighting bioterrorism,” said Bill Greaves, the gay liaison to Mayor Richard M. Daley.
Greaves discounted a rumor that the outbreak originated with a popular gay bartender who liked to kiss patrons and then died of the disease. With meningitis outbreaks, he said, there is no “patient zero.”

Legislators in tough economic times are using tobacco settlement money to desperately plug budget holes. Massachusetts state lawmakers in at least the last two years have used the funds to help cover general fund expenses as the deficit widened into the billions of dollars. In November, a $100 million economic stimulus bill passed that relied on more than $33 million in tobacco money. Two local law firms that helped the state win its $8.3 billion tobacco settlement are suing the commonwealth for $1.2 billion they say they’re owed in legal fees.
But ostensibly, the money is supposed to be spent to help educate young people to stop smoking and for other health-related programs.
That happened the first year the money came in. In 2000, a $326 million tobacco payment came in and 70 percent was saved or invested. The rest went to the Tobacco Settlement Fund for education programs, all according to statute. In 2001, $242 million came in, again at the 70/30 percent ratio.
But in 2002, $305 million came in, and 50 percent went to the general fund. The rest went to the Health Care Security Trust. In 2003, $303 million came in and all of it went to cover general fund expenses, a trend expected again this fiscal year.
Massachusetts established the Health Care Security Trust in 2000 to administer and invest the money as it came in. It’s a one-man office, run by 49-year-old Paul Todisco, who was transferred from the state pension fund to manage the money as it came in. Todisco recently talked to Boston Business Journal reporter Mark Hollmer about the tobacco money, where it’s been spent so far and how much of it has actually been spent on health care.

Q Tell me about the Health Care Security Trust office.

A It was created through the Legislature … and basically, we’re charged with managing and investing all the money generated by claims or actions undertaken by the attorney general’s office over the tobacco settlement.

Q How did the funding formula initially work?

A Initially the Legislature set up the formula in the statute that said 30 percent of annual receipts in this settlement would be used … for tobacco cessation (antismoking initiatives) and 70 percent … would be saved or invested for some future use for health care purposes.

Q How much money has come in to Massachusetts to date?

A About $1.2 billion.

Q How much has been saved or invested to date?

A In our most recent quarter we had a net asset value of $494 million.

Q Why didn’t you get any new money to invest this year?

A The state is in a budget crisis … and like many states around the country, we’ve taken receipts from the tobacco settlement and used it for general purposes as opposed to targeting health care. This is not anything that’s basically earthshattering, given the fact that practically all 50 states have had fiscal bumps on the road, (but) it’s the state’s prerogative.

Q Has Massachusetts used the money as the Legislature intended?

A Massachusetts has really been a model for other states around the country, as far as health care and using this money for tobacco cessation programs. It will be a leader once again once the state gets back on its footing.

Q What has happened to the tobacco settlement fund?

A In this last budget, the tobacco settlement fund was eliminated and folded into the general fund of the commonwealth.

We are considered a reserve fund. It is in the commonwealth’s prerogative to use the assets as they see fit for whatever purposes they feel are necessary.

BULLET POINTS on Todisco * Is executive director and sole employee of the Health Care Security Trust that administers and invests the state’s tobacco settlement money

* Oversees assets that are expected to reach more than $8.3 billion over 25 years

* On who holds the tobacco settlement purse strings: “We’re just kind of the bank. The state is the entity who decides how it gets spent.”

Thirty years after homosexuality was declassified as a mental disorder, a gay man takes the helm of a major health association
The American Psychiatric Association removed homosexuality from its Diagnostic and Statistical Manual of Mental Disorders in 1973. Almost, 30 years later, the American Counseling Association, a professional group with 52,000 members nationwide, elected Mark Pope as its president-the first openly gay head of a major mental health association.
The revealing nature of that coincidence is not lost on Pope, an associate professor of counseling and family therapy at the University of Missouri’s St. Louis campus, “I represent a final and total repudiation of that past” he says.
The 51-year-old Pope, whose long career includes the creation of counseling programs in Chicago and San Francisco, describes himself as a “poor gay Cherokee boy from a rural area of southeast Missouri. “He spoke to The Advocate’s Chris Bull during a recent stop in Washington, D. C., as he tours the country working to make his profession better for everyone.
Did sexual orientation become an issue in your election?
I’ve been openly gay since I stepped in the door of counseling. I knew that who I am would not be an obstacle to my advancement. A solid 53% majority elected me. But it’s true that there are some members who undoubtedly voted against me on [anti-gay] grounds. That’s just the reality. My tack is to focus on the issues that affect everyone in this profession. I can’t be a one-note leader.
How will you win over holdouts?
Everything is pointing in the right direction. When the mental health profession labeled gays and lesbians as sick, it was based on religious and political prejudices, not on data. There were no legitimate studies that made the case for homosexuality as a mental illness, and that’s even clearer today. A couple of years ago I was at a conference at the University of Indiana on sexual minority youth in the heartland. There was a panel of young people who said that the first person they came out to was their guidance counselor. It made it clear just how important our members are.
What happens when a counselor takes an anti-gay approach with a client?
When we find out about it, I call the counselor directly. I explain the research and the policies the association has adopted. I explain that there is no evidence that conversion and reparative therapies work and that even if they did, what kind of message do they send to young people? I ask them why they are doing what they are doing. Usually that person will come around and stop pushing a personal agenda.
On the subject of reparative therapy, do you think any gay people would want to be straight if there weren’t an antigay climate in this country?
There would be very, very few. It’s really just a numeric issue. There are more of them than there are of us. We are between 4% and 10% of the population. We grow up around heterosexuals, so no matter how accepting they are, it’s going to take some adjustment. I come from the Native American background of two-spirited people, which allows us to go against the dominant sexual orientation and gender roles of the majority. That’s something the rest of the culture needs to work toward.
Did you come out to a guidance counselor?
I came out to my minister in high school. He’d always been open and accepting, so I wanted to share my story with him. I expected him to be joyous, but he wasn’t at all. Then after I broke up with my first boyfriend in college, I decided to see a counselor. She was just the opposite: totally accepting. I saw the good side and bad side of counseling, and it gave me a desire to make it right. This is the chance I’ve been waiting for.

Boston’s Oral Health Foundation plans to give out $650,000 in new grant money to help six organizations statewide provide dental care to the poor.
The Community Health Connections Family Health Center in Fitchburg is set to receive the largest grant, at $206,000, to expand dental services to 40,000 lowincome residents.
The Boston Public Health Commission’s Oral Health Equity Project will get a $113,500 grant to help fund free dental screening exams and preventive care at Boston Housing Authority elderly-housing sites.
Cape Cod Dentists Care in Orleans will receive $70,000 to develop and launch a volunteer dentists program to treat lowincome and uninsured people on Cape Cod based on a sliding-fee scale.
In other awards: The city of Lowell Health Department’s One Smile at a Time II program will get $87,000; the Family Van Saving Smiles Program of Harvard Medical School in Boston will get $90,500; and the Operation Health Smile program in Marlborough will be awarded a $77,500 grant.

Planners should represent the interests of the communities they serve by working with others involved in housing and regeneration, Yvette Cooper tells Chris Griffin
On the eve of some crucial announcements for the future of planning, the junior minister with responsibility for housing, planning and regeneration nails her colours to the mast. Planning, says Yvette Cooper, “should be considered from the point of view of the local community”. The implication is that she is less concerned about the processes themselves.
She has already picked up extensive experience during her four years in government-first as public health minister, then during a brief stint in the Lord Chancellor’s department and, since last summer, at the ODPM. Married to Ed Balls, economic adviser to chancellor of the exchequer Gordon Brown, she was tipped by the US embassy earlier this year to become the UK’s second woman prime minister.
Cooper became interested in politics through her father, a trade union official: “We always had politics in the family.” Her first job was as economic researcher to the late John Smith during his time as shadow chancellor. “John had a passion about social justice and a strong moral sense about politics changing people’s lives, which I found inspiring,” she recalls. “That encouraged me to develop my interest in social exclusion and regeneration and their relationships to economics,”
She likes the way her integrated brief at the ODPM allows her to consider planning from the point of view of communities. “Most people have no concept of what planning is about,” she accepts. “Often their first contact is when they learn of an application or development near their home that they don’t like and don’t think should have gone ahead.”

Cooper explains that her Yorkshire constituency of Pontefract and Castleford includes two largish towns with two ex-collieries between them. “These communities have many views about the ways they think the land and the towns should be used,” she explains. “These are real planning issues, yet few people know about development plans or have been involved in the debate overthem.”

She elaborates: “People don’t feel that planning links in with the discussions and attitudes they have about what should be done in their area, particularly if it needs regenerating. They consider that it is experts, not members of the community, who make the decisions. We need to make the system faster and more transparent and link the development of local planning issues with community debate.”

The dual emphasis in the sustainable communities plan on market renewal pathfinders in the north and Midlands and growth areas in the south is correct, she insists. While Cooper is convinced that the emphasis on the southern growth areas is sustainable, she tactfully adds that “links between the housing market and the economy must tackle regional economic disparities and get more economic growth into the poorer regions”.

“Housing has to respond to the demands of the local economy, and a good planning system is one way to underpin the process,” she maintains. “One of the greatest mistakes has been the separation of housing policies from those affecting the local economy. In the housing renewal areas, these policies are linked. We need to know whether low demand is because the population has declined or because people want a different type of housing.

“We must recognise what the local workforce wants, assess the population projections and use appropriate processes to deliver accordingly. We need to generate growth in the regions themselves. If you look at the gap between London and our other regional cities compared to other countries, it is much wider. This suggests considerable potential for those cities to be the drivers of regional economic growth.”

Cooper points to latest figures showing that returns on property investment in many northern towns and cities are considerably higher than previously anticipated. “Getting entrepreneurs and investors to recognise the economic potential for the growth of jobs and opportunities and investment from property is now even more important,” she contends.

She also emphasises the need for good design of buildings, the spaces between them and the whole environment, revealing a particular interest in increasing green space provision in towns. “Environmental factors are important in attracting businesses and people to the north. Businesses won’t invest in places where their workforce doesn’t want to live,” she warns.

But in the drive to attract people and businesses, she does not accept that the minimum density of 30 homes per hectare in PPG3 should be relaxed. “Other countries manage to build attractively at greater densities and it means you don’t have to worry so much about using greenfield land. It’s also about bringing life back to town and city centres,” she stresses.

A regional focus is important in the high-demand areas of the south, Cooper believes. “You can’t only look at planning from the point of view of one village or estate,” she argues. “The introduction of a strong regional dimension into the planning process is critical in getting the right balance. While using a local democratic element, you require a decision that benefits the whole region and country.”

Will the rekindled notion of planning tariffs (Planning, 7 November, p2) help to deliver more affordable housing than the current system? “We are aware of the conflicting views and perspectives, but we are determined that any change will not weaken the delivery of affordable housing,” she says. “Everybody has grumbled about the way that the system works, from many perspectives.”

She was reluctant to speak ahead of next week’s preliminary announcements on the Egan review of built environment skills and training. But she accepts the need for closer collaboration between the planning, housing and regeneration professions. “I speak at housing, planning or employment conferences but rarely at integrated events,” she notes.

The new mechanisms outlined in the Planning and Compulsory Purchase Bill, especially regional spatial strategies, offer greatly improved opportunities to link planning, housing and regeneration issues, she insists: “We must bring all the disciplines into the same debate.” She also hopes that the interim report of the Barker review of housing delivery, also due next week, “will closely link housing and planning with the economic agenda”.

Gus Alexander wonders whether too much Health and Safety is bad for you

The trouble with working for the Health and Safety Executive (HSE) is that once everything has been made safe, you’re out of a job. For this reason the boundaries of what is not acceptable are being constantly extended.

Building construction represents 10 per cent of GDP and is the biggest industry in Great Britain. This is where the ramifications of Health and Safety have the widest impact. Nobody expects trades’ people to have to work on dangerous building sites, and nobody wants their own children out clubbing in fire traps, but there comes a point where enough is enough. In the building industry we reached this point in April 1995 with the implementation of the Construction (Design and Management) Regulations.

What this legislation said was that issues of health and safety had to be considered at the very outset of every (non-domestic) construction project, and a new role, that of ‘Planning Supervisor’, was created to monitor the whole process. Building a new airport? Right. Appoint a Planning Supervisor and instigate a Safety Audit immediately. Secondary consultants such as architects and engineers can come later.

Good designers have always considered the manner in which their creations are put together, if for no better reason than danger begets difficulty; difficulty begets expense; and things which are expensive tend not to get built in the way that they were designed. Half-decent commissioning clients don’t want their buildings to be made too dangerous or difficult to maintain, for the same reason. However, as building becomes more and more speculative, and the relationship between the initial developers and the end-users ever more remote, the idea of common sense among consenting adults can no longer be relied upon. Instead, a Health and Safety hare has been set loose and a huge paper trail is developing in its wake. This is not a ‘make everything safer’ trail, so much as a ‘cover my ass’ trail.

For a tiny fraction of the cost, and to massively greater effect, HSE could increase the number of building inspectors twentyfold and give the existing ones greater powers to shut down construction sites where they find operatives working near unprotected lift shafts or standing knee-deep in water and attacking 40 gigawatt live mains feeder-cables with De Walt power-saws. Instead the CDM Regulations have ensured that responsibility for safety is now buried in a file located miles away. As long as somewhere buried in this file there is a method statement which prescribes how operatives are going to ensure that the supporting agent (finger) will not become sited between the percussive compression plant (hammer) and the ferrous fixing agent (nail), HSE is satisfied. For as long as building clients are obliged to have such files filled, consultants will be more than happy to charge imaginatively for filling them.

But to what end? The drop in the number of construction-site deaths has been negligible since the introduction of the CDM Regulations in 1995. Indeed, the figures for 2002 show a slight increase. The regulations don’t apply to private residential work where half-a-dozen wholly uninsured labourers may be trying to construct an additional floor five storeys up in a howling gale.

Safety in the building business is full of anomalies. Far more onerous regulations are enforced for a balustrade on a fixed staircase in a building which people use everyday, under perfectly controlled conditions, than those applied to a cross-Channel ferry where the environment is not only a strange one for the majority of the users, but is also pitching and lurching 40 feet above a surging sea. On London’s Routemaster buses, folk of all ages are expected to navigate a staircase (a miracle of circulation design) where the treads rise almost vertically and are only inches wide at their narrowest point. Not only is the stair-well highly constricted; the whole operation is lurching forwards at 40mph, with passengers making their way down as you are going up.

All domestic electrical installations have to be fitted with earth leakage circuit-breakers. The ELCB is a serious-looking switch the size of your thumb sited next to the meter. The slightest leak and the entire supply is tripped out. Very admirable in its way – it stops you getting fried by the lawnmower or welded to the toaster. However, it does mean that if you happen to be walking downstairs at night, carrying a tray full of boiling hot drinks, you’ll be plunged into total darkness should your rogue mobile-phone charger misbehave for an instant. A safety measure in one field can become a health hazard in another.

We recently fitted out an inner-city 19th-century board school as a temporary shelter for 50 rough sleepers. The residents found themselves upgraded from diesel-soaked Toshiba box one night to full-specification Health and Safety accommodation the next. For reasons to do with funding we were obliged to have the hostel up and running before the local authority were in a position to test the fire alarms. My clients have a lot of experience of keeping derelicts dry, and employ an in-house safety consultant to certify installations in just such circumstances. Nevertheless, two weeks after the scheme had been tenanted, the local authority insisted on sending in its own inspectors. Notwithstanding the fact that this is an institution which is fully staffed day and night, the council insisted that the alarm system was activated, and tested in every single location.

One hundred decibels is what you hear when a Boeing 757 takes off 150 metres away across open country, so a 110 decibel alarm is a violently intrusive acoustic manifestation. Once activated, the target audience gets the general idea in about a fifth of a second. Noise at this level is capable of generating physical pain. Imagine being scaled into a K2 telephone kiosk with a police screech siren. ‘Just to be on the safe side,’ said the council officers, cocooned in their sound-attenuating ear-muffs, as they spent nearly 30 minutes walking along every corridor, and taking a meter-reading at the head of every single bed.

By the end of this exercise at least half the residents – fragile people at best -were running around the playground in circles, clutching their heads and screaming with pain. Of course, one or two managed to remain fast asleep in front of Bargain Hunt, blissfully unaware of the acoustic intrusion. What does it matter if some of the residents suffer from tinnitus for the rest of their lives? At least they’d be okay in a fire.

Once the HSE has dragged everything up to comply with its current safety standards, what next? Full illumination in cinemas so the exits are always visible? Permanent 100mm diameter holes in all external walls where there is a gas appliance evident? Self-closing, half-hour fire doors in two-storey houses? Fire-alarm testing on the hour? As long as the words ‘Health and Safety’ retain the power to invoke terror and anxiety in our legislators, there will be no limit.

Dr. Morton Rapoport leaves a legacy of integrity at the University of Maryland Medical System.
There’s just something about Dr. Morton Rapoport. He’s like a wise man with vision, standing atop some distant mountain telling all of us what he sees. But Dr. Rapoport, who just retired as president and CEO of the University of Maryland Medical System, is the kind of wise man who often looks down from the mountain. And if he sees one person hurting, one person in need, he’ll come down from the mountain, and won’t go back up till that person has been helped.

It’s almost as if while he’s descending, his soul is actually ascending.

Dr. Rapoport, 68, would probably scoff at such grandiose descriptions of himself. The man who literally restructured the landscape of health care in this region has a severe case of modesty. He doesn’t see himself as a visionary. He sees himself as a simple guy who likes to play tennis and watch Orioles games with his beloved wife, Rosalie.

But in fact, Dr. Rapoport’s accomplishments are astonishing. The only president and CEO of the University of Maryland Medical System (UMMS) since it was privatized in 1984, he took over an ailing University of Maryland Hospital and turned it into a regional powerhouse. The six-hospital system includes facilities such as Kernan, Mt. Washington Pediatric, University Specialty, North Arundel and Maryland General. World-class treatment centers such as the Greenebaum Cancer Center, the Gudelsky Clinical Tower, the Shock Trauma Center and the Weinberg Building all operate under its auspices.

UMMS now trains more than half the state’s physicians and is one of the state’s top five employers. Patient revenues have gone from $174 million in 1984 to $1.2 billion. Admissions over that time have tripled to 65,000 a year.

So just how does a modest physician trained in the study of infectious diseases, a doctor who once studied anthrax, turn to the business of medicine? On a quiet, pretty Sunday afternoon, when most of the area’s attention was focused on the Ravens, Dr. Rapoport sat with Rosalie in their Brooklandville home and pondered his professional journey.

Perhaps it began in a place called Rapoport’s Market near Memorial Stadium. There, young Morton Rapoport worked stocking shelves, bagging groceries and doing anything his parents, Aaron and Bessie, needed. The family lived on top of the store until he turned 12, when they relocated to Forest Park.

“I learned how to run an enterprise, and how to treat customers while working in the store,” he said.

Dr. Rapoport attended City College as well as Har Zion Hebrew School on North Avenue, Baltimore Talmud Torah and even the Hebrew College, where he learned from the late Dr. Louis Kaplan. He earned his medical degree from the University of Maryland School of Medicine,

Dr. Rapoport and Rosalie, a psychotherapist, actually knew one another in elementary school at School No. 50. Mrs. Rapoport also grew up near Memorial Stadium and Eastern High School. She went on to Towson University and the University of Maryland School of Social Work.

After the Rapoports left for Forest Park, the two didn’t come back into contact until Rosalie went on a blind date with Mort’s roommate. The Roommate never stopped talking about Mort.

And Rosalie hasn’t stopped since, either. Married for more than 45 years, the electricity and love between them is still apparent.

The couple became active members at Beth Israel Congregation, and count the late Rabbi Seymour Essrog and Toby Essrog as best friends and influences on their lives. Their first trip to Israel was with Rabbi Essrog in 1973.

“We were a Conservative family,” said Dr. Rapoport. “Our kids, though, became more frum [observant].” Daughter Esther (Marcus) lived in Israel for 11 years. Their other daughter Robyn (Spero) attended the Pardes Institute in Israel, while son Dr. Aaron Rapoport is a Baltimore physician, one of 20 in the extended family. The Rapoports also have 15 grandchildren.

Dr. Aaron Rapoport, 43, a hematologist and oncologist, said his father inspired him to become a doctor.

“He’s achieved a great deal, and he’s reached real heights in terms of his professional accomplishments,” he explained. “There are two words I’d use to describe him: integrity and humility. He’s very reachable and very approachable. I see that in the way the employees of the hospital look at him, the orderlies, the greeters, not the high and mighty but the workers. They think the world of him and feel a connection to him. He’s noticed them, he’s valued them, and he’s communicated that feeling of making them feel important and valued. He never lost touch with the capability of connecting with people at all levels.”

The younger Dr. Rapoport loved the walks he and his father would take together to synagogue on Shabbat, and how his parents embraced their children’s growing observance of Judaism.

“We feel very blessed,” said Mrs. Rapoport. “I can’t say it was something we forced. It was something they came to. But by observing our children, we became more observant.”

The couple is now affiliated with Congregation Shomrei Emunah. But they are looked upon as affiliated with everyone.

“Mort Rapoport is the Jew who makes all Jews look good,” said Rabbi Mitchell Wohlberg of Beth Tfiloh, where Dr. Rapoport is a trustee on the board of the Community Day School. “The way he carries himself and conducts himself. There’s a dignity, a mentschlikeit, a humanity and an intellect that make for a perfect combination. He’s more than a doctor, more than an executive. He’s a role model and an inspiration.”

Rabbi Wohlberg cited Dr. Rapoport’s habit of visiting Beth Tfiloh congregants in the hospital, whether he knows them or not, and regardless of their status or financial situation. He doesn’t do it, the rabbi explained, to curry favor: “He does it because he knows it’s the right thing to do.”

Associated: Jewish Community Federation of Baltimore former president Morton Plant describes Dr. Rapoport as quietly forceful.

“Look, he took that place [University of Maryland Hospital]. It was a downtrodden hospital, and he built it into a powerhouse. It’s comparable to Hopkins, and it’s continually vying for recognition because of Mort. He makes things happen.”

Dr. Nelson Sabatini, the state’s secretary of health and mental hygiene, worked for Dr. Rapoport for eight years. “He’s one of the best friends I ever had,” said Dr. Sabatini. “Most people will say that he’s a visionary and a leader, a physician and an astute businessman. He is just a very special human being. He’s got a sense of dedication and a sense of family I’ve only seen in few people. He’s a nice, good human being. I feel blessed to have him as my friend.

“He can be a very difficult, demanding boss,” continued Dr. Sabatini. “But you don’t mind, because he is just as difficult and demanding on himself. That’s Mort. That’s who he is.”

The positive impressions of Dr. Rapoport have made it all the way up to Gov. Robert L. Ehrlich Jr.’s office.

“Committed, bright, connected, important, friend, these are five words I think of when I think of Mort,” Gov. Ehrlich told the BALTIMORE JEWISH TIMES. “He not only made us the model for around the country and the world, but he also should get some credit for development of the west side of Baltimore City…. He is low-key. He is subtle. He’s never been about bringing attention to himself. It’s not his way. I know he says he’s retiring, but I told him real retirement is not an option. He’s too valuable. We’ll keep him busy.”

Fifteen years before becoming CEO, he was incrementally becoming more management-oriented in the business end of health care.

In 1984, the state legislature enacted a bill establishing the University of Maryland Medical System as a private, not-for-profit corporation. This freed the state from regulations that kept it from being competitive in the hospital marketplace. With the legislation in place, Dr. Rapoport and the system could reinvest cash, borrow money and raise money from philanthropic sources. Dr. Rapoport’s first major new project was the $44 million Shock Trauma Center in 1989, followed by the Homer Gudelsky Building in 1994, which houses cutting-edge facilities for cancer care, cardiology, neurocare and transplantation. During Dr. Rapoport’s 20-year tenure, the system raised more than $100 million in private gifts. And all of this from a doctor who specialized in medical research on metabolic changes in infectious diseases. Or to look at it another way, all of this from a man who grew up in his parents’ grocery store.

Dr. Rapoport’s name even turns up in conversations with people who might not have a University of Maryland Medical Systems connection. Yaakov Goldstein, the executive vice president of the Torah Institute of Baltimore, for example, went to Dr. Rapoport for advice on how to help his school become fiscally sound.

“When I think of Dr. Rapoport, I think of a person of deep compassion, gifted with great wisdom, who I have the privilege to know and learn from,” he says reverently.

Or as Jewish community leader Howard Friedman says, “I think of someone who is a dynamic, successful person who has been successful in his career but at the same time has a deep Jewish neshamah [soul]. He feels a responsibility to work for the Jewish community. He hobnobs with the best of them, be it [Orioles owner] Peter Angelos to the governor. He’s Doctor Baltimore or Doctor Maryland. Even when he was ultra busy, no one would be too small for him. He is just a real mentsch.”

“A credit to Jewish community and the overall community,” said the Weinberg Foundation’s president Bernie Siegel. “What he’s done for UMMS is absolutely amazing.”

Rosalie Rapoport fights back tears when she looks at her husband across the living room. She calls him a kiddush HaShem (a blessing to God). “In so many ways, he has touched the lives of people who have come to the hospital.”

Mrs. Rapoport explains that her husband, the person who expanded the hospital into prominence, is the same guy who will secure kosher food for a patient in need, even one he doesn’t know personally.

“Life with Mort has been an adventure,” said Mrs. Rapoport. “He always has a view of another mountain to climb.”

His daughter Esther Marcus, 41, says she smiles when she thinks of him.

“I always thought he was the greatest,” she said. “I don’t just look at him on a pedestal. I know him. He’s inspiring. He’s a good guy. He’s always trying to improve himself or others around him. And to me, he’s always been religious. He sees himself in a modest way as a servant of God.”

Daughter Robyn Spero, 38, added, “I think my dad is great. He used to say to us as kids when all else fails, think. I see my dad as a thinker.”

Even though he’s retired, Dr. Rapoport doesn’t like to talk about what he calls the “r” word. Instead, he prefers to call it the “t” word, for transition. He said he’s not clear yet what he’s going to do next. In a testimonial speech at Dr. Rapoport’s retirement dinner, Mr. Angelos jokingly offered the chairmanship of the Orioles to Dr. Rapoport, a rabid fan. “I politely declined.”

So, looking back, was there anything he didn’t get done? Were there frustrations along the way?

“What frustrated me is that I just wanted to go faster,” he said. “I have a certain impatience. Over the years I’ve had a burning desire to achieve. I come from a work ethic, and sometimes I am impatient and less tolerant of people who don’t have that same work ethic.”

And what about a relationship to God? He calls this a “hard question,” one that he needs time to answer.

“I look at my children and I know that they are more observant,” he finally began. “One of my daughters describes us as on a ladder or path. I’m still on that path, and I’ve been on that path for a long time. I’m a stronger believer than I was 30 years ago, and probably stronger than 10 years ago. Rosalie and I have been influenced by our family, by our parents and our children. They’ve been spiritual forces for us. God and family are synonymous for us.”

Ask him about heroes, and he talks of his late father’s faith in God and the work ethic he lived by.

The baton has clearly been passed. Dr. Aaron Rapoport lovingly tells a single, simple story that he says sums up the essence of his father.

A woman in the Jewish community needed to come down to the hospital for some important appointments. She didn’t have a way to get there, so she asked Dr. Morton Rapoport if he could help her arrange transportation. He said he’d take care of it.

And so, every morning, UMMS President and CEO Morton Rapoport came to the woman’s house to pick her up and deliver her to the hospital on time. The wise man on the mountain, remember, listens out for those in need and does whatever it takes to help them.

Offset presses are getting faster, cleaner and more efficient and the same is true of the cleaning chemicals used on them. Sadly though, where a printer may be happy to spend extra money to get every imaginable bell and whistle to improve the efficiency of a new press, when it comes to the consumables the purchasing decision can still be driven by price alone. But as Yarn national sheetfed manager Steven Haig says: “You don’t buy a RollsRoyce and then put two-star petrol in it.”

Washes are used to clean ink and other contaminants off blankets and rollers. Most blanket/roller washes are based on hydrocarbon solvents, and the blend of solvents is balanced for the speed of drying. The higher the volatile organic content (VOC) the faster the product will dry and the quicker the makeready. The downside is that washes with a higher VOC have a lower flashpoint.

VOCs are a hot topic right now. According to Haig: “There’s been a big drive to comply to the UK Health and Safety Executive solvent substitution scheme.” The scheme is voluntary at the moment but it’s been hovering around for a while and it’s only a matter of time before it becomes legislation. The Solvent Substitution Scheme’s aim is to introduce solvents that have a flashpoint above 55°C.

One of the biggest changes in the roller and blanket wash market in recent years has been the proliferation of automatic wash systems. The vast majority of presses use them and although they can reduce the amount of wash used and increase efficiency, as a rule the chemistry – more highly refined solvents or solvent substitutes with lower VOCs – comes at a premium. But lower or VOC-free products have the bene- fit of not only being safer for the user and compatible with auto-wash systems, but also better for the environment, as they have fewer, or even no, aromatic hydrocarbons.

It can be very important to make sure that you are using chemicals that are approved by the press manufacturer, especially for the state-of-the-art presses where using the wrong chemicals can not only damage the machine, but possibly invalidate your warranty. The manufacturers of solvents submit their products to Fogra and upon meeting the criteria the products are issued with a pass certificate, stating that the chemicals are suitable for use with the press’ auto-wash system. Details of approved products are available from the press maker, chemical manufacturer or Fogra itself (www.fogra.org).

One interesting development in terms of reducing the cost of wash chemicals, while at the same time becoming more eco-friendly is the Technotrans Ecoclean. It recycles the solvents from your presses so that once cleaned they only require a 5% virgin solvent solution to be added before being re-used on the press.

Manufactured low-cost solvents that use ketones or acetones tend to be more aggressive and, although cheaper initially, they can end up costing more in the long run in terms of reduced blanket and roller life. Some chemical manufacturers reduce the costs of their products further by using reclaimed solvents, but here product quality and safety is a contentious issue. Reclaimed chemicals may reduce the manufacturing costs of the wash but data is rarely available on the product’s origin or sometimes even its composition, which makes it hard to guarantee its quality or safety.

Plate cleaners differ from washes in that they’re generally still applied by hand and are sold in far smaller containers. They’re used to remove ink and other contaminants from the plate before storage or recycling. A good plate cleaner will help to repair surface scratch damage inevitably picked up by the plate during its transport around a shop floor.

When sourcing wipes, look for softness, absorbency and linting capacity. Virtually all wipes are now disposable, the launderable wipe is very nearly extinct. There has also been a definite shift away from wipes impregnated with a cleaning solution. In fact, no manufacturers we contacted offered impregnated wipes. With the vast choice of plate, blanket and roller washes now available, all with their own specialist applications, it no longer makes sense to pre-impregnate the wipes.